Sunday 31 March 2013

Gay partnerships – how far should we go in tolerating ‘evangelicals’ who endorse them?

The Bishop of Liverpool, James Jones (£), and Baptist minister Steve Chalke have both recently come out in support of the church affirming monogamous gay (sexual) partnerships.

James Jones says that gay partnerships are among a number of major moral issues where ‘the church allows a large space for a variety of nuances, interpretations, applications and disagreements’.

Steve Chalke has written a special liturgy for gay partnerships that he has published on his Oasis charity website along with a full ‘evangelical exegesis’ of his pro-gay stance (More here and here).

The House of Bishops’ pastoral statement on civil partnerships of July 2005 specifically precludes the clergy of the Church of England from conducting services of blessing for those who have entered into a civil partnership.

It states: ‘Clergy of the Church of England should not provide services of blessing for those who register a civil partnership.’

Steve Clifford, general director of the Evangelical Alliance (EA), has said that he believes the conclusions Chalke has come to on same-sex relationships are wrong. He has also expressed ‘sadness and disappointment’ at the way Chalke, an EA member, ‘has not only distanced himself from the vast majority of the evangelical community here in the UK, but indeed from the Church across the world and 2,000 years of biblical interpretation’. 

And yet both Justin Welby, the new archbishop of Canterbury, and Steve Clifford seem committed to an ongoing dialogue with those with whom they disagree. Welby has called for the church to disagree ‘gracefully’ over gay marriage and Clifford has stressed that ‘as we have this discussion let's remember that Jesus requires us to disagree without being disagreeable’.

Am I alone in finding this all rather disturbing?

To Jones and Chalke, the issue of whether or not one should bless gay partnerships is a secondary issue on which evangelicals can legitimately take different positions – in other words both views (acceptance and rejection of gay partnerships) fall within the boundaries of evangelicalism. 

Neither is offering his resignation. This is particularly interesting given that the Courage Trust resigned from EA in 2002 when it decided to take the same position on gay partnerships that Chalke is now espousing and affirming.  

But it seems to me also that, in spite of Clifford’s and Welby’s clear personal stance on the issue (both take the orthodox position that the only context for sex is within monogamous, heterosexual marriage), in practice they appear to regard gay partnerships as being in the category of what Paul called ‘disputable matters’,  issues (of the Romans 14 and 1 Corinthians 8 & 10 variety) on which evangelical Christians can legitimately disagree and yet remain 'in fellowship'.

I say ‘in practice’ because they appear to be taking the view that those who hold to and teach Jones’ and Chalke’s view on gay partnerships should be debated with ‘gracefully’ and ‘agreeably’ rather than being disciplined.

This approach seems to be at odds with EA's own official position which reads as follows (emphasis mine):

'We believe both habitual homoerotic sexual activity without repentance and public promotion of such activity are inconsistent with faithful church membership. While processes of membership and discipline differ from one church to another, we believe that either of these behaviours warrants consideration for church discipline

EA appears not to be abiding by its own policy but a far more important question is, 'Does ongoing 'gracious debate' square with what the Bible teaches?' I’m not at all sure that it does.

The ‘one man, one woman, for life’ (marriage) context for sexual relations of Genesis 2:24 is a creation ordinance for all mankind. Furthermore the complementarity and permanence of the marriage relationship mirrors the complementarity and permanence of Christ’s relationship with his body (and bride) the church (Ephesians 5:22-33).

Old Testament teaching on sexuality (detailed in Leviticus 18 & 20) makes it very clear that the only proper context for sexual relations is within (heterosexual) marriage. These two chapters straddle Leviticus 19 with its injunctions to ‘Be Holy because I the Lord am holy’ (19:2) and to ‘love your neighbour as yourself’ (19:18).

Jesus upholds the creation ordinance of marriage (Matthew 19:4-6) and indicates that sexual purity goes beyond mere actions to thoughts and motivations (Matthew 5:27-32).

Paul points out the unique nature of sexual sin (porneia) in that it involves sin ‘against one’s own body’ (1 Corinthians 6:18-20) and argues that sexual purity is part of sanctification, living a holy life (1 Thessalonians 4:3-8).

Furthermore we receive the grave warning in Revelation (21:8 and 22:15) that the unrepentant sexually immoral are destined for the lake of fire and will not partake of the tree of life.

The book of Hebrews (10:26) tells us that ‘If we deliberately keep on sinning after we have received the knowledge of the truth, no sacrifice for sins is left, but only a fearful expectation of judgment and of raging fire that will consume the enemies of God’.

The Bible is also very clear that homosexual practice in particular, as well as being included within the boundaries of sexual immorality (porneia), is also a specific marker of a society that has turned its back on God – Genesis 19, Judges 19 and Romans 1 are familiar examples.

