Right to choose, but...

IN MAY of 2007 a GP in Cornwall gave an interview to the Daily Mail in which she revealed that it was her practice to encourage patients seeking an abortion to consider other options, including giving birth. In the interview Dr Tammie Downes said she refused to sign abortion forms – as is her right – but was happy to see women wanting terminations and provide information and advice. She claimed that as a result eight babies were alive today who would otherwise have been aborted.

As a consequence Dr Downes was reported to the GMC accused of using her position to promote her anti-abortion views to patients. The matter was investigated and in July of last year a decision was made not to take the matter to fitness to practise panel. But the involvement of the GMC in this case highlights the need for all doctors to take account of the guidance on personal beliefs contained in Good Medical Practice and also in supplementary guidance issued in March 2008.

The core guidance advises that personal beliefs should not be expressed by doctors in ways that exploit patients’ vulnerability, nor should they adversely affect the treatment provided. If a conflict does exist and might affect treatment or the advice given to patients, doctors are advised to explain this to the patient so they can decide to exercise their right to see another doctor.

The supplementary advice – Personal Beliefs and Medical Practice – expands on this core guidance and reminds doctors that their prime duty is to make the care of the patient their first concern and this must not be prejudiced by personal views or beliefs. Should this not be possible then the onus is placed on the doctor to ensure that arrangements are made for the patient to see another colleague without delay. The guidance aims to balance the rights of doctors and patients – in particular the right to freedom of thought, conscience and religion alongside the entitlement to care and treatment to meet clinical needs.

Specific advice

Abortion is a particularly emotive topic but by no means the only area of potential conflict in the culturally and religiously diverse world in which we live and work. The GMC guidance provides advice in a number of specific areas.

Refusal of blood products. Doctors are advised not to make assumptions about decisions made in relation to the refusal of treatment with blood or blood products as is practised by Jehovah’s Witnesses. The views of the patient should be respected and questions answered honestly and to the best of a doctor’s ability. It is suggested that clinicians might contact hospital liaison committees established by the Watch Tower Society who are the governing body of Jehovah’s Witnesses. They can advise on Society policy regarding the acceptability or otherwise of blood products and provide details of doctors and hospitals who are experienced in ‘bloodless’ medical procedures.

Circumcision of male children. Doctors asked to carry out this procedure are advised to proceed on the basis of the child’s best interests and with consent. An assessment of best interests includes the child’s and his parents’ cultural, religious or other beliefs and values. Consent from the child if competent is required. If not, then both parents should consent. If there is a conflict then legal advice should be sought. The benefits and risks should be explained to the parents and child, if competent. A religious advisor may be asked to attend to ensure the operation is carried out in accordance with the faith.

Clothing and other expressions of religious beliefs. Doctors are advised that if patients feel that a veil worn by a doctor presents a barrier to communication and development of trust this should be responded to and personal and cultural preferences may have to be set aside to provide effective patient care.

Care of patients pre- and post- termination of pregnancy. Where a patient is waiting or has undergone a termination, a doctor has no legal or ethical right to refuse to provide treatment on the grounds of conscientious objection to the procedure. This applies to any procedure from which the doctor has withdrawn due to his or her beliefs.

Conscientious objection

It is clear from both Good Medical Practice and the supplementary guidance that whilst the doctor may have particular beliefs, such beliefs cannot impact on patient care which has to be the doctor’s first concern. The option of conscientious objection is protected and provided for with the qualification that patient care should not be compromised and neither should a burden be placed on colleagues.

The right to conscientious objection is enshrined in the European Convention on Human Rights in article 9 which provides for the ‘freedom of thought, conscience and religion’. The Human Rights Act 1998 has ratified this convention in UK law. Such a right is clearly essential in our changing world in order to achieve a balance between medicine and the competing principles of morality which can exist in the doctor–patient relationship. Excusing oneself because of religious or moral beliefs is never an easy option for any healthcare professional, particularly as they may find themselves accused of adding to the workload of colleagues.

In no other time have doctors been more tested, with views on ethics and morality ever shifting in the rapidly developing arenas of medicine, science, politics and the law. Policies on medicine and medical research can change with each new government as political parties change the moral agenda. One particular example is the law on abortion in the USA where President Barack Obama’s more liberal views are already dividing Roman Catholic support for him. His relaxation to an order made by President George Bush to grant federal funding to allow limited research to a small number of stem cell strains is another example of how political will can change the moral map.

Universal agreement over such complex areas will never be achieved, but to ensure the integrity of healthy debate in this area there will always be a need for those who are prepared to stand up for what they believe in. The GMC guidance, if followed properly, should ensure that doctors who choose to follow this route are protected from investigation whilst at the same time ensuring that patient care is not jeopardised in the process. If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You must be satisfied that the patient has sufficient information to enable them to exercise that right. If it is not practical for a patient to arrange to see another doctor, you must ensure that arrangements are made for another suitably qualified colleague to take over your role. Good Medical Practice, paragraph 8, GMC 2006

Lindsey McGregor is a solicitor at the MDDUS