Doctors and Morals

Discussion in 'Anesthesiology' started by ncdoc1974, Dec 4, 2008.

  1. ncdoc1974

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    Just curious what people think...Should doctors be allowed to refuse to do things that they view as morally wrong? For example, should a Catholic physician be legally allowed to refuse to prescribe birth control pills to a patient because it is against their moral values? A Bush administration bill is currently being discussed to address this issue...what do you think?
     
  2. Coastie

    Coastie Junior Member
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    You are never bound to treat patients against your will or moral judgement.

    That's all.
     
  3. Jeff05

    Jeff05 Senior Member
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    i know of departments that have a list of people who prefer not to do abortions. they are never assigned to those rooms.
     
  4. ncdoc1974

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    SO on the news this week I saw a story where a 23 y/o female was trying to sue her family practice physician for refusing to prescribe her birth control pills...She said that HE was refusing treatment to her because HE felt SHE was an immoral person...She did not think the doctor had the right to be the judge and jury in this situation...The new Bush bill would legally protect the doctor in this situation, however for now this doctor is facing a lawsuit...
     
  5. isoman2000

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    Not a doctor but I do not think any any physician should be forced to treat or perform a procedure that they find morally wrong, they just need to refer the patient elswhere, any other solution is called slavery.
     
  6. Noyac

    Noyac ASA Member
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    There are many physicians out there that are willing to do many things. All the pts have to do is find the right physician for them.

    Suing is not the answer.
     
  7. coldweatherblue

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    We discussed this case recently in medical ethics:

    http://abcnews.go.com/thelaw/Story?id=5604598&page=1

    It is a scary precedent. IIRC the physician in the lawsuit recommended an alternative care provider and offered to pay the cost difference, but the lady still sued and won for discrimination. If you don't want to read the article, it is about a homosexual woman who was denied artificial insemination and subsequently sued her physician.

    We were told that as long as you don't blatantly discriminate and are willing to make a referral to a specialist who is willing to perform the procedure you should be legally safe. Guess not...
     
  8. mamitch4

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    It seems like a distinction could be made in some of the above mentioned cases between a physician providing a service that they feel is morally wrong (e.g. an abortion) and a physician providing a service (OCP script, artificial insemination) to some patients but not others for non-medical reasons.
    The latter sounds an awful lot like discrimination. :thumbdown:
     
  9. nutmegs

    nutmegs ASA Member
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    should a pharmacist be allowed to refuse to dispense the product?
     
  10. Bertelman

    Bertelman Maverick!
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    If they can provide a referral to a pharmacy that will provide the script, I don't see a problem. As mentioned above, it should be a standing policy though, not a discriminatory judgment.

    I've been to a pharmacy that didn't stock a certain medication. They referred me to another facility across town, and I picked it up. No big deal.
     
  11. cchoukal

    cchoukal Senior Member
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    the problem with the pharmacy example is that many towns have only one pharmacy and that's Walmart, who, in many states are allowed not to carry emergency contraception and, I've been told, do not even dispense OCPs in some states.
     
  12. dhb

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    will the same persons still refuse when they'll be banking 300$ for a 5min procedure??
     
  13. Planktonmd

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    The disturbing part about the story is that the physician not only refused to prescribe the medicine to the woman but he also told her that her behavior was immoral and gave her a lecture.
    It's one thing to refuse to do something because it is against your beliefs but dispensing your religious opinions with your medical care is unethical and insulting to our profession.
     
  14. RussianJoo

    RussianJoo Useless Member
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    Yep, and I bet that's why he's being sued. not because he refused to prescribe her the ocps but because he lectured her and called her immoral. If he would have simply said I am sorry but this goes against my beliefs but here's a referral to a physician that can help you. Then there would be no lawsuit. This happens at my hospital all the time, there's one doc who doesn't mind doing abortions and many other groups refer those patients to him, none of them have been sued for refusing to care for a patient.
     
  15. drmwvr

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    As impossible as it is to believe, some things just aren't worth the $$$.
     
