Printed from: https://www.cmf.org.uk/advocacy/submissions/?id=40
Published: 30th November 2005
The Christian Medical Fellowship (CMF) is an interdenominational organisation with more than 4,500 British doctors as members. All are Christians who desire their professional and personal lives to be governed by the Christian faith as revealed in the Bible. Members practise in all branches of the profession, and through the International Christian Medical and Dental Association are linked with like-minded colleagues in over 100 other countries.
CMF regularly makes submissions on ethical and professional matters to Government committees and other official bodies. All our submissions are available on our website at www.cmf.org.uk
We welcome the opportunity to comment on the draft Good Medical Practice document. Before beginning we would like to set out our own Value Statement, as this provides the basis for our subsequent comments.
Medical practice demands more from the doctor than the accumulated knowledge and technical skills handed down from the past, and Good Medical Practice recognises that. The statement on 'probity' would appear to be setting a standard that is too high for anyone to meet at all times. Rather it sets an 'ideal' for a 'good doctor' to which the GMC would wish all UK practitioners to aspire. Similarly, a Christian doctor has an 'unattainable' ideal – to be guided, in his or her personal relations and attitude to work, by the ethical teaching of Christ as recorded in the Bible. The implications of this are outlined in the following statement.
Christian values can be summed up in Christ's two great commandments: 'Love the Lord your God with all your heart and with all your soul and with all your strength and with all your mind' (Deuteronomy 6:5; Luke 10:27) and 'Love your neighbour as yourself' (Leviticus 19:18; Luke 10:27). Specifically we aim:
We hope that thought will also be given as to how the high ideals of the Good Medical Practice document will be promoted and taught among undergraduates and in the context of continuing professional development. Young doctors are not suddenly going to become or remain ethically committed doctor simply by reading the document – if they indeed read it at all. Within medical schools, detailed consideration needs to be given to the content and teaching of ethics, including the hidden curriculum, as well as to the selection of students for medical training.
It is important that doctors are taught to be conscientious: to develop their own thoughts and opinions and be prepared to question the status quo. We believe that medical professionals should never become mere servants to the state and that educating doctors to think for themselves will make for better professional guidance and practice.
The Good Medical Practice document primarily concerns the interaction between the doctor and his individual patients. However, in the revised Duties of a Doctor, there is also a clause stating the doctor's duty to 'protect and promote the health of patients and the public'.
This clause needs consideration as it could be construed to contradict Paragraphs 5, 6 and 8 of the draft Good Medical Practice guidance. There is a danger that these paragraphs could be interpreted in a way that may result in doctors being 'gagged' in expressing their own considered opinions or conclusions on behaviours that are risky either to individual patients or to the public at large if propagated across a community or society. The profession needs to decide the extent to which doctors, both individually and corporately, play a part in educating society about the health consequences of risky behaviour. The politics of so-called 'sexual health' provide a good example here.
In short we believe the pendulum has swung too far from doctor paternalism to patient consumerism, with the result that patient autonomy has been overemphasised at the expense of medical expertise. The ideal position of shared decision making relies on a meeting of experts, where both the expertise of the patient in their illness narrative and worldview, meets with the medical expertise of the doctor. To facilitate this shared decision making the paternalism/consumerism pendulum must return to the centre. The word 'doctor' has the literal meaning of 'teacher' - doctors have a responsibility to be teaching society, recognising both the limits of our competence to do this and also that the teaching process must involve dialogue. The teaching process must always be reinforced by appropriate action, which may on occasion bring conflict with both patients and the state. The profession has a responsibility to speak out on the causes of ill-health and to oppose patient demands or political developments that are injurious to health.
Doctors have a duty to work constructively with local, regional and National Health Service management for the good of patients and society. We also have a duty together to resist work practices that may harm staff, and to oppose management practices that are not directed at equitable, efficient, and effective health care. Processes need to be in place to ensure that doctors can question macro resource decisions where they feel it is appropriate in the interests of the health of their patients. The management/doctor divide is not to be to be encouraged. Doctors should be a part of any management structure, so that they can bring their expertise and practical knowledge to the decision making process.
