New GMC Guidance on ‘Personal Beliefs and Medical Practice’ still gives scope for sensitive faith discussions within the consultation

Are doctors allowed to discuss their personal beliefs with patients or enquire about their patients’ beliefs? 

If so, in what circumstances?

The General Medical Council’s long-awaited revised guidance on ‘Personal Beliefs and Medical Practice’, published yesterday, attempts to answer these questions.

It shows there is still scope for doctors to share their personal beliefs within the medical consultation provided certain ground rules are followed.

The guidance also welcomes sensitive exploration of a patient’s own beliefs, as part of history-taking, provided that they are relevant to the presenting medical problem.

The new guidance has been issued with nine other sets of guidance on a range of issues alongside the revision of the GMC’s core guidance to doctors, ‘Good Medical Practice’.

All of these documents have been subject to a consultation process and I was particularly struck by how much the text has changed from the consultation draft (see below) presumably as a result of people’s feedback (See my previous articles here and here).

The new (2013) edition of ‘Personal Beliefs and Medical Practice’ comes into effect on 22 April and replaces the first (2008) edition. It also deals with the issue of conscientious objection which I will come back to in a later blog.

Like its forerunner, the new 2013 version recognises that:

‘personal beliefs and cultural practices are central in the lives of doctors and patients, and that all doctors have personal values that affect their day-to-day practice’

This helpfully give short shrift to the myth, held by some hard-line secularists, that only people who subscribe to a specific religious faith have ‘beliefs’ and ‘values’ and that atheists, by contrast, live their lives in a way that is belief and value free.  The reality is very different. Everyone has a worldview – a set of basic beliefs about the nature of reality – that profoundly affects how they think and act. This is a good starting point.

Also, like the 2008 original, the new 2013 version underlines the fact that personal beliefs need to be expressed in a way that is sensitive and appropriate.

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

This is foundational. All doctors are, to some extent, in a position of power over their patients who often come to them at times of great need and crisis. I can’t see anyone wanting to disagree with this.  

Absent this time, however, is any explicit statement that knowing about a patient’s beliefs can be an important in addressing their clinical problems. The following statement from the original 2008 edition has now been removed:

‘For some patients, acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to their care. Discussing personal beliefs may, when approached sensitively, help you to work in partnership with patients to address their particular treatment needs. You must respect patients’ right to hold religious or other beliefs and should take those beliefs into account where they may be relevant to treatment options.’

There is however additional text this time which partially compensates for this omission by stressing the importance of spiritual factors in history-taking:

‘In assessing a patient’s conditions and taking a history, you should take account of spiritual, religious, social and cultural factors, as well as their clinical history and symptoms (see Good medical practice paragraph 15a). It may therefore be appropriate to ask a patient about their personal beliefs.’

The 2008 guidance made it clear that ‘if patients do not wish to discuss their personal beliefs with you, you must respect their wishes’ and enlarged on this at some length:

‘You should not normally discuss your personal beliefs with patients unless those beliefs are directly relevant to the patient’s care. You must not impose your beliefs on patients, or cause distress by the inappropriate or insensitive expression of religious, political or other beliefs or views. Equally, you must not put pressure on patients to discuss or justify their beliefs (or the absence of them).’

These last two sentences in this paragraph are reproduced almost verbatim in the 2013 guidance, but more care is taken to unpack the first sentence giving still, I think, scope for mutually welcomed discussion of personal beliefs:

‘During a consultation, you should keep the discussion relevant to the patient’s care and treatment. If you disclose any personal information to a patient, including talking to a patient about personal beliefs, you must be very careful not to breach the professional boundary that exists between you… You may talk about your own personal beliefs only if a patient asks you directly about them, or indicates they would welcome such a discussion. You must not impose your beliefs and values on patients, or cause distress by the inappropriate or insensitive expression of them.’

So the key question is – ‘Has the patient either raised the issue or indicated that they would welcome such a discussion?’ I don’t imagine any GP with good interpersonal skills will have much difficulty reading verbal and/or non-verbal cues to determine a clear answer to that in any given case.

Christian doctors recognise that people’s beliefs and life choices do impact health significantly and there is a growing literature that recognises a positive correlation between Christian faith and health. 