  16. coprolalia

    coprolalia Bored Certified
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    It should be required to be publicly posted, if a doctor is unwilling to perform or prescribe certain accepted and sanctioned by the respective specialty board (but potentially controversial) medical practices, before the patient is even seen. If you go to a gynecologist who won't do abortions or a FP doc who won't prescribe birth control, it should be clearly posted in the office before the patient undertakes a fiduciary relationship with that physician.

    Otherwise, sue away. That's the only way this bad, paternalistic, moralizing behavior (by the physicians) get's abated.

    -copro
     
  17. Jeff05

    Jeff05 Senior Member
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    would you do something that you absolutely morally opposed for $300 bucks?
    or 500?

    i would not do things i really morally oppose for any amount of money.

    then again, there are very few things that i really morally oppose.
     
  18. Bertelman

    Bertelman Maverick!
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    I see that opening up an enormous opportunity for the crazies interested in harassing and attacking physicians willing to do those things.
     
  19. drmwvr

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    It would save those in opposition a lot of trouble, you're right. In some cases would even help business. But your generalization (paternalistic, moralizing behaviour) in the context of an "accepted" procedure begs a question. Involuntary euthanasia exists in Europe today. The line keeps being redrawn in a more and more subjective way by folks who haven't, necessarily, all view points at heart. Often it is the bottom line that is the determining factor of someone living or not. So the question is, when is it paternalism and when is it genuine consciencious objection? Is a distinction allowed, or are objectors SOL? If Obama signs the FOCA, I fear the latter.
     
  20. andypatch

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    No, I believe that pharmacists should have no role in the determination of what gets filled on a moral basis. Sure if the pharmacists feels that a certain medication is threatening to a patient's condition due to an interaction or what not, they can call to discuss it with the prescribing physician but under no circumstances should the retail pharmacist be given the authority not to dispense medications on moral grounds.
     
  21. coprolalia

    coprolalia Bored Certified
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    People who are pro-choice don't harrass doctors who refuse to perform abortions. It's the nutjobs who think Jesus is personally speaking to them on a regular basis who harrass the ones that do. I'm not suggesting those that are willing to perform those "controversial" procedures openly advertise. Just the ones that refuse too for personal reasons.

    -copro
     
  22. drmwvr

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    I can say that in my experience, this is not true. I've had a perinatologist look right over the drape during a case and disparage providers like me (radical, nut jobs) who recuse themselves from just providing anesthesia services for, leave alone doing, the actual termination.
     
  23. Bertelman

    Bertelman Maverick!
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    I understand, but if you require those unwilling to post their objections/limitations, those who are willing can be inferred by their absence from such lists.
     
  24. aphistis

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    This makes perfect sense. After all, the only doctors who should be singled out for harassment are the ones with whom you disagree, right?

    :rolleyes:
     
  25. peerie

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    :confused:

    Well, I am not aware of this. What does it entail? Can you apply it to unreasonable or really irritating in-laws? What about your own extended family? Especially over the holidays.
     
  26. coprolalia

    coprolalia Bored Certified
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    A perinatologist "disparaging" you (if this actually happened) would be grounds for reporting them to HR. Two "wrongs" don't make a "right". And, you are clearly wrong for not providing care... follow me here...

    Say that a Plastic Surgeon, who limits his practice to only doing reconstructions on people deformed by cancer or other accidental injuries, decides that perfectly normal and fine breasts don't need artificial inserts because "God made you that way" and it's immoral to mess with God's work. A woman, with low self-esteem and feeling that she can't be attractive without implants, goes to this plastic surgeon for a consult. She's not aware in advance that he doesn't perform implants on otherwise normal, healthy people.

    She fills out the paperwork. Sits in the waiting room. Finally sees him in his examination room. She tells him that this has been a lifelong problem for her. She's gotten counseling in the past. She's decided, after much serious thought, that breast implants will help her get over this lifetime of embarrassment and lack of sexual confidence.