Respect for human life
One of our ethical values is to 'maintain the deepest respect for human life from its beginning to its end'. Within this framework we recognise that human life in the physical sense has a natural end. A goal of medicine is to recognise that natural end, and we see no requirement to give all possible treatments to all possible patients in all possible situations just because those treatments exist. It is precisely this sort of meddlesome medicine that does not recognise that the natural end is drawing near that has led to over-treatment of some patients.
In other words, while believing it is always morally wrong and always unnecessary intentionally to kill patients, we also recognise that there are situations where it is appropriate to withhold or withdraw specific interventions, and allow a patient to die, with all appropriate care given. This is not euthanasia but good medical practice.
With this in mind we note with some concern the change in the Duties of a Doctor from the previous:
“Patients must be able to trust doctors with their lives and well-being. To justify that trust, we as a profession have a duty to maintain a good standard of practice and care and to show respect for human life…” (May 2001)
To:
“Patients must be able to trust doctors with their lives and health. To justify that trust you must:
The culture of patient centred care emphasises the need to show respect for human life as upheld in historical codes of ethics such as the Declaration of Geneva (1948) that talks of maintaining 'the utmost respect for human life… even against threat'. A culture of state centred care, however, emphasises human rights. State dictated permissible human rights will vary in time and in place, and will be informed by a variety of sources. This is not good medical practice and will not facilitate a climate in which patients are able to 'trust doctors with their lives and health'.
In light of pressure currently being exerted on the Government and medical profession to support and even promote the legalisation of 'assisted dying', it is vital that the 'respect for human life' language be retained in Good Medical Practice document.
We are concerned that the GMC are removing the 'respect for human life' clause because they are watching the euthanasia debate and waiting to see whether new legislation will result. However, pro-euthanasia organisations would argue that assisted dying does respect human life (within their terms of 'respect' 'life' and 'dignity'), therefore why remove the statement? It is a very good protection against any abuse against human life AND rights, but it goes further than just respecting rights recognising the intrinsic worth and value of each human LIFE regardless of how that individual or the state defines 'rights'. The importance of human rights is already satisfactorily accounted for elsewhere in the document.
The notion of 'respect for human life' is at the heart of Article 2 of the ECHR. Whatever the Government does or does not do on the issue of assisted dying, Article 2 will remain firmly grafted into English law. To excise the phrase 'respect for human life' and to urge doctors simply to 'respect human rights' is to produce a set of guidelines that is too vague to be helpful. Doctors are unlikely to know, without explicit guidance from the GMC, what is involved in respecting human rights. Reference to showing 'respect for human life' is the very least that should be expected in terms of exposition of doctors' obligations.
Patient and doctor autonomy
As Christians, we are happy with the language of autonomy in so far as it reflects the unique individuality of each human being, created 'in the image of God', and ultimately accountable to Him.
However, we further recognise the high value of human relationships in society. We are not dependent or independent beings. We are interdependent. Emphasis on rights must always be balanced by the concept of interdependence. For this we have concepts of responsibility within society and the restrictions framed by the law. This enables society to function and protect all its citizens. Prioritising the concept of autonomy, threatens this interdependence, which applies as much to the doctor as to the patient.
Personal autonomy can never be absolute. We are not free, in a democratic society, to do things that violate the reasonable freedoms of others or place vulnerable people at risk. Equally doctors should not be constrained by patient autonomy or state coercion to do things they believe are morally wrong, unethical or clinically inappropriate. We have laws and professional codes simply because we believe as a society that personal autonomy is not absolute. All laws and professional codes will restrict personal autonomy to some extent, and this is necessary and right in a democratic society.
