Expressions of Personal Belief and the Doctor-Patient Relationship

by Dr. Nileema Conlon Vaswani in

This week the General Medical Council (GMC) published a set of guidelines titled "Personal Beliefs and Medical Practice."  These guidelines build on an earlier document: Good Medical Practice and provide detailed guidance on how doctors ought to handle personal beliefs when treating patients. The guidance covers scenarios where the personal beliefs of doctors could influence their relationships with patients as well as occasions when the personal beliefs of patients could influence the way doctors treated patients who held beliefs different from theirs.  The Guidance covers issues where personal beliefs are most likely to create some degree of moral discomfort and include subjects such as termination of pregnancies, the wearing of religious clothing that conceals one's face, the treating of certain religious groups without blood products, male circumcision and cremation.  

The GMC is right to make its guidelines on the subject primarily patient-centred.  Although the guidelines are meant for doctors and do take into account the fact that sometimes doctors' personal beliefs will clash with those of their patients, the guidelines are right to focus on what is morally appropriate for the patient.  Patients visit doctors for the purpose of treating or curing their own medical conditions. These cures or treatments ought to take into account the patient and not solely the illness. This approach is routinely considered morally appropriate in today's society where the doctor-patient relationship is more consent-based and where the patient determines the course of treatment, and not paternalistically based, where doctors decide what is in their patients' best interests.  Similarly, where personal beliefs are concerned, it is those of the patient that ought to be considered when determining an appropriate course of treatment and not those of the doctor.  Apart from the fact that it would be morally wrong for the doctor's personal beliefs to influence the treatment that a patient receives, it would also not be relevant.  Patients have their individual conceptions of well-being and part of that conception sometimes includes factoring their personal beliefs into their decision-making process.  This also means that if doctors, as patients, were faced with the same situation, it would be entirely appropriate for their personal beliefs to influence their own care.  

The Guidance is explicit in advising that doctors ought not to express or discuss their personal beliefs with patients unless doing so is relevant to patient care.  And although it can be wrong to express or discuss a belief for the reasons discussed above, what does it really mean to express a belief?  Further, is it possible to express one without even intending to do so?

It might be possible to follow the GMC Guidance with regard to verbal communication but the Guidance does not and cannot account for non-verbal communication.  Even if doctors adhere to the Guidelines and refrain from discussing their personal beliefs, patients might draw their own conclusions about their doctors' personal beliefs through other methods.  It is near impossible to meet someone, whether or not the person is a doctor, and to draw no conclusions whatsoever about their personal beliefs.  Human nature is such that we observe, learn and ultimately draw conclusions or judge.  Whether we judge positively or negatively depends on what we consider positive or negative.  Many of these conclusions are based on factors that are not expressed verbally and are yet often visible such as nationality, ethnicity, accent, surnames, dress, the wearing of religious symbols, etc.  

The problem with these expressions of personal beliefs is not only that they are unintentional but also that they can be inaccurate.  Some religious symbols, for example, are also worn as jewellery.  Sometimes these symbols are worn because those who wear them may technically belong to a certain religious or cultural group but may not necessarily follow all the beliefs of that group.  And at other times these symbols are worn as a mark of respect for what they represent although, again, the individual may not follow all the beliefs of the group or faith that he or she is respecting.  If a non-verbal expression of personal belief is accurate, then its effect is similar to a verbal expression of personal belief.  But notice that even if it is not accurate, it has the same effect.  To the patient who has a certain perception, the conclusion that he or she may arrive at is the same.  For that individual, the doctor has a certain personal belief and this belief may influence treatment.  

These problems are not discussed in the GMC Guidance but given that they are irresolvable, the GMC is right to suggest that we focus on the patient and place his or her care and personal beliefs above those of the doctor.  What lies at the centre of the Guidance is the idea that personal beliefs ought not to threaten the doctor-patient relationship. The foregoing discussion is not intended to suggest that any part of the GMC guidance is flawed.  It merely draws one's attention to scenarios that are irresolvable regardless of any Guidance.  In light of these problematic scenarios, the Guidance deserves even greater moral consideration so that at the very least those problematic situations involving verbal expressions of personal belief that can be avoided are avoided.  The Guidance also states. "Patients may find it difficult to trust you and talk openly and honestly with you if they feel you are judging them on the basis of their religion, culture, values, political beliefs or other non-medical factors."  What is also true is that patients might find it difficult to talk openly and honestly to doctors if they (patients) are judging them (doctors) on the basis of the same factors.