Conscience Aside, Most Doctors Would Reveal Legal Medical Options to Patients

CHICAGO, Feb. 7 -- If physicians have a moral objection to a legal medical procedure such as abortion, it is ethically acceptable for them to explain this to patients, two-thirds of doctors said in a national survey.

But an even larger proportion of physicians said that it would be unethical to withhold information about all available legal options, or to refuse to refer the patients for a procedure the physician finds personally offensive, reported Farr A. Curlin, M.D., of the MacLean Center for Clinical Medical Ethics at the University of Chicago, and colleagues.

In all, 86% of doctors responding to a questionnaire agreed that physicians have an obligation to present all possible options to the patient, including information about obtaining the requested procedure, the investigators noted in the Feb. 8 issue of the New England Journal of Medicine.

But that still means that a sizeable number of doctors -- many of them who describe themselves as religious -- think they have the right to withhold information or services, the authors noted.

"If physicians' ideas translate into their practices, 14% of patients -- more than 40 million Americans -- may be cared for by physicians who do not believe they are obligated to disclose information about medically available treatments they consider objectionable," they wrote. "In addition, 29% of patients -- or nearly 100 million Americans -- may be cared for by physicians who do not believe they have an obligation to refer the patient to another provider for such treatments."

In light of recent news stories about some physicians who refused to prescribe -- and some pharmacists who refused to fill -- prescriptions for emergency contraceptives on religious or moral grounds, the investigators studied physician attitudes when their obligations to their patients clash with their personal beliefs.

They used data from a 2003 survey exploring how physicians' religious beliefs influenced their clinical encounters. The survey was mailed to 2,000 practicing physicians ages 65 and younger in all medical specialties.

Participating physicians were asked to make judgments about their ethical obligations and rights when a patient requests a legal medical procedure to which the physician objects for religious or moral reasons.

The situations included euthanasia (administering terminal sedation to dying patients), providing an abortion for failed contraception, and prescribing birth control to teens without parents' approval.

In the current study, the authors considered three primary variables based on responses to these questions:

• "If a patient requests a legal medical procedure, but the patient's physician objects to the procedure for religious or moral reasons, would it be ethical for the physician to plainly describe to the patient why he or she objects to the requested procedure?
• "Does the physician have an obligation to present all possible options to the patient, including information about obtaining the requested procedure?
• "Does the physician have an obligation to refer the patient to someone who does not object to the requested procedure?"

Physicians were asked to respond to each question with a yes, no, or undecided.

The participants were also asked whether they carried their religious beliefs into other aspects of their lives, and whether religion underpinned their approach to life, using questions derived from Hoge's Intrinsic Religious Motivation Scale, a validated clinical instrument.

Based on their responses, the respondents were rated as having low, moderate, or high intrinsic religiosity.

In all, 1,140 physicians of 1,820 potential respondents who could be contacted completed the surveys, yielding a response rate of 63%.

"On the basis of these results, we estimated that when a patient requests a legal medical procedure to which the doctor objects for religious or moral reasons, most physicians believe it is ethically permissible for the doctor to describe that objection to the patient (63%), and that the doctor is obligated to present all options (86%) and to refer the patient to someone who does not object to the requested procedure (71%)." the investigators wrote.

Doctors who were religious were more likely to say that physicians can present their moral objections to patients, and less likely to say that doctors are obliged to present all options, and to refer patients to someone who does not object to the requested procedure.

"As compared with those with no religious affiliation, Catholics and Protestants were more likely to report that physicians may describe their religious or moral objections and less likely to report that physicians are obligated to refer patients to someone who does not object to the requested procedure," they noted.

Those physicians who said they objected to abortion, and to birth control for adolescents without parental consent, were significantly more likely than those who didn't object to these practices to sanction physician expression of moral objections to patients (P