ACOG Insanity [Serge]

Medical organizations in general are advocacy and political bodies that often use substandard thinking in creating opinions, especially on ethics. Nothing could evidence this more than the ACOG opinion 385 that Jay blogged about here. Its hard to know where to start, so I'll offer a scenario.

A young woman of 18 decides she is tired of having her period every month. Her mother previously had a hysterectomy for uterine ca so she knows that a hysterectomy would be a permanent solution to her monthly "problem". She presents to a local OB-GYN in order to have this surgery. After being told the objective facts regarding the surgery and the risks involved, and the fact that her uterus shows no signs of pathology and is functioning well, she still insists that she wants her uterus removed.

What should the physician do? I believe any ethical surgeon would likely refuse to perform her surgery, on the basis that there is inadequate medical "need" and the risks far outweigh the so-called benefits of having a hysterectomy at that age. I'm also sure that there would be concern that this young patient would come to regret her decision in the future. Although performing a hysterectomy is completely legal, and the physician performs this surgery frequently, they would not elect to perform it on this patient in this case. I also don't believe this decision would be questioned as the best course of action. In fact, most OB-GYNs would consider performing the procedure as unethical.

Lets take a closer look at the reasoning behind the decision not to perform surgery in this case. Predominately, the physician would be conscientiously objecting to the procedure for reasons that are not completely "neutral" or "scientific". He (or she) would be making a value judgment on what was best for the patient in that circumstance, and by using their experience, knowledge, and yes, conscience, he would refuse to perform unnecessary surgery.

However, according to the ACOG opinion, this physician would be acting unethically if they refused to do the procedure unless they referred the patient to someone who would. Maybe there's another practice in their town that has questionable ethics and that the physician knows would do any procedure if the price was right (or the patient had good insurance). The physician would be acting unethically unless he specifically referred the patient to this other doc. In fact, the opinion actually states that the physician should seek to locate his practice close to someone with differing ethics in order to facilitate these types or referrals.

Of course this is completely ridiculous. It is unethical for doctors to give false information or to mislead patients in any way. However, we have an ethical obligation to give those who seek out our care our absolute best and to act in their best interest, even if occasionally this means not treating them for something that they would otherwise want that is not medically necessary. Our cognitive dissonance on the topic of ELECTIVE abortion should not change this.