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Thursday, October 30, 2008

Civil Disobedience for Autonomy

posted by on October 30 at 11:46 AM

One of the toughest things to imagine, if I get married, is making a difficult medical decision for my partner when she cannot do so herself. Intubation or death by asphyxiation? Call in the organ donation team, or the morgue?

It’s one of those promises we make to one another, when committing ourselves to a partner. In sickness and health. We agree to take on the horrible responsibility of being the one charged with making those difficult decisions for the person we love, thinking of and for them when they cannot.

Shortly, I’ll be returning to the wards, treating patients as a medical student. I’ll soon be the person asking husbands and wives for these difficult decisions. Stronger than most who find themselves in medical school, I believe in the autonomy of patients. I believe that everyone competent deserves to choose what happens to themselves in a hospital—when they choose to end their suffering, and to whom they wish to delegate this supreme authority. In these difficult and wrenching decisions, I believe the state, the community and even the doctor should be quiet. As a physician, it is my role to honestly present the choices and implement whatever course the patient or the person he or she loves decides. The churches, the ignorant and intolerant, the meddling sanctimonious crowd should stay silent.

The opponents of Washington’s I-1000 and proponents California’s Proposition 8 both wish to interject, to restrict choices for others with their notions of what is right and wrong, comfortable and uncomfortable. They wish to impose their narrow moral sense on everyone, using my hands as a doctor to do so. What if I refuse to follow their intolerant and meddling desires?

What if I refuse to ignore the pleas of a patient facing unbearable suffering?

If California’s Proposition 8 passes, David could very well get a letter informing him that his marriage is annulled. What if I refuse to listen to this letter, if it should come? David’s marriage is as real and as valid as any in my experience. Why should I allow the intolerant, even if it is a intolerant majority of the electorate, to dictate their false moral posturing through my actions.

Why should American physicians be expected to tell a sobbing husband he cannot see his husband in the hospital? To tell a mother in agony she must suffer for a few hours more, in service of those who cling to a medieval notion of the morality of human mortality? It’s all too easy to ask for bigotry and coercive enforcement of your faith in a voting booth. It’s quite another to the be individual who actually must execute these cruel acts. As a doctor, one of my central duties is to protect the right of my patients to make decisions for themselves, to stand up for their autonomy when they are too weak to do so.

I deeply and sincerely hope that the voters will recognize the right of each of us to steer the course of our own lives, and make our own decisions. If not, I should refuse to acknowledge unethical laws, laws that interject community power into a decision that should be left to our own conscience.

My fellow medical students and doctors should do so as well.

RSS icon Comments


Bravo!! Encore! Encore!

Thank you for this.

I'll be using yor post in a lecture this afternoon on how politicians need to stay the hell out of public health. The anti-hero will be Jesse Helms' role in preventing effective HIV prevention.

Posted by gnossos | October 30, 2008 11:55 AM

*your* duh

Posted by gnossos | October 30, 2008 11:56 AM

I recognize the difficulty of some of these decisions, but not the organ donor one; that's a no-brainer. Note that most people who decide not to donate their loved ones' organs end up regretting the decision, while absolutely NONE of the people who do donate end up regretting giving life to others -- often multiple others from a single donor.

Posted by Fnarf | October 30, 2008 11:59 AM

Thanks for your thoughtful perspective. Being from Canada, where we don't put minority rights to a vote (don't bother referencing the the Quebec sovereignty referendums -they were about more than rights) I find it really medieval that California of all places does. I cannot for the life of me, figure out why Americans, accept without challenge, the caustic notion that the majority should decide on the rights of a minority

Posted by loushka | October 30, 2008 12:04 PM

Call in the organ donation team, or the morgue?

Good question Now in my 8th year of the biotech debacleracket a couple of wild unemployed years thrown in there, ya know, no working furnace during JanFeb in some Columbia City flophouse reputable i have you Anyway the organ DoNaTioN thing is misconstrued Very Big Business in selling body parts sort of like that PETA ad with the girl all dotted traced like a Bovine for BUTCHER has anyone blogged about the the US largest kosher meat arrest in Iowa today Link to CNN So the point being uh duh do i ever have a point To the morgue sire, Sire, do you hear me

Posted by gry mklsk | October 30, 2008 12:09 PM

Here here.

(But I do hope neither of us has to go to jail to prove the point.)

