My series answering the New York Timesâ€™ Ethicist column with an active, leadership approach instead of an analytical, philosophical perspective continues with â€œCan a Doctor Refuse to Treat a Patient Who Takes Cannabis?â€.
A friend was recently diagnosed with multiple myeloma, a cancer of a type of white blood cell called plasma cells. There is often significant pain associated with this condition, and my friend has been treated with high doses of different opioid combinations, in addition to chemotherapy. My friend lives in Colorado, where he has easy access to medical marijuana, and he asked his oncologist if he could add this to his regimen in hopes of decreasing his dependence on opioids. The oncologist told him that he would refuse to treat my friend if he took any form of cannabis. Given his insurance coverage, my friend does not have the option of changing physicians.
The National Cancer Institute states that cannabis may benefit patients suffering from cancer-related side effects. Cannabis is routinely recommended for cancer patients to improve appetite, decrease nausea and alleviate pain. The medical literature is fairly consistent on the efficacy and minimal side effects of cannabis, which has specifically been shown to help patients decrease opioid dependence. There are even some reports that cannabis may be a valuable adjunct to chemotherapy in cancer patients.
Is it ethical for the physician to deny treatment based on my friendâ€™s taking cannabis? Is it ethical for my friend not to inform his oncologist if he chooses to use cannabis? — D.A. Kinderlehrer, M.D.
My response: Had you asked the legality, I’d say your question is legal/medical/other professional service. Talking to a professional will answer your questions more effectively than a newspaper columnist.
You asked if either activity was ethical. Since everyone has different values, you’ll just get a label that not everyone agrees on. There is no book in the sky or other measure of absolute right, wrong, good, bad, or evil that 7.6 billion people will agree to. If there were, you would have consulted it, gotten your answer and wouldnâ€™t have had to write here. There isnâ€™t, so you did.
The New York Times response: Let me start with your question about the right of doctors to refuse service. Doctors in the United States can be legally required to treat patients in medical emergencies. Otherwise, though, doctors can mostly refuse service â€” as long as itâ€™s consistent with whatever agreements theyâ€™ve made with their health care organizations or provider networks and isnâ€™t in violation of anti-discrimination laws. There are shortages of doctors in many places, so clinicians â€” especially the ones with the best reputations â€” often truthfully say they simply wonâ€™t take new patients on board.
While doctors donâ€™t have a general obligation to take patients, they do have obligations to patients they have taken. Yes, doctors sometimes â€œfireâ€ patients they find unpleasant, overly demanding or abusive. But the American Medical Association rightly calls for physicians to ensure â€œcontinuity of careâ€ in these cases â€” which involves making sure that the patient can secure another physician. You say that your friend has access to only this one oncologist. Thatâ€™s disturbing, if true. In a decent medical system, the ability to switch doctors is a central element in respecting patient autonomy. A situation in which a doctor can fire a patient but not the other way around strikes me as insupportable.
As a general rule, whatâ€™s more, noncompliance is a poor justification for terminating care. If this oncologist has medical reasons for objecting to your friendâ€™s use of cannabis â€” if he has specific concerns about drug interactions, say â€” he should explain them. (Iâ€™m assuming your friend isnâ€™t enrolled in an experimental protocol.) If itâ€™s just that he disapproves of legal marijuana use, thatâ€™s an abuse of the doctor-patient relationship. Patients arenâ€™t obliged to help their doctors enforce a tyrannical demand, so there would be no moral reason your friend should inform him of his cannabis use. Indeed, your friend might want to consider filing a complaint against the oncologist for making this threat.
As a medical matter, though, itâ€™s not a great idea to have a doctor who doesnâ€™t know what drugs youâ€™re taking. Ideally, your friend would enlist the services of a specialist in pain management or palliative care who could work with his oncologist. Treating pain involves subjective considerations that make it very different from giving chemotherapy, which is why people skilled at the second sometimes falter at the first. And if your friend canâ€™t come to terms with this oncologist, the oncologist is ethically required to find him another.
I have a friend in a long-term relationship who has always wanted kids but has been putting off getting married to her boyfriend and starting a family. I think itâ€™s because sheâ€™s ambivalent about him. Iâ€™m worried that she is going to lose her fertility window if she doesnâ€™t leave him soon and find a better match. I donâ€™t want to say anything because I donâ€™t want to add to her anxiety, but I donâ€™t want to see her miss her chance and later regret it. Is it more ethical to share my concern or to stay quiet? — Name Withheld
My response: You ask what’s ethical. Since everyone has different values, you’ll just get a label that not everyone agrees on. I suggest you want not a label but a practical plan to resolve your situation as best you can by your values and the values of others affected as best you can tell using empathy and projecting possible outcomes.
In any case, everybody involved seems a consenting, sane, informed adult. Anyone who wants to decline can.
The New York Times response: Everything you say about your friendâ€™s situation is, if true, known to her. What you want her to do is to draw what you think is the obvious conclusion: that she needs to break up with her partner, find a new one and settle down to motherhood. Perhaps you think that forcing her to face reality will get her to snap out of it and take some new course of action.
