Denialism

Doctors aren’t preachers (or at least they shouldn’t be)

—

by

MarkH
in ,

I’ve written a number of times about how a physician must be careful not impose his or her personal beliefs on patients.

Another interesting case has hit the news. The decision of the California Supreme Court hinged on interpretation of state non-discrimination law. I’m not a lawyer, but I do know a bit about medicine and medical ethics. Regardless of law, this doctor’s behavior was wrong. The details are a little sketchy, but an unmarried lesbian woman was denied fertility treatments by a California doctor because the treatment conflicted with the doctor’s faith.

Conflicted with the doctor’s faith. There’s the rub.

This is a particularly perverse form of prostelitizing. It doesn’t involve having coffee with an acquaintance and teaching them the Word. It involves a vulnerable individual, who comes to a qualified professional for help, and is turned away because of “improper” living and thinking. In this case, it is disputed whether the patient was denied care because of being gay or because of being unmarried. It doesn’t really matter. Either reason for discrimination is wrong. What matters is that the doctor felt that treating the patient would violate her own religious beliefs.

The measure of whether a treatment is appropriate is whether it conforms to standard of care, is safe, effective, and ethical (non-coercive, etc.). If a patient presents for infertility treatment, and is medically qualified, she should receive the treatment (assuming she doesn’t breed babies for snack food). The American Society for Reproductive Medicine recognizes this in several position statements. One specifically addresses unmarried and homosexual patients:

–Unmarried persons and gays and lesbians have interests in
having and rearing children.
— There is no persuasive evidence that children raised by
single parents or by gays and lesbians are harmed or
disadvantaged by that fact alone.
–Programs should treat all requests for assisted reproduction
equally without regard to marital status or sexual
orientation.

When you decide to become a doctor, you immerse yourself to the neck in ethical problems for the rest of your career. Patients make bad decisions. Other doctors make bad decisions. Ethically grey conundrums pop up on a daily basis. Standards set by professional organizations help to sort some of these out, but not always. The “most wrong” decision in an ethical debate is the cop-out. For a physician to deny a patient care based on their own beliefs is a cop-out, and is a coercive use of their paternalistic powers. This decision doesn’t just deny them your personal services. It may cause permanent psychological harm to the patient. And that’s not what doctoring is all about.

Comments

  1. Dagger Up The Strap

    I’m thinking of becoming a paramedic and inventing a religion that prohibits me from treating or transporting the religious.

    Working name: Church of Jesus Christ, Bastard

    We’ll be known as Christian Bastardists.

    Reply
  2. khan

    an unmarried lesbian woman was denied fertility treatments by a California doctor because the treatment conflicted with the doctor’s faith

    According to some religious beliefs, fertility treatments are against god’s will.

    Reply
  3. ERV

    One of PZs guest posters has a great vomit inducing post on this topic.

    Reply
  4. PalMD

    We have one too. It’s downright scary.

    Reply
  5. Chuck

    This is an elective procedure and no one’s life is in imminent danger, making matters a little greyer then the pharmacist issue. Rather than sexual orientation, the potential mother was a convicted child abuser saying she has “paid her debt to society”?

    Reply
  6. Ramel

    But she’s not a convicted child abuser, or mentally ill, or a serial killer, she’s just a lesbian.

    Reply
  7. PalMD

    Chuck, that’s idiotic. Medicine isn’t about only in extremis scenarios…it’s about treating people every day for everyday problems. One could argue about whether insurance should cover infertility etc, but if you chose a speciality with a specific set of moral issues, you better be ready to deal or learn to say “want fries with that?”

    And if you check my links, there is a position statement about parental fitness.

    Reply
  8. pelican

    Actually, Chuck’s position is both idiotic and ironic.

    A gay couple I know just adopted a child, voluntarily surrendered at birth by a 26 year old woman whose first *five* children were removed from her care due to her repeated abuse and neglect of them, due to substance abuse and likely mental illness. So, the right of known child abusers to procreate is completely unimpeded, and is in fact supported, as this woman was given all kinds of state and country assistance so she could “keep” her first five children, who eventually ended up being removed from her care after repeated episodes of abuse and neglect. Her sixth baby’s luckiest day is the day she was adopted by two wonderful and stable dads who will give her a terrific home.