Jesus himself calls the church of Thyatira to repentance over ‘(tolerating) that woman Jezebel’ who ‘by her teaching’ ‘misleads my servants into sexual immorality’ (Revelation 2:20-25).

Sex outside marriage is viewed very seriously indeed in Scripture but false teaching which leads people into sexual sin is viewed even more seriously (Luke 17:1-2) and warnings about the affirmation and endorsement of sexual immorality (2 Peter 2 and Jude are poignant examples) are particularly strong.

Those who lead ‘little ones’ astray (Matthew 18:6), like those they mislead, are in great danger. This is why it is so important for us to exercise godly discipline with them (Matthew 18:15-20; Luke 17:3-4; Galatians 6:1; James 5:19, 20) for their own sakes, as well as for those who they might mislead or have already misled.

Those who raise these uncomfortable issues in the church are often are told ‘not to judge’, but the Bible is very clear that in the case of sexual immorality or false teaching it is actually our responsibility as Christians to ‘judge’ and to exercise discipline (1 Corinthians 5:1-13).

When there was a serious issue that threatened the integrity of the early church (with whole groups being led astray) the apostles called a council. We read about it in Acts 15. The matter (in that case circumcision) was seen as serious and meriting prompt action. It is interesting that one of the conclusions of that first council was that all Christians were to avoid sexual immorality (Acts 15:29). When the church has encountered other serious issues throughout the centuries councils have similarly been called to bring resolution.

I am no expert on church history and cannot ever recall a church council specifically on sexual morality but I can also not recall a time in history when senior church leaders sought to affirm or bless sexual behaviour that the Bible clearly teaches is immoral.

Can we imagine the apostle Paul leaving a situation like this to smoulder and fester? Would he not rather have urged his co-workers to ‘command certain men not to teach false doctrines’ (1 Timothy 1:3) and to ‘gently instruct in the hope that God will grant repentance’ (2 Timothy 2:25). Would he have not insisted that false teachers ‘must be silenced’ (Titus 1:11)? 

Do we really think that Jesus himself, given his clear warnings about the dangers of false teaching, would have allowed a situation like this to persist unchallenged? Should we be acting any differently? Is it really enough to ‘disagree without being disagreeable’ and to debate ‘gracefully’?   

When false teaching is allowed to fester in the church, and when godly discipline is not exercised with those who are propagating it, whole households, churches and communities can be ruined (Titus 1:11).

I am becoming increasingly uneasy about how we evangelicals have allowed this particular situation to drift. I believe that the time for tolerance and discussion is over and that we need now to act.  

The real meaning of Easter: Why did Jesus have to die?

‘Agnus Dei’ (literally Lamb of God) is an oil painting of a bound lamb upon an altar by Francisco de Zurbar├ín which was started in 1636 and completed in 1640. 

The version opposite is one of six painted by the artist and hangs in the San Diego Museum of Art, USA.

It represents the teaching right at the very heart of the Christian faith whereby God makes peace with estranged and condemned human beings through the death of his Son Jesus Christ on a Roman cross.

Jesus is called the ‘Lamb of God’ because his death was an act of ‘substitutionary atonement’.

In other words Jesus died in our place receiving the judgement and wrath that our sins deserved.

We remember it on Good Friday, the day after the Jewish Passover.

This concept of ‘dying in our place’ has its roots in the very first book of the Bible -  in Genesis 3 -   where God protected Adam and Eve from his deserved judgement by turning them out of the garden of Eden and clothing them in the skin of slaughtered animals.

The theme is similarly central to Abraham’s offering of his son Isaac when God produced a sheep as a substitute.  

Also in the Passover, preceding the Exodus, the blood of a firstborn lamb smeared on the doorposts and lintels of Israelite homes protected them from the wrath of God that fell on the Egyptians. God ‘passed them over’ and did not give them what they deserved.

Substitutionary atonement is also the basis of the Jewish sacrificial system whereby bulls, goats, sheep and pigeons were killed instead of the people to forestay God’s wrath, and also the Day of Atonement, six months after Passover, where one goat carrying the nation’s sin was slaughtered in the place of the people and a second was sent out into the wilderness never to return.

All of these were imperfect means by which a temporary reprieve was achieved for sinful human beings. They all foreshadow the death of Jesus, the Lamb of God on the cross. As Revelation, the last book in the Bible declares, Jesus was ‘the Lamb who was slain from the creation of the world’ (13:8).

As the writer of Hebrews informs us, ‘the same sacrifices repeated endlessly year after year’ can never ‘make perfect those who draw near to worship’ because it is ‘impossible for the blood of bulls and goats to take away sins’.

