Saturday, July 05, 2014

Religious Beliefs Are Not Ethics

In the wake of the recent uproar over a doctor in Calgary refusing to prescribe hormonal birth control, and the SCotUS decision in Burwell v Hobby Lobby, it seems that there is more than a little bit of a misunderstanding about the distinction between a religious belief and ethical conduct.

In today's Calgary Herald, we have lawyer and right-wing activist John Carpay spouting off on the issue of the doctor.
Apparently Prentice believes that a doctor should simply do and provide whatever the patient wants done and provided, regardless of the doctor’s education, training, experience, conscience, and professional judgment. 
This raises some interesting questions. If a doctor, based on her experience and research, believes that liberation therapy (dilating and opening blocked neck veins) is not a good option for patients suffering from multiple sclerosis, must she provide that therapy simply because the patient demands it?
Let me point out first that professional ethics and practice guidelines are seldom "black-and-white", especially in matters where we are not necessarily talking about life-and-death, and to be sure, a prescription for birth control pills is hardly in that latter category.

However, there is an enormous difference between prescribing a birth control pill (with well known and quantified effects), and an experimental therapy that up until recently had no clarity around the degree of effectiveness of the treatment.  I would expect a doctor to provide enough information that a patient could make an informed decision in either case.
What about a doctor who is convinced that anti-cholesterol pills do more harm than good? What if a doctor refuses to prescribe birth control pills because she believes, apart from any religious teaching, that they compromise women’s health? Should this physician disregard her own research, analysis and conclusions and prescribe what she considers to be a dangerous product?
Like a lot of things, the question at that point becomes "where's your evidence?".  Medicine has moved beyond the era of "doctor knows best", and has been moving towards an informed consent model for a number of years.  Blanket refusals to provide this or that treatment without explanation speak more of condescension, and fragile belief systems, not rationally arrived at conclusions.
A free and democratic society allows consumers and providers to accept or decline each other’s business, without state coercion. In a free society, the government does not force doctors, lawyers, butchers and other people to do things that they do not wish to do.
A doctor is not in the same class of occupation as a butcher.  A doctor is dealing with people's lives.  Their duties supersede "personal beliefs" much of the time.  The doctor's blanket refusal ignores the potential risks to the patient.  For example, is it ethical for her to refuse to prescribe birth control pills to a woman who has been advised by a physician to avoid becoming pregnant because of the risk to her health?  (Yes, it does happen - it happened to my own Mother)

Oh wait ... women aren't supposed to _enjoy_ sex.  It's supposed to come with some kind of punishment (aka "consequences").

To put medical services into the same arena as buying a slab of meat at the butcher is a bit of a fallacy that ignores the more subtle complexities of the picture.  It's not like we have a surplus of doctors in Alberta.  In fact, we have a serious shortage even in urban areas, and heaven help you if you live in a small town and lack a car.  Further, a doctor's chosen profession reaches beyond the "free market", and the kinds of expertise involved are such that there is no guarantee of there being an alternative available - especially in small towns.

The issue that I have with this particular situation is not with the doctor herself, but rather with the "escape hatch" clause in the ethical guidelines that are involved.  I have no problem with the idea that someone may have strong beliefs in one respect or another.  That does not give them a free pass to decide that they are going to impose a blanket refusal on everyone based on those beliefs.

If there was real evidence that she had concerns about, that would be one thing, but based on a number of bits and pieces that we have seen in the media, her objections appear to be largely moral rather than evidence based and objective.

Quite frankly, I do not go to my doctor for "moral lessons", nor do I expect that my doctor is going to demand that I live by their moral code.  I expect my doctor to be informed, and to be able participate in helping me achieve an informed decision about whatever treatment I am seeking.  Individually, this doctor has essentially issued a blanket refusal which precludes her making an informed decision about any patient's situation.

On a higher level, I am not accusing the doctor of violating the ethical guidelines of her profession.  However, I am questioning if the "conscience clause" and its application here.  It seems to me that the clause itself is overly broad and untestable.  This has the unfortunate consequence of making it difficult for people to access health care - especially gender and sexual minorities, but even women - because at the outset the doctors are able to invoke this escape hatch without any evaluation of the patient, their situation or whether reasonable alternatives exist.

While I can appreciate that there are circumstances where a doctor will find themselves in a place which is in conflict with whatever moral beliefs they may follow, I think that the escape hatch in the practice ethics needs to be tightened up considerably.  At present it is overly broad at the detriment of the patient.

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