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ss nucleus - Easter 2011,  maintaining integrity as a Christian medic

maintaining integrity as a Christian medic

Laurence Crutchlow explores the challenges we face.

As the sunlight beams through the window late in the afternoon, the first consultation of early evening surgery begins. It is soon obvious that a big ethical issue is at stake. The young lady seeing me is obviously distressed. My likely refusal on ethical grounds to grant what she wants will worsen this, and may even lead to a complaint. An abortion request? Not this time! It may surprise some of you that though important, abortion and euthanasia are not the everyday fare of ethics for a GP. I see about 100 patients each week in general practice, but I discuss a request for abortion perhaps only ten times a year, and haven't been directly asked for euthanasia since I was a junior doctor.

Central to this encounter is a 'Statement of Fitness for Work', more commonly known as a 'sick note'. The patient (who is not real, but is based on a number of people I have seen over the years) is on her way to work an evening shift in a restaurant, returning from eight days off sick. She says that she's had a virus (although gives little detail), and needs a note to cover her absence. She's fully recovered and entirely well today.

Seemingly straightforward? But she has not consulted anyone at the practice during this illness, nor visited A&E, nor contacted the out-of-hours service. I have no evidence she has been unwell.

What should I do? I could just issue a note. This would be easy, and quick. She would be satisfied. But what are the consequences for her employer who might have to fund sick pay, for her in encouraging such behaviour in future, or for me, if it subsequently turns out she's been on a Mediterranean beach for a week? And aside from the consequences, can I in good conscience state that something is true when I suspect it is not?

I could flatly refuse. I might feel I've stuck to the truth, but there will probably be confrontation. A middle way might be not to issue a certificate, but just a simple statement such as 'Miss X stated to me on Tuesday that she had suffered from a viral illness for seven days, and was unable to work, though she had not consulted me during that time'. This in effect transfers responsibility to her employer, who probably knows the situation better than me. Such a statement is true, but can feel like dodging the issue.

Is telling the whole truth always appropriate? Should I always tell patients the full truth about a bad diagnosis? How do I deal with a minor overdose at age 17, now of little clinical relevance, but of great interest to an insurance company for whom I am completing a form? Can I ignore it? What about the financial and tax affairs of the practice, which occupy a surprising amount of professional time for a GP?

secular views on truth-telling

Telling the truth might seem an obvious obligation for a doctor. The GMC's Good Medical Practice (1) contains 21 paragraphs on 'probity', defined as 'integrity and uprightness; honesty'. (2) The first four paragraphs cover honesty with patients, and the other 17 deal with areas like research, report writing, financial affairs and conflicts of interest. It is often these nonclinical areas that tempt doctors and medical students, some of which have been dealt with in CMF literature before. (3)

The vast majority of UK medical students and doctors, whether Christian or not, would assent at least in theory to the GMC's principles even though their practice might not always reflect these codes.

But not everyone across the world thinks the same. As a junior doctor, I spent a week travelling with a CMF summer team in Russia. Organisers had invited a professor to the camp who worked in cancer care. She was adamant that patients should not be told if they had a terminal diagnosis, feeling it would deny them hope. Though a few students challenged this, her view reflected prevailing practice locally. Hiding the facts is still common in much of the world – and was not unusual in the UK in the past. Even in a modern UK context, diagnoses like dementia are often not fully explained. (4)

what is distinctive for the Christian?

Most people tell the truth most of the time, don't they? Is there really any reason that Christians might be different? Even though most medics who don't share our beliefs tell the truth, we are still fundamentally different.

We no longer live 'by the flesh', but our minds are set on what the Spirit desires. (5) There is a fundamental difference in how we perceive things, even though we still get things wrong from time to time. (6)

Most of us will remember the ninth commandment: 'You shall not give false testimony against your neighbour.' (7) Simple enough, we might say. But who is our neighbour? What is false testimony?

'Neighbour' is often now taken to mean those living close to us – and is frequently used in the Old Testament in this context. The meaning is often lost in modern cities, where relationships with geographical neighbours may be nonexistent. Luke's gospel records Jesus' parable of the Good Samaritan, (8) which implies a much broader definition of neighbour than that of the Old Testament law. Jesus is asked 'Who is my neighbour?' by an expert in the law. In reply, Jesus relates a story of kindness shown to a stranger, suggesting that obligations to neighbours apply to everyone we meet, not just those who live nearby, or are in some way similar to us.

