Most of the physicians in our survey reported that when a patient requests a legal medical intervention to which the physician objects for religious or moral reasons, it is ethically permissible for the physician to describe the reason for the objection but that the physician must also disclose information about the intervention and refer the patient to someone who will provide it. However, the number of physicians who disagreed with or were undecided about these majority opinions was not trivial. If physicians’ ideas translate into their practices, then 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. 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. The proportion of physicians who object to certain treatments is substantial. For example, 52% of the physicians in this study reported objections to abortion for failed contraception, and 42% reported objections to contraception for adolescents without parental consent.
The findings of this study may be important primarily for patients. They should know that many physicians do not believe they are obligated to disclose information about or provide referrals for legal yet controversial treatments. Patients who want full disclosure from their own physicians might inform themselves of possible medical interventions — a task that is not always easy — and might proactively question their physicians about these matters. Patients may not have ready access to information about physicians’ religious characteristics and moral convictions. Thus, if patients are concerned about certain interventions for sexual and reproductive health and end-of-life care, they should ask their doctors ahead of time whether they will discuss such options. If a patient wants a treatment that the physician will not provide, the patient may choose to consult a different physician.
Physicians’ judgments about their obligations are significantly associated with their own religious characteristics, sex, and beliefs about morally controversial clinical practices. Female physicians are more supportive of full disclosure and referral than are male physicians, perhaps because many controversial issues in medicine (e.g., abortion, contraception, and assisted reproductive technologies) disproportionately involve the sexual and reproductive health of women. Religious physicians are less likely to endorse full disclosure and referral than are nonreligious physicians, perhaps because, as many previous studies have shown, religious physicians are more likely to have personal objections to many controversial medical interventions. Thus, those physicians who are most likely to be asked to act against their consciences are the ones who are most likely to say that physicians should not have to do so.
These conflicts might be understood in the context of perennial debates about medical paternalism and patient autonomy. Strong forms of paternalism are based on the assumption that physicians know what is best for their patients and may therefore make decisions without informing their patients of all the facts, alternatives, or risks. Paternalism is widely criticized for violating the right of adults to self-determination. The inverse of strong paternalism is a strict emphasis on patient autonomy, which suggests that physicians must simply disclose all options and allow patients to choose among them. Models that emphasize patient autonomy to such an extent have been criticized for diminishing the moral agency and responsibility of physicians by making them mere technicians or vendors of health care goods and services.2,19–23
This study suggests that the balance that most physicians strike between paternalism and autonomy involves both full disclosure and an open dialogue about the options at hand. This balance resembles the interactive models proposed by Emanuel and Emanuel,19
Quill and Brody,20
These ethicists have all recommended models for the doctor–patient relationship that retain the moral agency of both the physician and the patient by encouraging them to engage in a dialogue and negotiate mutually acceptable accommodations that do not require either of the parties to violate their own convictions. In Emanuel and Emanuel’s terms, these interactive models retain a role for the influence of “the physician’s values, the physician’s understanding of the patient’s values, [and] his or her judgment of the worth of the patient’s values.”19
Although these models require physicians to disclose all information relevant to patients’ decisions, they do not require physicians to be value-neutral. Rather, they allow physicians to explain the reasons for their objections to the requested procedures.
The lack of consensus among physicians about whether referrals to other providers who will offer a controversial treatment should be required mirrors the ambivalence about this point within the field of bioethics. Childress and Siegler22
say that physicians “may” have a duty to inform patients about other physicians who would provide what the patient requests, and Quill and Brody20
comment that physicians are “perhaps” obligated to facilitate the transfer of care. This ambivalence stems from a long-standing concern that physicians not be asked to act in ways that “would violate [their] personal sense of responsible conduct.”23
Unfortunately, at times the only accommodation that is acceptable to both the patient and the physician may be termination of the clinical relationship.19,20,22,23
Our study has several important limitations. Although we did not find substantial evidence of a response bias,10,11
unmeasured characteristics may have systematically affected physicians’ willingness to respond in ways that bias our results. In addition, physicians in different specialties face different arrays of morally controversial practices. Because this study included physicians from all specialties, many participants were asked to report moral judgments about medical practices with which they may have had little or no clinical experience. Moreover, physicians’ judgments about their general obligations do not necessarily correspond with their judgments about any particular clinical scenario, and we do not know how their judgments about their obligations translate into their actual practices. Finally, we had three criterion measures and several predictors. Therefore, although hypotheses were theoretically specified and the expected associations were consistently observed, there was the risk of an inflated type 1 error due to multiple comparisons. For all of these reasons, our findings should be considered preliminary, and future studies should use vignettes, patients’ reports, or direct observation to measure more directly the ways in which physicians respond to moral conflict in the clinical encounter.
Notwithstanding these limitations, the results of our study suggest that when patients request morally controversial clinical interventions, male physicians and those who are religious will be most likely to express personal objections and least likely to disclose information about the interventions or to refer patients to more accommodating providers. Ongoing debates about conscientious objections in medicine should take account of the complex relationships among sex, religious commitments, and physicians’ approaches to morally controversial clinical practices. In the meantime, physicians and patients might engage in a respectful dialogue to anticipate areas of moral disagreement and to negotiate acceptable accommodations before crises develop.