Medicine and Society: Should Conscience Have a Role in Medicine?

Dr. John Lantos

Good afternoon. Welcome to Medicine and Society. My name is John Lantos. I'm standing in for Rosie Tong who couldn't be here today. We are going to talk today about some difficult issues of conscience in medicine and when doctors can refuse to provide treatments under certain circumstances to patients who want them. I am a pediatrician and bioethicist from the University of Chicago. and the Center for Practical Bioethics in Kansas City. And I'm joined here by two doctors from Charlotte who will introduce themselves.

Dr. Irene Zink

I am Irene Zink. I'm with the Department of Family Medicine, obviously a family physician. I'm the Associate Program Director with the department, and my specialty area is urban underserved medicine.

Dr. Theresa Sunderland

And my name is Dr. Theresa Sunderland. I'm with Presbyterian Hemby Children's Hospital. I'm the medical director of PIPS and the chairman of pediatrics there. And my specialty is pediatric critical care.

Dr. John Lantos

So the big question, I think, is, is there ever something a patient would ask you to do that's legal to do but that you would refuse based on your own conscientious beliefs?

Dr. Irene Zink

There are so many different things in medicine that can be controversial for individual physicians to deal with. whether it's their religious beliefs or their own personal beliefs. My thought is that, above all, do no harm to the patient and to also be an advocate for the patient. I mean, there's controversial issues like birth control, the morning after pill, which Plan B was just approved for 17-year-olds and up, physician-assisted suicide. There's lots of different subjects.

Dr. John Lantos

Let's start with birth control. Are there any circumstances under which you wouldn't give birth control to a patient?

Dr. Theresa Sunderland

The only instance that I wouldn't do that is if it would be harmful to the patient.

Dr. John Lantos

Let's say a 12 year old comes in and you ask the parents to leave the room because that's what adolescent docs recommend and she says, you know, me and my boyfriend, we're very much in love and we've decided to go all the way. Could you give me a prescription for birth control pills?

Dr. Irene Zink

Well, that is very hard because of her age. Sure. But what would be worse, a 12-year-old who is having unprotected sex and ends up pregnant or a 12-year-old who is having unprotected sex on the birth control pill and doesn't get pregnant? There's so many different issues that you have to discuss with that 12-year-old. First of all, you would really want her to be talking with her parents, and you would want them to know. But there's also... But

Dr. John Lantos

you've promised her confidentiality, right? Exactly.

Dr. Irene Zink

Her confidentiality was what I was just going to say. But the thing that you have to think about is educating this patient about her decision. The other thing is, you know, is this her choice? Is she being pressured into it? With my patients, I always like to teach them and educate them that it's their body. So it's what they want to do with their body. But that they have to be smart. and what they're doing with it and protect themselves, especially from sexually transmitted diseases and getting pregnant. In her case, I would prescribe the birth control with very lengthy talks and education. I would also bring her back. I would encourage her to bring her boyfriend in. I would also encourage her to talk with her boyfriend more about these issues, you know, Is this their first time together? Has he slept with anyone else? How old is the boyfriend? That's a big issue, too. I mean, if he's over the age of 18, that brings in many, many other factors and legal issues.

Dr. Theresa Sunderland

Yeah.

Dr. John Lantos

What do you think? I'm in

Dr. Theresa Sunderland

total agreement with you. I would definitely prescribe it, and I think we are bound by confidentiality unless she would harm herself.

Dr. John Lantos

I'm not so sure I would. I think... A 12-year-old having sex, I'd have a lot of trouble simply prescribing that without informing her parents.

Dr. John Lantos

I'd try to get her agreement that talking to her parents was a good idea, but if I couldn't, I might send her to someone else and say, I just can't do it. So how would you feel, though,

Dr. Irene Zink

when she came back in four months and she was pregnant at the age of 12 and a half?

