Facing the Right Moral Direction?

by Dr. Nileema Conlon Vaswani in

Patients are usually offended when their preferences are not honoured. They believe that some of their preferences, even non-medical ones, ought to be accommodated. This week, however, Mid Yorkshire Hospital Trust has been criticised for its proposals for Dewsbury District Hospital that entail making provisions for Muslim patients to have their beds turned to face Mecca so as to enable them to pray. The problem with these proposals is not that they are not well-meaning but that the preferences that they intended to honour may not have existed at all.

These proposals have been met with opposition for various reasons. Muslim patients have claimed that they are already happy with their care at the hospital. Some religious leaders consider the proposals unnecessary because when one is in hospital, religious obligations are lowered. Some opinions point to the fact that medical equipment that is connected to beds could get disrupted, and other views suggest that nurses are already overworked. And finally, people have also argued that these proposals portray Islam in a negative light.

It has been reported that the Trust is now downplaying the proposed changes but they are believed to have originally considered these proposals in cases where the patient was very ill and where it was also reasonably possible to do so. Whether or not these changes were genuinely proposed is difficult to determine. Whether they were proposed and have now been withdrawn is also unclear. Considering that the Trust has said that some of the press reports were inaccurate, it is not possible to debate whether or not these changes were really proposed and to what extent they were considered. The reason for this is that any "factual" information on which this article is based is also taken from press reports. Regardless, this issue does raise an important moral question: Ought hospitals to honour non-medical preferences of patients regardless of whether they are grounded in religion or have another basis?

We already honour religious preferences that have a medical bearing. The case of adult Jehovah's Witnesses who refuse blood transfusions is a case in point. But non-medical preferences also have their place in patient care. A patient who is a vegetarian, for example, ought to be able to expect to be given vegetarian meals while in hospital. An individual's meal preference could have a religious basis but it might not. A number of vegetarians have not made this choice because of religion.

There are other preferences that are not medical or religious but are still linked to patient care. The recent discussion surrounding honouring the wishes of terminally ill people to die at home is a good example of how people hold certain values that are not necessarily medical but still integral to their care. For many people, the idea of dying anywhere except at home or perhaps in their care home is unthinkable. They feel that they ought to have some say in how they spend the last few moments of their lives. Others, however, would prefer to be in hospital so as to be close to medical help as and when they might need it. As far as possible, we ought to aim to honour these preferences.

It is difficult to predict what an individual's values are and therefore also the preferences that emerge from these values. One cancer patient may prefer to die at home whereas another might prefer to be in hospital. The same is true of anyone who might be categorised into a particular group. In the current case of the Muslim patients, the proposals assume a uniform value set for them all, i.e., that they would all like to be able to pray while facing in the direction of Mecca. Although the consequences of the preferences in each of the following cases is different, this sort of assumption is similar to one that assumes that all Jehovah's Witnesses would like to refuse blood transfusions or that all Hindus cannot eat any meals that contain beef. In all these cases, it is being assumed that everyone, who technically falls into a category, also belongs to it in a substantive way. This is clearly not the case. Individuals have their own set of values that give rise to their preferences. Some of these values could be religious; others may exist for entirely different reasons. To group individuals in this way is arbitrary and consequently problematic because even though the intention might be to honour a preference, if the preference does not exist, we might well be failing to honour its opposite. People's value sets may overlap but that does not mean that we can predict how they do.

We set out to ask whether hospitals ought to honour non-medical preferences of patients. The answer is that, as far as possible, they ought to. However, what is equally important is that hospitals learn what people's preferences are so that these preferences can genuinely be honoured. If staff or management assume what people's preferences are, they are merely interpreting what they think people will want instead of asking people what they would like. If some Muslim patients would like for their beds to be turned to face Mecca because this is indeed important to them, then if it is possible to honour their request, their beds should be turned to face what is the right direction for them. But for decision-makers to predict what people would like without actually asking them will almost certainly take them in the wrong moral direction.