Kerr and Conscience

Dr. David Kerr is a renowned oncologist at Oxford University and writes regularly for Medscape. He recently published Are You Honest When Patients Ask, “What Would You Do?” Given his location and expertise, he often draws academics as patients. He wrote about one in particular, a mathematician, in which he spent, unusually, 90 minutes in consultation (to which he owes to having many other doctors on that particular morning).

Yet after this prolonged discussion, which felt closer to being interviewed or undergoing an examination as a medical student, I told him that I disagreed with his choice. Despite the quasi-logic up until then, it just felt wrong.

Dr. Kerr

After discussing in depth much of the statistical analyses of various treatment regimens, the patient expressed his choice. Dr. Kerr writes, “Yet after this prolonged discussion, which felt closer to being interviewed or undergoing an examination as a medical student, I told him that I disagreed with his choice. Despite the quasi-logic up until then, it just felt wrong.” It struck Kerr oddly that he said such a thing to a patient.

My stock answer is, “I don’t know. Unless I were in your shoes, unless I were a cancer patient, I can’t predict how I’d behave.”

Dr. Kerr

While he eventually asks the readers if they are honest answering that question, he already gives a beautiful answer. His typical response is, “I don’t know. Unless I were in your shoes, unless I were a cancer patient, I can’t predict how I’d behave.” This is the plain truth of human nature, and a cautionary tale for advance directives.

I want to focus on those situations when a clinician disagrees with a patient’s treatment decision. Shared decision-making is good patient-centered care. Sometimes patients come with alternative therapies they ask about. As Kerr says, if it is affordable, not harmful, and not done in lieu of conventional therapies for a serious illness, then fine. Other times, patients may choose differently than one would personally, but it does not cause a second thought or another word. This situation was different enough to evoke Kerr to express his dissatisfaction.

This was not just his disagreement with the patient’s choice, but also about his doubts with the therapy’s effectiveness.

While Kerr uses that encounter to create a reflection on truth-telling, several of the commentators, including me, saw this as possibly stirring his conscience. He felt so strongly that the data did not bear out the treatment that he spoke up. This was not just his disagreement with the patient’s choice, but also about his doubts with the therapy’s effectiveness. Would he administer a treatment he felt was bad for his patient?

That moral distress lies at the heart of conscience protection in medicine. Far from any kind of discriminatory practice, clinicians decline to administer, or refer for, treatments that the clinician believes are harmful. The clinician is rejecting the treatment, not the patient.

Healthcare professionals need the freedom to practice according to their consciences for their own well-being.

As Dr. Kerr’s encounter demonstrates, moral distress arises from many places, not just one’s faith. Moral distress arises when asked for a treatment that the clinician believes is bad for the patient, as in Kerr’s case. As it was first described in 1984 by Andrew Jameton, it is when clinicians are restrained from doing what is best for their patients. It also arises when the best approach to a seriously ill patient is unknown, particularly when deciding whether or not to continue life-sustaining treatments. Moral distress is inherent to clinical practice. Other than some extreme cases (abortion and assisted suicide not being among them), healthcare professionals need the freedom to practice according to their consciences for their own well-being. This is why medical conscience protection is essential.

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