    Instead of a receiving consultation, she's met with a lecture about how breast implants aren't "natural" for women with perfectly normal breasts, albeit small and maybe misshapen, and that he will not perform the surgery for her, despite being fully capable of performing this surgery and it being approved for this indication by the American Board of Plastic Surgery. At the end, she's sent a bill for the consultation.

    Damn right I'd sue that doctor!

    So, the question is: where do you draw the line, drmwvr? If the patients are willing to pay for the service (i.e. you're not doing it for free or on someone else's dime), and you aren't willing to provide it, how should you disclose this to patients in advance so they can avoid wasting both of your time? In my opinion, you have a duty to before you enter into a fiduciary relationship with the patient.

    And, carrying this to the logical conclusion... Are you going to refuse care to a convicted rapist? How about a child molester that was shot by an angry father? What about someone in the trauma bay who's drunk and just killed a teenager with his car? What about the guy who just shot and killed a cop?

    If you are unwilling to perform anesthesia for abortions, you should - at the very least - inform your practice and "recuse" yourself from the care of those patients in advance. This would have completely prevented your being in the situation of being "disparaged" in the first place. But, I still think that this is the wrong attitude.

    There are a lot of cases I'm involved in that I do not personally agree with the parties actions that led them to me, but I provide for them because I don't believe it is my right or responsibility to judge patients for whatever they did to themselves or to others that got them under my medical care. My providing care is not about me or my values, and if you cannot divorce yourself from that you should not be involved in patient care. Period.

    Sure, I bitch and moan about providing care to society's dirtbags. But, that is only because they don't pay... and have no plan to pay. I absolutely have never refused to provide care to anyone, though. And, as much as I bemoan the freeloaders, I will always give them the best of my ability as a provider because, when it comes down to it, I know that I have a lot of power and I absolutely take that responsibility selflessly and without personal bias in giving the best care that I'm charged with giving.

    Otherwise and despite what many of you believe, I'd not actually be following some Higher Power's wishes, but instead pretending that I know the will of that Higher Power and arbitrarily and willfully acting as his surrogate. Some people might simply call that playing God, which is apparently what a lot of you are quite comfortably doing on a regular basis.

    -copro
     
  27. drmwvr

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    Copr.

    I never once mentioned God. And it isn't about the individual requesting service. You are 100% correct about full disclosure prior to being put in the position of being asked/assigned to cases that violate one's conscience (see my prior post). The most difficult thing to convince folks of is the sincere compasion I feel for patients in the position they are in. But it isn't about that. Violating my conscience means I contribute to the erosion of the wall that separates the view that humans are valuable because they are human and humans are valuable as a means to an end or a purely utilitarian view of the individual human being. The child molester being shot by a pissed parent? Viscerally, I feely pretty good as I screw the tube in, you bet. I help him without reservation, though, because I'm not helping him violate the innocence of a child.
     
  28. CambieMD

    CambieMD cambiemd
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    The doc was unprofessional. He is being sued for being unprofessional. There are procedures that I will not perform based on my religious beliefs. I would not walk over to a patient and call call him/her immoral. The bedside is not the place for sermonizing.

    These issues have unfortunately become politicized. I am in a large enough department that I can decline to be involved in certain cases. The truth is if a physician doesn't want to be involved in certain procedures he should work for a church run med center.

    Reproduction rights have become a big political issue in this country. I find that unfortunate. This is a personal moral issue.

    Is it moral for someone to have a child that they cannot afford to care for?

    Cambie
     
  29. dhb

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    every man has it's price :cool:
     
  30. Bertelman

    Bertelman Maverick!
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    :confused:

    Most "Morality" is dictated by law. I'm not at all surprised it is politicized. I'm just disappointed abortion has become such a flashpoint issue that many citizens choose their candidates based solely on their abortion views, as though it is the most important issue facing this country.
     