    This legal case was about hate and the desire to discriminate, pure and simple. There is no valid “protect the children” argument to be made here.

    Reply
  9. Anonymous

    My own experiences:

    1) As a medical student, hearing an OB/Gyn tell a woman that she got herpes as a result of immoral behavior. In this case, “immoral behavior” was having sex with her husband in something other than the missionary position. No I am not kidding.

    2) One of my current partners who will not prescribe Viagra (or similar) to unmarried men.

    Reply
  10. LanceR

    Yes, Chuck, why *ARE* you religious types so full of hate and anger? What part of “turn the other cheek” do you not understand? “Love thy neighbor as thyself” ring any bells? “As you do unto these, the least among you”? “Thou shalt not bear false witness”? Any of this even a little familiar?

    Reply
  11. Ames

    Hey Pal – I just e-mailed you about this, but on a related note, the HHS reg is back in the news. Basically, Leavitt admits that it’s a “social statement,” and it’s downhill from there. Thought you might lend the righteous rage of an ethical physician to this.

    Anonymous (10:57) – both of those are amazingly tragic. I can’t hardly believe it. I remember Georgia had a statute prohibiting sex except in the missionary position, but it was never enforced. I thought it was a joke. I guess not.

    Reply
  12. William Wallace

    Well, what do you think about a doctor who asks patients if they keep a gun in the home?

    My doctor has done this. Still a good doctor, even though he’s a libturd.

    Reply
  13. Bob

    Nice, though the doctor didn’t take the next logical step, conclude that barren people are that way because of God’s will, and quit medicine to become a goatherd.

    Pull their certification and drop-kick them into the unemployment line. I wish there was a less drastic way to get the point across that the choice of being a religious bigot or a physician is an exclusive one but as long as people cling to nomadic desert traditions in modern industrial societies, I doubt there’s a more effective technique than booting them from the professional class. Good fucking riddance.

    Reply
  14. Dunc

    According to some religious beliefs, fertility treatments are against god’s will.

    According to some religious beliefs, medicine is against God’s will.

    Personally, I tend to feel that if you hold those sorts of beliefs, then perhaps a career in medicine is not for you.

    Reply
  15. PalMD

    Actually, Bill, we’re supposed to screen for safe storage and use of firearms…it helps prevent firearm deaths. We’re not supposed to tell people to get rid of them, just ask if they are stored properly etc.

    Reply
  16. Richard Eis

    If this was ever allowed allowed, then all blood transfusions can be stopped because the person doing it is a Jehovah’s Witness. I also hate to think what would happen if a christian scientist became a medical professional of some kind.

    Religion is a poor source for morals and the sooner it dies, the sooner we can get on with proper modern morality and the sooner your average doctor will have less to worry about.

    Reply
  17. Chuck

    “Yes, Chuck, why *ARE* you religious types so full of hate and anger? What part of “turn the other cheek” do you not understand? “Love thy neighbor as thyself” ring any bells? “As you do unto these, the least among you”? “Thou shalt not bear false witness”? Any of this even a little familiar?”

    How are you determining what religion I am LanceR? Are you just using your stereotypical views of all religions to bias and bigot your remarks?

    I could honestly care less about the religious views and practices of anyone. I care a great deal about the morality and ethics of the medical community because they can be forced upon society and individuals. In my example, you do not understand any of your own quotes if the convicted potential mother has atoned for her past transgressions and wants to start anew and is denied that by the medical community.

    Reply
  18. Natalie

    William, asking questions is a lot different than refusing treatment. My doctor asks me all kinds of questions about my sex life, but that’s her damn job. She’s trying to determine if I’m at high risk for various things, and give me suggestions to lower risks if I need/want them. If she refused to treat me because I’m “living in sin”, that would be unethical. Unless your doctor threw you out of his office when you told him you had a gun, your comparing bananas and coke cans.

