AMA Journal of Ethics^®

Case

Amber, 19, went to see her family physician about a sore throat. Amber and her family have been patients of Dr. Nowak for 15 years. They are members of the same evangelical church, Riverwood Community Church, and they have grown to be friends over the past few years.

Dr. Nowak examined Amber, performed a rapid strep test, which was positive, and informed her that she had a streptococcal pharyngitis. "Try not to kiss any boys this week," Dr. Nowak said with a smile.

"Actually, now that you mention it," Amber said, "that's something I wanted to ask you about. My boyfriend and I have been together for more than a year now, and we've been talking seriously about marriage."

"That's great! I'm glad to hear things are going well," Dr. Nowak said.

"Well, that's not all: we feel we're ready to start having sex, and I need to ask you to write me a prescription for birth control pills."

Dr. Nowak paused for a moment, then explained, "You know, Amber, I appreciate you sharing this with me, but I imagine you know how I feel about premarital sex. As your doctor, friend, and fellow Christian, I think this is an unwise decision, and I can't in good conscience help you do something I think is wrong."

"But doctor, we've both thought about it, and we love each other, so why put it off any longer?"

"As a physician," Dr. Nowak replied, "I'm committed to doing what's in my patients' best interest. And I believe, based on the Scriptures we both read and on our common understanding of God's nature and purposes for us, that sex is the consummation of a spiritual union between husband and wife. Sex is created by God to be enjoyed in the context of marriage, and saving it for that moment makes it all the more special. I realize that's difficult, and it's not what our culture at large believes. But if we call ourselves Christians, we need to carry our beliefs into every aspect of our identity—including something as personal as our sexuality."

Commentary 2

This case poses 2 specific questions, each of which introduces a far broader ethical inquiry. The questions, "Is Dr. Nowak's response to Amber ethical?" and "Why or why not?" force us to ask, "What is the good or not so good?" and "How do we determine what the good is?"¹ The case also asks us, "How should physicians respond to patients who are engaged in behaviors that the physician believes are immoral?" That is a question about other people's ethics, which my commentary addresses implicitly.

The Hippocratic Oath and the Oath of Maimonides recognize that physicians can exploit patients for their personal "needs." When Dr. Nowak talks about the teaching of their church about premarital sex, is that about herself or Amber? Whether she brings her beliefs, her experience as a mature woman, and her membership in the same church into her care of her patient or leaves them at the door, whom is she serving?

Maimonides says, "Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements." Does this particular encounter with Amber confirm the ethical guidance, the "established solutions" Dr. Nowak has received? Or does it ask her to examine those established solutions with the possibility of changing them to develop "novel solutions"?¹

Custom contributes to medical ethics by establishing solutions to common problems. Custom doesn't, however, prepare clinicians well to identify or resolve new ethics problems. Dr. Nowak may therefore have to break new ethical ground for herself. That will be a trial and error process.

John Stuart Mill observes in Utilitarianism that the absence of an agreed-upon first principle has made ethics not so much a guide as a consecration of a man's actual sentiments.² We get beyond consecrating our opinions about the good by testing them.

A customary test of Dr. Nowak's response asks about her rights. She has a right to express her views appropriately to her patients and to decide whether to fulfill their requests. As a physician, she voluntarily defers some autonomy to patients, but patient autonomy (self-rule) doesn't entail physician heteronomy (rule by others).

We are finished testing our solutions when they do not require us to address new problems either within ourselves or with others. Simply saying that Dr. Nowak has the right to decline Amber's request does not end the inquiry. We have to revise the original question and ask, "Is her action "ethically preferable"?

Many other tests are available. I prefer Clinical Ethics, by Jonsen, Siegler, and Winslade.³ They identify 7 goals of medicine. These goals make Beauchamp and Childress's principles (beneficence, nonmaleficence, respect for autonomy, and justice) specific.⁴ Some of these goals of medicine pertain to Amber's request, some don't. Promoting health and preventing disease (goal 1) and educating and counseling patients (goal 6) pertain, as does relief of symptoms, pain, and suffering (goal 2). Amber is suffering from unconsummated love. Less pertinent are cure of disease (goal 3), preventing untimely death (goal 4), and improving functional status or maintaining compromised status (goal 5). Despite its prominence in medicine, avoiding harm in the course of care (goal 7) is at risk. If Dr. Nowak prescribes the pills, she will harm Amber from her point of view, and if she doesn't, she will harm her from Amber's point of view.

Regardless of Dr. Nowak's beliefs about premarital sex, promoting health and preventing disease are paramount. That links directly to educating and counseling. In the sense of educare. Educating is more than telling. It "draws from" the other. Not drawing from Amber, Dr. Nowak inhibits her ability to educate and counsel. Instead she preaches.

Educating patients by asking, not just telling, leads to Jonsen, Siegler, and Winslade's next major category, patient preferences—what the patient consents to. We know Amber's preferences. But why does she make thisrequest of Dr. Nowak? This question expands "patient preferences" to "patient perspectives." By inquiring into Amber's perspectives on making love with her boyfriend, Dr. Nowak would have been more able to prevent disease, promote health, and relieve suffering and to postpone the standoff between Amber's request and her own conscience.

What is she asking of Dr. Nowak? A different "gospel," "good news" from medicine that trumps the church's teaching about premarital sex? Permission to act out? Help stiffening her spine against an insistent boyfriend? Reconciliation of her church's messages with those of her own body? Questions like these could have opened the door for a deep conversation that could have integrated Dr. Nowak's experience and her medical, religious, and personal convictions into her education and counseling of her patient and fellow church member.

A fundamental goal of medicine, Jonsen, Siegel, and Winslade say, is to improve or maintain the patient's quality of life (QoL). Concern about quality of life could easily prompt Dr. Nowak to ask whether the 2 of them could talk about the pros and cons of this decision for Amber's QoL. This conversation could include things that could go wrong with Amber's plan, such as, sexually transmitted diseases or the effect of premarital sex on her relationship with her parents and her church.

Contextual features concern the good of stakeholders other than the patient. In this case, it is important to give explicit attention to Dr. Nowak's own good. Here, when her integrity is at stake, it is important for Dr. Nowak to be clear in her own mind where she stands and what her responsibilities are to her patient. For quite a while, she wouldn't have to tell Amber anything. But there's a lot that she can ask. For example, "Could we talk about how are you thinking about our church's teaching concerning making love before marriage? Are you thinking about not staying in our church? (Remember—this conversation is confidential.) Another question that comes to my mind can be a little touchy, but it would be very understandable if you thought that a doctor might have an opinion that differs from the minister's. Could I ask if you had a thought like that?" And so on. What happens in that conversation will determine whether she needs to tell Amber her point of view. Dr. Nowak's relationship with others in the church may be at stake along with the church's teaching about sex and marriage. Dr. Nowak's professional integrity may also be at stake: Is the physician-believer a tool of the church? Or a closet hypocrite?

The goals of preventing disease and educating and counseling commend deep dialogue with Amber about the perspectives behind the preferences. Dr. Nowak's professional preparation could have helped her inquire, listen, and still retain her right to say, perhaps a bit later in the conversation and more gently, everything that she said in this scenario. She had an opportunity to consider and test a novel solution for integrating her person values into her care of patients. The main problem of this encounter is less with Dr. Nowak's response than with her lack of preparation to review a custom, and be open to revising it. Ethical deliberation can help with that.