Wednesday, August 08, 2007

'Personal Beliefs and Medical Practice'

The consultation is about a draft ‘guidance’ document, ‘Personal Beliefs and Medical Practice’ (‘PBMP’), from the General Medical Council. Using examples, the Guidelines aim to set out principles which should govern cases where patients ask for a type of treatment a doctor does not wish to give.

PBMP is, unfortunately, seriously confused. The first problem is its reference to two red herrings: first, the principle that doctors should not ‘discriminate’ on the basis of their own or their patients beliefs (or lifestyle, race, etc.), and second, the distinction between ‘personal beliefs’ and ‘clinical knowledge and judgment’.

On the first, although discrimination is not defined in the document, it would be reasonable to understand it, in the medical context, as treating different patients differently on the basis of non-relevant criteria. Thus, a racist doctor who consistently gave cheaper and less effective medicine to patients who were members of a particular racial group, would clearly be guilty of (wrongful) discrimination.

PBMP’s three examples are the circumcision of boys for religious reasons; abortion; and the refusal of Jehovah’s witnesses to use blood products. In each case, what the patient (or the patient’s parents) is asking for may not be what the doctor thinks is right. However, in none of these cases is discrimination an issue. A doctor who refuses to go along with the patient’s wishes would be applying to the patient in front of him the same judgements he would apply to everyone. The way the PBMP keeps returning to the principle of non-discrimination suggests that such a doctor might be guilty of discrimination, but this claim is never explained or justified.

The second red herring is the distinction between a doctor’s ‘personal beliefs’ and ‘clinical knowledge and judgment’ (para 16). Taking each side of the alleged distinction separately, PBMP acknowledges that doctors must be free to exercise their judgment as to what is clinically, medically, appropriate to a patient. On the other hand, by contrasting this with something ‘personal’, it suggests that clinical judgment is somehow ‘public’, or common to the profession. This is a mere slight of hand: clinical judgement is personal, and good doctors sometimes disagree. It would be better to talk about a doctor’s ‘personal, clinical judgement’. Again, the term ‘knowledge’ is misleading, as contrasted with ‘belief’, since the bases of clinical judgements will include opinions which couldn’t count as ‘knowledge’, including the doctor’s personal medical experience. So along with ‘personal, clinical judgement’ we must talk of the doctor’s ‘clinical views’, not limited to ‘knowledge’.

When we contrast a doctor’s ‘clinical views and personal, clinical judgement’ with his ‘personal beliefs’, there does not appear to be any contrast at all. However, what PBMP clearly intends to include under ‘personal beliefs’ are moral beliefs and values. It is mere rhetoric to assume these must be beliefs rather than knowledge (don’t we all know that paradigmatic cases of murder are wrong?). So the contrast PBMP is trying to make would turn out to be that between the doctor’s medical views, and his moral views.

There is, unfortunately, a serious problem with this distinction, arising from the fact that medical views and judgements are necessarily value-laden. Medicine is about giving appropriate treatment to patients, and thus depends on the concepts of health, well-being, and benefit, and their contraries. These are all clearly evaluative terms. When a doctor says that a certain treatment will return a patient to good health, or that the benefits of a certain operation will not outweigh the pain and inconvenience, he is making a value judgement.

If the GMC wishes to avoid this, they might insist that clinical judgments are purely instrumental: they are simply about how to get a patient from one physical (or mental) state to another. If a patient wishes to get rid of a back pain, or to walk without a limp, the doctor will advise on the best ways of doing this. If a patient wants to end up in what a doctor might, as the maker of value-judgments, regard as a worse state, the doctor will nevertheless, as a clinical technician, advise the patient how to achieve that. But the GMC cannot take this view, because it is committed, as the NHS and whole medical establishment is committed, to resisting the pointless demands of obsessive or deluded patients.

One example of such demands is that of a person suffering from a mental affliction known as ‘body integrity disorder’. Sufferers want healthy limbs amputated. It would be natural to say: such an amputation would not be medically or clinically justified. That claim, of course, makes use of the fact that medical/clinical judgements include judgements of value: the amputation won’t make the patient better off. However it is expressed, it is the doctor’s grasp of values, the value of health, and the purpose of medicine to advance human well-being, which enables him to resist requests to amputate healthy limbs.

