AMA Journal of Ethics^®

Case

Dr. M was a first-year resident in a family practice program. An Islamic woman, Dr. M intended to limit her practice to primary care of children, adolescents, and adult women. Because of her future practice plans and her religion, Dr. M stated that she would not participate during her residency training in procedures that required her to examine or treat genitorectal areas of males—procedures such as circumcision, urethral swabs, testicular exams, and digital prostate exams. Dr. M lived, and intended to practice, in a large US city. She maintained that her decision not to perform this limited set of procedures would not cause harm to any individual because those in need of these medical services would be able to secure them elsewhere without undo burden.

The residency program director, Dr. R stood firm on the requirements. He argued that satisfactory completion of his program was taken as certification that all residents had performed and mastered the required procedures. Dr. R. believed he was justified in specifying professional qualifications for that certification. He was not curtailing Dr. M's rights; he was setting professional standards. Dr. R contended that if he were to let Dr. M complete the program without experience in all required procedures, his family practice residency program would no longer certify that all graduates were experienced in all procedures they may be called upon to perform. Furthermore, he said, this exception would open the door to other exclusions. Individuals might ask to be exempted from learning any procedure that they attested they would not have to perform in the course of their practice.

In pursuing her case, Dr. M said that the door to exceptions was already opened. Physicians opposed to abortion were excused from performing them. Indeed, she argued, most residencies did not require or even teach physicians how to perform abortions, out of deference to strong religious antipathy to abortion prevalent in the US. She also pointed out that in most places Jehovah's Witness surgeons were exempted from giving blood transfusions. Dr. R's decision in this case, she alleged, was solely one of indifference to the tenets of her particular religion—Islam.

Questions for Discussion

1. The AMA's "Principles of Medical Ethics" state that, in non-emergency situations, physicians may choose whom to serve. Since the procedures Dr. M wishes not to perform are not life-saving procedures, she may ethically choose not to perform them. Does this also mean that she need not be expected to learn about them in her training?
2. Is Dr. R justified in saying that certification in a given residency should guarantee uniform competency among all graduates? If Dr. R decided to honor Dr. M's wishes, how might he indicate that her qualifications differ from those of other program graduates? Is it necessary to so indicate?
3. Would Dr. R's policy, if enforced in other family practice residency programs, mean that women who share Dr. M's interpretation of Islamic principles could not become family practice physicians in America? If personal moral values are at odds with professional ethics, and one is acting in a professional role, what should one do?
4. Does commitment to diversity mean that every educational and professional opportunity must be designed to accommodate individuals of every race, creed, ethnicity, sex, type of physical disability, sexual preference, and age? Are there differences in the weight of these various aspects of diversity? How can religion-based exceptions be honored without opening the door to honoring all closely held, non-reason-based values?
5. Patients are free to seek or reject treatment from physicians of a given ethnicity, race, or religion, or of one or the other sex. Should physicians have the same latitude in choosing patients that patients enjoy in choosing physicians?