    Reply
  19. Chuck

    Patients have been thrown out of doctor’s offices because the patient’s belief conflicted with the doctor’s beliefs. This example is just one of many and the bias goes both ways.

    Reply
  20. Amar

    Chuck,
    I am curious what you think about the rights of parents to deny their children medical care on the basis of their beliefs. What, if any, rights to those parents have? and what is the responsibility of the State or the local community?

    Reply
  21. Cat

    I’m from Canada, and was once refused the birth control pill from an ultra-religious, Catholic gynecologist. He refused it to me under the guise of being concerned about my health. His real motives were thinly veiled; the bible in the room and the religious quotes on the wall told me it was likely not about my health.

    I’m assuming it’s the same in Canada, that outright refusing to prescribe the pill to someone under a religious precept would be illegal. Anyone know for sure?

    Reply
  22. Interrobang

    Patients have been thrown out of doctor’s offices because the patient’s belief conflicted with the doctor’s beliefs.

    Chuck, seriously, name two. We’ve got actual examples of doctors inflicting their biases on patients, but I’ve never heard of a doctor throwing a patient out on the grounds that the doctor found the patient’s religious beliefs objectionable. If I were a doctor in the United States, I might try that — no fundamentalist religious nuts in my practice!

    I’m kind of a hard-liner on the subject. Your right to swing your fist religiously ought to end at the end of someone else’s nose, and I think that includes your kids’ nose. You, as an adult, elected to either be or stay in your wacktastic religion; your kids haven’t had the opportunity to make any such choice yet.

    Reply
  23. Interrobang

    Cat, I think it depends on where you are. In Ontario, Manitoba, Quebec, or BC, you’d probably have a good shot at making a Human Rights Commission case stick. In the Maritimes or Alberta, good effin’ luck. As far as I know, doctors in the Maritime provinces can deny reproductive health services to any woman for any reason citing “conscience” and not get rapped for it. In Alberta, I don’t think they hold with the idea of the Human Rights Commission at all. I can’t vouch for anything in the North at all. I would imagine the situation isn’t great, even if you have access to services.

    I had a similar experience with a Chinese Catholic doctor in Toronto who was really reluctant to prescribe me birth control, since I am not married. That was several years ago now, though.

    Anybody want to start a PAC to change the Canada Health Act to ensure uniformity of basic coverage province-to-province? (And make damn sure that all aspects of women’s healthcare are included?)

    Reply
  24. Cat

    Thanks for that info. Unfortunately for me, I am in Alberta, and it happened to me a few years ago, so I’m not sure it would be relevant now. It has stuck out in my mind though! I was only 25, not a smoker, and in perfect health, so he had no real reason not to prescribe it to me. Funnily enough, he offered me an alternative: use a fertility monitoring device to schedule sex around my ovulations. Knowing that that method has a much lower rate of pregnancy prevention than the pill, I wanted to ask him what I should do if I, an unmarried, non-religious woman, should do if an accident did happen, but I wasn’t quite brave enough at the time.

    Oh, and I’d be on board with anything that ensured the uniformity of coverage in all provinces!

    Reply
  25. hedberg

    Doctors are supposed to screen for safe storage and use of firearms? Damn, that’s bizarre. Firearm safety has absolutely nothing whatsoever to do with the practice of medicine.

    So, who has decided that doctors are “supposed” to screen for this? Is this some sort of government meddling or is this being taught in medical school, or both?

    Reply
  26. hedberg

    I’m curious about physicians’ opinions on a question that appears to me related. Doctors who are in the business of providing safe, effective, and permanent contraception (i.e. sterilization) routinely deny this service to young, childless patients regardless of marital status. From an ethical perspective, is there a difference between doctors who deny such services for religious reasons compared to doctors who deny such services from some misguided and inappropriate, but religion free, sense of superior judgment? In other words, is there something uniquely unethical about a doctor who acknowledges the religious basis for the prejudices imposed on the patient?

    Reply
  27. Tercel

    Generally the reasoning behind this is that doctors should avoid harming a patient, even if that patient desires such harm. In the case of life altering and irreversible procedures such as sterilization or sex change, there could be severe psychological anguish if the patient were to change his or her mind later in life. This is why one must undergo extensive psychological screening and a long waiting period before sex change operations.