The clinical/moral distinction, accordingly, collapses. PBMP tries to buttress the distinction by reinforcing it with a distinction between what is non-personal, and what is personal, and again between knowledge and mere belief. But none of these distinctions works in the way PBMP needs it to work.

However the distinction is understood it turns out to be irrelevant to the GMC's argument, as will emerge below.

The crucial part of the guidelines is paras 18-21, which tell doctors what they must do if a patient asks for a treatment the doctor does not judge appropriate (based on the doctor’s ‘personal beliefs’).

Para 19 tells us that doctors are not required to refer the patient to another doctor. On the other hand, ‘you must ensure’ the patient is capable of seeking another opinion; if the patient is not capable, para 20 tells us that the conscientious doctor must arrange for another doctor to take over the case, ‘without delay’. Finally, para 21 tells us that doctors opposed to certain procedures should inform their employers, so their employers can find a way to make sure the procedures remain available through other doctors.

I have shown that the clinical/moral distinction will not work. Doctors may and indeed must make all-things-considered judgements about what will benefit patients, as a basis for refusing to accede to patient demands, where those demands are misguided. The GMC might retort, all the same, that in such a case a patient has the right to a second opinion, and the doctor has the duty to facilitate the patient in seeking a second opinion. If another doctor may come to a different judgment, so be it.

Thus, if Doctor A regards a possible operation as so risky, and of such limited benefit to the patient, that it would not be right to perform it, and if the patient persuades Doctor B to perform it, then Doctor A can simply wash his hands of the matter. Presumably, Doctor B has made a different assessment of the risks and potential benefits, and thinks the operation justified.

It is this kind of case which PBMP seems to have in mind, to supply the principles to deal with conscientious objections: the principle that the patient’s right to a second opinion is paramount. However, this principle is only operative within a certain range of cases. Doctor A knows he has made a prudential judgment which other doctors whose judgment he respects may agree or disagree with. It is a different matter where a patient has asked for a procedure which is ruled out, not by a prudential judgment, but by a fundamental medical moral principle. If a patient asks for an unnecessary amputation, a doctor who refused might be sufficiently confident in his colleague's judgement that allowing the patient to seek a second opinion would do no harm. If he lacked that confidence, however, taking steps to assist the patient get a second opinion would be wrong, because it would be taking steps to violate the fundamental value of the medical profession, that medicine seeks the patient’s welfare. This patient is mentally ill, and seeking something which, if he recovers mentally, he will bitterly regret, which will cause him pain and loss of function, with no good effects at all, apart from the satisfaction of a disordered desire. This is not something a doctor should be assisting, even by referring the patient to another doctor.

Again, if a patient asks for a supply of psycho-active drugs for recreational use, a doctor who refuses should not refer the patient to another doctor for a second opinion, unless the first doctor had complete confidence in his colleagues’ probity. This would be so even if the law allowed doctors to supply such drugs for such purposes. As things stand, the law recognises that the patient’s good is more important than the patient’s wishes, and forbids doctors to cooperate with the giving of drugs for recreational purposes.

The problem, in the case of abortion, is that the wrongness of abortion, the fact that it is never in the interests of the patient, is no longer recognised by law, or by the medical profession as a whole. The fact remains, however, that from a conscientious doctor’s point of view, it is a case like that of the unnecessary amputation or the recreational drug use, and not like the risky operation. It should be contrary to the evaluative, medical judgment of a doctor to assist in or recommend or in any way to cooperate in an abortion. This problem is in part recognised by the ‘conscience clause’ of the Abortion Act itself, and by PMBP itself, where it wishes to force a conscientious doctor to refer a patient to another doctor only where, in the GMC’s view, this is absolutely necessary.

Clearly, however, PBMP still seeks to force doctors to cooperate with abortion, by assisting patients’ getting a second opinion. As I have argued, this would make sense if the doctors who refused to perform the operation did so from a prudential calculation which another doctor might re-evaluate in good faith. It is wrong to ask a doctor to act against his judgement when this judgement is based on a fundamental principle: that abortion can never be in the interests of a patient, all things considered.

1 comment:

Anonymous said...

Mr. Shaw-As a Catholic medical student faced with such quandaries, I find your post quite timely and informative. Thanks!