  31. dr doze

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    #31 dr doze, Dec 7, 2008
    Last edited: Mar 11, 2009
  32. drmwvr

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    OK then, look at it in terms of being problematic socio-politically. Countries all over the world are experiencing zero or negative population changes and are looking at at least a 20% population loss by 2050. An artificially aging population with less young workers is devastating economically. That has never happened before, not even after major global conflict where millions die. An eastern european country (Ukraine?) suspended abortions recently for one week and others are providing incentives for couples to have more kids. The inclination of folks to play the "stop moralizing" card is an appeal to emotion meant to end the argument. More to all of this than one person making a decision.
     
  33. CambieMD

    CambieMD cambiemd
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    I do not know if most morality is dictated by law. Look @ the housing meltdown. Many home owners received mortgages with terms that they ultimately could not handle. The mortgage brokers knew this. Someone tried to sell me a house for more than it was worth. My bank(remember Indy Mac bank) saved me. It is immoral to sell someone a mortgage that they cannot afford but at this point it is not illegal. I could go on and on but I have to study for the oral board exam.

    Because most morality isn't dictated by laws we must have a moral compass of our own to guide us. As physicians we have the standard of care and what is in the best interest of our patients to help guide us.

    Cambie
     
  34. coprolalia

    coprolalia Bored Certified
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    Judge patients by their standards, not your own. Otherwise, you're being, at best, a moralizing obstructionist or, at worst, playing God. You are there to advocate for and facilitate your patient's wishes, not decide and mandate your own.

    It's not your job to decide what's best for your patients unless they are incapable of doing that on their own.

    -copro
     
  35. Bertelman

    Bertelman Maverick!
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    Pro-lifers use a much greater emotional appeal when arguing their case. I'm not at all interested in the population characteristics of individual countries. The fate of republics and economies are constantly in flux. I'm much more interested in the population trends of this world. Try a 50% net increase in humans on this earth in the next 35 years. (see requisite internet argument wikipedia entry for global population)

    You think hunger and war and genocide are a problem now? Try throwing 3 billion more people in the mix.

    Unfortunately, abortion will never be the answer. Prevention. Condoms. Birth control education. That's what we need.
     
  36. Bertelman

    Bertelman Maverick!
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    I may have overvalued the extent to which morality is governed, but I guess what I was trying to say is laws step in when one's morality has failed. The two are certainly intertwined. See Mark Cuban, Martha Stewart, or anyone else involved with insider trading. Morality would drive most to understand they are putting themselves above others unfairly. When that failed, a law was created.
     
  37. coprolalia

    coprolalia Bored Certified
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    Yes. Yes. Yes! Very adeptly put, Bertelman.

    I'm interested to know how many of you would provide anesthesia for a patient who wants to have a perfectly healthy limb amputated. Have you ever heard of this condition? This was a great case-study from medical school.

    http://www.nytimes.com/2005/03/22/health/psychology/22ampu.html

    -copro
     
  38. drmwvr

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    Hunger, war and genocide have been present with world population in the hundreds of millions. They exist today only because of people behaving badly, immorally, if you will. China is trying to engineer themselves out of the problems their philosophies have brought about by doing just what you suggest and are facing a future that will mean bleakness for Chinese citizens and and those who will be in conflict with China. You can't try to macro manage population without major unintended consequences. As far as world population is concerned, any number of people that is thrown out as the absolute limit the planet can support isn't even speculation. At the very best it is a wild guess.

    As for Copro's question, I'm in this deal to help patients get better from illness, not to contribute
    to it. So, no, I wouldn't participate. Is that a "moralizing" position to take?
     
  39. coprolalia

    coprolalia Bored Certified
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    Yes, okay. But, many of these patients are "better" once the limb is amputated. They feel "cured". And, if you don't offer to do the amputation (because of some objection to what you perceive as right and wrong), they will often go and grab a chainsaw or, in one case, lay their arm across a railroad track and await a passing train in order to satisfy their sensory perception of this "extra" limb needs to be removed.

    This is precisely the point.