If you had reason to be confident that your promptings would guide her to a life as a happily married mother, it would certainly be ethical to proceed. Youâ€™d be offering a gift of friendship. But I suspect you donâ€™t have reason to be confident about this. And youâ€™ve identified the downsides: adding to her anxiety, sparking her resentment. It is an important maxim, widely ignored, that intervention is a good idea only if it is likely to make things better. Many people think that a mediocre partner is better than no partner at all. And depending on their character and temperament, they may be right.
At the gym, I often see a woman who appears to be severely underweight; I canâ€™t help thinking that she may have an eating disorder. Iâ€™m not a medical professional, I donâ€™t know her, I donâ€™t work at the gym and I donâ€™t have any information that isnâ€™t plainly visible. I donâ€™t want to intrude on her privacy (for all I know, this woman may have some other underlying medical condition and already be receiving medical care for it), but at the same time, itâ€™s difficult for me to see someone looking so painfully thin. For what itâ€™s worth, Iâ€™ve seen this woman at the gym for a year or more, which suggests that her weight is relatively stable, albeit very low.
What is the most ethical course of action? And how would it be most helpful to engage with this woman if ethics demand that I canâ€™t simply be a bystander? — Name Withheld
My response: Labeling something ethical or not doesnâ€™t change your situation. You probably want to resolve it more than label it. I suggest that more than a New York Times columnist labeling a course of action for you, youâ€™d benefit from developing the social and emotional skills to resolve the situation and improve your emotional well-being. Youâ€™ll lose the excuse to say, â€œBut the New York Times told me toâ€ but gain the ability to resolve these inevitable parts of life without needing othersâ€™ help. Youâ€™ll make mistakes, but youâ€™ll learn from them. Experience is the best way to learn these things, Iâ€™ve found, as have millions of others. I recommend accepting the missteps youâ€™ll make, looking at them as learning experiences, and using them to learn and grow.
You’re asking how to lead someone, meaning you want to improve your leadership. If you’ll allow me a quick analogy, if you want to learn to create art, taking academic classes in art appreciation may help you appreciate art others made but not to create it. You have to practice, starting with the basics.
Nearly every resource I’ve seen on leadership is leadership appreciation—that is, books on principles and such that help you appreciate others’ leadership but not to lead. To learn to lead you have to practice, starting with basics.
To answer your question on how to lead people, I recommend my book, Leadership Step by Step, which gives you exercises to practice the skills of leadership, not just to appreciate others’ practice. You have to do the work of the exercises, not just passively read it, but what expressive or performance-based practice can you learn without work?
I’m not just plugging my book. I wrote it because nothing existed to give you experience and skills, not just appreciation.
Unit 4 covers what you want, though I’d start at the beginning and do the exercises in order.
The New York Times response: You know almost nothing about this woman and have no relationship with her. Unless sheâ€™s completely friendless, thereâ€™s almost certainly someone who is better placed than you to judge whether sheâ€™s ill and, if so, to help her deal with it. Maybe that has already happened.
You donâ€™t have very good reason, in short, to involve yourself here. And bear in mind that one feature of eating disorders is a preoccupation with how you look to others; being addressed by a stranger in a gym who is worried by your appearance is likely to exacerbate that problem. Shame is part of the psychic burden of many eating disorders (she may be struggling to recover from it), but so is a profound body dysmorphia. Hearing that sheâ€™s too thin may have the opposite effect than what you intend, by making her feel pleased that her behavior has succeeded in making her look the way she wants to look. As I cautioned in my previous answer, we should intervene only when weâ€™re likely to make things better.
I recently started a new job. During the application process, I was asked if I would be applying to graduate school in the near future, as their intention was to have the new hire stay on for two to three years. At the time, I was not intending on applying to graduate school, but this has since changed. Must I inform my new employers of my change in plans? There is a chance I may not be accepted into a program or receive enough funding to attend. I also took on personal risk by moving to the other side of the country when accepting the offer. — Name Withheld
My response: Must you? There is no book in the sky or other measure of obligation that 7.6 billion people will agree to. If there were, you would have consulted it, gotten your answer and wouldnâ€™t have had to write here. There isnâ€™t, so you did.
If you’re going to do something that involves others, involving them in the process generally helps. I suggest the question is not if you’re obliged in some abstract, philosophical way but how to do involve them in the process.
You probably want to resolve your situation more than label it. I suggest that more than a New York Times columnist labeling something for you, youâ€™d benefit from developing the social and emotional skills to resolve the situation and improve your emotional well-being. Youâ€™ll lose the excuse to say, â€œBut the New York Times told me toâ€ but gain the ability to resolve these inevitable parts of life without needing othersâ€™ help. Youâ€™ll make mistakes, but youâ€™ll learn from them. Experience is the best way to learn these things, Iâ€™ve found, as have millions of others. I recommend accepting the missteps youâ€™ll make, looking at them as learning experiences, and using them to learn and grow.
The New York Times response: Unless you promised your new employers not to apply to graduate school, the truthful answer you offered in the interview was what you owed them. You might consider sticking around for a year, though, so that you could give them a good chunk of what theyâ€™d been hoping for. That youâ€™re not obliged to do so doesnâ€™t mean that it wouldnâ€™t be a decent thing to do.
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