Gabow, P. A., & Wynia, M. K. (2024).
JAMA, 10.1001/jama.2024.10761.
Advance online publication.
The bond between physicians and their patients has long been considered a unique, even sacred, relationship sealed with publicly professed oaths. Historically, an essential and ubiquitous component of physicians' oaths and their related ethical codes is the promise to place patients' interests above any others, including their own. This is a high bar, but it is the bar physicians swear to meet when entering the profession. For generations, many physicians have courageously met this bar, including putting their lives on the line during pandemics like COVID-19.
Today, physicians face rising challenges in fulfilling this core professional promise not from a virus but from 3 converging fronts: personal conscience, employment contracts, and laws. How these challenges to putting patient interests first have emerged and interrelate deserves elucidation because understanding these dynamics can help shape appropriate professional responses.
Personal Conscience
The First Amendment to the US Constitution forbids the establishment of a state religion (establishment clause) and protects individual religious freedom (free exercise clause). As these paired clauses demonstrate, integral to prohibiting a state religion was establishing respect for individual conscience, and in 1809 Thomas Jefferson declared, "No provision in our constitution ought to be dearer to man than that which protects the rights of conscience...."
Formal support for a physician's conscience to override their commitment to their patient's interests, however, was not codified in federal legislation until the Church Amendments of 1973, which exempted federally funded individuals and entities with moral objections from performing or assisting in abortions or sterilization procedures. This prioritization of physician conscience over patient interests has since been extended by other federal laws and regulations, and many states have passed conscience laws ensuring that physicians can refuse without penalty to provide, or even refer, patients for care a physician deems against his or her conscience.
Here are some thoughts:
The physician-patient relationship, once considered sacred, is facing unprecedented challenges from three converging fronts: personal conscience, employment contracts, and laws. Historically, physicians have sworn oaths to prioritize patients' interests above their own, but recent developments have eroded this commitment. The prioritization of physician conscience over patient interests has been codified in federal laws and regulations, while employment contracts have introduced additional constraints on physicians' ability to put patients first.
To address these challenges, physicians must recommit to their sworn oaths and codes of ethics, examining the difference between professional responsibilities and personal beliefs. They should be aware of ethical guardrails that protect patients' trust, such as informing patients about limitations of care and making referrals when necessary. Furthermore, physicians should carefully examine employment contracts and work collectively through professional organizations to change contracts and laws that privilege institutional or state-level conscience rights over patient-centered care. By vigorously defending their authority to make medical decisions with patients' interests at heart, physicians can reclaim their profession's commitment to prioritizing patients' needs.