Dr. John Lantos

If that happened, I would feel terrible. I wouldn't be completely confident that prescribing her birth control pills would prevent that since I'd worry a little bit about the judgment of a 12-year-old, either making a decision to start sexual activity or to continue to take a birth control pill every day. So I think I'd want to know a lot more about what was going on both in her family and with the boyfriend before I'd feel comfortable. It would mean imposing my values, but I think whatever we do, we impose our values, whether it's by giving people permission or by restricting what they do.

Dr. Irene Zink

So are you saying that our values are like, you're 12, go have sex?

Dr. John Lantos

I think you are certainly giving permission for that. I'm not sure you're endorsing it, but I don't think you're making a value-free decision.

Dr. Irene Zink

And I appreciate what you're saying. um and you know if it was my twelve-year-old I'd have to think about what you know how what I would think but I would hope that there'd be open conversation there um and you said some very important things um that I appreciate and that is if you couldn't do it then you would send her to someone else

Dr. Theresa Sunderland

right

Dr. Irene Zink

the other thing that you brought up is talking to her parents which I think both you and I would feel the same way um but you know confidentiality is an issue um and You also have probably, I'd like to think that this is maybe a patient that we had been seeing for some time maybe. That's an important issue. That's another issue too. Definitely

Dr. Theresa Sunderland

that would have follow-up with.

Dr. Irene Zink

Exactly. I mean, I don't think either you or I would give her the birth control prescription and say, hey, see you later, take care. Usually I will bring them in another, in like about a two-month to three-month period of time. to make sure to see how they're doing on the pill and just review kind of all the educational things and see how they're doing just with their decision in life.

Dr. John Lantos

Another area where issues of conscience tend to come up is not so much the beginning of life but the end of life. In this country today there are three states where physician-assisted suicide is legal. uh... if it was legalized in north carolina and uh... one of your let's say adult patients came to you and said doc i want you to give me a prescription for enough medicine to kill myself what would you want to know before you wrote that prescription or would you write it at all

Dr. Theresa Sunderland

uh... i could see myself writing a prescription for that uh... some of the things that i would be concerned about is specifically what is their illness is at terminal, assess their pain levels. I would like to have family members involved in those discussions. And also it would be important to have hospice care and support with this person when they decided to take the medication. I would not feel comfortable just handing something and sending somebody home with that, but I think there needs to be a very close network of persons with them.

Dr. John Lantos

So the idea of assisting someone in suicide is not morally repugnant to you as long as it's done in the right circumstances with the right support networks in place? Yes.

Dr. Theresa Sunderland

That's my opinion.

Dr. John Lantos

How about you?

Dr. Irene Zink

Well, it's a... big issue and it's something to think about and it really depends on the patient and the patient's circumstances. You know, daily when you're carrying on the hospital service, you know, there's many patients that are at the end of life and you're making decisions on their care daily, even hourly at some places or points. And I think it It's a conversation that you would have to have with the patient and with their family. You know, it would totally depend on the patient's illness and prognosis. Of course, I'm not going to just give a prescription to assist someone to die who's just, you know, hey, I'm 80, I've lived a good life, and I'm ready to go. You know, I really don't have anything to live for. My wife has, you know, died. My kids have all moved away. that would not be a reason. But if I had a patient who had metastatic lung cancer, really was having difficulty breathing, having difficulty getting around, the quality of life was not there, then definitely that's something that I would do and consider. Only after though a conversation with the patient, if the patient was lucid and able to make decisions, And if not with the patient, then with the family.

Dr. John Lantos

Yeah, it gets much harder if the patient's not lucid. Even in Oregon and Washington, only a competent patient can request this. Families can't ask for lethal medication to kill their family members. So that would be one limit that most states would put on it. But it is interesting that you're sort of figuring out the criteria that you would apply to decide when it's permissible or not rather than letting the patients decide. Your 80-year-old just said, hey, I've lived a good life. All my family's gone. I'm lonely and I'm ready to go. You'd say no?

Dr. Irene Zink

Then I think that I would be taking the position of playing God almost.

Dr. John Lantos

Well.

Dr. Irene Zink

Because, I mean, and then this brings in the whole religious aspect, but, you know, if it wasn't in... God's plan, depending if you believe in a higher power, that it was his time to go to assist him in dying by giving him a prescription. Aren't we playing God in a way?

