The General Medical Council is about to review ‘Good Medical Practice’, its general guidance to doctors, and new draft guidance is due to be issued later this month.
Early indications are that the revised guidance will give more latitude to doctors attempting to provide whole-person healthcare (including spiritual care) but will take a harder line than at present on doctors who attempt to share their own faith with patients in the context of a consultation.
But given that there is a substantial body of evidence which suggests that religious faith benefits health, does withholding ‘spiritual care’ constitute a breach of GMC guidelines?
One doctor decided to pose exactly this question to the GMC and has given me permission to post his letter along with the reply he received.
Letter to GMC from Dr David Chaput de Saintonge
Thank you for your detailed reply to my letter of 27.5.2011.
In fact, my query was not ‘… whether doctors are permitted to offer or provide spiritual care of their patients’ though I'm pleased to note the GMC’s acceptance of this, always providing it is done sensitively.
The question I asked was when it would be allowable to contravene GMC guidelines by withholding spiritual care which is shown to be beneficial?
Of course I recognise that, as you state, the committee cannot, require doctors to offer faith-based management options. I don’t think that is the point. Your guidance on consent: patients and doctors making decisions together (Part 1; para 5) clearly states:
‘The doctor and the patient make an assessment of the patient's condition, taking into account the patient's medical history, views, experience and knowledge. The doctor uses specialist knowledge and experience in clinical judgement, and the patient's views and understanding of their condition, to identify which investigations or treatments are likely to result in overall benefit from the patient. The patient weighs up the potential benefits, risks and burdens of the various options as well as any nonclinical issues that are relevant to them. The patient decides whether to accept any of the options and, if so, which one.’
However the patient will be unable to weigh up the risks of an intervention which has not been discussed with them. They will therefore be denied the freedom of choice which your guidelines indicate they should be given and spiritual care might be wrongfully withheld.
I recognise, of course, that the doctor might consider that spiritual interventions ‘would not be of overall benefit to them’ and would advise against any such intervention.
However, according to your guidelines, this does not absolve the doctor of the responsibility taking the patient's views into account when entering into this discussion.
Clearly the doctor cannot fulfil this requirement with respect to spiritual care without ascertaining the patient's views. It would therefore seem an essential part of the assessment not just to enquire about physical, social and psychological aspects of the patient's condition, but the importance to the patient of spiritual aspect also.
Failure to do so restricts the patient's choice and is would appear to be a denial of their autonomy.
It may be I have misunderstood the GMC’s position on this. If so I'd be very grateful for your clarification.
Reply from Jane O’Brien, Assistant Director, Standards and Fitness to Practise Directorate
Dear Dr Chaput de Saintonge,
Thank you for your letter of 30 August 2011.
I think your analysis of our guidance is absolutely right, and where there is medical treatment that is clinically appropriate for the patient and likely to provide overall benefit, doctors should raise this with the patient as part of the consent process.
The more difficult issue is where the boundaries lie between medical treatment and management, which are within the expertise of doctors and properly provided by the NHS or other health funding bodies; and the provision of spiritual support and care, which is generally provided by religious or faith leaders or others with expertise in this area. The GMC does not place a duty on doctors to provide 'spiritual care' - but rather to recognise patients' need for such care and to facilitate patients’ access to it, where the patient would welcome this and is not in a position to do so him or herself.
There are some therapies that might be regarded as 'faith based', including meditation and yoga, but in general it is difficult to identify treatment options which would be available only as part of faith-based management of conditions. Where such treatment options exist, they should be discussed with patients.
I would not claim to be an expert on the research on the impact of faith or spirituality on health, but much of the most accessible evidence relates to the health benefits of practising religion or having a 'spiritual' life more generally. We encourage doctors to help patients to take an interest in their health (see paragraph 6 of Good Medical Practice), for example by talking about the benefits of lifestyle choices, such as taking exercise or losing weight. Of course, doctors can also tell patients about the evidence of the impact on health of being an active member of a faith community or otherwise engaging in a spiritual life.
Finally, the GMC fully supports a holistic view of patient care. You will see in our guidance on consent and treatment and care towards the end of life, in particular, that we encourage doctors to think about the patient’s overall needs, and to take into account their values and beliefs. You may be interested to note that as part of the review of Good Medical Practice we will be consulting shortly on changes to our guidance on good clinical care. This will include the following (additional text in bold type):
If you assess, diagnose or treat patients you must provide a good standard of clinical care: Good care will involve:
a. Adequately assessing the patient’s conditions, taking account of their history (including the symptoms, and psychological, spiritual, religious, social and cultural factors), the patient’s views, and, where necessary, examining the patient.
If you would like to be sent an alert when the consultation is launched later this month, please let me know.
The GMC letter makes a number of statements that Christian doctors will welcome, namely:
1.Where faith-based treatment options exist, they should be discussed with patients (but what does the GMC actually understand by the term 'faith-based'?)
2.The GMC fully supports a holistic view of patient care (but what does it understand by the term 'holistic'?)
3.Good care, which doctors must provide, involves taking a spiritual, cultural and religious history.
But there is still lack of clarity over whether providing information about spiritual care and access to it is a duty or an option.
On the one hand the GMC says that doctors must recognise patients’ need for spiritual care and facilitate their access to it, when they would welcome this and are not in a position to access it themselves.
On the other hand the GMC seems to give doctors an option about whether or not to tell patients about the evidence of the impact on health of being an active member of a faith community or otherwise engaging in a spiritual life.
But if patients are not aware of the benefits of faith to health then how can they be in a position to welcome spiritual care?
The GMC is moving in the right direction but needs to be clearer on its requirements so that doctors understand their duties and patients understand their rights.
Perhaps the key problem here is that while the GMC is recognizing the importance of spiritual care for health, it has not yet managed to define what spiritual care actually is. They will need help from doctors practising spiritual care on the front line to do this effectively.
I would urge Christian doctors to respond to this consultation in order to ensure that a whole person approach - including spiritual care - is universally implemented; that doctors are given freedom to practise it and that patients are given full opportunity to make use of it. A majority of patients actually want their doctors to practise whole person medicine which involves the spiritual dimension. Shouldn't that be the bottom line?