We can only be ‘made holy through the sacrifice of the body of Jesus Christ once for all… For by one sacrifice he has made perfect forever those who are being made holy’ (Hebrews 10:1-10).

It is said that God’s wrath and mercy meet at the cross. If God was purely a God of justice our judgement as a human race would have been immediate and final. But because God is also a God of mercy, He has provided a means by which our sin could be completely paid for.

Jesus through dying on the cross took the wrath and judgement that our sins deserved; and because he has taken that wrath and judgement in our place we receive mercy and are thereby forgiven. 

The idea of substitutionary atonement, that Christ died in our place for our sins, is central to both Old Testament and New Testament.

Nowhere is it spelt out more explicitly in the Old Testament than in Isaiah 53, the last of the four servant songs, written 700 years before Christ was crucified but written in anticipation of it:

‘Surely he took up our pain and bore our suffering,
yet we considered him punished by God, stricken by him, and afflicted.
But he was pierced for our transgressions, he was crushed for our iniquities;
the punishment that brought us peace was on him, and by his wounds we are healed.
We all, like sheep, have gone astray, each of us has turned to our own way;
and the Lord has laid on him the iniquity of us all.’ (Isaiah 53:4-6)

The central theme in Isaiah 53 (v7) is that of the ‘agnus dei’, the Lamb of God, who ‘did not open his mouth’, was ‘led like a lamb to the slaughter’ and ‘as a sheep before its shearers is silent’.

The idea of substitutionary atonement is frequently returned to in the following verses of the chapter: ‘for the transgression of my people he was punished’, ‘the Lord makes his life an offering for sin’, ‘my righteous servant will justify many’, ‘he will bear their iniquities’, ‘For he bore the sin of many’.

In the same way substitutionary atonement is the central teaching of the New Testament.

Paul says that Jesus died ‘for us’ (Romans 5:6-8; 2 Corinthians 5:14; 1 Thessalonians 5:10) and also that he died ‘for our sins’ (1 Corinthians 15:3; Gal. 1:4).

Jesus describes his own ministry as giving his life ‘as a ransom for many’ (Matthew 20:28; Mark 10:45) and Peter says ‘He himself bore our sins in his body on the tree’ (1 Peter 2:24).

Christ, Paul tells Timothy, ‘gave himself as a ransom for all people’ (1 Timothy 2:6). The writer of Hebrews adds that Christ ‘died as a ransom to set them free from the sins committed under the first covenant’ (Hebrews 9:15).

Peter sums it up in saying that ‘Christ also suffered once for sins, the righteous for the unrighteous, to bring you to God’ (1 Peter 3:18).

To further unpack this theme the New Testament explains substitutionary atonement with four main metaphors.

First is the metaphor of the altar of sacrifice. Christ is the sacrificial lamb whose blood is shed in our place. It is we who deserved to die but Christ substituted himself instead.

Second is the slave market. Christ paid the redemption price that we could not pay in order to free us from bondage. He bore the cost for us.

Third is the law court. Christ is our justification, that is, he took the punishment that we deserved in order than we might not be condemned.

Fourth is the metaphor of relationship. Christ’s death on our behalf brings reconciliation after our unilateral abandonment of God. 

Like any metaphor, each of these illustrations provides merely a picture of what actually happened when Jesus died on the cross in our place. But in each case he did what we, in our weakness and sin, were unable to do (Romans 5:6-8).

He saves us from sin, judgement and Hell, to which we would inevitably be going had he not intervened at great personal cost.

The question for us is how we respond to this act of Jesus Christ.

Knowing that Christ, the creator and sustainer of the universe, whom we abandoned through passive indifference or active rebellion, sought us out and paid the ultimate price because it was the only thing that was sufficient to achieve our forgiveness and reconciliation, how can we possibly respond?

The only right response is surely to fall as his feet, to acknowledge him as master and deliverer and to give our lives to love and serve him – to come to him in repentance (turning from sin) and faith (trusting obedience).

And to those who do this he offers not only the forgiveness of sins – a clean slate – but also a renewed life and new nature (2 Corinthians 5:17), the power to change through the gift of the Holy Spirit (Romans 8:9), the gift of service (Ephesians 3:7), the certainty of eternal life (Jude 24) and the promise that nothing will ever separate us from his love for all eternity.

‘Who shall separate us from the love of Christ? Shall trouble or hardship or persecution or famine or nakedness or danger or sword?...  No, in all these things we are more than conquerors through him who loved us. For I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord’ (Romans 8:35-39).

(See also 'Jesus’ resurrection: what evidence is there that it really happened?')

Saturday 30 March 2013

The creed which still encapsulates the spirit of the age

British journalist Steve Turner's poem 'the Creed' is now over 30 years old but still beautifully encapsulates the spirit of the age as expressed by atheists, liberals, New Agers and secular humanists. I first heard it as a medical student. Enjoy!

