Friday, 27 August 2010

Religious doctors more likely to flout professional guidelines on end of life care

A study finds that doctors who are religious are less likely to discuss options about end-of-life care than non-religious doctors (specifically, options relating to deep sedation and withdrawal of treatment that may be expected or partly intended to end life). These findings, reported in all the major media yesterday, suggest that religious doctors break GMC guidance (the UK General Medical Council) which states that end-of-life care issues such as withdrawal of feeding, 'do not resusitate' orders, and treatment decisions that may hasten death should be discussed with patients who have a terminal illness at the earliest appropriate opportunity.

Darwin used to extol the virtues of writing down any and every thought that might refute one's favoured hypotheses, and consider them at length. The results of this study agree with how I think religious doctors are likely to think and act. So, in case I am blindly accepting empirical data with preconceived notions, let's try to consider if the papers conclusions could be wrong: that it's possible that religious physicians are NOT more likely to break GMC guidance on end of life care. Possible methodological flaws that make this more likely include:

1) The doctors to whom the questionnaires were sent are not representative of their profession, or faiths.
2) The doctors who returned questionnaires represent a biased sample.
3) The doctors who returned questionnaires incorrectly recalled (or deliberately mis-stated) how they handled the cases of their last patient who died.

The paper, by Prof. Clive Seale at London University and published in The Journal of Medical Ethics, considers each of these possibilities. With regards to 1), the sample of doctors was selected to include disproportionate numbers of palliative care specialists, geratologists, and neurologists, whom are involved in complex end-of-life cases (e.g. in the case of neurologists, multiple sclerosis, motor neurone disease). The sample is thus biased, but biased in order to better elicit a good answer to the question in hand. With regards to 2), 42.1% of the 373 doctors sent questionnaires replied, and the proportion was as high as 67.3% for the palliative care specialists. This seems a relatively decent response rate for a postal survey to busy professionals. Furthermore, the author presents data to show that responders were not significantly different in attitudes from non-responders (whose attitudes were elicited by follow-up in another study).

3) is likely to be a far more valid criticism of the study, but it is also a problem with any attitudinal/self-report study. Although the questionnaire was anonymous, if I were a devotee of a religion which held as a core tenet that life should be preserved at all cost (even if the patient's suffering is increased as a result of my belief), I would certainly want to report that I never consider treatment that might shorten patients' lives (in case my deity took note of my response). And if I were an atheist doctor, I might want to show my support for the doctrine of double effect by answering that I consider terminal sedation a great way to avoid unnecessary suffering, even (but no because) it hastens death (the study also found that non-religious doctors are approximately twice as likely to report having taken treatment decisions that might be expected or partly intended to hasten death).

The British Medical Association said in response to the study: "Decisions about end-of-life care need to be taken on the basis of an assessment of the individual patient's circumstances - incorporating discussions with the patient and close family members where possible and appropriate. The religious beliefs of doctors should not be allowed to influence objective, patient-centred decision-making. End-of-life decisions must always be made in the best interests of patients."

Likewise, Dr Ann McPherson, the Oxford academic, GP, and patron of the charity 'Dignity in Dying' added that "The fact that some doctors are not discussing possible options at the end of life with their patients on account of their religious beliefs is deeply troubling". And, in spite of being an argumentum ad verecundiam, as a recipient of a CBE for her lifetime campaigning for patient choice, as well as being a terminally ill patient herself, Dr. McPherson's views might be thought somewhat more weighty than the author of this blog.

Unfortunately for those such as Dr. McPherson who believe that patients have a right to be involved in decision-making about their treatment, where ethical guidelines clash with religious beliefs, doctors appear to prefer the codes of their ancestral belief systems instead of the latest GMC guidelines. Whilst quality of end-of-life care is ranked higher in Britain than any other country, the moral of the story is, as soon as you are diagnosed as terminally ill, ask whether your doctor is religious. Or get a tattoo.


  1. This is interesting, because as far as I know no one discussed end-of-life treatment with either my father, who was terminally ill, or me, who had Power of Attorney for care. They did give him morphine and I think that it hastened his death, but no one wanted to see him in pain. His viewpoint was very time-limited by then as he was extremely forgetful.

  2. I wish that someone had discussed it, but they seemed determined to sweep it under the carpet. Maybe we have forgotten how to die well.

    The surgeon came along later and patted himself on the back about prolonging my father's life, approximately doubling the survival time since surgery. He didn't say anything about not following up to get my dad in for checkups which might have prevented the recurrence of cancer. But even if he did, my father would have forgotten to go.

    By the way, you should mention that "GMC" stands for the U.K.'s General Medical Council. I had to do a web search to find out.

  3. Thanks Mona for your thoughtful comments. I think (hope?) many healthcare professionals feel a pang of shame (or what might be termed ‘ethical dissonance’) when prolonging a life which ‘isn’t worth living’. At the moment the assisted suicide/terminal sedation/life-shortening treatment/euthanasia debate is controlled by individuals who profess that protection is needed for those who might feel under pressure to have their lives shortened. We are much less mindful of those many patients (and their relatives) who feel under pressure to have their lives LENGTHENED by the status quo, frequently with appalling consequences to dignity and suffering. Ed

  4. p.s. good point about GMC and using acronyms which is something doctors are extremely guilty of. Have amended post to make it clearer!