    You may believe that you are doing best by the patient by enforcing your will or idea of what's right and wrong. This can be accomplished by flat-out refusing to care for someone. But, while you can go home and sleep at night believing you took the moral high road, you really don't know what the psychological or physical consequences of your actions may be.

    Perhaps, in the smugness that comes with the belief of doing "God's will", you maybe shouldn't quite sleep so soundly...

    -copro
     
  40. Bertelman

    Bertelman Maverick!
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    I'm well aware those bad things have existed as long as mankind has. You can't honestly argue those problems will improve with a larger population. Those things don't exist because of bad morals. They exist because of power struggles.

    I'm not sure what poor unintended consequences you suggest may occur with macromanaging populations. I'm quite positive you will encounter equally poor outcomes by failing to manage population at all. Talk to any rancher and they will be able to tell you their land can support a fixed number of livestock. It's no different with the world. We're talking about a finite commodity. If you are dreaming of some day when we can mass-produce food with nascent technologies reliant on less square footage of crop space, I'm here to tell you that time is much further away than 35 years.

    I'm not suggesting 9 billion is the absolute number this planet can support. I am saying there is a number, and 9 billion is much closer than 6 billion. As our population continues to expand exponentially, we approach that number even sooner. Maybe not within my lifetime, but it will happen.

    You also can't possibly suggest China's current problems regarding population control are the sole reason for their future concerns any more than you can deny their past history of population explosion are as much to blame.
     
  41. drmwvr

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    Innocent people suffer, die and are targeted in power struggles. There is no moral component there?

    Grazing cattle are dependent on what forageable grasses grow on that finite land area. Iowa wheat, California rice and Idaho potato can be in the Sudan in a month with the technology that exists today. Betting that that won't be possible in 2050 (for the sake of argument) and taking active measures to pre-emptively curb population growth is a dangerous prospect. There is no reason at all to believe that won't be possible in the future, short some global catastrophe and then it won't matter.

    The bad unintended consequences are an artificially aging population without the means, i.e. young workers, to support them.

    Finally, what I meant about China was that what they say are problems related to population are more likely consequences of their politics. Totalitarianism/communism as practiced in SE Asia and China lead to poverty. Does North Korea have too many people or are they poorly governed? Why doesn't Japan have a one child policy? Pretty crowded on that little island and there aren't starving masses there.
     
    #41 drmwvr, Dec 7, 2008
    Last edited: Dec 7, 2008
  42. Bertelman

    Bertelman Maverick!
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    I didn't claim there was no moral component to war. Just stating greed and power are the primary motivations. Of course morals are lacking, but so are many other principles. When you look at terrorists and leaders of genocide, you don't typically imagine you could prevent such tragedies if the perpetrators only had a few good moral lessons. Their aggression and hatred lie far deeper.

    I don't know much about Sudan beyond the fact that they have been engaged in civil war for the better part of the last 50 years. It doesn't sound like the kind of environment I would rely upon to sustain my people. And to think that simply sending crops and resources to establish farming, economy and trading might stabilize the region is short-sighted and naive.

    I agree that China's problems are primarily a function of their policies and govt. And of course national population values are no predictor for a country's success in governing and supporting its peoples.

    Back to our original discussion, I do indeed believe there is a finite number this Earth can support with our current technology, consumption and political climate. Whether you agree with Al Gore's version of global warming, it is hard to turn away from problems of human consumption like deforestation. I think human innovation and intelligence have allowed us to thrive far beyond what is reasonable considering the typical course of species on this planet. I think we have at best a cursory understanding of our planet's balance that was achieved allowing us to prosper. Yes, our species is adaptable, and yes, Earth is resilient. I just happen to like the planet as it is now, and would prefer to push for mandates to keep it so. Population control is one of those issues for me.
     
  43. drmwvr

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    OK, very reasonable. Just to clarify, I didn't mean to suggest that sending food solves regional problems. Just that because there are people starving doesn't mean there are too many of them. That would be naive.
     
  44. Bertelman

    Bertelman Maverick!
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    Agree that famine is a product of political climate, not population.
     