The Creed 

We believe in Marxfreudanddarwin.
We believe everything is OK
as long as you don't hurt anyone,
to the best of your definition of hurt,
and to the best of your knowledge.

We believe in sex before during
and after marriage.
We believe in the therapy of sin.
We believe that adultery is fun.
We believe that sodomy's OK
We believe that taboos are taboo.

We believe that everything's getting better
despite evidence to the contrary.
The evidence must be investigated.
You can prove anything with evidence.

We believe there's something in horoscopes,
UFO's and bent spoons;
Jesus was a good man just like Buddha
Mohammed and ourselves.
He was a good moral teacher although we think
his good morals were bad.

We believe that all religions are basically the same,
at least the one that we read was.
They all believe in love and goodness.
They only differ on matters of
creation sin heaven hell God and salvation.

We believe that after death comes The Nothing
because when you ask the dead what happens
they say Nothing.
If death is not the end, if the dead have lied,
then it's compulsory heaven for all
excepting perhaps Hitler, Stalin and Genghis Khan.

We believe in Masters and Johnson.
What's selected is average.
What's average is normal.
What's normal is good.

We believe in total disarmament.
We believe there are direct links between
warfare and bloodshed.
Americans should beat their guns into tractors
and the Russians would be sure to follow.

We believe that man is essentially good.
It's only his behaviour that lets him down.
This is the fault of society.
Society is the fault of conditions.
Conditions are the fault of society.

We believe that each man must find the truth
that is right for him.
Reality will adapt accordingly.
The universe will readjust. History will alter.
We believe that there is no absolute truth
excepting the truth that there is no absolute truth.

We believe in the rejection of creeds.

Steve Turner

Wednesday 27 March 2013

The GMC’s new guidance on ‘Personal Beliefs and Medical Practice’ – how effectively does it address our concerns?

The General Medical Council published its new guidance on ‘Personal Beliefs and Medical Practice’ (PBMP) earlier this week.

This was one of ten supplementary documents accompanying its core Guidance ‘Good Medical Practice’ – all of which were released on the same day.

Last year I outlined a number of issues of concern in the PBMP consultation draft so I was keen to see how well these had been addressed in the final version.

It was not an easy question to answer as the whole document has been substantially rewritten to the extent that the original draft is now barely recognisable within it.

The original draft had 15 numbered paragraphs in four main sections. In addition there were seven endnotes running to four pages dealing with issues as diverse as male circumcision, abortion, blood transfusion and cremation forms.

The final version has 31 numbered paragraphs in nine sections and a new ‘legal annex’ summarising relevant legislation. The endnotes have gone with only one of the seven being moved in any substance to the main text. 

Of the 15 original paragraphs in the draft document only one has escaped the editor’s red pen. One has been removed completely and ten have had whole sentences or phrases added or removed along with other more minor changes.

The result is a document that is easier to read and more logically arranged which, in the main, attempts to provide principles rather than detailed advice about specific issues. It also more readily refers doctors to seek legal advice rather than trying to interpret and apply legislation.

Overall it is a big improvement and the legal errors in the first draft have been largely (although not I believe completely) dealt with.

The guidance recognises that ‘doctors have personal values that affect their day-to-day practice’ and asserts that the GMC doesn’t wish ‘to prevent doctors from practising in line with their beliefs and values’ provided that ‘they act in accordance with relevant legislation’ and ‘follow the guidance in Good Medical Practice’.

It also recognises that doctors ‘may choose to opt out of providing a particular procedure because of (their) beliefs and values’ as long as the legal rights of others are not breached. It also concedes that ‘it may… be appropriate to ask a patient about their personal beliefs’ and ‘to talk about your own personal beliefs’ in certain circumstances.

But how good is the new guidance?

In reviewing the draft last year I highlighted five main areas of concern and we addressed these in our official CMF submission.

How many of these recommendations have the GMC taken on board? Some, but not all.

My first concern was the lack of reference to whole person medicine. Although the draft guidance addressed in the prologue 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 was 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.

I was therefore pleased to see that the patient’s ‘views and values’ have been added as factors to take into account in history taking. This is an improvement in the direction of acknowledging that all patients have a worldview which should be taken into account in considering their treatment options. 

This is also helpfully acknowledged in the (now) clearer statement that ‘personal beliefs and cultural practices and central to the lives of doctors and patients’. 

My second concern was the further tightening of restrictions about discussing personal beliefs. The draft guidance said 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 (eg. The patient has a Bible or Quran with them or some other outward sign or symbol of their belief)’

We suggested that the guidance be amended to make it clear that patients may indicate they would welcome such a discussion in the course of giving a spiritual or religious history in response to sensitive questioning. Doctors should not have to rely solely on unlikely nonverbal clues (such as carrying a Bible or Quran!) to obtain this information. 

