Recently, for no obvious reason, I found myself wondering if there could ever occur a situation where I would refuse to participate in care of a specific individual. Could there be a circumstance so morally or ethically noxious that I would refuse to be involved in someone’s health care? After a week’s rumination, I decided that almost certainly I would refuse to participate in the execution of another human being, presumably as a physician and not the executioner. I suspect most physicians would feel the same way. But, what if my own life or those of my family were threatened if I did not assist in these circumstances? Would I then reluctantly participate in the health care of someone sentenced to death?
What if I were expected to deliver health care in a concentration camp used to exterminate other human beings? I think this represents a much easier problem: Of course, I would do whatever I could to relieve the inmates’ suffering. But, would I be willing to care for the guards and camp administrators? Might I participate in their health care, if only to gain their trust so that I could continue to care for the inmates? My understanding of the situation some years ago in Chile when General Pinochet was ruling that country was that some physicians did participate in torturing political prisoners. Were they threatened with dire consequences to family and friends if they failed to cooperate? How did they feel subsequently when democracy was restored to Chile? I think it is interesting to contemplate how one might have reacted if placed in the same situation.
It is well known that in times past, physicians have participated in morally and ethically reprehensible practices, for example, in the Nazi death camps. These are extreme examples; however, each of us faces more modest ethical conundrums many times during our professional careers. I believe that we need to contemplate what our reactions might be in such situations. Medical curricula these days do present students with a variety of ethically challenging scenarios for class discussion in order to prepare them for a time when such events might occur.
I remember one such personal experience. In the mid-1970s, I was head of the coronary care unit at the Naval Regional Medical Center in San Diego (NRMCSD). Richard Nixon was president, and during a stay in California he developed lower extremity deep venous thrombosis and was hospitalized in the Los Angeles area. We were told that if Nixon’s condition worsened he might be transferred to our facility. Because I was considered to be knowledgeable about deep venous thrombosis and pulmonary embolism because of prior training in Boston, it was certain that were Nixon to come to NRMCSD, I would be involved in his care. I, like most of my student and trainee friends in Boston, disliked Nixon intensely, feeling that he was untrustworthy, dishonest, and deeply prejudiced. Nevertheless, I knew that if he became my patient, I would care for him with the same effort that I expended for all my other patients. Although I disliked him, I would not refuse him care any more than I would refuse care for anyone else brought to my hospital for treatment.
Although I am not personally opposed to abortion, considering it a bad solution to a worse problem, I would not condemn a colleague who refused to perform this procedure because of ethical, moral, or religious principles, nor would I openly criticize a colleague who felt they could not in good conscience perform an act that they found to be reprehensible.
Each of us in our daily practice unconsciously follows a set of widely recognized ethical and moral precepts, such asprimum non nocere. This code of physician behaviors has existed for many hundreds and even thousands of years. In addition, each of us is imbued with individual cultural, ethical, and moral backgrounds that will differ, usually modestly. Therefore, perceptions about whether or not to participate in a particular procedure or care environment will differ. I would like to believe that I would respect the decision of another physician that was markedly different from my own tenet of beliefs. I would certainly not interfere with another physician who performed an accepted procedure that I personally would not do. For example, I would not want to personally perform an abortion, but I fully recognize the need for such procedures to exist in daily medical practice in the US.
I would be interested to hear from other physicians whether they agree with my comments in this editorial or if they can think of other scenarios where they might or would certainly refuse to participate in the care of a patient. Comments can be sent to our blog at https://amjmed.org.
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–Joseph S. Alpert, MD (Editor-in-Chief, The American Journal of Medicine)
University of Arizona Health Science Network, Tucson
This article originally appeared in the April 2014 issue of The American Journal of Medicine.
