I read something the other day on Medscape that gave me pause and made me reconsider several things about my career as a nurse. After reading the article and reflecting some on it, I came to the conclusion that there’s a bit of an ethical crisis happening in medicine right now.
The article itself was about birth control and teen pregnancy. You can read the article here, and I will of course be pulling out bits and pieces for our discussion. The central premise of the article is this:
“The real goal is to empower women, not to reduce pregnancy,” said Neha Bhardwaj, MD, from the Mount Sinai Health System in New York City. “If someone wants to have children in their teens, you can’t tell them not to, she told Medscape Medical News. “We really have to reframe the conversation,” Dr Bhardwaj stressed in her presentation on contraception and coercion. “You can’t think of teen pregnancy as a disease.”
I can certainly get behind empowering women. And teen pregnancy is not a disease, that I can agree on. But then the article goes on to state:
“Teen pregnancies may contribute to high dropout rates, incarceration rates, and social costs,” but you still have to look at contraception through the lens of choice, she said.
And this is where I started thinking: does choice really trump dropout rates, incarceration rates, and social costs? I think one could make an argument that it doesn’t. But that’s the lens that’s been thrust upon the bulk of medicine: patient autonomy is everything. To the point that really nothing else matters. And to a certain degree patient autonomy certainly is important and does need to be respected. But what kind of position does that put the clinician in? What kind of position does that put society in?
The author admits, readily, that teen pregnancy leads to higher high school drop out rates. And incarceration rates. And that there are substantial societal costs. But there are medical considerations, too. Teen pregnancy is more likely to result in premature birth and low birth weight, which come with a unique set of medical risks and challenges for the baby. Doesn’t that deserve consideration? Is there no argument for waiting to have a child until you’re physically, emotionally, socially, and economically able to? If the argument is that we should empower women, isn’t it imperative that we help women make the best choice, not just the choice they have in a given moment? I am not the same person I was when I was 17. My ideas and values and goals changed significantly.
Now, that isn’t to say you shouldn’t provide pregnant teens with the best possible prenatal care. That isn’t to say you shouldn’t respect a patient’s choices or beliefs. But at some point you have to weigh belief and choice with potential harm. If you don’t, that leaves clinicians in an ethically unsavory position. I’ll give you an example.
In my job I give a lot of vaccines. I encounter a lot of parents who either outright refuse certain vaccines or what to make up their own schedule. Here, I’m hit with two ethical situations that I’m not comfortable with. The first is that the parents are not the patient, the child is. Yes, I realize that an infant or young child doesn’t have decision making capacity, but that means they’re completely at the mercy or their parents’ ignorance and fears. It also reinforces this notion that children are property that parents own. But that’s another blog post.
But, since I have to respect patient choice and autonomy, I have to comply with the parent’s wishes, which brings to situation number two: I have to release a child into the world unprotected against wholly preventable diseases. It’s one thing for parents to have their own set of beliefs, but this push for autonomy over everything else means that suddenly I’m complicit in what’s essentially medical neglect; I’m aiding and abetting parents in the harming of their children by being forced to respect ignorance and misinformation. I don’t like that.
There’s a similar movement with regard to culture in medicine. We’re taught to try and deliver care within the context of the patient’s cultural beliefs. Well, what if their cultural beliefs about health don’t overlap with modern medicine? Letting people wander around thinking that their diabetes was caused by ‘the evil eye’ instead of insulin resistance caused by diet and obesity seems like a bad idea. Isn’t it unethical to let people go through life refusing evidence-based treatments due to some misguided attempt to respect a culture that doesn’t understand or value evidence-based science? Doesn’t that just propagate pseudoscience? Just look at this slide:
“Science is not the highest value to which all other orders of value should be subordinate.” I’m sorry but yes, science should sometimes overrule values. Sometimes the objective really is better than the subjective. The subjective does not need to be protected if it means objective harm is caused simply to maintain some kind of equivalency. To use a non-medical example here, think of climate change. I don’t care if you think God won’t flood the world again because he promised Noah that he wouldn’t, because that belief doesn’t mesh with objective observations of reality, and thinking that can lead to catastrophic harm for millions of people. Is respecting subjective values really worth losing lives?
In some respect, I see this as an extension of the overly-PC culture we live in. Except that unlike an issue of free speech, where nobody is physically hurt by banning a Halloween costume or renaming a sports team, people really are physically harmed when we compromise care so as not to offend people.
In the end, this really boils down to two classic ethical dilemmas:
- Individual rights vs the collective good,
- Do your individual rights trump someone else’s individual rights?
I’m personally of the school of thought that in the first scenario, the collective good always outweighs the rights of the individual. The second situation is more tricky. In a situation where there are two parties, how do you decide if one person’s rights are more important than another’s? Think of the medical care of children: is the parent’s right to believe what they want and determine their child’s healthcare equal to or greater than the child’s right to health? Courts would say no, as they’ve ruled in the past that the right of a child to health is greater than a parent’s right to religious or philosophical beliefs.
Yet somehow the conversation in medicine (and science in general) seems to be taking the opposite approach frequently. I’m not arguing that we should be allowed to refuse care to someone simply for believing something different than us or because we don’t agree with them. Not in the slightest, as that comes with it’s own ethical consequences. But there does seem to be an ethical disconnect here. I don’t really know what the solution to that disconnect is, but I think it’s a conversation that medicine needs to have instead of being swept up in identity politics.