Thursday, February 08, 2007

Clinicians, Conscience, and Information

The paper, Religion, Conscience, and Controversial Clinical Practices, published in the current issue of the New England Journal of Medicine, examines U.S. physicians' attitudes about disclosing information to patients concerning "legal but morally controversial medical procedures." Essentially, the doctors were surveyed about whether they would withhold information, treatment, or referrals from patients if they personally objected to the procedure in question. A summary:

Who Was Included: Practicing U.S. physicians who were 65 years old or younger chosen randomly from a database of all U.S. docs. A modest incentive ($20) was offerred for participation in the survey.

What Was Done: A 12-page questionnaire [PDF] was mailed to physicians for them to complete and return. Participants were informed that the survey was intended to assess physicians' perspectives on religion and spirituality in medicine, and were asked questions about their own religiosity and opinions on refusing treatment and withholding information based on their beliefs.

What Was Asked:
Physicians were asked a number of questions to assess their own religiousity, how often religious discussions occur with patients, and how, their level of objection to controversial procedures (abortion, birth control for adolescents without parental consent, and physician-assisted suicide/"terminal sedation"), the physician's obligation to the patient when the procedure is legal but the physician objects on religious or moral grounds, and general patient, workplace, and individual demographics.

Findings: 1114 surveys were returned to the researchers. Among the results:
  • 83% have no objection to "terminal sedation," 48% do not object to abortion, and 58% do not object to prescription of birth control to adolescents without parental consent.
  • 37% reported low,27% reported moderate, and 36% reported high religiosity, while 46% reported attending religious services twice a month or more.
    When the doctor objects to a legal medical procedure requested by a patient:
  • 63% thought it would be ethical to explain in detail to the patient why he or she objects to the procedure.
  • Only 86% thought they had an obligation to present all possible options to the patient (including about the procedure objected to); 6% were undecided, and 8% believed they had no such obligation.
  • Only 71% believed they were obligated to refer the patient to another doctor who does not object to the procedure, while 11% were undecided, and 18% believed they were not obligated to refer the patient to another provider.
  • "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." (Jewish, None, and Other were the remaining categories)
  • "Physicians who objected to the three controversial medical practices were less likely to report that doctors must present all options and refer patients to other providers. The associations for religious characteristics and objections to controversial clinical practices persisted after controlling for age, sex, ethnic group, region, and specialty."
  • "Physicians who objected to abortion for failed contraception and prescription of birth control for adolescents without parental consent were more likely than those who did not oppose these practices to report that doctors may describe their objections to patients." The researchers did not find a connnection between objection to terminal sedation and believing it was appropriate to discuss these objections with patients.
  • Male physicians were more likely than their female colleagues to both believe it is appropriate to present personal religious/moral objections to patients and to be willing to withhold information/referral from the patient.

    The survey was conducted in 2003 - I think the debate over pharmacist refusals to women has heated up since the time of the survey, but I don't know how/if that would affect a suvery conducted now. Doctors were not asked how often they actually had refused information or referral to a patient or told patients about their religious/moral objections. Rather, they were asked if they believed those refusals are appropriate. The authors also point out that because they surveyed physicians from a number of medical specialties, many of the responding physicians may not be in the position to provide or be asked to provide the "legal but morally controversial" procedures, thus making their opinions about what is appropriate perhaps not representative of what happens in real practice. For example, a set of OB/GYNs asked about birth control and abortion might respond differently overall than a set of cardiologists asked the same thing, but the issue would almost never come up in the cardiologists' medical practice, whereas the OB/GYN's opinions may affect real patients.

    Don't you really want to believe that 100% of the time, if you ask your physician about something, you'll be provided with all of the relevant information about your options, and referred somewhere else if your physician believes he or she cannot care for you?

    Citation: Curlin FA, Lawrence FE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med. 2007 Feb 8;356(6):593-600. Free full-text.

    Blogger C-A said...

    Wow, really interesting statistics. Quite shocking and makes you think about those conversations with your doctor where you don't really feel like you are on the same page....

    8:52 AM  

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