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Good Medical Practice - A Draft for Consultation

Response to the General Medical Council from the Christian Medical Fellowship

30 November, 2005
Christian Medical Fellowship (United Kingdom)
Reproduced with permission


When may a general practitioner refuse to accept a patient?

We quote this excerpt from the GMCs Contractual arrangements in health care: professional responsibilities in relation to the clinical needs of patients (May 1992, paragraphs 15 - 17):

'(15) … Since the NHS began a few general practitioners have used their right to remove patients from their lists for reasons which have included, for example, old age, severe disability or drug addiction, on the grounds that such patients are costly in terms of time and effort needed to provide care. … (16) … The general position is worth re-stating. Patients have a right, enshrined in law, to choose their family doctor. Doctors have a parallel right to refuse to accept patients, or to remove them from their lists, with no formal obligation to give reasons for their decision. These rights flow from the belief that a satisfactory relationship between patient and doctor will arise only where each is committed to it; consequently, if either party believes that the relationship has failed, they have a right to end it. …

(17) … Given this, family doctors, as the professionals involved, have special responsibilities for making the relationship work. In particular, it is unacceptable to abuse the right to refuse to accept patients by applying criteria of access to the practice list which discriminate against groups of patients on grounds of their age, sex, sexual orientation, race, colour, religious belief, perceived economic worth or the amount of work they are likely to generate by virtue of their clinical condition.'

We have particular concerns about the issues relating to conscientious objection. Currently this mainly operates in relation to abortion, although there is also a clause in the HFE Act, and if assisted dying is legalised in the UK we expect another similar conscience clause. Some doctors will have issues of conscience for example if asked to sign off a 'welfare of child assessment' for a lesbian couple to have IVF treatment, or perhaps to refer some couples or single patients for infertility treatment. Many doctors will struggle to maintain a clear conscience while prescribing contraceptives for teenagers, or counselling a 12 year old who is seeking an abortion and refuses to have her parents consulted.

It is increasingly important to our members that the laws which define acceptable medical practice do not also force them to provide to patients whatever is deemed 'acceptable' within the law.

We therefore feel it is important that the freedom of doctors to take a patient off their list is retained and emphasised. We have concerns about the activism expressed by certain groups to 'out' doctors with conscientious objection.[1] We are also aware of other groups that may tend towards activist approaches in their campaigning. In light of this we feel it is important that doctors should be able to remove someone from their list if they feel threatened in this way, or judge that they may frequently be unable to meet the patients' treatment requests.

Questions 31-32 / Paragraph 6:
Conscientious objection and referral

31. Is it clear this paragraph relates to doctors' beliefs about procedures and not their beliefs about their patients?

Yes.

However, regarding referral, we are concerned that this might have the effect of requiring a doctor who had a conscientious objection to abortion to refer a patient requesting abortion to a doctor who would have no such qualms. We believe that as a matter of law such a requirement would fall foul of the conscientious objection clause in the 1967 Abortion Act. To refer is certainly to participate in abortion. To say otherwise is to assert that referral is a merely administrative act - a conclusion which would have worrying ramifications for general practitioners and hospital clinicians alike: it would imply that the GP was simply a post-box and that hospitals could ignore as unconsidered what the GP said. Further, to require such involvement in abortion would be to breach the doctor's right under Article 9 of the ECHR. A guideline imposing such a requirement would accordingly be unlawful and susceptible to judicial review.

Comments on other paragraphs
Paragraph 27: Maintaining trust in the profession / expressing personal beliefs

Paragraph 27 is open to broad interpretation, and needs to be clarified. The way we express beliefs in everyday life can be perceived in many different ways. A belief expressed in one way may be perceived by one listener as not distressing, and another as distressing. Our knowledge of the person concerned may allow us to predict the response, but we can often be wrong. The same applies to doctor patient interactions. Instead of using the phrase 'in ways which are likely', which is open to interpretation, motivation should be used: 'You must not use your professional position to express personal beliefs in a way motivated by a desire to cause distress or exploit the patients vulnerability.'

It may be further problematic, as sometimes patients need to hear comments that they may initially find distressing but which are for their ultimate good. For example, asking 'Do you think it is good for your health to be sleeping with so many partners?', and expressing an opinion on that topic (see our above response to Questions 3-8 / Paragraph 5).

Some might see discussion of faith issues in the course of a consultation as likely to cause distress, as it inherently introduces ways of looking at the world that may be new, unfamiliar and challenging to the patient. However, this may ultimately work for the patient's well being if it encourages them to think through their lifestyle choices more, or gives them opportunity to investigate a helpful faith perspective that they may not otherwise have had. There is abundant medical literature now on the clear link between faith, lifestyle and good health; and the sensitive and appropriate use of discussion about spiritual values and faith perspectives may well provide benefits for the patient.

We are concerned that the case for being 'vulnerable' could apply to any doctor-patient relationship and so might be used to outlaw any mention of spiritual matters or faith perspectives in the clinical setting.

Quoting from the GMC's Annual Report (1993:4) regarding Doctors' use of professional standing to promote personal interests or beliefs:

'The Committee's attention was drawn to the activities of a very small number of doctors who use their professional position to proselytise patients, or who offer diagnoses based on spiritual, rather than medical, grounds. The Council has hitherto taken the view that the profession of personal opinions or faith is not of itself improper and that the Council could intervene only where there was evidence that a doctor had failed to provide an adequate standard of care. The Committee supported that policy and concluded that it would not be right to prevent doctors from expressing their personal religious, political, or other views to patients. It was agreed, however, that doctors who caused patients distress by the inappropriate or insensitive expression of their personal views would not be providing the considerate care that patients are entitled to expect.'

This statement affirms that discussion of personal religious, political or other views by the doctor to the patient is admissible provided that it is done in a way that is both appropriate and sensitive. We recommend that this statement, or words to the same effect be incorporated into the guidance so that the situation is further clarified. It is important that the doctor as an individual, with all that s/he brings to the consultation, is recognised and upheld in the Good Medical Practice document as an autonomous being who is free to express opinion and belief.