Dr. John Lantos

Well, at least we're invoking our own consciences and our own beliefs about what's permissible or not permissible and saying, I can go this far, but if you ask me to go farther than that, I have to draw the line. I couldn't do that. Whether you'd condemn a colleague who did it or not would be a different issue.

Dr. Theresa Sunderland

What about condemning a colleague? I definitely would invoke my right to the length that I went to, such as I'll draw the line here and I'm not going to help the 80-year-old who is just tired. But I forgot what you said. One of

Dr. John Lantos

the interesting things about the data from Oregon, where physician-assisted suicide has been legal now for 10 years, people have studied the patients who come to doctors and ask for prescriptions. They can't study the people who have filled the prescriptions and used them, obviously. But of the people who ask, some of the reasons that everybody thought would motivate decisions did not turn out to be the ones. That is... Most people who asked for a lethal prescription did not say it was because they were in intractable pain. In fact, most people said, one, I'm lonely, and two, I fear being a burden on my family. Those were the two main reasons why people did it, which raises some interesting questions about whether helping people kill themselves would be one approach versus trying to hook people up with social support, churches. groups of friends, getting them a puppy might be

Dr. Irene Zink

a way of approaching

Dr. John Lantos

this.

Dr. Irene Zink

I have to say I work in an urban underserved clinic for Carolinas Medical Center and there are a lot of patients that I see that are at the end of their line, especially with the economy the way it is now. I was in private practice for five years and am now seeing patients who I was seeing in private practice who had a great job and had insurance, and here they are coming to a clinic for sliding scale.

Dr. John Lantos

Can you think of a particularly tough case without violating anybody's privacy? So,

Dr. Irene Zink

you know, an elderly patient in his mid-70s who is depressed, really doesn't have anyone in his life, doesn't have a good relationship with his children.

Dr. Irene Zink

I haven't been approached and asked to be given the prescription, but they just feel like there's nothing more to live for. I'm ready to go.

Dr. Irene Zink

In this patient's case,

Dr. Irene Zink

there was a medical problem that he was having. I've been trying to not do any HIPAA, but he was having hematuria. He had chosen that he didn't want to work that up anymore. I felt with him that if that was his choice, it was his choice to refuse further medical workup for that. But if he had come to me and said all those things that, okay, well, I'm just ready to go on and die, I would not give him a prescription to do that. But when he would be expressing these things to me, obviously he was depressed, so we addressed the depression. We tried to address things that he can do during the day that can make his life easier. more enjoyable and that he can find the quality in it again.

Dr. John Lantos

Can you think of any recent cases you've dealt with where you felt a conflict?

Dr. Theresa Sunderland

Many.

Dr. John Lantos

Being

Dr. Theresa Sunderland

in the ICU, we have to deal with that continuously.

Dr. Theresa Sunderland

I have never had anybody outright ask me for a prescription to have assisted suicide. We do have cases where children terminally ill and

Dr. Theresa Sunderland

there most of our instances are that you try to withdraw or limit treatment rather than just give medication and then you have to give medications to treat and make sure that they're comfortable pain and sedation if you were to limit treatment or if you to withdraw and

Dr. Theresa Sunderland

There is a question as to how much you need to give them and a dose that you're not quite sure if it would be lethal or not.

Dr. John Lantos

So just to be clear, sometimes trying to control pain and suffering seems to cross a boundary to hastening death?

Dr. Theresa Sunderland

Yes, definitely. And I think it's a very fine line and those are tough. Those decisions are tough.

Dr. John Lantos

Have you ever had situations where parents have asked about whether their child could be an organ donor and they were not braindead?

Dr. Theresa Sunderland

No, I've

Dr. John Lantos

never

Dr. Theresa Sunderland

been in

Dr. John Lantos

a

Dr. Theresa Sunderland

situation.

Dr. John Lantos

Those come up sometimes. But it sounds like, as we're talking about this, we all have situations where we would draw a line. We would respect patients' requests up to a point. We think patient autonomy and their right to make decisions for themselves is very important. but there's some boundaries where we'd have to just say no.

