The Duties of a Doctor. Morality and conscientious objection…

Medical practitioners who wish to practice medicine in the UK must by law be registered with the General Medical Council (GMC). If you do not practice, you are not required to register. The GMC is a regulatory body which publishes guidance on the ‘Duties of a Doctor’. Much of this is about registration, and practice in general. In the Republic, the [Irish] Medical Council performs a very similar regulatory and guiding role today (here). The British Medical Association (BMA) is a trade union; membership is voluntary.

Registered medical practitioners who use social media to write about medical matters are expected to identify themselves by name (§ 17, here). I am no longer registered with the GMC. The BMA has similar advice, available as a pdf from here; I am no longer a member of the BMA. It is wholly inappropriate for me to offer medical advice to an individual beyond ‘you should see your own doctor’; I am entirely free to comment on policy and politics in health care.

The GMC’s guidance on the Duties of a Doctor is also available as a pdf here, and begins:

1. Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law. [Emphasis added]

The GMC does recognise the personal beliefs of the clinician and how these may interact with practice (here; pdf here):

52. You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role.

54. You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or are likely to cause them distress.

You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients. This means you must not refuse to treat a particular patient or group of patients because of your personal beliefs or views about them. And you must not refuse to treat the health consequences of lifestyle choices to which you object because of your beliefs.*

*For example, this means that while you may decide not to provide contraception (including emergency contraception) services to any patient, you cannot be willing to prescribe it only for women who live in accordance with your beliefs (eg by prescribing for married women but not for unmarried women).

These are statements of secularism; the freedom of belief, the freedom from belief. You are entirely free to practice your chosen religion; your moral viewpoint may be informed by your religion. But you are not entitled to let the tenets, creeds, precepts and dogma of your religion form the basis for your medical practice. The Christian Medical Fellowship (CMF) is a trinitarian, evangelical organisation whose aims include “Sharing faith…We seek to equip and encourage our members in reaching out to others with the Gospel” (here). The Secular Medical Forum (SMF) opposes religious influences in medicine where these affect practice, and “campaign[s] to protect patients from the harm caused by the imposition of religious values and activities on people who do not share the same values and beliefs”.

This GMC guidance is rather theoretical and abstract; the GMC is cautious about particular circumstances, and their guidance is general rather than particular. However, they do make clear, for example, that if you have no objection to male circumcision for religious/cultural reasons, you may perform the procedure (§ 18-23, here). For children this is problematic; it assumes that the child assumes the religious affiliations of the parents; is this in the best interests of the child? You may prescribe the contraceptive pill to an underage girl (16 years in UK) but are not required to inform her parents against her wishes (§ 70-71 here). (This guidance follows the tests of ‘Gillick competence’ formulated by the House of Lords in response to a challenge to the law.) Now, carnal knowledge of an underage girl is a criminal offence; the GMC’s reasoning is not spelled out, but seems to be based on the idea that if the girl is sensible enough to request contraception, her integrity should be respected, and she should be so provided, and also advised about STIs; but that the practitioner is at a remove from any illegal activity, neither condemning or condoning it. (The age of consent—an arbitrary concept—is 16 years in the UK; it was 13 until 1885, and before mid-Victorian times was 12 years. In the Republic of Ireland the age of consent is 17 years. The concepts of ‘childhood’ and ‘innocence’ are Victorian inventions.)

A practitioner may not evangelise about his or her particular religion to a patient (§ 54). ‘Gay conversion therapy’, sometimes called ‘pray your gay away’, is not accepted by reputable organisations (here) and practitioners may be sanctioned by the GMC if a complaint is made (here). Being ‘gay’ in the 1950s was criminalised; the accepted medical treatment for what was then seen as an illness was aversion therapy or chemical castration, as Alan Turing was given. Yet medical thinking does change over time; what was once illegal, an illness, is now unremarkable; treatments which were once accepted as good medical practice are today anathema. Such change over time is inevitable, it is progress.

Female circumcision, more properly female genital mutilation (FGM) is illegal in the UK. No right thinking doctor would agree to perform it; no right thinking parent would take a daughter abroad for the procedure—this, too is an illegal act. Most Islamic authorities do not require it; rather it is cultural. Women who have had FGM may need to be ‘opened’ to permit childbirth; afterwards, they may request to be ‘sewn up’. To do this in the UK is illegal.

Abortion is a particularly difficult issue, one that concentrates the difficulties around moral viewpoints and conscientious objection while yet making the care of patients the first concern. Crudely expressed, opinions range from ‘never under any circumstances’ to ‘on demand’. And contrary to general opinion, those who perform abortions where this is legal can and do find the procedure unpleasant; but they recognise that their first duty is to their patient and not to themselves. By refusing to perform a termination, practitioners are placing their moral views and needs above those of their patients; such paternalism, widely practised in the past, should have no place in modern medical practice. The 1967 Act permits medics to opt out of performing an abortion on grounds of conscience; but they may not opt out of their duties to the patient either beforehand or afterwards. Midwives are in a similar position, following a recent Supreme Court judgement, here. Abortion in most of the UK is now possible, where before 1967 it was totally illegal; only in Ireland has there been no (effective) change. And like homosexuality, the acceptance and toleration of what was once criminalised is a reflection of societal change; but such toleration does not require the conversion of those who cannot and will not accept it.