False testimony would at first seem to refer to speaking in court. But a wider meaning is likely in the context of the rest of the Bible. Consider how Jesus is often described. John's gospel not only says that he is 'full of grace and truth', (9) but even records Jesus describing himself as the truth. (10) John's gospel also contrasts truth with lies, which are described as the devil's 'native language'. (11) Truthfulness is also commended in Proverbs, (12) amongst other places.

It seems clear that we should generally tell the truth. But are we expected to tell the whole truth at all times? Would a family hiding Jews from the Nazis have been right to lie to German troops about the Jews' whereabouts? Alongside this article, I would recommend a previous exploration of this question in Nucleus. (13)

Of course in an ideal world, free of sin, such scenarios would never arise. There would not have been Nazi troops seeking out Jews if it weren't for sin. There will be nothing impure in heaven, (14) so such problems won't arise. But in our fallen world, the effects of sin mean that difficult situations arise, in which a simple set of rules don't always help.

The Bible records some examples. Shiphrah and Puah, the Hebrew midwives, were told by the King of Egypt to kill any Hebrew boys born. The midwives let the boys live, (15) and were summoned to explain why. They answered the King by saying that 'Hebrew women are not like Egyptian women; they are vigorous and give birth before the midwives arrive'. (16) Though plausible, this clearly wasn't the real reason that the boys were living. They had obeyed God rather than the King, and lied in the process. Yet they were blessed: 'And because the midwives feared God, he gave them families of their own'. (17)

Why were they blessed after an apparent lie? The key is in the first part of Exodus 1:21. They feared God. This is the reason for their blessing, rather than their action. Even though what they said hadn't been truthful, they had acted with fear of God as their main motivation, and they were commended for this.

Another example would be Rahab, who is clearly documented to have lied in Joshua 2. She is spared from being killed as the other natives of Jericho were, (18) and is commended later in the Bible. (19) Yet once again, it is her faith and her welcome that are commended, rather than the lie she told.

These stories imply that our motives are what are tested in these difficult situations. It is hard to imagine that Jesus would have acted quite as the midwives or Rahab did, since he often found a 'third way', frequently answering questions with more questions. But scripture is clear that the attitude of faith in God and fear of him that motivated the midwives and Rahab is the right one, and should inform the choices we make.

We won't therefore necessarily discern God's will for difficult circumstances by following the world's logic. Instead we need to fear him and trust in him. As our minds are renewed, we will better understand his will. (20)

what are the challenges?

Even if we earnestly desire to follow God's will in telling the truth, there will be challenges along the way. How do you respond when a friend asks you to sign them in for a seminar that you know very well they aren't attending? The chances are that no one will find out. But are we really trying to emulate Christ if we accept small breaches of trust like this?

Plagiarism is a constant temptation. Some readers will remember an intriguing story related by a prospective medical student on his UCAS form, describing an incident where he had set fire to his pyjamas as a small boy. (21) Unfortunately for this applicant, 233 others had told an identical story, cut and pasted from a website. This would have probably gone undetected even ten years earlier. But now antiplagiarism software is widely used. While few Christians would directly copy other work, how often might we fail to reference sources, effectively passing off others' work as our own?

The underlying issues are the same when qualified, though the exact temptations are different. Questions over telling truth to patients and signing certificates are not just for GPs. Will you always tell the truth to consultants when something has gone wrong? What about ensuring that ultrasound forms only contain accurate clinical details, rather than slightly embellished ones that might get the scan done a few hours earlier? Telling the truth about time worked can be a particular challenge if under pressure from hospital management to underreport hours to comply with targets.

If we have practised integrity as a student or junior, it will be easier to cope with the growing challenges faced as a more senior doctor, or in management. The issues with patients remain much the same, but there is more opportunity to be less than straight about finances - often a bigger temptation. Records kept principally to monitor targets rather than treat patients are often seen as soft options for lies – especially when you don't believe in the target in the first place!

where might falsehood lead?