We were therefore pleased to see that the GMC had added into this section the need to take account of ‘spiritual, religious, social and cultural factors’ in ‘assessing a patient’s conditions and taking a history’ and removed the rather comical reference to the patient carrying a Bible or Quran. The wording has also been slightly changed in giving permission for a doctor ‘to talk about your own personal beliefs only if a patient asks you directly about them or indicates that they would welcome such a discussion’. 

It is hard to see how this wording will not invite some vexatious complaints but it could have been worse and at least grants some flexibility and freedom to tactful doctors. But 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. I’ve written at more length on this section of the guidance here.

My third concern was that the draft guidance was not clear enough about doctors having a legal right to object conscientiously to some procedures.

Like the draft, the final version confirms, in the legal annex, 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’. So far, so good.

However it is much more vague, and I think legally inaccurate (I am currently seeking advice on this) about abortion. The 'Legal Annex’ now reads as follows:

'In England, Wales and Scotland the right to refuse to participate in terminations of pregnancy (other than where the termination is necessary to save the life of, or prevent grave injury to, the pregnant woman), is protected by law under section 4(1) of the Act. This right is limited to refusal to participate in the procedure(s) itself and not to pre- or post-treatment care, advice or management, see the Janaway case: Janaway v Salford Area Health Authority [1989] 1AC 537'

Does Section 4(1) of the Abortion Act really not exempt doctors from 'participating' in 'pre or post management care, advice or management'? This is actually still a grey area legally and not nearly as clear cut as the GMC implies.

I believe the GMC’s analysis is rather an over-reading of the Janaway case which defined ‘participation’ as ‘actually taking part in treatment designed to terminate a pregnancy’. If so this is quite serious as the GMC is then misleading doctors about what the law actually says (For a thorough explanation of the current law on conscientious objection to abortion see ‘Conscientious objection to abortion - ethics, polemic and law’ by Charles Foster in the CMF journal Triple Helix).

My fourth concern was the implication that doctors who have a conscientious objection to a particular procedure have a duty to make arrangements for patients to be seen by another colleague who doesn't share their objection. Many doctors would regard such action as unethical complicity. To put this in context, if euthanasia became legal, how would you feel about being struck off for refusing to ‘make arrangements’ for patients requesting euthanasia to see colleagues who would do the deed? I suspect none too pleased!

But Section 13 says, with respect to procedures one has a conscientious objection to, that:

'If it’s not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made – without delay – for another suitably qualified colleague to advise, treat or refer the patient. You must bear in mind the patient’s vulnerability and act promptly to make sure they are not denied appropriate treatment or services.'

The use of the word 'must', according to paragraph 5 of 'Good Medical Practice' implies that this is an overriding duty or principle. But on what basis is the GMC saying this? It is not at all clear that this is a legal obligation, so on what basis is the duty or principle absolute? There is of course nothing to stop the GMC recommending this course – in which case I would have expected them to have used the word ‘should’ rather than 'must'. But again the GMC may be overstretching itself here and could be vulnerable to judicial review.

My fifth concern was the implication in the draft guidance that doctors had no right to conscientious objection in the case of ‘providing gender reassignment’ or ‘prescribing contraceptives to unmarried people’.

We challenged the GMC on both of these, saying that they were misrepresenting the provisions of the Equality Act 2010.

I was therefore pleased to see that the GMC had completely back tracked in the case of ‘gender reassignment’ (see more detail on this here) but concerned to see that they were still arguing that doctors could not prescribe contraceptives for married people but refuse to prescribe for the unmarried. I don’t expect this issue will affect many doctors, but there will be some and being ‘unmarried’ is not actually a protected characteristic under the Equality Act. In other words this might also be open to a legal challenge.

Overall the guidance is not too bad and could have been considerably worse. It was clearly worth responding to the consultation as our responses, and those of others, have had a considerable impact on the final draft. This is important as it is the standard against which doctors will be judged.

There are however some assertions in the guidance that are still, I believe, less legally clear than the GMC has implied. These deserve further exploration and possibly even legal challenge.

In this era of increasing hostility to Christian faith and values Christian doctors will undoubtedly face more vexatious complaints from patients and colleagues who feel they should be silent about their faith convictions or be forced to provide services to which they have a conscientious objection.

In the main they will find this new GMC guidance on ‘Personal Beliefs and Medical Practice’ more of a help than a hindrance.

But the real test will be to see how the new guidance is applied by the GMC in individual cases.

I suspect the bigger threat will come from some of the new legislation introduced over recent years and the way it has been misinterpreted (or over-interpreted) by NHS Trusts and medical institutions (see here).

