Doctors all get roughly the same
basic medical training, but they don't all get the same
moral education. There are medical options available
today — abortion and euthanasia being the most
obvious examples — that are anathema to some doctors,
even though those doctors may sometimes be expected
to help patients seek these treatments out.
The extent to which doctors' treatment
choices are guided by their moral beliefs is explored
in two large surveys of physicians published this month.
One, in the February 8 New England
Journal of Medicine (NEJM), found that only 71%
of American doctors responding to a questionnaire agreed
that it was their duty to refer patients for medically
available treatments that they consider objectionable.
The other, in the fetal and neonatal
edition of the Archives of Disease in Childhood (ADC),
questioned Australian and New Zealand neonatologists
on their willingness to shorten the lives of severely
disabled newborns in whom further treatment was considered
useless. They found a surprisingly strong correlation
between physicians' attitudes to treatment and their
feelings about the prospect of their own eventual death.
CONSERVATIVE
Tx
The NEJM's American questionnaire results imply
that the streak of social conservatism running through
that country is present in its doctors. While only 17%
objected to sedating dying patients to the point of
unconsciousness, 42% objected to prescribing birth control
to teenagers without parental consent and 52% objected
to abortion after contraceptive failure.
Of the 1,144 respondents, 86% felt
obliged to present all treatment options to the patient,
including those they found controversial. But only 71%
believed they had a duty to help the patient find such
treatment. Sixty-three percent said they had a right
to mention their own objection to the patient.
Lead author Dr Farr Curlin of the
University of Chicago said it's natural that people
will disagree on moral issues in such a pluralistic
society, but advises patients to take it into account.
He notes that certain characteristics were prevalent
among the doctors who felt entitled to voice their objections
or refuse to participate in controversial treatment.
They were more likely to be male and Christian, and
they were more likely to have moral objections to certain
treatments. "Those most likely to be asked to act against
their consciences are the ones most likely to say physicians
should not have to do so."
His colleague and co-author Dr
John Lantos, who discussed the findings with colleagues,
found a spectrum of opinions, but most "felt that doctors
had the right to follow their conscience, and patients
had a right to legal, medically approved treatment."
I
FEAR DEATH
Perhaps rather closer in cultural terms to Canada, the
Australia and New Zealand survey of neonatologists looked
away from cultural issues to focus on hard clinical
questions.
What degree of withdrawal of treatment
and hastening of death is acceptable in severely disabled
neonates with no chance of recovery? In both Australia
and New Zealand, denying treatment in such cases is,
for all practical purposes, quite legal.
Almost all of the respondents had
shortened an infant's life at some point. One in three
was willing to use painkillers or sedatives to hasten
death in severely disabled newborns. A further 48% were
prepared to hasten death by denying food or treatment.
One in five found the idea of hastening death unacceptable.
These physicians also completed
a validated questionnaire called the Multidimensional
Fear of Death Scale. It emerged that those most willing
to hasten death had significantly more personal fear
of the "dying process" and of "premature death" than
those opposed to the practice. Conversely, those against
hastening death had significantly more "fear of being
destroyed."
It seems natural enough that religious
people, who have a comforting belief in an afterlife
to fall back on, would be less frightened of dying,
yet more frightened of "being destroyed." So the obvious
implication of this study would be that — as one
might expect — religious people are more reluctant
to hasten death in very sick newborns.
POOR
SHOWING
Both studies validated what appears to be an iron rule
of research: when physicians are sent research questionnaires,
the proportion who bother to respond is rarely less
than 50% or more than 60%.
The NEJM study had a response
rate of 57%, after sending 2,000 questionnaires to physicians
of all specialities. The ADC study had a 56%
response rate, after sending 138 questionnaires to all
Antipodean neonatologists.
Whether the near-half of physicians
who never seem to answer these questionnaires are adequately
represented by these samples is an enduring mystery.
Logic might suggest that those with particularly strong
moral opinions are more likely to take the time.
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