Dr. Theresa Sunderland

I feel in making some of those decisions, the longevity of life for that patient, their diagnosis, their illness, and also how much pain they're in, what supports they have tend to help make those decisions and give you an idea.

Dr. John Lantos

Have you had situations where parents asked you to stop treatment and you thought the prognosis was so good that you couldn't respect that request?

Dr. Theresa Sunderland

Yes, and I will draw a line there, too. If I truly don't think something is terminal, I could not bring myself to... I can if somebody has a chronic illness and... such as children that have neurologic disabilities, they tend to aspirate and get pneumonias and your child gets older and they have more and more pneumonias and you can see that this child is on a path to where they're going to get sicker and sicker and they spend more of their time in the hospital than not. Where you do decide maybe with a parent that you don't want to treat the next pneumonia but make them comfortable and that's kind of a different way of approaching things rather than just giving a prescription to end things. And it's almost like letting the natural course happen without intervening. The decision not to treat. Right.

Dr. John Lantos

Let me change the topic a little bit since we just have 10 minutes left. One case that was in the news a lot recently where people thought the doctor should have just said no involved Ms. Nadja Suleiman, the woman in California who gave birth to octuplets. Do you have any thoughts about that case?

Dr. Irene Zink

The Octomom.

Dr. John Lantos

The Octomom. I

Dr. Irene Zink

definitely have

Dr. John Lantos

thoughts. Should the doctor lose his license?

Dr. Irene Zink

That's an interesting

Dr. Theresa Sunderland

question. Yeah, very.

Dr. John Lantos

Or how would you analyze that case? Where do you see the ethical issues?

Dr. Theresa Sunderland

I'm not so sure I could comment on his license. But ethically, I think he did reach out of bounds. He went beyond the standards of care, although they're not deeply ingrained in our society, but there's some guidelines out there. And he did go above and beyond this limit that

Dr. John Lantos

we have. Recommended by his professional society.

Dr. Theresa Sunderland

And also,

Dr. Theresa Sunderland

maybe I wasn't there when he made the decision.

Dr. John Lantos

No, there's a lot we don't know.

Dr. Theresa Sunderland

From our perspective, did not investigate fully how this mother would care for these children and even having those children being pregnant with eight could cost you your life.

Dr. Irene Zink

Well, and from what I understand is she has a total of 14 children. And I believe that the physician assisted her with getting pregnant with the total of the 14. And I think this comes back down to the physician doing no harm. You know, in caring for a patient, our prescribed treatment or the treatment we provide Is it going to harm the patient? Is it going to harm anyone else? I'd have to think about the fact that, okay, so I am giving this mother 14 children. What is the life going to be like for those children?

Dr. John Lantos

What are her support systems? Not so much harming his patient, but harming the children.

Dr. Irene Zink

And, I mean, eight children are... What do you call them, the octuplets? The octuplets. I mean, they had a very fortunate outcome. I mean, usually a pregnancy of eight is not successful. I haven't heard much lately about, and I don't know if you know, if there's been any of their growing or developmentally disabled. No,

Dr. John Lantos

I haven't heard much follow-up. But let me just push you a little bit. What if a woman said, I want you to transfer three embryos? So I can have triplets. That would also place her at some risk, and the children would be at higher risk of being born prematurely with all the problems that should cause. Should a doctor just say no at that?

Dr. Theresa Sunderland

I kind of always go on my fallback as, would this be a natural thing? And having three babies at once and having triplets is not... It is natural in some cases, but it's extraordinary. Not many people have triplets. So... To do that with the intention of having triplets, no. I would not agree to

Dr. John Lantos

do that. Sounds like by those criteria you'd have to ban all in vitro fertilization. That's pretty unnatural.

Dr. Theresa Sunderland

You do have a point there. Maybe

Dr. John Lantos

infertility exists for a reason.

Dr. Irene Zink

That's interesting to bring up because you always think about that.

