Ethics question - contraceptive pill?

[anbuitachi]

What is the rule on if a pt want a pill for ie contraception, but its against the doctors beliefs? Does he have to prescribe or can he say no?

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[loveoforganic2]

Step hates when you refer, but I think this is where it's actually the right answer. I would pick whichever answer involves referring the patient and facilitates that process in every way possible

 

[Brain Bucket]

What is the rule on if a pt want a pill for ie contraception, but its against the doctors beliefs? Does he have to prescribe or can he say no?

Just...

Can such a question even be asked? What's next? A doctor who doesn't believe in antibiotics?

 

[operaman]

As far as medical ethics are concerned, no doctor has any ethical obligation to violate his or her own deeply help principles. They do, however, have an ethical obligation to refer the patient to another provider who is comfortable with it.

 

[anbuitachi]

Ok Thanks! i was thinking of refer too.

 

[Darrka]

Don't hold the responsibility on yourself. You aren't making her take the pill, and she'll get it from somebody else either way. Whatevs.

I wouldn't do an abortion, though.

 

[HoboCommander]

The real question is, where will Dwight Howard go?

 

[iansarria]

Referral is never the answer(Uworld says this on many example questions).
If the questions says that the patient ask doctors opinion about OCPs(+/- other treaments) then he should not give his opinion because is biased by moral/religion etc

Do you have the available choices?
It would be easier that way.

 

[loveoforganic2]

Don't hold the responsibility on yourself. You aren't making her take the pill, and she'll get it from somebody else either way. Whatevs.

I wouldn't do an abortion, though.

Ambitious premed, ambitious

 

[Darrka]

Ambitious premed, ambitious

Perhaps. I know I'll take flack for being a premed and commenting on such a thing, but things like that are gonna happen. Better think about it earlier than later.

 

[operaman]

Referral is never the answer(Uworld says this on many example questions).
If the questions says that the patient ask doctors opinion about OCPs(+/- other treaments) then he should not give his opinion because is biased by moral/religion etc

Do you have the available choices?
It would be easier that way.

This is actually an exception to the 'never refer' rule and is likely to be asked in some form on the exam. Another would be something emergently surgical like testicular torsion, but I'll keep this to ethics.

I don't know if the OP is referring to a specific question or not, but here are the answer choices I would write for such a question. Lets assume the patient is 19 years old:

a) Advise the patient about the fertile point of her menstrual cycle and to avoid sexual activity at that time
b) Refer the patient to another provider without a moral objection to prescribing OCPs
c) Inform the patient about the risks of taking OCPs such as stroke, DVT, and drug interactions
d) Ask the patient about her history of sexually transmitted diseases
e) Perform a pelvic exam, pap smear, and STD panel since the patient is sexually active


a - wrong because this is paternalistic, disregards her best interest and her autonomy
b - correct
c - Discussion should include risks AND benefits; discussing only risks could be construed as trying to manipulate the patient
d - certainly a question to ask any sexually active patient, but not the next step in this case
e - Patient is below the recommended age to begin pap smears


The concept that doctors are not required to violate their own deeply held beliefs is important and very testable. Remember the 4 pillars in every ethical question and think about how they intersect. In the United States, we generally tend to organize them as follows:

Do no harm > Autonomy > best interest > justice

For the pt seeking OCPs, a referral is not doing any harm, it respects the autonomy of the physician, and the referral acts in the best interest of the patient. Remember, autonomy is a negative right, not a positive one. Not sure if this gets taught anymore -- it was popular when my undergrad professors were in school so they all did but it may be out of fashion now -- but a negative right is the right NOT to have something done to you whereas a positive right is the right TO something.

Medical ethics autonomy is almost always a negative right, so a pt has a right to tell you not to operate or do a procedure, or do a test --- except in some specific circumstances. Any positive right (ie. the right TO getting OCPs, or the right TO antibiotics for a virus) carries with it an implied obligation for someone else to provide it and therefore doesn't carry the same weight, especially if it violates your own negative-right autonomy (ie. deeply held belief).

Another classic is the pt demanding antibiotics when you don't think they are medically indicated. In this case, prescribing them is risking harm (at least on exams) and therefore trumps the positive autonomy of the patient.

 

[hardee17]

This is actually an exception to the 'never refer' rule and is likely to be asked in some form on the exam. Another would be something emergently surgical like testicular torsion, but I'll keep this to ethics.

I don't know if the OP is referring to a specific question or not, but here are the answer choices I would write for such a question. Lets assume the patient is 19 years old:

a) Advise the patient about the fertile point of her menstrual cycle and to avoid sexual activity at that time
b) Refer the patient to another provider without a moral objection to prescribing OCPs
c) Inform the patient about the risks of taking OCPs such as stroke, DVT, and drug interactions
d) Ask the patient about her history of sexually transmitted diseases
e) Perform a pelvic exam, pap smear, and STD panel since the patient is sexually active


a - wrong because this is paternalistic, disregards her best interest and her autonomy
b - correct
c - Discussion should include risks AND benefits; discussing only risks could be construed as trying to manipulate the patient
d - certainly a question to ask any sexually active patient, but not the next step in this case
e - Patient is below the recommended age to begin pap smears


The concept that doctors are not required to violate their own deeply held beliefs is important and very testable. Remember the 4 pillars in every ethical question and think about how they intersect. In the United States, we generally tend to organize them as follows:

Do no harm > Autonomy > best interest > justice

For the pt seeking OCPs, a referral is not doing any harm, it respects the autonomy of the physician, and the referral acts in the best interest of the patient. Remember, autonomy is a negative right, not a positive one. Not sure if this gets taught anymore -- it was popular when my undergrad professors were in school so they all did but it may be out of fashion now -- but a negative right is the right NOT to have something done to you whereas a positive right is the right TO something.

Medical ethics autonomy is almost always a negative right, so a pt has a right to tell you not to operate or do a procedure, or do a test --- except in some specific circumstances. Any positive right (ie. the right TO getting OCPs, or the right TO antibiotics for a virus) carries with it an implied obligation for someone else to provide it and therefore doesn't carry the same weight, especially if it violates your own negative-right autonomy (ie. deeply held belief).

Another classic is the pt demanding antibiotics when you don't think they are medically indicated. In this case, prescribing them is risking harm (at least on exams) and therefore trumps the positive autonomy of the patient.

Good post. I think the moral objection item would arise on an abortion question though, not OCPs. The whole concept is stupid though. If you want to impose your morality on others, you should go join the church or something.

 

[operaman]

Good post. I think the moral objection item would arise on an abortion question though, not OCPs. The whole concept is stupid though. If you want to impose your morality on others, you should go join the church or something.

Yeah, the NBME generally stays away from uber-controversial topics for obvious reasons. The OCP thing is not particularly controversial in this country, especially among younger people, so it might actually get used.

If I were writing a question to test this ethical point, I would stay away from morality questions and go after something a little more interesting. I'd probably give you a q about a demented patient with pneumonia and a bowel obstruction. I'd give a history that makes surgical repair of the obstruction dubious at best. Then I'd have the family asking for it to be done anyhow and ask what you would do if you were the surgeon asked to perform the operation and you didn't feel it was warranted in this case. Then I'd write 5 annoyingly plausible answer choices.

This still tests the concept of physicians not being ethically obliged to perform something that goes against their conscience, but this avoids those annoying social issues that have been so politicized over the past 30 years. This kind of vignette also allows me to write really good distractors about referring the case to the ethics committee for discussion, etc., and things like that.