Ryan E. Lawrence

Clash of Definitions: Controversies About Conscience in Medicine

What role should the physicians conscience play in the practice of medicine? Much controversy has surrounded the question, yet little attention has been paid to the possibility that disputants are operating with contrasting definitions of the conscience. To illustrate this divergence, we contrast definitions stemming from Abrahamic religions and those stemming from secular moral tradition. Clear differences emerge regarding what the term conscience conveys, how the conscience should be informed, and what the consequences are for violating ones conscience. Importantly, these basic disagreements underlie current controversies regarding the role of the clinicians conscience in the practice of medicine. Consequently participants in ongoing debates would do well to specify their definitions of the conscience and the reasons for and implications of those definitions. This specification would allow participants to advance a more philosophically and theologically robust conversation about the means and ends of medicine.

Autonomy, religion and clinical decisions: findings from a national physician survey

Background: Patient autonomy has been promoted as the most important principle to guide difficult clinical decisions. To examine whether practising physicians indeed value patient autonomy above other considerations, physicians were asked to weight patient autonomy against three other criteria that often influence doctors’ decisions. Associations between physicians’ religious characteristics and their weighting of the criteria were also examined. Methods: Mailed survey in 2007 of a stratified random sample of 1000 US primary care physicians, selected from the American Medical Association masterfile. Physicians were asked how much weight should be given to the following: (1) the patient’s expressed wishes and values, (2) the physician’s own judgment about what is in the patient’s best interest, (3) standards and recommendations from professional medical bodies and (4) moral guidelines from religious traditions. Results: Response rate 51% (446/879). Half of physicians (55%) gave the patient’s expressed wishes and values “the highest possible weight”. In comparative analysis, 40% gave patient wishes more weight than the other three factors, and 13% ranked patient wishes behind some other factor. Religious doctors tended to give less weight to the patient’s expressed wishes. For example, 47% of doctors with high intrinsic religious motivation gave patient wishes the “highest possible weight”, versus 67% of those with low (OR 0.5; 95% CI 0.3 to 0.8). Conclusions: Doctors believe patient wishes and values are important, but other considerations are often equally or more important. This suggests that patient autonomy does not guide physicians’ decisions as much as is often recommended in the ethics literature.

MET molecular mechanisms and therapies in lung cancer

The MET tyrosine kinase signaling pathway is upregulated in many cancers, including lung cancer. The pathway normally promotes mitosis, cell motility and cell survival; but in cancer it can also promote cell proliferation, invasion, metastasis, and angiogenesis. The activating ligand, hepatocyte growth factor, is normally secreted by fibroblasts and smooth muscle cells, but can also be produced by tumor cells. MET upregulation in lung cancer is caused by overexpression and mutation. These mutations can vary with ethnicity. MET signaling affects cytoskeletal proteins such as paxillin, which participates in cell adhesion, growth and motility. Therapeutic approaches that block MET signaling are being studied, and include the use of: small interference RNA, Geldanamycin, competitive HGF homologues, decoy receptors, and direct MET inhibitors such as K252a, SU11274, PHA665752 and PF2341066. It is hoped that blocking MET signaling may one day become an effective treatment for some lung cancers.

Physicians' Beliefs About Conscience in Medicine: A National Survey

Purpose To explore physicians’ beliefs about whether physicians sometimes have a professional obligation to provide medical services even if doing so goes against their conscience, and to examine associations between physicians’ opinions and their religious and ethical commitments. Method A survey was mailed in 2007 to a stratified random sample of 1,000 U.S. primary care physicians, selected from the American Medical Association Physician Masterfile. Participants were classified into three groups according to agreement or disagreement with two statements: “A physician should never do what he or she believes is morally wrong, no matter what experts say,” and “Sometimes physicians have a professional ethical obligation to provide medical services even if they personally believe it would be morally wrong to do so.” Results The response rate was 51% (446/879 delivered questionnaires). Forty-two percent and 22% believed they are never and sometimes, respectively, obligated to do what they personally believe is wrong, and 36% agreed with both statements. Physicians who are more religious are more likely to believe that physicians are never obligated to do what they believe is wrong (58% and 31% of those with high and low intrinsic religiosity, respectively; multivariate odds ratio, 2.9; 95% CI, 1.2–7.2). Those with moral objections to any of three controversial practices were more likely to hold that physicians should never do what they believe is wrong. Conclusion A substantial minority of physicians do not believe there is ever a professional obligation to do something they personally believe is wrong.

Predictors of hospitalised patients' preferences for physician-directed medical decision-making

Background Although medical ethicists and educators emphasise patient-centred decision-making, previous studies suggest that patients often prefer their doctors to make the clinical decisions. Objective To examine the associations between a preference for physician-directed decision-making and patient health status and sociodemographic characteristics. Methods Sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center were examined. The primary objectives were to (1) assess the extent to which patients prefer an active role in clinical decision-making, and (2) determine whether religious service attendance, the importance of religion, self-rated spirituality, Charlson Comorbidity Index, self-reported health, Vulnerable Elder Score and several demographic characteristics were associated with these preferences. Results Data were collected from 8308 of 11 620 possible participants. Ninety-seven per cent of respondents wanted doctors to offer them choices and to consider their opinions. However, two out of three (67%) preferred to leave medical decisions to the doctor. In multiple regression analyses, preferring to leave decisions to the doctor was associated with older age (per year, OR=1.019, 95% CI 1.003 to 1.036) and frequently attending religious services (OR=1.5, 95% CI 1.1 to 2.1, compared with never), and it was inversely associated with female sex (OR=0.6, 95% CI 0.5 to 0.8), university education (OR=0.6, 95% CI 0.4 to 0.9, compared with no high school diploma) and poor health (OR=0.6, 95% CI 0.3 to 0.9). Conclusions Almost all patients want doctors to offer them choices and to consider their opinions, but most prefer to leave medical decisions to the doctor. Patients who are male, less educated, more religious and healthier are more likely to want to leave decisions to their doctors, but effects are small.

