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.

General Pharmaceutical council & conscientious objection

Though the first of the seven principles of pharmacist professionalism published by the GPhC is "To make patients your first concern", the GPhC's draft standards allow pharmacists to refuse to hand over items that they find distasteful to their beliefs such as emergency contraception. This 'conscience clause' sounds to me as though the first concern is the pharmacist, not the patient.

As this article from the BBC details, a pharmacist refused to hand over the contraceptive pill to a woman, who was told to come back the next day when a member of staff who did not have such objections would be available.

Similar goings on in the US; in 2004 a rape victim was refused emergency contraception in Denton, Texas by 3 pharmacists, who refused to dispense the prescription due to their religious beliefs. In 2005 a Milwaukee pharmacist berated a woman with a prescription for EC shouting “You’re a murderer! I will not help you kill this baby. I will not have the blood on my hands.” In the US, the legislative situation is complicated; conscience clauses are endorsed or forbidden by local state law or alternatively by pharmacy boards, and these laws/codes may apply either to the pharmacy or indvidual pharmacists. Three states have passed laws mandating pharmacies to fill valid prescriptions (with a further state - Illinois - legislating that pharmacies must dispense birth control pills if stocked); a further three have pharmacy board statements requiring pharmacists to dispense valid prescriptions (source: Guttmacher Institute and National Women’s Law Center, 2008).

Back in the UK, the GPhC's draft standards state "3.4 Make sure that if your religious or moral beliefs prevent you from providing a service, you tell the relevant people or authorities and refer patients and the public to other providers".

The draft standards are available at http://www.pharmacyregulation.org/imagesandvideos/gphcstandardsconsultationfullsetoffourstandards2417.pdf

A consultation exercise is running on the draft standards until 28th May 2010 at http://www.pharmacyregulation.org/getinvolved/consultations/standards/fullconsultation/index.aspx

The council should be urged to remove the 'conscience clause' which essentially gives pharmacists the arbitrary right not to dispense medication that has been legally prescribed by a doctor. Whilst conscience clauses may be acceptable in certain situations e.g. a pacifist stance upon conscription to the army, pharmacists are not conscripted. As LaFollette and LaFollette state in an excellent article in The Journal of Medical Ethics (J Med Ethics 2007 33: 249-254):

Some medical professionals want to follow their private consciences without having to sacrifice their livelihood. We understand that. However, since their actions standardly affect others, often profoundly, we should not straightforwardly let them act on that conscience, especially since in their roles they uniquely satisfy some public needs. We should not recognise—nor should medical professionals claim—an unqualified right of conscience.

(Thanks to Epsilon Clue for this one: The Washington Post reports on a 'pro-life' pharmacy which recently closed down due to a lack of customers).