religion and profession
Jul. 18th, 2006 08:39 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
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osewalrus posted an excellent essay on conflicts between religion and one's profession. He and I agree: you are completely free to practice your religion, but if doing so causes complications in your life, you -- not the rest of society -- need to deal with that.
How do you avoid...
Date: 2006-07-19 01:08 pm (UTC)I was ordered by the Medical Command Physician to not provide any treatment to a newborn infant. We were to let the child die. He felt the infant was too young to survive, based on a highly questionable gestational age. I am not trained to evaluate gestational age and had reason to question the mother's report of the gestational age. I refused the order. They sent another physician out to meet our truck enroute to the hospital. The responding physician agreed that I made the correct decision. The infant did die, but had we done nothing, we would have been guilty of abandoning the patient and possibly manslaughter. The MCP apologized to me in person.
I've actually worked in the medical field. I've had to make ethical judgment calls. Repeatedly, we were forced to choose between "following orders" and doing the moral thing. I refused to leave my ethics at home, which is why I was threatened, forced to quit, and eventually vindicated after testifying against my superiors and co-workers.
I do not like what some of these people are doing. Their refusals are obviously harmful. But if we ban conscientious objection in medicine, it's not a slippery slope, it's a cliff we're already dangling on the edge of with only one hand. The question I'd have to ask you is, would you feel the same if their conscientious objection was something you agreed with?
There were people in Stalinist Russia who did not do their jobs. They did not follow orders, and as a result some Jews were not murdered. Should they have either left their ethics at home or quit their jobs? The medical professionals treating the victims of the Tuskegee experiment and the forced sterilizations and exposures of civilians to radioactive agents to study the effect of radiation on humans left their ethics at home.
Some people don't want to be bothered with the "moral thing." They're more interested in what they think they can get away with.
You're asking for something that is without a doubt dangerous.
Re: How do you avoid...
Date: 2006-07-19 01:28 pm (UTC)I don't see how that analogy can be extended to an employer requiring a pharmacist to give the morning-after pill to the rape victim and the pharmacist refusing. If the professional code of ethics barred morning-after pills and the employer said "I don't care", that would be analogous -- but that's not the case.
I don't know what happened in the wake of Katrina -- if those doctors intended to relieve pain (a norm of their profession) or to kill the patients (obviously shaky territory). I suppose that's what the court is going to try to find out.
If you have voluntarily undertaken employment that comes with certain rules, you are bound to those rules. If you don't like them, you should seek other employment. Things are different if either party later changes the rules, or if the association isn't voluntary (e.g. conscription into the military).
I don't see a difference
Date: 2006-07-19 05:14 pm (UTC)Still, for the pharmacists who hold this incorrect opinion, they are being asked to give a drug which they believe will kill a living human being. (It's worth noting that my objection to the objection to Plan B is exactly because of this: Plan B does not cause abortions. It prevents conception. By not permitting the drug, the possibility of having to destroy a living being for soeone else's crime would arise. I'd rather avoid the decision.)
If that same pharmacist was given a prescription by a parent for an obviously lethal dose of a sedative for a mildly retarded child, should the pharmacist refuse it? It's a valid prescription from a valid doctor: can the pharmacist say "no?"
Also, you interpret the medical code of ethics incorrectly. If someone calls and requests treatment with morphine for addiction, we as paramedics are not obligated to "treat" them with morphine. Had the infant been clearly non-viable, the order to not treat would have been the correct one, although I would have still argued for basic comfort measures (drying, warming). If a person is clearly dead, we are not required to start CPR, even though the next of kin demands everything be done.
Deciding when medical care is and isn't appropriate is difficult.
While riding on a Notartzwagen in West Germany in the late 1980s, the physician decided to not treat a patient for chest pain. The patient called, asking to be taken to the hospital. The physician turned the patient down and left. His reasoning was that the patient had lived long enough. I specifically asked if it was a question of the patient being terminal and a DNR -- it wasn't. I questioned other W.G. doctors, and in their medical system, physicians were permitted to make unilateral decisions. I tried to argue, but they couldn't conceive of my reasoning. I do not believe what happened in Katrina would have been a problem in West Germany. No one would have complained. I couldn't help think what ethical geniuses the Germans had been 50 years earlier.
The situation is exactly analogous to the pharmicist conundrum.
I believe the reason you do not wish to permit these people an "exception of conscience" is because you disagree with them. Were the conscience objection about something you felt strongly, you would side with them.