Obstetrician-gynecologists' beliefs about assisted reproductive technologies.

OBJECTIVE: To characterize the prevalence of objections to assisted reproductive technologies among obstetrician–gynecologists. METHODS: We conducted a national probability sample mail survey of 1,800 practicing U.S. ob–gyns. Criterion variables were whether physicians object to artificial insemination or in vitro fertilization. We also presented seven patient scenarios and asked respondents if they would discourage use of assisted reproductive technologies and if they would help patients access such technologies. Covariates included physician demographic and religious characteristics. RESULTS: Of 1,760 eligible ob–gyns, 1,154 responded (66%). Few (less than 5%) object to artificial insemination or in vitro fertilization, and even fewer (less than 3%) would not help patients access these technologies. However, the majority of ob–gyns would discourage using assisted reproductive technologies if pregnancy has a 25% mortality risk (95%), if the patient is 56 years old (88%), or if the patient has human immunodeficiency virus (73%). Fewer would discourage use of assisted reproductive technologies if the patient already has five healthy biological children (24%), if she plans to be a single parent (17%), if she is not married to her male sexual partner (14%), or if her sexual partner is female (14%). Male (odds ratio, 2.2–2.8) and religious physicians (3.6–4.7) were more likely to discourage using assisted reproductive technologies if the patient was lesbian, single, or unmarried. CONCLUSION: Few ob–gyns object to assisted reproductive technologies. Most discourage use of such technologies for patients with advanced age or medical comorbidities. Male and religious physicians are more likely to limit access for lesbian, single, or unmarried patients. LEVEL OF EVIDENCE: III

Religion and Suicide Risk: A Systematic Review

Although religion is reported to be protective against suicide, the empirical evidence is inconsistent. Research is complicated by the fact that there are many dimensions to religion (affiliation, participation, doctrine) and suicide (ideation, attempt, completion). We systematically reviewed the literature on religion and suicide over the last 10 years (89 articles) with a goal of identifying what specific dimensions of religion are associated with specific aspects of suicide. We found that religious affiliation does not necessarily protect against suicidal ideation, but does protect against suicide attempts. Whether religious affiliation protects against suicide attempts may depend on the culture-specific implications of affiliating with a particular religion, since minority religious groups can feel socially isolated. After adjusting for social support measures, religious service attendance is not especially protective against suicidal ideation, but does protect against suicide attempts, and possibly protects against suicide. Future qualitative studies might further clarify these associations.

Genetic Testing in Psychiatry: A Review of Attitudes and Beliefs

The advent of genetic testing for psychiatric conditions raises difficult questions about when and how the tests should be used. Development of policies regarding these issues may be informed in a variety of ways by the views of key stakeholders: patients, family members, healthcare professionals, and the general public. Here, we review empirical studies of attitudes towards genetic testing among these groups. Patients and family members show strong interest in diagnostic and predictive genetic testing, and to a considerable extent psychiatrists share their enthusiasm. Prenatal test utilization seems likely to depend both on parental views on abortion and the seriousness of the disorder. Parents show a surprising degree of interest in predictive testing of children, even when there are no preventive interventions available. Many persons report themselves ready to alter their lifestyles and plans for marriage and family in response to test results. Respondents also fear negative consequences, from discrimination to being unable to cope with knowledge of their “genetic fate.” Empirical studies of beliefs about genetic testing suggest tests are likely to be embraced widely, but the studies have methodologic limitations, reducing the certainty of their conclusions, and indicating a need for further research with more representative samples.

Obstetrician-gynecologists' views on contraception and natural family planning: a national survey

OBJECTIVE The objective of the study was to characterize beliefs about contraception among obstetrician-gynecologists. STUDY DESIGN National mailed survey of 1800 US obstetrician-gynecologists. Criterion variables were whether physicians have a moral or ethical objection to, and whether they would offer, 6 common contraceptive methods. Covariates included physician demographic and religious characteristics. RESULTS One thousand one hundred fifty-four of 1760 eligible obstetrician-gynecologists responded (66%). Some obstetrician-gynecologists object to intrauterine devices (4.4% object, 3.6% would not offer), progesterone implants and/or injections (1.7% object, 2.1% would not offer), tubal ligations (1.5% object, 1.5% would not offer), oral contraceptive pills (1.3% object, 1.1% would not offer), condoms (1.3% object, 1.8% would not offer), and the diaphragm or cervical cap with spermicide (1.3% object, 3.3% would not offer). Religious physicians were more likely to object (odds ratio, 7.4) and to refuse to provide a contraceptive (odds ratio, 1.9). CONCLUSION Controversies about contraception are ongoing but among obstetrician-gynecologists, objections and refusals to provide contraceptives are infrequent.

Primary care physicians’ and psychiatrists’ approaches to treating mild depression

Lawrence RE, Rasinski KA, Yoon JD, Meador KG, Koenig HG, Curlin FA. Primary care physicians’ and psychiatrists’ approaches to treating mild depression.