We need to count the cost and be prepared for conflict, whilst working hard with patients and colleagues to defuse potential conflicts and find ways forward that enable conscientious objection to be respected.

Reasonable accommodation of those who wish to conscientiously object is far better than forcing them to do things they believe are profoundly wrong.

Tuesday 26 March 2013

GMC backs down on requiring doctors to provide 'gender reassignment' as lobby group brings 98 patient complaints

The General Medical Council has backed down on requiring doctors to provide 'gender reassignment' just as a lobby group has brought forward 98 patient complaints. 

The blog was prompted by new draft guidance issued by the General Medical Council which implied that doctors who refused to provide ‘gender reassignment’ risked being struck off the medical register.

The draft guidance, ‘Personal beliefs and medical practice’ allowed doctors to opt out of providing procedures or treatments to which they had a conscientious objection provided that they made sure that ‘the patient has enough information to arrange to see another doctor who does not hold the same objection as you’.

But it made an exception in the case of ‘providing gender reassignment’ (P5 footnote) for which it said doctors had no right not to be involved.

It justified 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. 

Understandably the report generated some media interest at the time.

The GMC has now published its definitive guidance and has backtracked significantly apparently as a result of responses to its consultation.

In its consultation it asked specifically:

‘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 cannot be withheld because of doctors’ personal beliefs, without breaching the Act. Is this guidance on gender reassignment clear? If no or not sure, please say why.’

In fact the statement was not only unclear but legally incorrect.  We made the following response in our official CMF submission:

‘Answer – No

a. The guidance is not clear on gender reassignment and appears not accurately to reflect the requirements of the law. We recommend that the confusing footnote to p5 on gender reassignment be removed.

b. In the footnote to paragraph 5 it states that doctors have no right to ‘opt out of providing’ ‘gender reassignment’ but it does not clearly define what ‘providing gender reassignment’ actually entails. Does it include just gender reassignment surgery and/or hormone treatment or does it also entail being part of the referral pathway?

c. The treatment of gender identity disorder (alternatively gender dysphoria) is extremely controversial and many doctors do not believe that surgery or hormone treatment is clinically appropriate or ethical in many (or even any) cases. To force such doctors to ‘provide’ such ‘treatment’ with no option to opt out is inappropriate.

d. The argument that provision of ‘gender reassignment’ is required is we believe a misapplication of the Equality Act 2010. The natural reading of the law is that doctors should not refuse to treat patients who have already undergone gender reassignment for conditions that they would treat other patients for (eg. Infections, heart disease).

e. It does not mean that doctors are required to provide ‘gender reassignment’ to those diagnosed with gender identity disorder. This interpretation would place doctors under an obligation to provide treatments that they regarded as unethical to the other eight groups protected under the Equality Act 2010 also and would undermine their professional status by making them servants of the state. It could also be open to legal challenge.’

I was therefore most gratified to see that the GMC which issued its definitive guidance earlier this week had completely rewritten the section on gender reassignment.

The definitive guidance (para 8 page 2) now reads as follows:

‘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.’

A footnote (footnote 3 page 2) now makes it clear that this does not mean that doctors must provide ‘gender reassignment’, but rather that they must not withhold treatments from transgender patients which they would provide to others (eg antibiotics, pain killers, infertility treatment etc):

‘For example, this means that you must not refuse to provide a patient with medical services because the patient is proposing to undergo, is undergoing, or has undergone gender reassignment. However, you may decide not to provide or refer any patients (including patients proposing to undergo gender reassignment) for particular services to which you hold a conscientious objection, for example, treatments that cause infertility.’

This now protects doctors who have a conscientious objection to providing gender reassignment ‘treatment’.

It seems that this change has come not a moment too soon.

According to Pulse magazine (and Gaystar News) transgender activists have assembled a list of 98 patient complaints after a survey of transgender patients about their experience of dealing with medical professionals which it submitted to the GMC earlier this month.

The regulator has confirmed that a meeting with a group of transgender rights activists has resulted in 39 cases warranting an initial investigation, although they are at a ‘very early stage’.

Campaigner Helen Belcher, a member of the UK Parliamentary Forum on Gender Identity, said 15 GPs may be investigated by the GMC as a result.

The complaints include reports of sexual abuse, humiliation, inappropriate diagnoses, and denial of treatment. Patients also complained their transgender status was brought up when they were seeking treatment for entirely unrelated health concerns.

It is interesting that news of this campaign hit the media on the very day that the GMC released their revised guidance.

Was this in anticipation of the possibility that the revised guidance might aid such a campaign? I wonder.

It appears however that given the GMC’s revised wording it will be much harder now for activists to target doctors who simply wish not to be involved in providing ‘gender reassignment’.