I wonder what a study would show comparing the number of "nothing can be done" calls compared to "CPR initiated" calls for the half hour before a shift change compared to a half hour anywhere else in the shift. Whether an attempt to save someone's life is initiated or the crew gets to go home on time depends on the ethical mindset of the responding crew.
Actually, that's disingenuous. I know full well what the study would show. Not only did I have to fight it in co-workers, there were days I had to fight it in myself. I view ethics as a court of last resort, a court that forced me to behave in ways I can look back on and live with.
THAT is the real problem wea re facing. THAT is why there are no easy answers to this question.
If you remove the people with consciences, the medical profession is turned over to sociopaths. Trust me, there's already enough sociopaths in medicine without working to artificially increase the number.
Crap. It won't let me register under my livejournal name.
Rob of UnSpace.
Clarification
Date: 2006-07-19 06:55 pm (UTC)Without such an approach, I believe the rate of resuscitations started would, in fact, vary with time to shift change. This was a hypothetical statement that I thought obvious in intent, but was pointed out to me wasn't.
I do need a proofreader, don't I?
part 1 of 2
Date: 2006-07-20 02:48 am (UTC)Surely there is a middle position -- how else do pharmacists currently deal with possibly-forged prescriptions and ambiguous cases? It doesn't come up in my field, but if I were told to do something that I thought would be lethal, I'd sure as heck push that issue up my management chain instead of just saying "yah, sure, whatever". I mean, what does a pharmacist do if someone comes in with a prescription and says "I'm also taking $drug and I'm concerned about interactions", and the pharmacist doesn't know whether that's a problem?
Also, you interpret the medical code of ethics incorrectly. If someone calls and requests treatment with morphine for addiction, we as paramedics are not obligated to "treat" them with morphine.
I would have assumed that paramedics aren't allowed to dispense morphine no matter who's asking. Besides, when do patients get to make these kinds of calls?
Deciding when medical care is and isn't appropriate is difficult.
Certainly true.
The [German] situation is exactly analogous to the pharmicist conundrum.
If you're syaing that pharmacists refusing to fill prescriptions is exactly analogous to physicians refusing to treat elderly patients, well, that's a little extreme, but I'll agree. If you're trying to say that the pharmacists are analogous to you in that situation, rather than to the negligent doctor, I don't see how.
part 2 of 2
Date: 2006-07-20 02:49 am (UTC)I don't think that's the case. I invite you to propose a scenario.
I feel very strongly that (1) I have an obligation to live a moral and ethical life in accordance with the principles I have come to understand, (2) that has costs, and (3) that's my problem, not yours. If my ethics compel me to intervene in a situation, I must do it in a way that is consistent with those principles. For example, suppose I think the proposed nuclear plant in town will poison the atmosphere and kill my family -- that's clearly something I care about. (It's also a ficticious example.) I will try like hell to block their access through legal channels -- zoning hearings, lobbying my representatives, publicizing the threat to rally the neighbors, applying whatever market forces are relevant, and so on. I will not simply turn tail and move (I was there first and that would be a PITA), though if I lose I might conclude that I have to to protect myself. But I don't get to lace the building site with land mines (that miraculously destroy equipment but not people), or hack their financial systems to prevent payment to their contractors and employees (in hopes that they'll quit).
Here's one a little closer to home. Suppose I work for a government contractor (true), and suppose we are told to work on a domestic-spying program (false, just to be absolutely clear about this). I won't work on the project, at the risk of my company not having enough unobjectionable work to go around. I know people who would work on the project but deliberately introduce bugs; I would not. My choices are to do the work honestly, be excused from the work, or seek out a more-agreeable employer. I think this is analogous to the pharmacist who has a personal (as opposed to objective) objection to a legal prescription.
I wonder what a study would show comparing the number of "nothing can be done" calls compared to "CPR initiated" calls for the half hour before a shift change compared to a half hour anywhere else in the shift.
I don't wonder. I may be a cynic sometimes, but I'm pretty sure I know the answer to that one. :-(
If you remove the people with consciences
Who said anything about removing the people with consciences? Heavens no! But do not make the mistake of assuming that there is one universal idea about what acts are conscientious and what ones are not. That is the problem: the employer's and customer's consciences permit an act that the employee's conscience does not permit, and the employee attempts to make a unilateral decision.
Are you ok with the idea of, say, the guy at the all-night emergency vet clinic saying "sorry, I don't think people should own birds so I won't treat yours -- go see your vet in the morning"? How is that different from the pharmacist and the rape victim who wants to prevent conception?