Posted by M2 | October 30, 2008 12:12 PM

Fnarf, some people do not believe in organ donation for religious reasons. While I do believe in donation and am a donor, my partner is not, and I would honor his wishes. Also, stating that no organ donor ever regrets his decision to donate is a red herring - few donors (bone marrow, kidney, maybe partial liver) are alive after the surgery to either reaffirm or regret their decision.

Posted by Lucky | October 30, 2008 12:14 PM

Hey, I didn't know you were a med student! Cool.

And, I agree. Well said.

Posted by violet_dagrinder | October 30, 2008 12:21 PM

@7, I was referring to the survivor, not the actual tissue donor. No one ever regrets giving up their loved one's tissues, EVER -- but MOST people who say "no" do regret it later.

If your religious beliefs are against organ donation, you're full of shit. There is no grey area here. FULL OF SHIT.

Posted by Fnarf | October 30, 2008 12:30 PM

Excellent, Excellent, Excellent post.

You are absolutely, positively, 110% correct, sir. May the rest of humanity catch the fuck up with your thoughtful, compassionate reasoning.

Posted by merry | October 30, 2008 12:39 PM

My husband doesn't want his organs donated, but I sort of snicker and say too bad. I'm the one who gets to makes the decision, buddy. Your bits are going to the chopping block.

And I'm serious -- like Fnarf I think that there's no gray area here.

Posted by Julie in Chicago | October 30, 2008 12:40 PM

Some pharmacists might start exercising their civil disobedience and not dispense Plan B, based on this reasoning. I applaud your stance, but this is why we have laws. So people in positions such as yours don't have to make this decision - it's already been decided. I hope that every caregiver I come into contact with respects my wishes - or what my partner deems - but we need the law to clearly state that and not leave it up to individual caregivers to decide.

Posted by Jill | October 30, 2008 12:41 PM

Maybe someone more knowledable than I could comment on this, but my understanding is that Article 1, Section 10 of the constitution prohibits states from passing any law that invalidates a contract. A marriage is a specific type of contract, correct?

So wouldn't the only thing this law do is make it so that there could be no more NEW gay marriages?

Posted by Collin | October 30, 2008 12:41 PM

Most lawyers believe that any marriage can't be annulled once it's completed.

So I wouldn't worry.

Posted by Will in Seattle | October 30, 2008 2:08 PM


The clear difference is: Golob would respect the autonomy of patients, while wingnut pharmacists would trample it.

Posted by M2 | October 30, 2008 2:14 PM

As for the religious argument: Don't take your organs with you, God knows we need them here.

Posted by Schweighsr | October 30, 2008 2:28 PM

@4 - Because to get anything on the ballot in California (and most western states), all you need is a certain number of voter signatures. No involvement of government officials is required and there aren't any restrictions on the content of initiatives. There's a long history of strange initiatives being passed by voters in California.

Posted by Jeff | October 30, 2008 3:51 PM

I'm all for respecting patient autonomy and people's right to commit suicide. But as a med student I don't believe physicians should take an active role in hastening their patients' deaths, just as they should not use their expertise to take part in executions, torture, elective abortion, etc. I'll be voting against I-1000. I would be open to the idea of licensing specialized "death practitioners" maybe as a part of a hospice team, but physicians should not take part.

Posted by dmowen | October 30, 2008 5:24 PM

I align with the political intentions your post is geared toward. But I have two problems with your reasoning.

1. Where does provider autonomy fit in to the law?
2. Who would want to get an abortion from a doctor who a) doesn't believe they are moral or b) hasn't actually done many.

The most important part about medicine is actually not a contractual agreement between doctor and patient, it's the personal relationship. Not only do strong trusting alliances between patient and provider leave people happy, they encourage health and reduce litigation. The concept I am getting at here is the therapeutic alliance. In my estimation this is a give and take partnership, not a fee for hire arrangement.

If it were the latter, physicians would be relegated to mere technicians.

I am in medicine for the therapeutic alliance. I fully support Roe v. Wade, I voted for I-1000, but I wouldn't perform an abortion. I would refer the patient to Planned Parenthood or a provider I would trust to do the procedure safely.

Posted by thomas | October 30, 2008 6:06 PM

superwill in seattle @14

for the love of jebus & the FSM...

PLEASE STFU! your stupidity amazes me.

you aren't funny or relevant, and with every post you just confirm your douche status.

or is that what you're shooting for?

Posted by you fucking douche | October 30, 2008 9:41 PM

@ 20: What is FSM?

Posted by Mike in MO | October 31, 2008 3:59 AM

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