Values Play Into Treatment Recommendations, Study Finds

By Rob Stein
Washington Post Staff Writer
Thursday, February 8, 2007

Many doctors believe they have the right not to tell patients about treatments that they object to on moral or religious grounds and to refuse to refer patients elsewhere for the care, according to the first study to examine physicians' views on such situations.

In the survey of 1,144 doctors nationwide, 8 percent said they had no obligation to present all possible options to patients, and 18 percent said they did not have to tell patients about other doctors who provide care they found objectionable.

Based on the findings, the researchers estimate that more than 40 million Americans may be seeing physicians who do not believe that they are obligated to disclose information about legal treatments the doctor objects to, and 100 million have doctors who do not feel the need to refer patients to another provider.

"They are a minority of doctors, but it's fairly substantial minority," said Farr A. Curlin, a bioethicist at the University of Chicago who led the study, published in today's issue of the New England Journal of Medicine.

The survey was prompted by an intense debate over medical workers who refuse to deliver care that runs contrary to their moral or religious beliefs, asserting a "right of conscience" or "right of refusal." Some pharmacists, for example, refuse to fill prescriptions for birth control and emergency contraceptive "morning-after" pills. Some doctors and nurses refuse to participate in abortions, prescribe birth control pills or withdraw or withhold care from dying patients.

The refusals have led to bitter clashes between medical workers and patients around the country. Dozens of states have considered legislation that would either require medical workers to deliver all legal forms of care or protect those who refuse. The issue is expected to intensify as medicine continues to move into controversial areas, such as therapies based on embryonic stem cells.

Curlin and his colleagues mailed 12-page questionnaires to 2,000 physicians from all specialties in 2003 asking them if they had objections to three controversial practices -- sedating dying patients to the point of unconsciousness; prescribing birth control to teenagers without parental consent; and performing abortions after failed contraception.

Of the 1,144 who responded, 17 percent objected to "terminal sedation," 42 percent objected to providing birth control to teens without parents' consent and 52 percent objected to abortion after failed contraception.

When the researchers asked the doctors about their sense of obligation when patients request such procedures, they found that 86 percent felt obliged to present all possible options. But 6 percent were undecided and 8 percent felt no such responsibility. Sixty-three percent felt it was ethical to tell patients about their objections, and 18 percent felt no duty to refer patients to another doctor. Eleven percent were undecided.

Male doctors and those who described themselves as religious were the most likely to feel that doctors could tell patients about their objections and less likely to believe doctors must present all options or offer a referral.

"It's a difficult issue," Curlin said. "Patients understandably expect to have access to legally permissible care and expect their doctors to provide legally permissible and medically accepted medical interventions. At the same time, at the foundation of medical ethics is to not do what you believe to be unethical. I think that leaves a difficult dilemma."

Curlin said the findings indicate that patients should be aware of the possibility that their doctors may object to providing certain care and that they should question them about that.

"I think doctors have an obligation to disclose information to the extent that is required to be respectful to patients," Curlin said, adding that he did not believe they were "obligated to help patients obtain things they have strong feelings of conviction that should not be obtained."

R. Alta Charo, a bioethicist at the University of Wisconsin at Madison, said the results were disturbing, particularly the belief by a significant proportion of doctors that they do not have an obligation to inform patients about all options.

"How are patients supposed to make choices when they don't even know the range of choices that they have?" Charo asked. "Failure to inform completely disables a patient. It makes it impossible for them to even know what to ask or whom to ask or where to go to ask."

But Al Weir, director of Campus and Community Ministries for the Christian Medical & Dental Associations, defended doctors' rights to adhere to their personal beliefs.

"The doctor has the right to follow their own moral compass and their own moral integrity," Weir said.

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