We are concerned that in medical ethics and elsewhere, society has over-weighted rights and neglected the necessary balance with responsibilities and restrictions. Though we emphasise our support for patient autonomy, it is also imperative that the doctors personal autonomy is equally valued and recognised within the doctor patient relationship. Shared decision making and interdependence is the way forward. We are therefore concerned that doctors should not be devalued to being mere 'technicians of the state', where their actions are determined solely by the patients rights and autonomy. On the rare occasions where a shared decision is not possible, and the patient reaches a conclusion about their 'best interests' but the doctor holds another, it is important that the doctor is not forced or coerced into participation in a decision that is contrary to his autonomous decision. The GMC's code is, after all, the code that defines the doctor's professionalism. It would be ironic if it had the effect of diluting that very professionalism by making the doctor a puppet who had to dance to whatever tune the patient sang. The doctor who merely does what his patient asks will often let that very patient down.
Patients cannot act with true autonomy without possessing all relevant information. Out of respect for the principle of autonomy, therefore, the GMC must protect the doctor's right, and assert the doctor's duty, to provide without fear of sanction, what the doctor considers is the relevant information and advice.
We quote this excerpt from the GMCs Contractual arrangements in health care: professional responsibilities in relation to the clinical needs of patients (May 1992, paragraphs 15 - 17):
'(15) … Since the NHS began a few general practitioners have used their right to remove patients from their lists for reasons which have included, for example, old age, severe disability or drug addiction, on the grounds that such patients are costly in terms of time and effort needed to provide care. … (16) … The general position is worth re-stating. Patients have a right, enshrined in law, to choose their family doctor. Doctors have a parallel right to refuse to accept patients, or to remove them from their lists, with no formal obligation to give reasons for their decision. These rights flow from the belief that a satisfactory relationship between patient and doctor will arise only where each is committed to it; consequently, if either party believes that the relationship has failed, they have a right to end it. … (17) … Given this, family doctors, as the professionals involved, have special responsibilities for making the relationship work. In particular, it is unacceptable to abuse the right to refuse to accept patients by applying criteria of access to the practice list which discriminate against groups of patients on grounds of their age, sex, sexual orientation, race, colour, religious belief, perceived economic worth or the amount of work they are likely to generate by virtue of their clinical condition.'
We have particular concerns about the issues relating to conscientious objection. Currently this mainly operates in relation to abortion, although there is also a clause in the HFE Act, and if assisted dying is legalised in the UK we expect another similar conscience clause. Some doctors will have issues of conscience for example if asked to sign off a 'welfare of child assessment' for a lesbian couple to have IVF treatment, or perhaps to refer some couples or single patients for infertility treatment. Many doctors will struggle to maintain a clear conscience while prescribing contraceptives for teenagers, or counselling a 12 year old who is seeking an abortion and refuses to have her parents consulted.
It is increasingly important to our members that the laws which define acceptable medical practice do not also force them to provide to patients whatever is deemed 'acceptable' within the law.
We therefore feel it is important that the freedom of doctors to take a patient off their list is retained and emphasised. We have concerns about the activism expressed by certain groups to 'out' doctors with conscientious objection.[1] We are also aware of other groups that may tend towards activist approaches in their campaigning. In light of this we feel it is important that doctors should be able to remove someone from their list if they feel threatened in this way, or judge that they may frequently be unable to meet the patients' treatment requests.
We find the majority of the proposed new guidance agreeable and therefore have not answered all the individual questions laid out in the consultation document. Rather we have focussed on areas that are of specific concern to us as Christian doctors.
We have addressed paragraphs of the draft guidance in the order they appear in the questions of the consultation document.
3. Do you agree that doctors must respect their patients' right to live their lives the way they choose?
Yes, with the following reservations
We agree that doctors should respect their patients' right to make choices about how to live their lives. However, this must not and cannot preclude doctors from educating patients about the differences between healthy and unhealthy lifestyle choices. There will often be an obligation, enforceable in the civil law, to point out those differences. The GMC's code must make it clear that compliance with that legal obligation can never raise any sort of inference that the doctor did not respect the patient's right to live as he chose. A doctor who fails to point out the health consequences of lifestyle choices to his patients is not fulfilling his obligation to practise good medicine.
