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  • Editors' IntroductionExamining Deeper Questions Posed by Disputes About Conscience in Medicine
  • Farr A. Curlin and Kevin Powell

Over the past decade, scores of articles have been published debating whether and when it is ethical for physicians to refuse requests from patients for legal, professionally permitted interventions. Numerous voices have condemned "conscientious refusals" for obstructing patients' access to needed and "standard" health-care services, for imposing physicians' personal ideologies on patients, and for contradicting physicians' professional ethical obligations. Conversely, other voices argue that conscientious refusals are essential for maintaining the integrity of clinicians as moral agents, for assuring the renown of the broader medical profession, and for preventing the imposition of moral viewpoints onto minorities in a pluralistic society. This is particularly important in areas in which there is longstanding debate about whether the practice belongs in medicine, as in the case of abortion, physician-assisted suicide, and futile treatment.

The dialogue has often been hindered by participants talking past one another, using contested terms in different ways without argument, and leaving unspoken the participants' premises regarding what medicine is for and how practicing conscientiously relates to good medicine. This collection of essays aims to overcome these limits. [End Page 379]

Toward that end, the collection begins with a paper by Lauris Kaldjian, which argues that the exercise of conscience is inseparable from ethics and from the practice of medicine. Kaldjian proposes that the public should grant physicians substantial latitude to refuse to participate in practices that the physician, in his or her "final and best assessment," believes fall "outside the scope of healing" (389). Importantly, Kaldjian argues that disputes about conscience reflect deep-seated moral pluralism.

Contributors were asked to explicitly explore concepts that underlie disputes about conscience in medicine. To help stimulate the collection, contributors were asked to analyze one or more of the following scenarios:

  1. 1. J.P., a 40-year-old man with unremarkable medical history, asks for antibiotics to treat an upper respiratory infection. J.P.'s physician believes the infection is caused by a virus. J.P. listens to and acknowledges the physicians' reasons for not recommending antibiotics, but makes clear that he willingly accepts the risks of adverse side effects of antibiotics. Moreover, he notes that prescribing antibiotics in such cases is both legal and commonly practiced by physicians. "Don't I have a right to make an informed choice?" the patient asks. J.P.'s physician refuses to prescribe antibiotics.

  2. 2. H.W. is a 72-year-old with advanced non-small cell lung cancer. He was intubated for respiratory failure five days prior and now has evidence of acute renal failure. H.W.'s family insists that everything be done, including hemodialysis, to keep the patient alive as long as possible. H.W.'s physicians refuse to initiate hemodialysis.

  3. 3. E.K. is a 14-year-old of male sex who for the past several years has identified as female gender. E.K. and his parents present to E.K.'s long-time pediatrician asking for referral to a local "gender care" clinic that offers treatment plans in which exogenous hormones are used to block the maturation of secondary sex characteristics until the patient can make a firm choice regarding gender transition surgery. E.K.'s physician believes that such practices will damage E.K.'s health and refuses to make the referral.

  4. 4. M.G. is a 30-year-old woman, living in California, who suffers from an advanced glioblastoma multiforme brain tumor. She anticipates progressive neurological decline and inevitable death within several months. After much reflection and consultation with her family and friends, M.G. presents to her primary care physician to request a prescription for medications that she can take to cause her own death. M.G.'s physician refuses to write the prescription or to refer the patient to someone who will.

  5. 5. A plastic surgeon applying for credentials focuses her practice on limb reattachment and cleft palates. She plans to start a regional, multidisciplinary, cleft palate clinic. She does not intend to perform purely cosmetic surgery, such as elective breast implants or facelifts. Other local plastic surgeons are doing those. She has not done any...


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pp. 379-382
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