People who have been discriminated against, sexually abused, humiliated or denied medical treatment because they belong to a minority group deserve justice and protection. Doctors found guilty of such misdemeanours must be dealt with promptly and effectively.

But to force doctors to collude in ‘treatments’ which they consider to be inappropriate or unethical is another thing altogether.

If there are any cases of this latter kind in the dossier of cases these activists have presented to the GMC then I hope the GMC will give them short shrift.

‘Gender reassignment’ - through hormones and/or surgery -  is legal in this country but remains very controversial. Many doctors in this country, for a variety of reasons, do not wish to be part of providing this ‘treatment’, either through prescribing hormones, or acting as surgeons or anaesthetists or as part of the referral pathway or pre-operative assessment.

It is good that the GMC has now recognised that these doctors do actually have a legal and ethical right not to be involved, while still offering the same standard of medical care to transgender patients as they do to any other patients.

(A much fuller treatment of Gender Identity Disorder is available on the CMF website)

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

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).

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.

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)

Monday 25 March 2013

Doctors should identify themselves on line and respect colleagues and professional boundaries, says GMC

The General Medical Council (GMC), the regulatory body for doctors, has today published advice on doctors’ use of social media for the very first time.

The news comes as the Medical Defence Union, which provides legal advice and protection for doctors reveals that more doctors than ever have been asking for advice on use of social media. 

The GMC’s new booklet, ‘Doctors’ Use of Social Media’, is just one of ten sets of supplementary guidance published today by the GMC alongside an updated edition of its core guidance for UK doctors, Good medical practice. 

The long-awaited guidance, last updated in 2006, comes into effect on 22 April and all doctors will have to show they are complying with the updated standards for their revalidation - the new system of regular checks that came into force in December 2012. 

Serious or persistent failure to follow GMC guidance puts a doctor’s registration at risk.

The new GMC guidance says that doctors’ use of social media (facebook, twitter, blogs, you tube etc) can benefit patient care by ‘engaging people in public health and policy discussions, establishing national and international professional networks and facilitating patients’ access to information about health and services’.

However it also warns that ‘standards expected of doctors do not change because they are communicating through social media rather than face to face or through other traditional media’.

Specifically it says that doctors should be scrupulous to maintain professional boundaries, guard patient confidentiality, treat colleagues fairly and with respect and avoid hiding their personal identities. 

Doctors who are contacted through their private profile by a patient should explain that they cannot mix social and professional relationships and, where appropriate, direct them to their professional profile.

They are warned that they must not use publicly accessible social media ‘to discuss individual patients or their care with those patients or anyone else’; ‘must not bully, harass or make gratuitous, unsubstantiated or unsustainable comments about individuals online’; and that ‘if you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name’.

When interacting with or commenting about individuals or organisations online, doctors ‘should be aware that postings online are subject to the same laws of copyright and defamation as written or verbal communications, whether they are made in a personal or professional capacity’.

The MDU, which represents over half of UK doctors, said it received around five calls each month in 2012 from GPs and hospital doctors with concerns about Facebook, blogs and other websites.

Common concerns included complaints and allegations made about doctors by patients on social networking sites; friendship requests from patients; and doctors who had found themselves in difficulties after posting comments and images online.

MDU adviser, Dr Catherine Wills, said: ‘Social media can be a force for good in medicine, for example, by helping doctors to network more effectively and giving patients access to more healthcare information. But there are risks too, particularly when it comes to maintaining boundaries with patients and acting professionally and we are pleased that the GMC’s guidance has addressed such a growing issue for our members.’

Doctors using social networking sites are advised by the MDU to:

  • Keep your profile private - limit access to friends only and don't accept requests from patients to become a friend.
  • Be professional in your comments, especially about patients or colleagues.
  • Be cautious about posting anything that may bring the profession into disrepute.
  • Be aware that anything you upload on to a social networking site may be distributed further than you intended.
These new GMC guidelines are most welcome and help to clarify the legal and professional boundaries for doctors in social networking whilst encouraging its proper use.

Doctors need to take seriously the fact that abuse of social media could put their revalidation or registration at risk, but I hope the new guidance from both GMC and MDU also means that many more doctors get involved in making use of the many benefits of social media in a responsible way. 

Sunday 17 March 2013

Psychiatrist who supplied report to man with dementia so he could kill himself at Dignitas needs to be investigated by the police

The Sunday Times (£) reports this morning that an 83 year old British man with dementia is to travel to Switzerland for an assisted suicide. If he does so he will become the first known Briton suffering from the condition to die at Dignitas, the Swiss suicide organisation.

The professional man, whose dementia is at an early stage, has apparently obtained a report from an (as yet unnamed) London psychiatrist that states he is ‘mentally competent’ to decide to end his life. 