We would also add that the content of 'respect' in various situations needs clarification. It is one thing to respect a patient's ability to make free choices that do not involve a third party, but quite another where the doctor is involved in facilitating the patient's choice in some way. It seems that the GMC acknowledges this in its guidance about the limits of professional confidentiality. There will sometimes be an ethical duty (and in a few circumstances a legal duty) to breach a professional confidence. A caveat referring to this needs to be inserted into the draft clause.
(See also our comments above under 'The limits of autonomy in the medical setting', and our answer to questions 31-32 below.)
4. Is this adequately expressed in paragraph 5?
Paragraph 5, as currently worded, would threaten any challenge to the patient's lifestyle -- an important though often overlooked part of a doctor's role.
Facilitating behaviour change in relation to smoking, drugs, sexual health and obesity requires judgments about what is good for health and what is not. Discrimination can be positive and negative. The problem is that what is perceived as negative discrimination by one is seen as positive discrimination by another. A doctor may be more likely to accept chaotic appointment attendance in drug addicts and chaotic personalities. This is positive or appropriate discrimination. Doctors may also challenge patients about smoking, drug taking and encourage healthy behaviour change – this is also appropriate discrimination. It is in the area of sexual health where doctors are most likely to encounter charges of inappropriate discrimination – but the doctor who fails to warn a patient about the health consequences of sexual choices is failing to practise good medicine.
We are concerned about the phrase 'you must not refuse or delay treatment because you believe that patients' actions have contributed to their condition'. There appears to be no scope for shared decision making here. A patient might not want referral and time to reflect further is often appropriately used as a therapeutic option within the consultation.
Furthermore, we wonder how this fits practically with the standard practice of using limited resources in the most 'efficient' way possible. The courts have repeatedly upheld rationally considered policies which decree which classes of patients can have particular types of treatment – such as refusing Coronary Artery Bypass Graft's (CABG) to smokers. One can also rationally query the wisdom of performing a liver transplant on an alcoholic who expresses no intention of tackling their addiction.
Regarding the phrase 'you must not let your views about patients' [lifestyle characteristics]…. adversely effect your professional relationship with them…'. We would like to refer again to the section from the GMCs Contractual arrangements in health care: professional responsibilities in relation to the clinical needs of patients, quoted above, and assert that the ability to take a patient off your list, or for the patient to change doctors, provides a protection for both patient and doctor if a situation arises that inevitably effects the professional relationship. This seems a more fair way of dealing with such conflicts, as opposed to doctors feeling 'gagged' from expressing certain opinions or feeling pressure to act in a way that is contrary to their moral beliefs or to arrange treatment that they believe is not clinically appropriate.
5. Do you agree that the GMCs role in these issues is different in relation to colleagues than in relation to patients?
No specific comments
6. Do paragraphs 5 and 44 (respect for colleagues) express reasonable, achievable standards?
We are concerned that there should be recognition of the differences between unfair discrimination and fair discrimination – and that perhaps these need clarification in the document, both in relation to patients and colleagues. Doctors need to be able to make judgements and decisions without fear of recriminations.
There may also be legitimate concerns about how one doctor's lifestyle will affect the practice of his or her colleagues. The paragraph as it stands could be used to justify, in deference to political correctness, chaotic personal behaviour that will inevitably impact the way a doctor will practise.
7. Do you think these paragraphs accurately reflect doctors' duty to promote equality and value diversity?
No specific comments
8. If not how could we express these concepts as practical, attainable standards?
No specific comments
25. Does this statement adequately express a doctor's duty to provide palliative care?
No.
In light of the pressure being brought to bear upon the House of Lords, and potentially the Government, to legalise assisted dying, we would like to see stronger wording in the document – perhaps elsewhere– to promote palliative care.