Dr. Irene Zink

And then you have to think about the parents out there that are having children, then that's a whole other ethical or judgmental issue, whether who's going to be a good parent and who's not. What you do have to think about, though, is the mom who's coming to you, whether she's a single mom or a married mom who wants a child, but when they're coming back for the... seventh time for in vitro fertilization and that's where I think you know it's not our place to say you can only have this many children you know we're not living in China but you also have to take in part what is going on in that person's life and

Dr. John Lantos

now I'm a little confused you're not supposed to say you can only have this many children but if she comes back for the seventh time and has six children at home under the age of seven

Dr. Irene Zink

Well, the other thing is that she wasn't a working mother, and

Dr. John Lantos

that's another judgmental thing. So she's not going to be able to take care of them. Should the doctor just say

Dr. Irene Zink

no? I think that in that case, you do have the right to say no. And then you can say, but, you know, it's a free world, or we're a free country.

Dr. John Lantos

You would refer them to somebody else.

Dr. Irene Zink

And it wouldn't be someone else, you know, that would just... I would refer them to someone else who would consider possibly doing that, but also look at the whole picture. Because I really think in the long run, it's those children that are suffering. And I don't know what favor we did for her besides now that she has a face that's known all over the world.

Dr. John Lantos

Well, the publicity is a whole different issue, and whether that did anybody a favor or not is difficult to tell. It seems like a theme, though, in all these cases is that we're trying to do as conscientiously as possible what we decide is best for our patients. And in seeking that goal, we try to listen as hard as we can to what they say they want. But sometimes we decide that what they think is best for themselves is not what we think is best for them. And sometimes when we feel that way, we don't agree or don't abide by their wishes. Is that how conscience works for you in your

Dr. Theresa Sunderland

practice? It does. And I think Dr. Zink had a good point. If this person were to come back for the seventh time and you don't feel comfortable, I think we kind of owe it to our patient to help them get another opinion.

Dr. Theresa Sunderland

if this is something that they really think that they need i think it's fine uh... to refer them out i think it's kind of our duty to do that too

Dr. John Lantos

although it seems like you'd hope that most doctors would share the same conscientious concerns that you would and it would be hard to find someone who would accept such a mom in referral

Dr. Theresa Sunderland

well when you refer not necessarily to somebody who would do it just another opinion and another physician so

Dr. Irene Zink

maybe with repetitive opinions they would understand where you're coming from. But I think that any physician, you would hope, would practice with conscience. How they define their conscience and what their beliefs are are individual for each physician. And I think in talking, the three of us, we all have found out a little bit more about our conscience in medicine and what we would do. But it's also, I think, something to learn of, you know, when things like this come up, let's Talk about it, talk to your colleagues about it.

Dr. John Lantos

Yeah, and I think the big controversy on the national stage where, as you may know, President Bush had enacted a broad protection for physicians and other health professionals who invoked conscience claims in order to refuse to do certain things. By that guideline, pharmacists who refused to fill prescriptions for emergency contraception would be protected and couldn't be fired President Obama overrode that or repealed that directive and it's been thrown back I think to the states and the courts to decide so I think we're going to be hearing a lot more about the controversy about the limits of conscience and when individual physicians can just say no and when the state or other Regulatory agencies or even hospital administrations will say, no, if you're going to work here, if you're going to practice here, if this is part of your job, there are certain things you need to do, and that may include things like prescribing or dispensing emergency contraception.

Dr. Irene Zink

At least advising and educating patients, helping them to make the best decision on their treatment.

Dr. Theresa Sunderland

Definitely.

Dr. John Lantos

Or referring.

Dr. Irene Zink

Exactly, if you can't provide the care that they're looking for.

Dr. John Lantos

And I would hope that's something almost all physicians would agree upon, that at least giving patients information so that they can make decisions for themselves, even if we refuse to do certain things, is a professional obligation.

Dr. Irene Zink

Above all, do no harm to the patient.

Dr. John Lantos

Okay, well, it's been great talking about various conscience issues in medicine. As I say, Rosie Tong couldn't be here today, but we hope we'll be back for the next show. I'm John Lantos. Thanks for watching Medicine in Society.