He says he cannot face suffering more advanced dementia, nor the strain it will place on his loved ones.

Michael Irwin (pictured), a retired GP and co-ordinator of the ‘Society for Old Age Rational Suicide’ (SOARS), which campaigns for elderly people to have the legal right to have help to kill themselves, even if their medical conditions are not life-threatening, is helping the man with his travel arrangements and appears to be the source of the story.

Irwin argues that the elderly may prefer resources that would be spent on their healthcare to instead go to their grandchildren.

‘The desire to “stop being a burden” on one’s family, and to avoid squandering financial resources perhaps better spent on grandchildren’s further education, could become the final altruistic gesture… Part of what makes a patient’s suffering intolerable could be the realisation that it is . . . ruining other people’s lives. Then, a doctor assisted suicide could be a rational moral act.’

Irwin was previously head of the Voluntary Euthanasia Society (now euphemistically rebranded 'Dignity in Dying'(DID)). His new organisation SOARS uses the same arguments as DID but has a more radical agenda, believing that assisted suicide should be available for all elderly people, whether terminally ill or not.

Irwin was previously
struck off the medical register by the General Medical Council in 2005 for trying to help a friend kill himself. He admitted obtaining sleeping pills to help his friend die and a GMC panel found him guilty of serious professional misconduct. 

He has since helped no less than nine people kill themselves, previously begging the Director of Public Prosecutions (DPP) to put him away so that he could become a martyr for the pro-euthanasia movement. 

Irwin has curiously however not been prosecuted for any of these cases on the basis that he has not fulfilled the DPP’s criteria for a prosecution being in the public interest.

Assisting or encouraging a suicide is a criminal offence which potentially carries a custodial sentence of up to 14 years under the Suicide Act 1961. But prosecutions can only take place on the authority of the DPP. It is very important to note that since 2009, when the Act was amended, the offence of encouraging or assisting suicide can be committed even where a suicide or an attempt at suicide does not actually take place.

The DPP has to decide in a given case both that there is enough evidence to bring a prosecution and also that it is in the public interest to do so.

In establishing the latter he takes into consideration 16 factors tending towards prosecution and six factor sending against.

Irwin has escaped prosecution before under these criteria and it seems likely that he may do so again.

But the unnamed London psychiatrist who allegedly provided the report to say that this man with dementia is mentally competent enough to have assistance to kill himself in Switzerland is in a different position altogether.

The DPP guidance makes it clear that ‘a person who does not do anything other than provide information to another which sets out or explains the legal position in respect of the offence of encouraging or assisting suicide under section 2 of the Suicide Act 1961 does not commit an offence under that section.’

It was on this basis that the UK General Medical Council on 31 January this year advised that doctors ‘who provide access to a patient’s records where a subject access request has been made in accordance with the terms of the Data Protection Act 1998’ are unlikely to face scrutiny.

However this psychiatrist seems to have done more than that.

One of the DPP’s criteria that makes a prosecution more likely is that ‘the suspect was acting in his or her capacity as a medical doctor, nurse, other healthcare professional, a professional carer [whether for payment or not], or as a person in authority, such as a prison officer, and the victim was in his or her care.’

In line with this, the GMC, in its own 6-page guidance for pre-hearing investigators, makes it clear that censure, including being struck off the medical register, is probable when:

•the doctor’s encouragement or assistance depended upon the use of privileges conferred by a licence to practise medicine (such as prescribing) or took place in the context of a doctor-patient relationship
•the doctor knew, or should reasonably have known, that their actions would encourage or assist suicide
•the doctor acted with intent to encourage or assist suicide

It is also ‘likely’ when a doctor is:

•writing reports knowing, or having reasonable suspicion, that the reports will be used to enable the person to obtain encouragement or assistance in committing suicide

The police and the GMC both need to investigate this psychiatrist who, if the reports in the Sunday Times are correct, may well have committed the criminal offence of encouraging or assisting suicide even though the man in question has not yet travelled to Dignitas. 

As I told the Sunday Times earlier this week, we’ve seen in European countries that have legalised euthanasia that once you allow it in any circumstances at all you inevitably end up widening the category of people to be included.

This case shows that if we were to change the law in this country there would be pressure to apply it to dementia patients as is already happening in the Netherlands.

Our current law provides the right balance. On the one hand the penalties it holds in reserve act as a powerful deterrent to exploitation and abuse. On the other hand it gives some discretion to prosecutors and judges in dealing with borderline and hard cases. It does not need changing.

Any change in the law would inevitably place pressure on vulnerable people to end their lives for fear of being a burden upon loved ones and this pressure would be particularly intensely felt at this time of economic recession when many families are struggling to make ends meet.