'But it does no harm!', you might say, as you 'forget' a piece of data on a form to improve your figures. In the UK, we're often shielded from the earthly consequences of lies, as we are blessed with relative freedom from corruption. Yet even here, it is estimated that the NHS loses about £10 million each year via about 500 cases of reported fraud. (22) This is only about 0.01% of the annual budget – but how many extra consultants could we appoint if it were recovered?

The impact of corruption is more obvious in the developing world, as previously outlined in Triple Helix. (23) We may think 'this wouldn't happen in the UK', but surely there is little moral difference between the underlying actions, even if the consequences may appear different?

conclusions

It would be very difficult to go through an entire medical career and not look back to occasions where we feel we've been less than truthful. We will have come across situations where we have been hurried, or where worry over our own interests has got in the way of being objective.

We need to think now how to minimise this. Habits formed as a student often persist throughout our careers, so although many issues raised here may seem to concern senior doctors, we need to get the small things right early on.

Paul calls us to 'examine ourselves'. (24) The context here is about examining our beliefs, but it seems sensible to apply this more widely to our day-to-day conduct. We've illustrated that many denials of truth are subtle, and might not be apparent if we don't examine our lives carefully.

We can also support each other as Christians. Scripture is intended for rebuking as well as teaching, (25) and sometimes this will be necessary - particularly if someone doesn't realise that their actions lack integrity. But it is easy to get a rebuke wrong, so be careful to follow Jesus' instructions in Matthew, (26) and involve people more mature in the faith than you. If we are not sharing our lives with other Christians, no-one may notice a problem in the first place. A CMF student group could easily talk through issues like this, and support each other in day-to-day challenges.

The good news of the gospel is that forgiveness extends to all areas. Peter was forgiven for denying Jesus three times at a crucial moment. (27) Whatever mistakes we've made in maintaining our integrity, whether as students or later on in our careers, are forgiven. Jesus' blood purifies us from all our sins. (28) Hearing Jesus' Word, and believing the God who sent him is enough for our salvation. (29)

Maintaining integrity isn't easy. Sometimes telling the truth will be very simple, and how to apply the Bible's commands will be obvious. Other occasions will need much discernment and thought. At these times, only through God's renewing of our minds will we get it right.

Therefore, I urge you, brothers, in view of God's mercy, to offer your bodies as living sacrifices, holy and pleasing to God - this is your spiritual act of worship. Do not conform any longer to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God's will is - his good, pleasing and perfect will. (30)

References
  1. 1 www.gmc-uk.org/guidance/good_medical_practice.asp
  2. 2 www.dictionary.com
  3. 3 Leinster, S. Integrity in Research. Triple Helix Winter 2007: 8-9
  4. 4 Vassilas CA, Donaldson J. Telling the truth: What do general practitioners say to patients with dementia or terminal cancer? BJGP 1998; March: 1081-1082. tinyurl.com/5rq9yzu
  5. 5 Romans 8:5-8
  6. 6 1 John 1:8
  7. 7 Exodus 20:16; Deuteronomy 5:20
  8. 8 Luke 10:25-37
  9. 9 John 1:14
  10. 10 John 14:6
  11. 11 John 8:44
  12. 12 Proverbs 12:19, 14:25
  13. 13 Saunders, P. Dionysius Dialogues – Obeying the Law. Nucleus Spring 1995: 30-34
  14. 14 Revelation 21:27
  15. 15 Exodus 1:17
  16. 16 Exodus 1:19
  17. 17 Exodus 1:21
  18. 18 Joshua 6:25
  19. 19 Hebrews 11:31
  20. 20 Romans 12:2
  21. 21 The Times, 2007 tinyurl.com/2odxm7
  22. 22 tinyurl.com/6dhws88
  23. 23 Fouch, S. Medical Corruption: A new global health threat? Triple Helix Spring 2006: 6
  24. 24 2 Corinthians 13:5
  25. 25 2 Timothy 3:16
  26. 26 Matthew 18:15-17
  27. 27 John 18:15-18, 25-27; 21:15-19
  28. 28 1 John 1:7
  29. 29 John 5:24
  30. 30 Romans 12:1-2
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