They will therefore not wish to exclude the possibility of discussing personal beliefs and values with patients provided this is welcomed, is relevant to the consultation and can be done with sensitivity, permission and respect.

They will rather see it in the context of building a relationship, practising holistic care, or as part of the normal social intercourse that may take place within any other professional/client or tradesman/customer interaction.

In other words, if you can talk to a taxi driver, hairdresser or builder about politics, morality or religion, then why should you be prevented from doing the same with your doctor if you are both up for it and have the time?

Good doctors will recognise when such discussions are appropriate and will be sensitive about professional boundaries.

Of course, the real test of the new guidelines will be the way they are interpreted and applied in practice by the GMC itself. Will we see them applied with wisdom, discretion, flexibility and tact, or will they be used as a stick to police and beat doctors with? I hope it will be the former.

Christian doctors need to be to continue to be as innocent as doves and wise as serpents: innocent as doves because we are in a position of power and patients can be needy and vulnerable, and wise as serpents because there are those who would like to stop all faith-related discussions in the medical consultation and others who will be only too willing to provide the vexatious complaints.

But this is by no means a one-way street.

Secularist doctors who reveal their own anti-religious prejudices, or who express their political or moral views in a way that exploits vulnerability, causes distress or is otherwise inappropriate need to realise that they too may be equally running the risk of censure, or worse.

Full wording of the 2008, 2012 and 2013 versions on discussing personal beliefs

Personal beliefs and medical practice (2008 edition)

9 For some patients, acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to their care. Discussing personal beliefs may, when approached sensitively, help you to work in partnership with patients to address their particular treatment needs. You must respect patients’ right to hold religious or other beliefs and should take those beliefs into account where they may be relevant to treatment options. However, if patients do not wish to discuss their personal beliefs with you, you must respect their wishes.

19 You should not normally discuss your personal beliefs with patients unless those beliefs are directly relevant to the patient’s care. You must not impose your beliefs on patients, or cause distress by the inappropriate or insensitive expression of religious, political or other beliefs or views. Equally, you must not put pressure on patients to discuss or justify their beliefs (or the absence of them).

Personal beliefs and medical practice (2012 draft for consultation)

12 In assessing a patient’s conditions, it may be appropriate to ask them about their personal beliefs. However you must not put pressure on patients to discuss or justify their beliefs, or the absence of them.

13 During a patient consultation, you may talk about your own personal beliefs only if a patient asks you directly about them or if you have reason to believe† the patient would welcome such a discussion. You must not impose your beliefs and values on patients, or cause distress by the inappropriate or insensitive expression of them. You should keep the discussion relevant to the patient’s care and treatment and, as with disclosing any personal information to a patient, you must be very careful not to breach the professional boundary‡ that exists between you, and must continue to exist if trust is to be maintained.

Personal beliefs and medical practice (2013 final version)

29 In assessing a patient’s conditions and taking a history, you should take account of spiritual, religious, social and cultural factors, as well as their clinical history and symptoms (see Good medical practice paragraph 15a). It may therefore be appropriate to ask a patient about their personal beliefs. However, you must not put pressure on a patient to discuss or justify their beliefs, or the absence of them.

30 During a consultation, you should keep the discussion relevant to the patient’s care and treatment. If you disclose any personal information to a patient, including talking to a patient about personal beliefs, you must be very careful not to breach the professional boundary that exists between you. These boundaries are essential to maintaining a relationship of trust between a doctor and a patient.

31 You may talk about your own personal beliefs only if a patient asks you directly about them, or indicates they would welcome such a discussion. You must not impose your beliefs and values on patients, or cause distress by the inappropriate or insensitive expression of them.

Changes between consultation draft (2012) and final (2013) edition (tracked below)

What’s wrong with the General Medical Council’s draft guidance on ‘Personal Beliefs and Medical Practice’?

The General Medical Council (GMC) is currently consulting on a range of new guidance to doctors.

Overall there are no less than nine separate documents up for discussion.

The most contentious and controversial of these is ‘Personal Beliefs and Medical Practice’ (PBMP), which deals with issues around faith discussions within a medical consultation and conscientious objection.

The review is crucially important because, once finalised (definitive guidance will be published in November), these nine documents will be the basis on which doctors are judged and those who breach the rules will be at risk of disciplinary proceedings and losing their medical registration.