    As far as the justification for such obstacles, yes there is and should be some assumption of superior judgment on the part of the doctor. This is exactly why they are the doctor.

    Reply
  28. Natalie

    hedberg, it’s neither. It’s a policy of the American Medical Association, a professional organization.

    Reply
  29. DuWayne

    hedberg –

    Public health issues are something that doctors (should) have a profound interest in. Because they are healthcare practitioners, it is logical that they would ask questions related to public health. Same reason that they ask about things like sexual activity, drug use and other public health issues.

    Reply
  30. hedberg

    Tercel:
    “For a physician to deny a patient care based on their own beliefs is a cop-out, and is a coercive use of their paternalistic powers.” To apply this principal to a doctor who desires to deny fertility treatments to an unmarried lesbian and not apply this principal to a doctor who denies sterilization services to young, childless patients regardless of marital status or sexual orientation, is, to put a kind word on it, ironic. I don’t know that you are guilty of such irony, by the way. I’m making an observation, not an accusation.

    1. If the doctor has no special reason to doubt the patient’s competence or to suspect impulsiveness or whimsy, all family planning decisions, even the decision to procreate at all, are ultimately the patient’s responsibility. I would suggest that it is within the purview of the doctor to investigate the patient’s rationale in either the fertility treatment case or the sterilization case, but in either case, the doctor must guard against unduly influencing the patient for any reason, whether explicitly religious or not.

    2. In general, the doctor has no way to judge which course of action (providing or not providing sterilization) causes the greater risk of “severe psychological anguish.” Sterilization should be considered permanent and irreversible, but unwanted pregnancy is also. The risks are for the patient to assess, not for the doctor. I did a quick search of the inernets on this and it seems that there is very little, if any, evidence that increased risk of harm to childless patients is real. Apparently, childless people who are voluntarily sterilized are probably no more likely to regret their decisions, or to seek reversals, than are those who are sterilized after becoming parents. But, apparently, lots of doctors don’t care about the facts.

    3. Voluntary sterilization is not life-altering in the way that either sex change surgery or unwanted procreation is life-altering. I wonder how a study of the life-altering nature of abortion compared to the life-altering nature of sterilization would turn out? Or the life-altering nature of 18+ years of child support payments?

    4. The doctor is the doctor because the doctor has expertise in the science and mechanics of medicine, not because the doctor has superior judgment as to whether people should be subjected to unnecessary risk of unintended parenthood.

    Reply
  31. DuWayne

    I have to say that it would be irresponsible, as well as unethical for a doctor to just greenlight a sex change without the preceding psychological review. I know three trannies who have undergone complete sex change operations and all of them believe that the counseling is essential, including two who didn’t believe that they needed it before hand. It is, at it’s root a psychological issue, even though the actual surgery is a physical one.

    I should note that I know four other trannies who opted out of or put off the surgery during and because of the counseling that precedes the operation.

    I do however agree that young people should be able to get “snipped” if they damn well want to. I am irritated to no end that they were trying to get me to see a counselor before I went through with getting a vasectomy and I’m 32 year old parent of a six year old and a eight month old who is struggling to keep a roof over their heads. I need another mouth to feed and shelter like I need a good dose of the black plague. Yet the nurse was required to make sure I didn’t feel the need for counseling, by asking me three times if I was sure. Not her fault – health system’s requirement.

    Fuck that. It was my body when I was eighteen – clearly my own. I don’t like the notion that one should require counseling before they make the choice to never reproduce, even when they are young.

    Brings to mind the shit a bi-polar friend of mine went through when he decided at nine-teen to ensure he would never reproduce (you know, because he didn’t want to make a bi-polar baby). They required him to go through a couple months of counseling sessions before they would finally snip him. His repeated mantra throughout was; “I can’t even take care of myself, I couldn’t take care of a baby. If I have a baby, it would likely have the same problems that I have.”

    This from a guy who tried to kill himself a couple of times, nearly killed his best friend in a fight and spent more than four years total in institutions while he was a minor.

