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Dallas Morning News, February 8, 2007

Silent treatment: Doctors' morals can limit options

Study finds significant minority don't feel obligated to discuss all procedures

By JEFFREY WEISS

Millions of Americans have doctors who may not tell them about morally controversial medical procedures, according to a study published in Wednesday's New England Journal of Medicine.

A significant minority of physicians who responded to a survey conducted by researchers at the University of Chicago said that doctors are not obligated to tell patients about procedures that the doctors object to, or to refer the patients to other doctors.

Doctors who consider themselves more religious were more likely to approve of restricting information than doctors who said they were not religious. Female doctors were more likely than their male counterparts to say a doctor is obligated to disclose all information.

"The general teaching is that doctors need to be candid and open with their patients," said Dr. Farr Curlin, lead researcher on the study. "I think doctors are ethically obligated to be candid."

He said he hoped the study would prod patients and their doctors into discussing these ethical questions, so that patients will know where their physicians stand.

The study asked about three morally controversial procedures: sedating dying patients to the point of unconsciousness, providing abortion for failed contraception, and prescribing birth control to adolescents without parental approval.

Doctors who said they had moral objections to one or more of the procedures also were more likely to say they did not feel obligated to tell their patients about them or refer patients to doctors willing to perform the procedures.

For the representative sample of American doctors, 86 percent said that doctors were obligated to tell their patients about all medically available procedures, and 71 percent said doctors were obligated to refer patients to colleagues who did not object to a medical procedure. And 63 percent said they believed it was ethical for doctors to explain their moral objections to their patients.

Doctor knows best?

While patients have the legal right to determine their treatments, as a practical matter, many don't contradict their doctors, said Dr. Tom Mayo, a medical ethicist and professor at the Southern Methodist University law school and UT Southwestern Medical School.

"You see it in end-of-life care, people who are reluctant to raise an issue that bothers them because they don't want to get the doctor mad at them," he said.

That means a doctor who isn't careful can coerce a patient into a treatment the patient might not want, he said.

Getting information about alternatives from the doctor may be less important for many patients today because of the Internet, said Dr. James T. Norwood, president of the Dallas County Medical Society and an obstetrician and gynecologist who practices at Baylor University Medical Center at Dallas.

"Many patients come in and already know the alternatives," he said. "They are coming to me for guidance."

And that's where doctors have a moral obligation to disclose their biases, he said.

"You have to let the patient know that these are my personal biases or beliefs without using those biases or beliefs to embarrass the patient or to force the patient to make a decision they're not comfortable with," he said.

The question of doctor disclosure and referrals is even more important in rural areas, where a patient might not have a convenient alternative, Dr. Norwood said.

The survey in Wednesday's report was taken in 2003 and included a random sample of 1,114 doctors. The results offer 95 percent confidence that the margin of sampling error is no larger than plus or minus 3.5 percentage points, and for some questions the margin was much smaller, Dr. Curlin said.

While religion and gender were factors, age was generally not. So recently graduated doctors apparently understand their ethical obligations about the same as their older colleagues.

Duty to patients

Dr. John Sadler teaches the "Clinical Ethics in Medicine" course at the UT Southwestern Medical School. The response of his students mirrors the new survey, he said. He tells his students that they have an obligation to give their patients all relevant information.

"Because the physician's duty is to patients, she is obligated to disclose medical options that society has legitimated, however controversial in the moral or religious sphere," he said.

But that doesn't mean that doctors are obligated to perform procedures they find to be morally objectionable, he said.

Lance Simmons is chairman of the philosophy department at the University of Dallas, a private Catholic school. He teaches about medical ethics but said he was torn by the issues raised in the new study.

Clearly there is a limit to a doctor's obligation to refer the patient to any procedure, he said, noting how a 1995 episode of The Simpsons turned the question into farce. Homer wanted to become morbidly obese so he could be declared disabled and would be allowed to work from home. He asks his doctor for help:

Dr. Hibbert: "My God, that's monstrous. I've never heard of anything so negligent - I'll have no part of it!"

Homer: "Can you recommend a doctor who will?"

Dr. Hibbert: "Yes."

"I think there's something wrong with Dr. Hibbert's willingness to refer Homer to a quack," Dr. Simmons said.

A joke's a joke, but in the real world, a doctor is supposed to give all information about a medically available treatment or refer to someone who will, said Dr. Arthur Caplan, a bioethicist at the University of Pennsylvania.

"If you are withholding information on your own moral grounds, you are violating a key tenet of the doctor-patient relationship," he said.

Dr. Mayo at UT Southwestern agreed.

"If you can't refer patients, you should probably be in a different line of work," he said.

Dr. Mayo said the new report covers topics he hears doctors discuss informally once in a while. Based on those conversations, he was not surprised by the survey responses.

He said he's heard doctors talking about the decision of some pharmacists to withhold drugs on moral grounds and not refer patients to another provider. The doctors generally agreed that pharmacists are a "means to an end" and should not stand between a patient and doctor-prescribed medication.

"But the next comment," he said, "is usually: 'But doctors are different.'"

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