Autonomy Quickly Translates to Tyranny
November 2, 2017
by Jonathan Imbody
This excerpt is the second in a series of essays on conscience in healthcare, by Jonathan Imbody, Vice President for Government Relations of the Christian Medical Association and Director of Freedom2Care. Essay #1 is available here. The essays respond to "Physicians, Not Conscripts — Conscientious Objection in Health Care," Ronit Y. Stahl, Ph.D. and Ezekiel J. Emanuel, MD, PhD, New England Journal of Medicine 376;14, April 6, 2017.
By contrast to the patient-physician dual protections of Hippocratic medicine, Dr. Emanuel Ezekiel and Ronit Stahl assert that the "rights of patients" in healthcare trump everyone else's rights. But why? On what basis?
It's one thing to expect physicians to do everything possible to advance healing for patients. It's quite another to insist that whatever the patient wants, the patient gets—so the physician must provide it at risk of his or her career.
Whenever one group gets its way regardless of the impact on others, that is not autonomy; that is tyranny.
As I wrote in my book Faith Steps, "The trouble with adopting autonomy as the only guiding 'rule' is that while compromise and avoidance may work for a while, conflicting worldviews inevitably produce an irreconcilable conflict. By definition, autonomy is utterly incapable of resolving an irreconcilable conflict. The rule of autonomy can only avoid judgment; it cannot make a judgment."
Autonomy (literally, self-law) is by definition impossible whenever one depends on others. The fact that patients depend on physicians, on payers and a myriad of other health entities by definition means patients are not and cannot be autonomous. So a medical ethic that insists on pure patient autonomy is at best unworkable and at worst disruptive to the entire healthcare system.
To achieve health goals, no one party can assert autonomy in our complex and interwoven healthcare system. Healthcare professionals can't do whatever they want, and patients can't get whatever they want. Payers can't exist without premiums or government funds and the accountability and regulation that comes with both.
Success in our healthcare system requires cooperation—not domination. And cooperation requires addressing the goals and needs of each party.
In the authors' view, however, in cases of conflict, patients get what they want regardless of the conscience concerns of health professionals or institutions: "Making the patient paramount means offering and providing accepted medical interventions in accordance with patients’ reasoned decisions."
Suddenly a patient's "reasoned decision" replaces medical judgment and nullifies longstanding principles of medicine that include conscience protection.
The authors deploy the phrase "reasoned decisions" in an effort to paint any opponents as by definition unreasonable; they argue with a patient's "reasoned decision." The authors never specify, of course, what qualifies as a "reasoned decision." One can only imagine what a patient's "reasoned decision" might sound like in practice:
- "Oh don't worry, doctor—I saw a commercial about this drug and researched it on the internet."
- "Well, I'm saying that my back still hurts and I want another prescription of Oxycontin now."
- "I know I'm only 14, but my college boyfriend says I need to start taking the pill. And don't tell my mom."
Besides asserting a patient oligarchy, the authors also attempt to conflate asserted rights of patients with the wellbeing of patients. Yet asserted rights and wellbeing are not always compatible.
What happens, for example, when a patient asserts a right to a prescription or a medical procedure that medical evidence and/or professional judgment indicates would not advance the patient's wellbeing? Isn't that exactly the point at which we want qualified healthcare professionals to intervene, to prevent harm to the patient?
Choosing a healing profession does not mandate killing
The question of harm to the patient comes into focus in the issue of abortion. Many OB/Gyn physicians see their task as tending to two patients—the mother and her developing baby. Most women visiting an OB/Gyn for prenatal care clearly share this view.
Yet Emanuel and Stahl apparently see no contradiction in compelling OB/Gyn physicians, who chose a profession of healing, to participate in killing an unborn child through abortion. As to the wellbeing of the patient who is also a mother, the authors mention no consideration of abortion's potential for emotional or physical harm as a legitimate reason for a physician to counsel a patient against abortion. (For a listing of selected abortion sequelae research publications, click here.)
Not only do the authors fail to see abortion as antithetical to a healing profession and a blatant violation of the Hippocratic Oath, but they also they go so far as to contend that abortion is "medically not controversial." They frame abortion not as antithetical to but as integral to patient care. Therefore, they reason, ending the life of a pregnant patient's developing baby constitutes "patient care," and abortion on demand thus trumps a physician's conscience freedom.
The patient wants an abortion, the patient gets an abortion, end of story. Any physician who disagrees does not deserve to remain in the profession: "Health care professionals who are unwilling to accept these limits have two choices: select an area of medicine, such as radiology, that will not put them in situations that conflict with their personal morality or, if there is no such area, leave the profession."
Of course, erecting such barriers to everyone who does not share the ideological persuasions of the authors would eliminate from medicine tens of thousands of physicians at a time of critical shortage of physicians. The result would be a catastrophic loss of healthcare for tens of millions of patients.
But those who breathe the rarefied air of radical ideology have no patience to contemplate real-life consequences. They aggressively, relentlessly, blindly drive toward their goal of ideological conformity—at any price.