nonstandard patients, nonstandard doctors, nonstandard procedures

This reflection from Leah Libresco about her unfortunate experience of ectopic pregnancy and her deviation from the standard procedure is worth reading. She describes being offered “the standard of reproductive care”, which is basically a medication abortion. While this course of treatment is not specifically forbidden by Catholic teaching, it is at the very least extremely controversial (see this brief introduction to the ethical principles here). Leah gave two reasons for refusing this course of care: “I am a Catholic and I am a statistician.” She points out that 50% of the time, ectopic pregnancy ends with a natural and safe miscarriage, and opted to wait for this rather than intervene with what she felt was an ethically dubious intervention.

She goes on to describe both a recent 538 article that raised concerns about Catholic hospitals in rural America that routinely deviate from the medical consensus because of religious convictions before turning to a perennial problem in women’s care: women whose symptoms don’t fall into a typical pattern or who suffer from symptoms with no immediately apparent cause are dismissed or ignored — sometimes with life-threatening consequences (such as when they present with atypical symptoms of a heart attack), but virtually always with discouragement when medical professionals dismiss them. She also mentions the (incredibly common) practice of treating symptoms when the underlying cause is either unknown or difficult to treat, grouping all three as “standards of care”.

Where I think Leah is correct is that doctors are trained to think in terms of systems and are befuddled when patients don’t fall into neat little boxes. The problem with medical education is that one must first learn to inquire carefully, recognize patterns, and apply standards — a doctor who cannot apply basic heuristics is going to be a poor doctor indeed. Then they must learn what to do when the rules don’t apply or they cannot find an immediately applicable answer, and here oftentimes it seems that a doctor’s behavior is mostly going to be determined by their personality and the environment they practice in as much as their training. If they’re inclined to be suspicious, dismissive, or lazy, that is unfortunately how they are going to tend to act around patients whose diseases don’t reveal themselves with standard investigations and whose symptoms don’t respond to standard treatments. What we know of the complex interplay between stress, trauma, and the body is still very little, but what we do know is that the most vulnerable people often have problems that make a mockery of our heuristics.

This is different, however, from both of the other scenarios she mentions. Part of the problem is that what we mean by “the standard of care” is very different in a clinical sense in different situations; it is a more of a legal concept delineating what you can’t not offer to patients. It’s what you have to do and say in order to not be negligent. In common usage, though, it is the palette of options that a clinician and his or her patients consider (hopefully together) for diagnosing and treating.

Papering over or “masking” symptoms when we cannot definitively diagnose or cure a condition is a big part of what doctors do; this is particularly true for common but frustrating women’s health problems like PCOS or endometriosis. The “standard of care” here is not like antibiotics for pneumonia or a tetanus booster for someone who’s stepped on a nail; what is on offer is what has been shown to help some patients. It is different further still from the standard of offering methotrexate for ectopic pregnancy.

In the latter case, methotrexate is offered because 50% of the time there isn’t a natural miscarriage; in those cases an intervention must be performed one way or another to remove the child that cannot survive and save the mother who will not survive if the child is not removed. Methotrexate is not merely a matter of convenience for the woman to avoid a surgery (though reducing the risk of major surgery is something all good doctors want to do whenever they can); it is also a matter of trying to keep women from dying if they wait too long for an emergency surgery. Ectopic pregnancy is not the only scenario where our ethical directives conflict, but it is certainly the most common — and there the standard of care is oriented towards preserving life. There is never any “standard patient”, but the modal patient is probably a few standard deviations away from the analytic skills of a Catholic statistician like Leah — and so what they are offered is not only to not be negligent, but also to reduce the likelihood of life-threatening problem.

Different still are the issues surrounding Catholic hospitals; in these cases the most common exemptions are not for life-threatening problems or matters of inscrutable clinical inquiry but rather involve elective procedures and medications for contraception. While I personally think that Catholic moral thought in these matters fails people insofar as it fails to take stock of the whole of the natural law (a post for another day!), I agree that it’s not really fair to go after Catholic hospitals for matters of conscience. (FWIW, I think FiveThirtyEight is otherwise doing a great job highlighting the issues with rural hospitals, and even focusing on conservative Christians to boot!) We ought to allow Catholic hospitals and other medical professionals with ethical objections to various “standards of care” to have their exemptions, but we also have to recognize that these themselves are systematic standards and they will have exemptions-within-exemptions.

So we ought not lump the very different problems of straightforward religious exemption, difficult clinical cases, and common-but-ethically-tricky cases together. The “standard of care” in each is not only different, but different in scope and meaning. And while all individual physicians are indeed required to do whatever it takes to help their individual patients, heuristics be damned, we have nothing but chaos if we don’t have the heuristics and the standards in the first place to work from.