AMA Journal of Ethics^®

Case

Dr. Charles, a gastroenterologist, had been volunteering one night per week at a charity clinic that was operated by a group of Roman Catholic physicians and nurses. Although these physicians and nurses started the clinic as a way to live out their Catholic faith, they welcomed volunteer staff members of any faith or no faith who wanted to treat the underserved in their clinic. There were many non-Catholic physicians who volunteered at the clinic, of whom Dr. Charles was one.

For some months he had been treating Ms. Bates, a 23-year-old waitress with no insurance who had Crohn’s disease. Together, they were able to keep her disease under control with a drug regimen she could afford. In the process they developed a good patient-physician relationship, and she viewed Dr. Charles as her primary physician since she had no other regular doctor.

At one of her visits, after they had discussed her health status, she said, “Dr. Charles, I’ve got something else I want to talk to you about. I’ve got a boyfriend now, and we’re having sex. I’m really worried about getting pregnant. I barely have enough money to take care of myself, especially with the Crohn’s. I don’t think I could manage if I had a baby. I know about condoms, but my boyfriend doesn’t always use them. Is there anything you can recommend for me?”

Dr. Charles paused. He believed the Catholic Church’s position on birth control could be bent when a woman’s health might be compromised by pregnancy, and if Ms. Bates had come to him in his private clinic, he would gladly have counseled her about contraception. Indeed, he felt it to be his obligation as a physician to provide such counseling. He was aware that Ms. Bates did not have access to another physician due to her financial situation. It was this clinic’s policy, however, to follow the teaching of the Catholic Church, and it did not allow clinicians to recommend any method of birth control except total abstinence or periodic abstinence (the rhythm method). He had known about this policy, but as a gastroenterologist had not given much thought that the issue would come up in his practice.

Commentary 1

Whether or not Dr. Charles should provide contraception counseling to Ms. Bates is really two questions. We will address each in turn. 

1. Is Dr. Charles ethically obligated to offer means of contraception that are not morally permissible in Roman Catholic teaching?

The ethics and law concerning the physician’s role in the informed-consent process are well established. The physician is to identify, from among technically possible and physically available alternatives for managing the patient’s condition, the diagnostic and therapeutic alternatives that are medically reasonable. In the language of medical ethics “medically reasonable” is beneficence-based: there is an evidence-based expectation that a diagnostic or therapeutic intervention will result in a greater balance of clinical goods over clinical harms for the patient as these are assessed from a clinical perspective. This is a professional obligation that all physicians have [1].

Individual or institutional limitations on this professional responsibility are ethically impermissible because the presentation of information about medically reasonable alternatives is independent of the patient’s subsequent decision to accept one of the medically reasonable alternatives, which is a function solely of the patient’s autonomy, not the physician’s. The individual conscience of a physician or the moral commitments of a health care organization are therefore not threatened by the physician’s fulfilling his or her professional responsibilities in the informed-consent process [2].

It follows from the concept of the physician’s responsibility in the informed-consent process that the answer to the first version of the question is “yes.” As a matter of strict professional responsibility. Dr. Charles is obligated to inform Ms. Bates about possible means of contraception. It should be added that this answer applies to all of the health care professionals employed by or volunteering their services in this clinic. The ethics of informed consent are not somehow distinctive or unique to physicians but also apply to nurses, physician assistants, and other health care professionals.

2. After offering all medically reasonable alternatives, should Dr. Charles recommend only those forms of contraception permitted by the clinic’s religiously based policies?

In the informed-consent process, after having presented the medically reasonable alternatives (along with information about their clinical benefits and risks), the physician is ethically justified in recommending one of the medically reasonable alternatives when, in evidence-based reasoning, it is clinically superior to the other in its outcomes. In the language of medical ethics, such an alternative is ranked first in beneficence-based clinical judgment [1]. The clinic’s policy, however, is based not on evidence but on religious commitments and values. To be sure, these are important and serious moral commitments, but they are not medically evidence-based and therefore should not influence or interfere with what Dr. Charles may or may not recommend. The answer to this second question is therefore “no.”

Dr. Charles has a larger question to consider, though. Should he continue working in this clinic if he believes its policies might interfere with his providing optimal care to his patients, even if he expects such interference to be rare?

Organizational policies of the clinic that are not consistent with every physician’s professional responsibility to patients in the informed-consent process are ethically impermissible for two reasons. First, the clinic is a moral cofiduciary with its physicians of all patients for whom the clinic assumes responsibility [3]. It follows that, as a cofiduciary, the clinic is ethically bound by the same standards of professional responsibility that its physicians and other health care professionals are, as we described above. Second, the organization is not ethically justified in invoking the moral integrity of the commitments of the Roman Catholic faith community out of concern that fulfilling professional standards of informed consent will somehow make the clinic responsible for the subsequent decisions of patients to use accepted, safe, and effective pharmacologic contraception in violation of the teachings of the Roman Catholic faith community. As we pointed out above, these subsequent decisions are the function solely of the woman’s autonomy. It is therefore a mistake for the clinic to assume that there is a straight line between provision of information about pharmacologic contraception and a patient’s election of it. After all, some women, having learned of the risks of such contraception, elect against it. Similarly, other women elect against barrier techniques or IUDs because they are not as effective in preventing pregnancy as these women prefer. Still other women will not accept forms of contraception that are inconsistent with their religious or other moral beliefs, including women who are not Roman Catholics.

It follows that, if the clinic does not recognize its cofiduciary responsibilities in the informed-consent process and change its policies, then continuing to work there violates professional integrity. The answer to this question is, therefore, “no.” Dr. Charles should not continue to work in a clinic if its policies interfere with his providing optimal care to patients.

Does Dr. Charles have an obligation to advocate for change in policy given that patients at the clinic, such as Ms. Bates, might not have other options due to their poverty?

The counseling policies of the clinic do not pass muster in the professional ethics of medicine and this is the main reason that Dr. Charles should oppose them as a matter of cofiduciary responsibility to all of the patients who seek care at the clinic. It is ethically significant that patients like Ms. Bates are under serious economic constraints in their ability to gain access to medical care. Such patients may, in reality, not be free to seek contraceptive counseling elsewhere, a constraint on their autonomy to which the clinic should be responsive. But this is a buttressing reason for Dr. Charles (and all of the health care professionals in the clinic) to oppose the clinic’s counseling policies. The main and unavoidable reason that he has such an obligation to the clinic’s patient arises directly from professional integrity, i.e., practicing medicine to standards of intellectual and moral excellence. The standards of moral excellence in the informed-consent process are not matter for compromise. Otherwise, Dr. Charles destroys his own professional integrity, which, ethically, he is not free to do. The answer to this last question is, therefore, “yes.”