The GMC has a footnote about contraception, above. Similarly, if your beliefs as statements of faith, as a practitioner, do not permit of abortion under any circumstances you must make alternative arrangements for patients who wish the procedure. And if the sanctity and superiority of your beliefs means that you would choose to see a woman die when an abortion could save her life, then I suggest that you are firstly inhuman; secondly, you would do well to question your beliefs—if this is allowed; and thirdly that you are in the wrong profession. Simply stated, you have expunged the words empathy and compassion from your vocabulary.

In the 1960s a GP who had a practice in Crescent Gardens, Belfast, was widely known as a provider of ‘irregular services’, including abortion. His patients were very grateful; the GMC took a sterner view, striking him off the medical register (though for other reasons). In those times, if you had the money and the contacts in N Ireland, there was no difficulty getting an abortion locally. Was this doctor making the care of his patients his first concern, or was he a common criminal?

***

Now, try a thought experiment. Replace ‘doctor’ in the above with ‘politician in N Ireland’. Can you imagine it?

 

  • “Female circumcision, more properly female genital mutilation (FGM) is illegal in the UK.”

    As should male circumcision be. The West has collectively defined and prohibited FGM as the excision of tissue–no matter how small–from the female genitals apart from true medical need and apart from the individual’s consent, even if that individual is an infant or child whose parents retain general decision-making power over her.

    Why, then, in this age when gender equality is so passionately pursued in every sphere, has MGM not likewise been defined and prohibited as the excision of tissue–no matter how small–from the male genitals apart from true medical need and apart from the individual’s consent, even if that individual is an infant or child whose parents retain general decision-making power over him?

    You can’t argue health: the vulva is, statistically-speaking, more of an infection risk than a foreskin, and we banned FGM without any inquiry into the potential health benefits of its lesser forms. And you can’t argue aesthetics since that’s entirely subjective. Likewise, it is entirely arbitrary to argue that religious and cultural support is reason enough to support male cutting but not female cutting. One could just as well argue, equally arbitrarily, that religious and cultural support is reason enough to support female cutting but not male cutting. Ban ALL unnecessary cutting of children’s genitals. It’s incredible that here, in the year 2015, we actually have to have this discussion.

    http://notyourstocut.com/2015/03/21/theres-no-comparison-between-male-and-female-circumcision-seriously/

  • Granni Trixie

    Brilliant punchline – v apt.

  • ruhah

    Patients are those who suffer, and the alleviation of that suffering may not correspond with their own personal judgement about how they should be treated. The realities of “care” are informed by normal practise, reasoned morality and increasingly these days… resource.

    I would love if politicians in NI, acted like doctors, and continued to give the populace the medicine it needs rather than what it selfishly wants.

  • Jerzy Freitag

    The hippocratic oath: “First do no harm”

    This simply forbids any surgery on infants without a medical need. Male circumcision based only upon parents whish is as unethical as FGM is.

  • Korhomme

    Thank you! And would you care to comment further? Please, pretty please GT!

  • Korhomme

    In the Islamic faith, male circumcision is performed at the time of puberty, around 13 years of age. Previously this was achieved with an axe and a block—don’t ask—though today the procedure will be done in a hospital.

    In the Jewish faith, male circumcision is performed on the 8th day by a mohel who may be a trained surgeon or rabbi or both.

    In N Ireland, I have heard that the procedure varied between a ‘radical’ and a ‘token’ procedure. Occasionally, a urologist had to correct problems after circumcision.

    In the 19th century, circumcision was popular in the UK amongst the upper classes, initially because of it’s supposed anti-masturbatory potential. It was later intended to prevent the spread of syphilis—this doesn’t work. A recent resurgence suggests its use to prevent AIDS.

    I have been unable to find out how many circumcisions are performed in N Ireland for religious reasons; the official statistics do not give details. A very unscientific poll amongst active surgeons suggested that there were no more than a handful of patients per year.

    The main point of my argument, as Granni T identified, was not the strictures under which doctors practice (and legal advocates have similar requirements), but why our local politicians seem to think that they are above any such considerations, that they are in Stormont or wherever to propagate their own (very limited) views which seem incapable of change through reason.

  • whatif1984true

    “A handful of patients” how i laughed.

  • Korhomme

    All right, ‘A very small number which can be counted on the fingers of one or two hands’. Better?

    Now, as to the main point…