We have serious concerns about the current provision of palliative care and the realities of accessibility. Quoting the Royal College of Nurses[2]: 'Patients do not always have adequate choice in palliative care. Differing provision across the UK has created a system where the level of palliative care received is often dependent on location. … Many palliative care services originated from local voluntary organisations and voluntary hospices continue to provide around 75 per cent of inpatient palliative care services. Although this model served to stimulate provision of palliative care services, provision is sporadic and frequently dependent on the fundraising capabilities of the local communities. Further, charitable funding is directed at the patient group for or by whom funds are raised, and many adult palliative care services cater only to cancer care. For example, studies into palliative care for patients with chronic obstructive airways disease (COPD) have shown that COPD patients are often stranded at home with little support.' [3]
The final report of the Health Committee stated that lack of equity in the provision of palliative care was a major concern, further noting that these inequalities were compounded by provision being disproportionately present in areas of affluence, whilst the greater needs were is areas of social deprivation.[4]
It is imperative that assisted dying, if it becomes legal, should never be used because such care facilities are unavailable.
Furthermore we urge the GMC to oppose any changes to the law, at the very least until palliative care facilities are available and accessible to all those in need of them.
We would like the Good Medical Practice guidance to recognise this issue, and assert that doctors should take responsibility to promote palliative care provision and to make every effort to ensure that their patients are able to access palliative care services.
31. Is it clear this paragraph relates to doctors' beliefs about procedures and not their beliefs about their patients?
Yes.
However, regarding referral, we are concerned that this might have the effect of requiring a doctor who had a conscientious objection to abortion to refer a patient requesting abortion to a doctor who would have no such qualms. We believe that as a matter of law such a requirement would fall foul of the conscientious objection clause in the 1967 Abortion Act. To refer is certainly to participate in abortion. To say otherwise is to assert that referral is a merely administrative act – a conclusion which would have worrying ramifications for general practitioners and hospital clinicians alike: it would imply that the GP was simply a post-box and that hospitals could ignore as unconsidered what the GP said. Further, to require such involvement in abortion would be to breach the doctor's right under Article 9 of the ECHR. A guideline imposing such a requirement would accordingly be unlawful and susceptible to judicial review.
32. Do you agree that this is as far as the GMC should go in guidance to the profession, given that a serious or persistent breach of the guidance will put a doctor's registration at risk?
No specific comments.
39. Does the wording of paragraph 8 accurately reflect the extent of the duty for a doctor to treat a patient who may pose a risk to their (the doctor's) own safety?
Paragraph 8 is open to interpretation and as it stands unsafe. One of the cardinal rules in resuscitation is to make sure that the area is safe before you proceed. If there is doubt about safety you do not proceed. Abiding by this statement necessitates that for doctors in a resuscitation situation, personal safety is less important that for a passer by. Is this really the case? Also what happens if the doctor is pregnant? Does this change things and if so how?
39. Does this paragraph reflect what you think doctors should do to show respect for their patients?
Paragraph 19. 'Work in partnership with patients': this should be when possible. With certain patients a more paternalistic approach to care is needed. Examples are: patients who are in emergency situations; patients who are unable to fully comprehend and understand; young children and some patients with mental illness. A doctor can show respect for these patients without it being a partnership in the way the term is commonly understood.
40. Is there anything else which you think should be included?
No specific comments
47. Do you feel this is an acceptable way of dealing with this issue? If not, please suggest an alternative.
Probity: 'moral excellence, integrity, rectitude, uprightness, conscientiousness, honesty, sincerity'.
The ideal of probity is a high ideal for doctors to aim at. We uphold this ideal. However, we also recognise that every doctor will frequently fall short of such a high standard throughout his or her working life. Referring to our section above on 'The importance of Good Medical Practice in undergraduate education and continuing professional development', we would like the GMC to consider how they will encourage and teach 'probity' to medical students and similarly through CPD during a doctor's career.
Paragraph 27 is open to broad interpretation, and needs to be clarified. The way we express beliefs in everyday life can be perceived in many different ways. A belief expressed in one way may be perceived by one listener as not distressing, and another as distressing. Our knowledge of the person concerned may allow us to predict the response, but we can often be wrong. The same applies to doctor patient interactions. Instead of using the phrase 'in ways which are likely', which is open to interpretation, motivation should be used: 'You must not use your professional position to express personal beliefs in a way motivated by a desire to cause distress or exploit the patients vulnerability.'
