Policy responses and statements

Name of organisation:: General Medical Council
Name of policy document:: Personal Beliefs and Medical Practice: consultation on supplementary guidance
Deadline for response:: 21 September 2007

Background: The GMC publishes a range of guidance that expands on the principles set out in its core publication, 'Good Medical Practice'. The GMC has now consulted on a new piece of supplementary guidance on 'Personal Beliefs and Medical Practice'.

This guidance has been prepared to provide further explanation of the principles in the sections of 'Good Medical Practice' that deal with doctors' obligation to provide equitable to provide equitable access to care for all patients, and with doctors' conscientious objections to particular forms of treatment. It also provides some examples of how these principles apply in practice. It is not intended to provide a comprehensive guide to religious or other beliefs and how these impact on medical care or treatment.

COMMENTS ON
GENERAL MEDICAL COUNCIL
PERSONAL BELIEFS AND MEDICAL PRACTICE: CONSULTATION ON SUPPLEMENTARY GUIDANCE

The Royal College of Physicians of Edinburgh is pleased to respond to the General Medical Council on its consultation on the supplementary guidance on Personal Beliefs and Medical Practice. Our responses to the consultation questions are as follows.

1 Do you think the guidance is clear?

Generally yes, with reservations.

Comments:

The guidance is clear in general terms but there are inconsistencies and uncertainties in the document that should be clarified.

Paragraph 16 gives a list of those issues, represented by societal groupings, which should not influence treatment decisions. The list is relatively complete. Paragraph 18 reduces the categories where discrimination should not occur to sexual orientation, gender and race. While these are likely to be among the most common causes of a need to conscientiously object, they are not exclusive. Objections may be raised on the basis of other factors listed in Paragraph 16. A reference to Paragraph 16 in Paragraph 18 would thus help.

The distinction made in Paragraph 19 between the action of referring a patient to another specific practitioner and ensuring that the patient is aware that they can see another doctor is relatively subtle. It protects the position and conscience of a doctor for whom the referral of a patient explicitly to another practitioner, for a procedure which they believe to be inherently wrong, would be close to taking the same action themselves. It does not necessarily result in a patient receiving treatment which they might reasonably expect the health services to provide. To meet the needs of the patient they would need to know how to find a practitioner who could meet their needs. This goes beyond the basics of the right to see another doctor and discuss their needs which, uninformed, could result in a second conversation with some one of a similar view. This is a situation where conflict is probable and so there is need for the guidance to be specific.

Many remote communities are served by a single medical practitioner. In the context of the advice in paragraphs 19 and 20, access to another doctor can thus be difficult especially if patient confidentiality is to be preserved, as in the case of a person wanting a termination without the knowledge of a partner or parents.

Paragraph 21 refers to the employer or contracting body. What should happen in the case of independent general medical practitioners?

Paragraph 23 is self-contradictory. If the objecting doctor has no legal right to refuse to provide care before or after termination of pregnancy, then he clearly has to provide that care; following the advice in 18-21 (referring to a colleague) clearly cannot be an option in this circumstance.

2 Is the guidance helpful in further explaining the relevant paragraphs of Good Medical Practice?

Yes.

3 Are there any other issues relating to personal beliefs in medical practice on which guidance from the GMC would be helpful?

Yes.

Comments:

Although there is separate GMC guidance in the complex areas around resuscitation, euthanasia and end-of-life care, it would be appropriate to highlight some general principles about that in this document.

It would also be appropriate for this document to give specific advice to gynaecologists on the performance of termination of pregnancy, rather than leaving it to local negotiation as paragraph 21 does.

Although the document considers the issue of male circumcision, the GMC should compare the advice here with that given on female circumcision. Both are religious/cultural practices and it may be that there are doctors, possibly from countries where female circumcision is performed, who find themselves under pressure to perform it in the UK. The GMC should reflect on whether their advice is consistent in the two cases.

There are issues around questions of, for example, diet, body weight and shape which, while not explicitly part of a religious system have similar characteristics. A vegetarian or vegan diet and associated life style can be adopted for reasons which parallel decisions on the basis of faith. This can in some result in adverse health outcomes. Extending guidance to deal with this and other diet related matters would be appropriate. More marginally, in the current context, many of those undertaking sports activities will request advice on diet, muscle development, exercise etc which can challenge personal beliefs on activities likely in the longer term to result in harm. Guidance as to proper response in such situations would help.

4 Do you have any other comments on the guidance?

Yes.

Comments:

In discussing the issue of the doctor’s personal beliefs, the guidance does not consider how the practitioner should respond if the patient asks what the doctor’s beliefs are. Also, it is indicated in paragraph 8 that discussing the patient’s beliefs sensitively, in the context of the partnership between doctor and patient, can be an important aspect of a holistic approach to their care. Might sensitive discussion of the doctor’s beliefs also be part of this holistic approach?

The document rightly notes that doctors may need to respond to a patient’s needs by removing facial barriers to communication. However, that should work in the other direction as well. Without requiring a patient to remove a face veil, the doctor may wish to explain to the patient that this could inhibit communication, possibly to the patient’s disadvantage, and advice on this would be appropriate.

Paragraph 24 leaves the question of workplace dress to local negotiation, although it can be argued that there should be national guidance on when control of infection, for example, should take precedence over religious or cultural requirements.

Paragraph 26 represents a practically based instruction based on current practice. It is unclear, however, why the demands of conscience should be put aside in this situation when they become over riding in situations linked to terminations. For some, objections to cremation can be as strongly held as the views of others on termination. While refusal to sign would occasion distress, so does refusal to assist with termination, especially in situations like those resulting from rape. This is not to argue against the right to object to terminations, but to ask why there is no provision to exercise a right to objection against cremation.

In paragraph 26, reference to a coroner is not appropriate in Scotland, so the guidance should clarify the situation for Scotland.

Although the document is principally concerned with the relationship between doctor and patient, consideration should be given to the pressure that arises through the absence from work of colleagues for religious reasons and how that should be approached.

The GMC might wish to consider the availability of support mechanisms for practitioners to aid reflection on these issues.
An appendix of some examples where generic advice is not being given would be useful in stimulating discussion of the principles at stake in this document.

It is intended to update this document. It would be helpful to have an indication of a timetable for this updating and the process to be followed for doing so.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[21 September 2007]