The consultation is part of the on-going review of the GMC’s core guidance Good Medical Practice and is open to anyone who wishes to comment on the issues raised. It opened on 18 April and closes on 13 June so there are less than three weeks of an eight week consultation period left to respond.

So the time to respond is now.

You can respond either directly online via the GMC website (you will need to register) or by filling in an emailable pdf covering all nine documents to send to the GMC (Note that you must type directly into this form and cannot cut and paste an answer from another document!)

CMF’s recent comments on the 2008 draft of 'Personal Beliefs and Medical Practice' are available on the CMF website.

However the new 2012 draft for consultation has been substantially rewritten and builds on the latest draft of ‘Good Medical Practice’ which, ironically, has not yet itself been published.

It states that ‘we don’t wish to prevent doctors from practising in line with their beliefs and values, as long as they also follow the guidance in Good Medical Practice’ but also makes it explicit (p4) that in situations of conflict ‘we expect doctors to be prepared to set aside their personal beliefs’.

This means in essence that when there is any conflict, 'Good Medical Practice' trumps the doctor’s conscience.

The main points to note about the new draft ‘Personal Beliefs and Medical Practice’ are as follows:

1.Whole Person Medicine

Although the guidance addresses the importance of ‘adequately assessing the patient’s conditions, taking account of their history (including the symptoms, and psychological, spiritual, religious, social and cultural factors)’ there is very little if anything on the relationship between personal beliefs and health or of the importance of practising holistic care which addresses these issues in practice.

Instead the emphasis is on not expressing ‘personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or that are likely to cause them distress’ or, alternatively, not ‘allowing your personal views to affect your professional relationships or the treatment you provide or arrange’ (based on paragraphs 54 and 60 of ‘Good Medical Practice’).

2.Sharing personal beliefs

There has been further tightening of restrictions about sharing personal beliefs. The guidance now says (para 13) that:

‘During a patient consultation, you may talk about your own personal beliefs only if a patient asks you directly about them or if you have reason to believe the patient would welcome such a discussion. You must not impose your beliefs and values on patients, or cause distress by the inappropriate or insensitive expression of them. You should keep the discussion relevant to the patient’s care and treatment and, as with disclosing any personal information to a patient, you must be very careful not to breach the professional boundary that exists between you, and must continue to exist if trust is to be maintained’.

It is hard to see how this will not lead to a greater number of vexatious complaints. Surely it would have been sufficient simply to have said that any sharing of personal beliefs must be done with permission, sensitivity and respect and with the patient’s best interests foremost. Trust is after all best built through openness and compassion.

3.Abortion and Artificial reproduction

The draft guidance notes (p3) that ‘in some areas the law specifically entitles doctors to exercise a conscientious objection’. It amplifies in a footnote that ‘in England, Wales and Scotland the right to refuse to participate in terminations of pregnancy is protected by law under Section 4(1) of the Abortion Act 1967’.

It further clarifies, in a footnote to Endnote 5, that this includes ‘care which is necessary preparation for performing a termination’. It also confirms (P3 footnote) that ‘the Human Fertilisation and Embryology Act 1990 prevents any duty being placed on an individual to participate in any activity governed by the Act’.

By offering some further clarification about preoperative care for abortion this is a slight improvement on the 2008 draft.

4.The obligation to refer

The guidance says (p5) that doctors ‘may choose to opt out of providing a particular procedure because of (their) personal beliefs and values’ and must tell the patient (p8b) ‘that they have a right to (see) another practitioner who does not hold the same objection’.

If it is ‘not practical for a patient to arrange to see another doctor’ then there is a duty to ‘make sure that arrangements are made – without delay – for another suitably qualified colleague to advise, treat or refer the patient’.

So it appears that there is actually a duty to participate in procedures to which a doctor might have a conscientious objection by referring patients for them. Many doctors would see this as complicity or ‘participation’. Duties should surely end with informing patients of their right to see another doctor but without the obligation to refer, especially with regard to abortion.

This clause was recently the result of a successful legal challenge(1) by doctors in New Zealand when guidance similar to ‘Personal Beliefs and Medical Practice’ was issued by the New Zealand Medical Council. The Council's proposed guidelines were held to ‘overstate the duty of a doctor with conscientious objection, by failing to give adequate recognition to the ability of that doctor to decline to provide the service requested’.