    Reply
  32. hedberg

    Natalie and DuWayne:

    When I go to the doctor, it’s because of things having to do with medicine specifically, not because of questions about public health in general. I don’t want advice about how to thaw frozen chicken, whether or not to wear seat belts, or how I should store a gun (if I have one). I don’t expect a typical medical professional to have any particular expertise in any of these areas. (Of course, there are experts in all these areas that happen to be doctors — but none of them is my doctor). If I went to my doctor to have my prostate checked and my doctor started to talk to me about gun safety, I’d be as stunned as if the clerk selling me bullets (if I were to buy some) put on a rubber glove.

    Just curious, do doctors and the AMA think that bothering patients about gun safety will have any effect on anyone?

    Reply
  33. hedberg

    DuWayne:

    I won’t go into details, but I do have some experience with the sterilization question. It appears that you and I are in total agreement on this one. Perhaps this is one of those areas in which it just does not pay to tell the truth. If someone goes to the doctor for a vasectomy, the only reply to give when asked for a reason is that there is a history of Huntington’s in the family. Can they test for that now? If so, perhaps a history of schizophrenia would do it.

    Reply
  34. PalMD

    hedberg, there are a host of issues regarding sterilization, some of which are medico-legal and somewhat unique to the litigious environment of the US.

    As to public health, well, tough shit. There is not way to separate my advice to lose weight and exercise from my advice to wear a seat belt.

    Reply
  35. Anonymous

    PalMD:

    Are there cases where doctors have been successfully sued by sterilized patients who have requested the procedure and expressed complete consent? I suppose it could happen, but even though there are a lot of doctors who won’t sterilize the young and childless, there are doctors who will. Surely the risk of litigation can’t be oppressive, can it? I readily accept that doctors in the US today must be mindful — vigilant, perhaps — about avoiding law suits, but I think the more likely cause for denying sterilization on demand is rank prejudice.

    If your patients don’t mind that you counsel them about wearing seat belts, it’s no concern of mine. You would probably find prayer more effective, however.

    Reply
  36. hedberg

    the above snarky comments were mine. Sorry for the “anonymous.”

    Reply
  37. DuWayne

    hedberg –

    I understand that you didn’t go to the doctor to hear a lecture about gun safety, but for some people that may be the thing that convinces them to lock their guns so the kids can’t get at them. Likewise, it may be that visit that convinces them to quit smoking or lose a few pounds. The point is that for some folks, the only time they hear about this or that public health issue is when they see their doctor.

    Personally, I believe that it is my doctor’s job to look out for my health all around. Honestly, if I go in because I have this headache, I expect my doctor to do a little digging and see if there isn’t another problem they might help me with.

    Reply
  38. Amar

    I guess Chuck doesn’t want to answer my question. Are there any other trolls out there that want to take a stab at it? Does anyone else?

    I am curious what you think about the rights of parents to deny their children medical care on the basis of their beliefs. What, if any, rights do those parents have? and what is the responsibility of the State or the local community?

    Reply
  39. Chuck

    Amar,

    You are only addressing 1 out of 3 possibilities for phrasing your question.

    1) Parent’s ability to deny children their rights (Amar)

    2) Children’s ability to deny parents their rights (Chuck)

    3) Government / medical community’s ability to deny patients their rights (Chuck)

    State or the local community fail as surrogate caregivers due to budget constrains and no vested interests to individuals within their jurisdictions.

    Arguments on “medical care” are many and heated. Some say relying on faith/religion rather then scientifically proven methods is denying them “medical care” (non-religious views pushed on religious).
    Some say that denying a child the right to be born is denying them medical care (religious views pushed on non-religious). How does society benefit from these exchanges? I can’t solve world peace either.

    Reply
  40. MarkH

    Ok, having just finished pediatrics I will explain the gun safety issue. As always, it’s an example of something right wingers like to jump all over because it can be misrepresented as some kind of liberal plot against weapons but when you understand the reasoning behind it most can not argue with it in principle.

