Patient’s Demands = Doctor’s Duty?

Should a patient’s demands always be met?  Are ‘scientific’ reasons the only basis for clinical decisions?  If medical technology can, does that mean we should, every time patients ask? Are doctors automatons of the state?

Patients demand many things:

• CT head for minor head injury
• MRI for anterior knee pain
• Urgent referrals for chronic abdominal complaints
• Large amounts of narcotics for unspecified pain
• Repeat referrals for second opinions
• Tests to determine blood type or Vit D level
• Referrals for massage ‘because my insurance covers it.”
• Handicap parking stickers
• Same day, urgent appointments for chronic issues
• Notes for work after recovery for an illness that was never assessed
• Referrals for cosmetic work

A Patient’s Demand Unmet

A 25-year-old woman popped into an Ottawa walk-in clinic recently to refill her birth control.  The physician refused.  She got angry…especially when the doctor told her why.

[Hormone therapy is more than popping a pill to prevent pregnancy.  It includes medical risks (e.g., blood clot and stroke), requires clinical judgment to prescribe safely and should include regular follow-up.  Many make a solid case against walk-in clinics refilling ongoing prescriptions that require monitoring.  Of course walk-in clinics could do it, but discontinuous, episodic care from multiple providers for chronic care is not ideal.]

She got a form letter stating that for “…reasons of my own medical judgment as well as professional ethical concerns and religious values…” the physician would not prescribe her oral contraceptives in the walk-in clinic.  Kate Desjardins shared her suffering at the hands of religious prejudice on social media.

Sermon by the Toronto Star

The Toronto Star flew to the rescue with “Doctors who play God can be pastors, not physicians.”

Martin Regg Cohn, a journalist, launched a jeremiad on doctors who dare to listen to conscience.

His angry harangue drips with clichés like “safeguarding our best interests. Not indulging their own beliefs” [italics original].  He assumes a simplistic understanding of medicine where a particular diagnosis implies a specific treatment, no judgment necessary.  But medicine is rarely specific or particular.  He raises moral alarm with “Instead of carrying out their medical oath to “do no harm,” they opted for “do not help.””

Cohn wags his finger “Remember, too, that our health-care system is publicly funded. While doctors keep insisting on their independence, they must still play by the rules — not impose their own private moral framework.”  States have rules and good citizens must comply.

Cohn counsels physicians that they are “merely a medical practitioner.”  He assumes doctors require merely medical acumen, not clinical judgment or moral reasoning.

“A doctor is neither a judge nor a priest, merely a medical practitioner. If an MD wants to judge people, he should study law, not medicine. If a physician wants to impose religious barriers rather than provide contraceptive barriers, he should study divinity, not doctoring.”

With slightly pompous self-importance Cohn pontificates,

“Doctors who refuse basic family planning shouldn’t sign up for family practice or show up at walk-in clinics. Let them choose pathology — dealing with death, not life.”

Responding to Nonsense

Why bother responding to name-calling and logical fallacies?

We must respond because many unconsciously support anti-freedom, pro-state ideology.  An editor agreed to publish the piece.  Popular journalists promoted his article on social media.  Talk show hosts piled on with the same message.

Cohn’s article assumes public servants, specifically physicians, should not have freedom of conscience.  No doubt, this will emerge as a theme during debate about euthanasia in Ottawa next month at the Canadian Medical Association’s Annual General Meeting.   Do physicians have the right to refuse intervention that society deems appropriate?  If society demands euthanasia (or anything else), do physicians have a duty to provide it?

Freedom Trampled

The Star’s disdain for freedom and individual choice should raise alarm.    History offers many examples of political systems pursuing utopian dreams of social uniformity: states that dictate morality, provide for all citizens’ needs and expect unquestioning obedience from civil servants.  We should be alert to this thinking even when it’s twisted to appear patient focused.  Though my medical practice differs from the physician in this story, I fiercely support his right to follow conscience and explain why.

Medicine, Morality and Freedom

Medicine is a moral enterprise.  It directs courses of action (deontology) and reflects moral values (axiology).  Physicians apply practical reasoning (phronesis) and use current scientific understanding.  Physicians attempt to help, always aware of their own frailty and imperfection, and require freedom to do so.  Medicine cannot be reduced to a technological product dispensed by the state.  Patients’ demands can never define a doctor’s duty; both patients and physicians would suffer for it.

 (photo credit: change.org)