As a result the guidance has never come into effect in New Zealand. It is not inconceivable that doctors might bring a similar case here.

5.An absolute duty to participate in 'treatment'

For the first time the guidance states that there are two procedures to which doctors have no right to conscientious objection, namely ‘providing gender reassignment’ (P5 footnote) and ‘providing contraception to unmarried women’ (Endnote 2). It justifies this stance on the grounds that these procedures are ‘only sought by a particular group of patients (and cannot therefore be subject to a conscientious objection)’ under the Equality Act 2010.

It is not clear why a similar argument does not apply to providing male circumcision for religious or cultural reasons as this is also sought only by groups who are supposedly protected under the Act. The GMC appears to be applying the law here in an inconsistent way and may well also be opening itself up to potential legal challenges in the future. It might be argued that very few doctors are involved in gender reassignment anyway and those who are, given that it is a specialised field, would not wish to exercise conscientious objection.

However it is likely that the clause on gender reassignment will be interpreted to include everybody in the referral and treatment pathway and potentially many GPs. Similarly, most doctors do not have an objection to prescribing for unmarried women but there are some who do and argue their case strongly on grounds of protecting the patient’s best interests. And there are circumstances where most doctors would hesitate to prescribe, especially if they were concerned about sexual coercion or abuse.

But the thing which is perhaps most concerning about this new absolute duty to ‘provide’ certain ‘treatments’ or ‘procedures’ is that it seriously undermines a doctor’s professional judgement and conscience. Doctors simply should not be forced to do things they believe are morally wrong, clinically inappropriate or not in a patient’s best interests. Reasonable accommodation should be made. The GMC should be upholding conscience, not eroding it.

The consultation questions

The GMC is asking doctors six yes/no questions about the draft guidance and for each of these gives options of answering ‘yes’, ‘no’ or ‘not sure’ as well as leaving space for comments.

The consultation deals only very superficially with the issues raised by the guidance, misrepresents to some extent its real contents and doesn’t ask specifically about the things which raise the most concerns. It also does not invite comments on how the text should be specifically reworded to address concerns doctors might have.

The six questions on 'Personal Beliefs and Medical Practice' are found on pages 26-29 of the emailable pdf. If you are only responding to this document (the pdf deals with all nine) then you need only fill in these pages and the personal details and survey from page 41. The questions (with preamble) are as follows:

Consultation Questions

Personal beliefs and medical practice was first published in 2008 in response to enquiries from doctors and others on issues in this area. We asked for views about the current guidance earlier this year (February 2012) before we redrafted (see CMF’s comments on prior draft). Now we’d like to know what you think about this draft guidance.

1 Do you think it’s helpful to have guidance on this topic?

The guidance provides more detail about what doctors should do if their beliefs conflict with carrying out particular procedures, or giving advice about them. Currently we allow doctors to withdraw from providing all arranging treatments or procedures on the grounds of conscience, whether or not this is covered by legislation.

2 Do you think this is a reasonable position for us to maintain?

At paragraph 5, we explain that gender reassignment is only sought by a particular group of patients who have ‘protected characteristics’ as defined in the Equality Act. Gender reassignment can not be withheld because of doctors’ personal beliefs, without breaching the Act.

3 Is the guidance on gender reassignment clear? If no or not sure, please say why.

4 Are there any references to supporting information we could include to make the guidance more helpful to doctors?

5 Is the guidance clear?

6 Do you have any other comments on Personal beliefs and medical practice?

I would encourage all doctors, and anyone else with an interest, to respond to the consultation.

Once the guidance is set in stone it will be the standard all doctors are judged against.

1.HALLAGAN And Anor V MEDICAL COUNCIL OF NZ HC WN CIV-2010-485-222 [2 December 2010]

Jesus’ Nazareth Manifesto as a basis for healthcare mission

Jesus Christ’s dynamic entry into first century Palestine was marked by miraculous healing of many illnesses for which even today there are no known treatments. But along with his compassion to restore health he brought the gospel message of healing of broken relationships - between human beings, between human beings and the planet and most crucially between human beings and God.