    It is not common for all doctors to ask about weapons in the home. If you were asked as an adult by a PCP I’d be somewhat surprised but then, I am in the south. The instances in which it’s specifically recommended as part of the patient interview is with people being screened for mental illness/depression/suicidality and in the pediatric interview. In particular, with pediatrics, it accompanies questions like “do you have a car-seat?” and “do you make your child wear their seat-belt?”. The reason is that when it comes to deaths of children the leading causes are accidents, trauma, firearms and abuse. The pediatrician is not your doctor, they are your child’s doctor first and foremost, and since the things that are most likely to impact the child’s health are safety issues, they are reasonably interested in asking safety questions.

    So, we ask if there are guns in the home. If so, are they locked up? Are they accessible to the child? Do you realize that children have no capacity to understand the lethal power of firearms? Do you realize that some 50% of young children, even those warned against handling guns, will immediately pick one up and pull the trigger when they find one? It’s been studied, they do it almost reflexively.

    This isn’t a judgment of gun ownership. This is sensible safety screening amongst susceptible populations. And while the average scienceblog reader may think such interview questions are beneath them, one must realize that we are dealing with the entire population, and a good many of people may be quite surprised to learn that the greatest threats to their children aren’t illness and the homosexual agenda but their own parents, cars and guns.

    As far as the rest stop feeding the troll!

    Reply
  41. hedberg

    I, for one, was not suggesting that a doctor’s query about firearms safety was evidence of any sort of liberal plot.

    In the context of a conversation between a pediatrician and a parent, it seems like a reasonable topic even though accidental firearm deaths among children seems to be quite rare. According to the CDC, in 2005 there were 75 deaths of children under 15 as a result of firearms accidents out of almost 40,000 deaths among those under 15. Deaths as a result of illnesses were much more common as were, of course, deaths in motor vehicle accidents. It looks like both gun death frequency (largely self-inflicted) and motor vehicle death frequency are much greater among older teens and young adults rather than among young children

    So, I would say that the threat posed to children by guns is probably about as great as that posed by the “homosexual agenda” even though I have no idea what the “homosexual agenda” is or whether it causes any threat to children at all. But, it is small consolation to anyone involved that it is a rare occurrence for a young child to be injured or killed as a result of a gun accident, so I suppose a discussion about gun safety (and other areas of accident avoidance) with the parents of small children isn’t out of line.

    I tried to determine whether deaths by firearm accidents among young children had decreased significantly in recent years, but couldn’t readily find good data in comparable form. It appears that there may have been some decreases between about 1980 and about 1996 or so but I can’t be sure. If this is so, I would guess that it probably has to do with changes in the law about trigger locks (and such) and more awareness among the general population about the dangers of poor firearm safety.

    Also mentioned were interviews involving the mentally ill, the depressed, and the possibly suicidal. I’ve never been interviewed and asked about firearms under any of these circumstances, but I have had the opportunity to observe much more of such situations than I would have liked. If I ever found myself personally in such a situation, I know what my answer would be.

    Reply
  42. Natalie

    I don’t want advice about how to thaw frozen chicken, whether or not to wear seat belts, or how I should store a gun (if I have one). I don’t expect a typical medical professional to have any particular expertise in any of these areas.

    That may be, hedberg, and if it comes up with your regular doctor you can ask them to stop asking you about it. My regular doctor has responded to that well. I assume asking about guns is AMA policy for the reasons MarkH explained, and as far as I know that policy only applies to pediatrics and psychology.

    Reply
  43. Fruitfly

    hedberg, I’m not sure frequency is that important when it comes down to this:

    http://minnesota.publicradio.org/collections/special/columns/news_cut/archive/guns/

    Reply
  44. hedberg

    FruitFly,
    Frequency is important if we are talking about “the greatest threats to . . . children,” and that is the context of my comments about the number of young children killed in gun accidents. As I also wrote, “it is small consolation to anyone involved that it is a rare occurrence for a young child to be injured or killed as a result of a gun accident.”

    Reply
  45. tütüne son

    I tried to determine whether deaths by firearm accidents among young children had decreased significantly in recent years, but couldn’t readily find good data in comparable form.

    Reply

Leave a Reply

Your email address will not be published. Required fields are marked *