Academic journal article Ethics & Medicine

On Referring

Academic journal article Ethics & Medicine

On Referring

Article excerpt


In this essay, I examine the practice of a physician's referring patients to other healthcare providers for medical treatments the performing of which would violate the referring physician's conscience. I argue that, in some cases, but not all, this practice is ethical. It would not, for example, be ethical in cases in which the treatment that a physician could not bring himself to perform is both itself intrinsically unethical and is known by the referring physician to be intrinsically unethical. The discussion of this topic is deeply enriched by examining the methodology of a recently published study in the New England Journal of Medicine by Curlin et al. that examines physicians' perceived rights and obligations when patients request legal medical procedures to which physicians object on moral or religious grounds.

There is an art to referring.

Referring's being an art accounts, at least in part, for the substantial difficulties one encounters when attempting to convey to potential consultees what constitutes an 'appropriate referral'. Typically, referral sources' primary requests for consultation with psychiatrists are expressed in terms of referred patients' requiring psychiatric evaluations to gauge whether psychotropic medications are appropriate, either alone or as adjuncts to their existing psychotherapeutic treatment regimens. When patients are sent back to their referral sources without the expected prescriptions or recommendations for medications, this is often viewed as an occasion for disappointment, both for the patients and for the consultees by whom the patients were referred. Patients often expect that, since they were referred specifically for medication evaluations, prescriptions or recommendations for medication should have been the result. This disappointment on the parts of patients often also influences the reactions of consultees. It is not uncommon for consultees to feel, in such instances, that they have referred badly. For, it is commonly believed, at least part of what it means to refer well is for one to receive a certain result, namely, an expected, specific exercise of the consultant's expertise. In the case of a psychiatric referral, this typically means a prescription or a pharmacological recommendation. For the referred patient to return to the consultee with anything less is often viewed as a failure on the part of the consultee; specifically, the consultee in such instances appears to have failed to realize that the patient really was not an appropriate candidate for medication after all and should never have been referred in the first place. Now the consultee must face both the disappointment expressed by the patient in not receiving the treatment that was expected and disappointment in his or her own abilities to assess and to refer well.

These disappointments are, of course, often unjustified. I sometimes explain to consultees that referring well is compatible with more than that one expected (namely, pharmacological) outcome. But then what is it, precisely, to refer well? Certainly not just any referral is a good referral (just as, contrary to what many teachers claim, not just question is a good question). Suppose that a family practitioner referred all of his patients who suffer from uncomplicated common colds to ear, nose, and throat (ENT) specialists. The family practitioner in such cases would not be referring well. Nor would a family physician be referring well if he did not refer any of his patients with cholesteotomas to ENT specialists. In the former instance, he would be referring when he should not be, and in the latter instance he would not be referring when he should be. In neither case, therefore, is he good at the activity of referring. In neither case would he be referring well.

Now, one might think that referring is really not an 'ethical issue' at all, that it is, instead, merely a 'medical issue'. This frequently made alleged distinction between an issue's being 'merely medical' and an issue's being 'ethical' itself requires extended comment, although not here. …

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