  45. drmwvr

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    First off, you are making an argument of an absolutely extreme nature. Does it happen? Apparently. Is it rare? Very. I'm not responsible for nor am I able to predict when something bad may happen if I apply my "moral test" if you will. I have to do it nonetheless. Something very good may come of it as easily. Secondly, I can't know what "most patients feel 'better' " means. What happens when they feel so much better they want another limb taken off? All four? Where do you draw the line? Before they need a wheel chair but after they need a g-tube? This is doing no harm? There is a risk of consoling ones self with a false altruism that has as it's basis the life of a patient in need. Surgery for psychosis? Not going to bet that has a happy ending. Get someone else, sorry.

    As an aside, I haven't mentioned God once, while you have a couple of times apparently in attempt to discredit my arguments. Arguments should stand on their own merits and are not validated or invalidated by the associations of the individual, supernatural or otherwise. Quit it
     
    #45 drmwvr, Dec 9, 2008
    Last edited: Dec 9, 2008
  46. coprolalia

    coprolalia Bored Certified
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    The very fact that you ask these questions leads me to believe that you feel that it is up to you to decide what's best for the patient, and not the patient himself. This specific disease, this specific example, leads patients to harm themselves - potentially killing themselves in the process - despite the fact that they have already approached doctors asking for help, have received counseling, and are turned away.

    For these particular patients, I don't know what the right answer is. Letting them put chainsaws to themselves or lay on railroad tracks, after they've asked for my help, doesn't seem like the right thing to do. However, what really worries me are the people like you that seem to so easily decide what that right answer is - refuse to engage in, at all costs, what is personally morally repugnant to you despite the fact that it might ultimately help the person.

    Come on, dreamweaver. Don't jerk my chain. This is precisely about your religious beliefs and purported moral superiority. Don't be coy.

    -copro
     
  47. drmwvr

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    It isn't "morally" repugnant to me. This is a matter of giving the patient the benefit of the doubt that he will become whole again. I'd want to do the best thing for the patient. OK, to be honest, in the wild limited scenario you describe where, say, the pt. has already mutilated himself I'd say he does't have much to lose. I've participated in heroics/futile care in the past and I will again. But this is an extraordinarily exceptional example, bordering on the ridiculous.

    And yeah, my ethics are rooted in my faith. So what? If I had agreed with you would my religion still invalidate what I said? You would then, according to your logic, be wrong just because I agreed with you. People of my faith, I assure you, share your ethics. So am I wrong because of where I come from, or am I wrong because my argument is wrong?
     
  48. coprolalia

    coprolalia Bored Certified
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    You're wrong because patient care is not about you and your beliefs.

    -copro
     
  49. Arch Guillotti

    Arch Guillotti Senior Member
    Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    And I think that you are wrong.

    I believe this because of a conversation I had over lunch many years ago with a VERY well respected hematologist-oncologist who also happened to be a very well respected professor of bioethics. He was frequently involved in life or death decisions (obviously on a less acute basis than we are as anesthesiologists). Frequently his patients has terrible conditions with complicated diagnoses and treatment options. Many of these patients were simple folk without a lot of education. This physicians feeling (which I agree with) was that pt. autonomy was of the utmost importance (duh) but there were many times when the patients in fact wanted to give up their autonomy and wanted him to make the decision for them. When simple folks are faced with a huge decison that easily overwhelms them, they WANT the doctor to do what is right for them and what THE DOCTOR feels is the best course of action. In this example, the physician in question was an extremely wise caring guy with 30+ years of experience. If someone couldn't make up their mind or was unsure about what to do many of his patients felt 100% confident in placing the ball in his court. he was all for pt. autonomy but for goodness akes, we are physicians and have the ability to do what is right for patients.
     
  50. coprolalia

    coprolalia Bored Certified
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    Arch,

    You are confusing the issues here. The patient has made up their mind - using autonomy - and the caregiver is refusing to give care based on his/her own beliefs.

    Apples and oranges, my friend.

    -copro
     

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