Luke, probably the first ever Christian doctor, tells us that Jesus sent his followers out ‘to preach the kingdom of God and to heal the sick’(Luke 9:2). Right from the beginning ministry to the spirit and ministry to the body have gone hand in hand.

For the last 2,000 years, Christian doctors and nurses, inspired by the example and teaching of Jesus, have been at the forefront of efforts to alleviate human suffering, cure disease, and advance knowledge and understanding.

Many of medicine’s pioneers were men and women who had deep Christian faith: Pare, Pasteur, Lister, Paget, Barnado, Jenner, Simpson, Sydenham, Osler, Scudder, Livingstone and many more.

In the 21st century, whiles some avenues for missionary work are closing, others are opening wide. Christian health professionals, and particularly doctors, have a passport to limited access and creative access countries that those of many other professions do not. But what is their mandate and what should be their priorities in playing the part in fulfilling Jesus’ great commission?

Jesus’ Nazareth manifesto in Luke 4 provides a biblical basis for healthcare mission.

We are told that when standing to read in the synagogue on the Sabbath in his home town, he was handed the scroll of the prophet Isaiah and ‘found the place where it is written’:

The Spirit of the Lord is upon me, because he has anointed me to preach good news to the poor. He has sent me to proclaim freedom for the prisoners and recovery of sight for the blind, to release the oppressed, to proclaim the year of the Lord’s favour (Luke 4:18,19)

The Jews listening would have recognised this quote from Isaiah 61, which actually ends, ’And the day of vengeance of our God’ (Isaiah 61:1,2). Jesus didn’t read these words but stopped mid-verse presumably to illustrate that redemption and judgment were going to be separated in history. Judgment would be delayed in order to allow people to repent. The Jews didn’t understand God’s mercy in delaying judgment, his love or the scope of his redemptive plan.

The manifesto starts, ’The Spirit of the Lord is upon me, because he has anointed me’. Elsewhere Jesus says, ’As the Father has sent me, I am sending you... Receive the Holy Spirit’ (John 20:21,22)

It goes on to reveal Jesus’ four-fold ministry, which is to be our own model: preaching, healing, deliverance and justice.

(Excerpted from paper delivered at a dialogue session at the Third Lausanne Congress, Cape Town 2010. The full text is available on the Lausanne Conversation Website)

Christianity provides medicine with a whole person perspective

When I was medical student I was required to write an essay on the nature of man.

The secular world has developed many different models for human beings. There are psychoanalytical models like that of Sigmund Freud who saw man as the product of a complex reaction between superego, ego and id. Then there are the behaviourists like B F Skinner who see human beings as complex stimulus-response machines. Then there are the physical anthropologists who see man as simply a clever monkey, and finally the biochemists who see man as nothing other than a complex chemical reaction, the product of matter, chance and time in a universe without meaning or purpose.

All these views are 'reductionist' in that they reduce man to simply the sum of his individual parts.

As doctors we know that the biochemical, anthropological, behaviourist and psychoanalytical models are all useful in understanding how human beings function. We learn our biochemistry, physiology and anatomy because we know that human beings are physical entities. We learn our psychology, social anthropology and sociology because we know that human beings are more than just physical entities - they need to be understood also as thinking entities existing in relationship. We learn our philosophy and religion because we know that human beings ask deep questions about morality, purpose and destiny. Human beings are also spiritual.

Biblical Christianity teaches that human beings are a complex unity of spirit, soul and body; and that these elements together form an inseparable whole. We can be understood in physical terms because we are made from physical elements, but we are more than just physical beings. We have souls and spirits too, and these three parts of our natures – body, soul and spirit - interact in a complex fashion.

We know that our physical health has profound effects on the way that we think, and that illness causes us to ask questions about meaning and purpose. We know that the mind can also affect physical health in the case of psychosomatic illness. We know that major life events like bereavement or divorce can have profound effects on our health.

If we treat our patients simply as physical bodies we will be doing them a gross disservice. It is true that they have physical bodies and that they may need their biochemistry corrected, their physiology normalised and their anatomy realigned.

However they are also souls enmeshed in a complex set of relationships and spirits asking serious questions about hope, meaning and destiny. These factors have profound implications for health and need to be addressed too.

Jesus Christ healed physical illness but he also restored broken relationships, forgave sin and reintroduced people to their creator.