Not long ago I bought a book, published in 1922, titled Syphilis of the Innocent. Needless to say, the title implied a corollary: for if syphilis could be contracted by the innocent (as, for example, in the congenital form of the disease), it could also be contracted by the guilty.
In general, however, physicians do not inquire after the morals of their patients, except in so far as those morals have immediate pathological consequences. They do not refuse to treat patients because they find them disgusting, because they find them unappealing, because they are appalled by the way they choose to live. They try to treat them as they find them; they may inform, but they do not reprehend.
However, in practice things are sometimes more complex than this ecumenical generosity of spirit might suggest. According to an article in a recent edition of the New England Journal of Medicine, some doctors have been turning away patients on the grounds that they were too fat (one physician suggested that she did so because, ridiculously, she feared for the safety of her staff once the patients weighed more than 200 pounds), or that their children have gone unimmunized. Is such discrimination by physicians legitimate or illegitimate, legally or morally speaking? Is there not a danger that physicians may hide behind pseudo-medical justifications to express their personal prejudices or to coerce patients into doing what the physicians think is good for them?
Let us take the question of immunization of children as an example. Some general practitioners have refused to treat families whose children are not immunized according to the recommended schedule. They do so on the grounds that a visit to the doctor’s office by an unimmunized child may pose a threat to children who happen to be visiting at the same time. Yet the empirical risk is probably not known and very likely to be small, if it exists: probably much smaller than that of leaving a child of a crankish family without medical advice. In other words, the refusal is an expression of the physician’s irritation, perhaps even of wounded amour propre, rather than of concern for the welfare of children.
Obesity also raises questions of medico-political philosophy. Surgeons, for example, sometimes refuse to operate on very fat people, especially for conditions that are not life-threatening, because the results are poorer and the rate of complications higher. This is important not only for the patient, but for the surgeon who might be judged by his results. No doubt physicians who refuse to treat the fat are more likely to see them as weak-willed rather than the victims of genetic endowment, physiology or even of society; but some doctors refuse to treat the fat on the grounds that they do not have the special equipment needed to do so. The authors of the article suggest that this is wrong; that the correct approach is that they, the doctors, ought to buy the necessary equipment. The authors, though, do not tackle the question of who is to pay for it: the doctors, the fat themselves, or the other patients? The answer given will depend crucially on one’s moral attitude to obesity.
In practice, say the authors, not many patients face discrimination; doctors still try to do their best for people as they find them. But they conclude:
Overt discrimination is rare. Evidence suggests, however, that even medical professionals are susceptible to implicit based on race, social class, sex, weight, and myriad other factors that may affect the care they provide.
This sounds ominously like an Inquisition’s charter to me. Perhaps there can be no freedom without tolerance of discrimination.
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