Response

Dr Pope makes an excellent point that is vitally important to the debate about what to do when patient and provider values conflict. Pellegrino’s advice seems reasonable at first: if values are in conflict, the provider and patient must part ways and the patient must seek assistance from a physician who shares her or his values.

In acute care this usually means transferring the patient to another facility. But because providers often share meanings and values, and perhaps also because providers shy away from cases involving conflict, it is usually difficult or impossible to find a facility that will accept a transfer in this circumstance. Thus when a physician decides to withhold or withdraw treatment against the patient or family’s wishes (“unilateral withdrawal”), offering the option of transfer to another facility is often not meaningful. Does this mean the physician is compelled to continue treatment against her conscience? There are...