It may be further problematic, as sometimes patients need to hear comments that they may initially find distressing but which are for their ultimate good. For example, asking 'Do you think it is good for your health to be sleeping with so many partners?', and expressing an opinion on that topic (see our above response to Questions 3-8 / Paragraph 5).
Some might see discussion of faith issues in the course of a consultation as likely to cause distress, as it inherently introduces ways of looking at the world that may be new, unfamiliar and challenging to the patient. However, this may ultimately work for the patient's well being if it encourages them to think through their lifestyle choices more, or gives them opportunity to investigate a helpful faith perspective that they may not otherwise have had. There is abundant medical literature now on the clear link between faith, lifestyle and good health; and the sensitive and appropriate use of discussion about spiritual values and faith perspectives may well provide benefits for the patient.
We are concerned that the case for being 'vulnerable' could apply to any doctor-patient relationship and so might be used to outlaw any mention of spiritual matters or faith perspectives in the clinical setting.
Quoting from the GMC's Annual Report (1993:4) regarding Doctors' use of professional standing to promote personal interests or beliefs:
'The Committee's attention was drawn to the activities of a very small number of doctors who use their professional position to proselytise patients, or who offer diagnoses based on spiritual, rather than medical, grounds. The Council has hitherto taken the view that the profession of personal opinions or faith is not of itself improper and that the Council could intervene only where there was evidence that a doctor had failed to provide an adequate standard of care. The Committee supported that policy and concluded that it would not be right to prevent doctors from expressing their personal religious, political, or other views to patients. It was agreed, however, that doctors who caused patients distress by the inappropriate or insensitive expression of their personal views would not be providing the considerate care that patients are entitled to expect.'
This statement affirms that discussion of personal religious, political or other views by the doctor to the patient is admissible provided that it is done in a way that is both appropriate and sensitive. We recommend that this statement, or words to the same effect be incorporated into the guidance so that the situation is further clarified. It is important that the doctor as an individual, with all that s/he brings to the consultation, is recognised and upheld in the Good Medical Practice document as an autonomous being who is free to express opinion and belief.
The question is how the information should be shared. Traditional referral letters were fine. However with new initiatives, for example referral management centres, many non-clinicians are having access to sensitive information, and the number of people having access to each letter is increasing. This could compromise the amount of information provided in a letter. Emergency admissions also pose problems in that referral letters may not be complete, and a phone call accompanies the referral. One issue here is that reduction in hospital working hours has compromised continuity of care and information transfer. The complex situation needs to be acknowledged. Paragraph 47 is ambiguous in that it does not state referral letters per se. It should clarify what it means by referral and the method used.
Whilst there is a lot in the draft Good Medical Practice guidance to be recommended, there are specific concerns that we, as Christian doctors, have in relation to the document. Medicine as a practice is changing significantly in our modern society, a society which we, as Christians find ourselves increasingly 'at odds' with. We are often concerned that our ability to practise whole-person medicine with integrity will be adversely affected by these changes, and by the incorporation of new practices into law. We hope that the General Medical Council will do its utmost to protect and encourage Christian doctors in their medical careers as much as any other physicians, without discriminating in favour of either. We would be more than happy to answer any further specific queries or give oral evidence to the committee responsible for the Good Medical Practice guidance if this would be at all helpful.
Miss Jacky Engel, Ethics Researcher
Mr Charles Foster, Barrister
Dr Mark Houghton, GP
Dr Rhona Knight, GP
Dr Chris Richards, Consultant Paediatrician
Dr Peter Saunders, CMF General Secretary
Dr Trevor Stammers, GP
Steven Fouch (CMF Head of Communications) 020 7234 9668
Alistair Thompson on 07970 162 225
Christian Medical Fellowship (CMF) was founded in 1949 and is an interdenominational organisation with over 5,000 doctors, 900medical and nursing students and 300 nurses and midwives as members in all branches of medicine, nursing and midwifery. A registered charity, it is linked to over 100 similar bodies in other countries throughout the world.
CMF exists to unite Christian healthcare professionals to pursue the highest ethical standards in Christian and professional life and to increase faith in Christ and acceptance of his ethical teaching.