Again, in this particular thread we've been talking about emergency situations (mostly), but I think the real issue isn't about emergencies -- it's about taking a job where, as a matter of course, you will run into duties that you find objectionable. Everyone's stressed in an emergency and we make the best calls we can, but if you know that you're going to run into a problem and you take the job anyway, without making arrangements with your employer, then you have erred.
Re: How do you avoid...
Date: 2006-07-19 03:47 pm (UTC)My wife is a pharmacist. If she decides in her professional judgment that giving a patient Plan B is contra-indicated because the patient has a history of cardiac problems and Plan B has potentially bad side effects for cardiac patients, and overrides a doctor's judgment because she believes after consultation with the doctor that the doctor simply does not understand the drug issues, that's one thing. It is an exercise of professional judgment coupled with moral judgment on where her responsibility as a professional lies.
OTOH, if my wife decided that, as an Orthodox JEw, she could never give Plan B under any circumstances, that is something that should be disclosed to an employer. If the employer maintains that dispensing Plan B is part of the job, and cannot be refused simply because my wife doesn't want to give it, then the employer should not hire her. (Please note, my wife has no such issue. I use it as an example.)
The argument that a requirement for a person to disclose their inability to perform job tasks under all circumstances, and to suffer the consequences for this refusal, is unrelated to the more substantive question of when specific circumstances require the exercise of moral and professional judgment.
To return to your case for a moment. Both you and the Medical Command Physician agree that, as a general principle, it is the duty of treating medical professionals to save life. under the moral and ethical standards of your profession, as you yourself maintain in the story, this general obligation required you to give aid. The order given was inappropriate. You refused to obey. This is similar to any case where an illegal order is given. Covered by UNSMC and most other military codes since WWII.
The "conscience objectors" in the article do not fall into this catagory. The standards of the profession call for them to act one way. They refuse, siting their moral objections. This is, to me at least, rather like joining the army and then declaring you can't be sent into combat because you refuse to kill.
We call such "consciencious objectors" "deserters". They new when they joined the army they could be asked to participate in killing. They have no right to refuse a legal order to enter combat.
Why is the case of the "conscious pharmacist" who refuses to dispense Plan B in all circumstances, not simply as an exercise of moral/professional judgment applied to unique circumstances, different?
A particular about changing situations...
Date: 2006-07-19 08:02 pm (UTC)Re: A particular about changing situations...
Date: 2006-07-19 11:14 pm (UTC)Most pharmacists realize it is not an abortificient in any way, but to them, contraception is the moral equivalent of abortion.
The goal is to start with a confusing subject, get the public on their side, and then start moving the goalposts.
It's the same thing with embryonic stem cell research. Why ban that and not IVF, where (unless you are rich and willing to pay to take the precautions) a lot of embryos will probably be destroyed after you're done? Simple. IVF is currently accepted. Ban stem cells first; go after IVF down the road, after you've changed society sufficiently.
South Dakota, BTW, is a terrible disruption of this gradual process. If the pro-Choice side wins, it will be because of the legilators of Sout Dakota.
Now the person whose morals change over the years...what happens to a trauma surgeon who becomes a Jehovah's Witness? Does he (or she) have the right to refuse to give trauma victims blood?
Re: A particular about changing situations...
Date: 2006-07-19 11:15 pm (UTC)replace "Most pharmacists" with "Most objecting pharmacists."
Re: A particular about changing situations...
Date: 2006-07-20 01:45 pm (UTC)Case 3 varies a great deal depending on the local situation. If the other pharmacist is standing next to me ("Fred, can you fill this order?"), then no problem. Other than that, I think it is morally wrong for the pharmacist to hold him or herself out as capable of performing all the duties of his or her profession when this is not the case.
The exceptional case is the Pharamcist proprietor (or one who works for someone with similar moral qualms) who puts a big sign up saying "We Do Not Carry Any Contraceptives OR Fill Prescriptions for Abortificients" (I'm excluding drugs where this is a possible side effect but not the reason for the prescription -- a fact that will likely be evident to a professional pharmacist). Here, the pharmacist does not hold himself out to the public as carrying the medication, and those seeking the drug will need to go elsewhere.
It has been argued that all pharmacies should be required to carry such drugs and all pharmacists required to fill such prescriptions. But that is a different level of argument. It is one thing to say that a pharmacist must diclose any known moral objections that would interfere with performance of his or her duties. It is another to require a pharmacist to always perform an action he or she finds morally repugnant, even where disclosure is made. I'm not saying the argumnent cannot be made -- there are times when society choses to impose duties that create such choices -- but it is a different argument.