I knocked, paused briefly, entered the exam room and introduced myself for the first time. Mr. Larson, a distinguished appearing elderly man, with a carefully groomed crown of white hair greeted me with piercing blue eyes. As I shook his wasted hand with its papery-thin skin, I noted the clear plastic nasal cannula in each nostril, which wound down to a large green tank of compressed oxygen. As he took a breath to speak, I observed the muscles at the base of his neck contract with each breath; with his barrel-shaped chest, it was clear he had emphysema.
“Doc, I want a prescription … it’s not time yet, but when I get worse I want something to help me — do you know what I mean?” My colleague had declined his request for ethical reasons; assisted suicide was not legal, even in Oregon, at that time three decades ago.
According to a recent commentary (“We must not weaponize religious beliefs,” July 3), a physician who will not prescribe a lethal dose of medication for a patient like Mr. Larson is in danger of “weaponizing” his or her religious beliefs by “permitting those in positions of authority or power to impose their values and beliefs on vulnerable people … a cynical way of using religious liberty to block access to and the use of legal medical services.” Is declining to assist in taking a life when it is against the doctor’s personal ethic desirable in a doctor, or is it a weapon?
In my mind’s eye, I picture the goals of doctors and patients as two separate but partly overlapping circles. The area of overlap is where we have aligned motivations and goals. Patients put up with seeing my name every day on their pill bottles, paying for and taking those pills, knowing they are the means to our common goal, such as avoiding a stroke in a person with high blood pressure, or using statins and beta-blockers to avoid another cardiac event. All treatments involve trade-offs, expense, inconvenience and side effects on the part of patients. When the goals are shared, we accomplish great things.
When my goals and values do not overlap with the patient’s, I’ve learned I am not going to make much headway. There are patients who are not ready to address their _______ (you fill in the blank), no matter how beneficial the treatment might be. The Rehnquist court affirmed that patients have the right to decline treatments they do not want.
What happens when the patient wants something that is incompatible with the doctor’s goals and values? Some of this is easier; we expect clinicians to be evidence-based — to decline treatments that are potentially harmful in certain settings, such as unnecessary antibiotics or opioids. We expect doctors to not offer treatments that are not in a patient’s best interest even when it might be faster and easier to give what is requested and move on. We also expect doctors to resist insurance company requests that might save money but could hurt individuals, and not accede to corporate dictums or personal tendencies to cut corners to increase patient throughput. We expect doctors to have clear boundaries. In short, we expect them to be moral agents.
Back to Mr. Larson — what would he want? What he was requesting then was not legal, but now it is legal in 10 states (though not Minnesota). There are doctors who will provide abortion and assisted suicide. Would Mr. Larson want a physician to be required to violate his or her personal beliefs? Which beliefs specifically would he want him to violate and for what reason? How trustworthy could the doctor be in future encounters?
Congress over the last four decades in multiple pieces of legislation has guaranteed protections for clinicians who believe referring for, or participation in, abortion or assisted suicide is wrong. Far from weaponizing health care, the rules Health and Human Services administers operationalize the law and protect the public and physicians. The suggestion to speak out against the Protecting Statutory Conscience Rights rule to “stand up for religious freedom” is incoherent; the rule protecting these rights is already recognized in law. A doctor is not a vending machine — to expect physicians to perform procedures or recommend treatments which conflict with their internal ethic is neither safe nor just.
Dr. Steven C. Bergeson is a family physician in Shoreview. The views expressed here are his own.