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.

I had calling from God to be a doctor, says GP who admits to shortening patients' lives

Dr. Howard Martin, age 75, has admitted he shortened the lives of "scores" of patients by administering large doses of opiate drugs (morphine/diamorphine), to enable them to die at home. He did this out of "Christian compassion":

"I don't believe I've killed any patients. I believe I've made them comfortable in their hour of need. But I am deemed to be arrogant because I used my discretion. They want to extrapolate that to say I'm choosing to kill people. It's not like that. The patients are about to die and I want to make sure they are comfortable. How can a so-called caring society not understand that? How can I be reckless with someone who is about to die?"

Dr. Martin is no doubt correct that there are serious problems with end of life care in the UK and that there is frequently a dissonance between public opinion and criminal law regarding voluntary euthanasia. However, he has also admitted that in two cases he hastened patients deaths without their permission. Professor Steve Field, chairman of the Royal College of General Practitioners, said:

"I'm horrified that the doctor seemed to indicate in the interview that he actually hastened the death of two patients without their consent - I'm speechless."

It is perhaps unsurprising that the GMC panel found that he had an "autocratic attitude" and believed he was always right.

“On Judgment Day I will have to answer to God, and my answer will be this: that I did my best for my patients.”

Dr. Martin's frequent religious references seem to indicate that there is a link between his faith and his medical care (or lack thereof, depending on viewpoint). As considered in a previous post, to make decisions using texts that exalt the stories of a group of iron-age shepherds (instead of using a process of rational and exhaustive ethical decision-making) is a recipe for poor decisions in which the patient comes second to the decision-maker's desire for supernatural approval.

For these reasons, and in spite of the importance of the topic and need for its careful reform, I find it difficult to imagine a worse medically-trained ambassador for end of life care issues than Dr. Martin.

OK, maybe one.

Nun excommunicated for allowing abortion

Various sources are reporting the excommunication of Sister Margaret McBride for allowing a fetus to be aborted which, if the termination had not taken place, would almost certainly have resulted in the deaths of both the mother and the fetus. Bishop Thomas J. Olmstead, after finding out about the abortion, ordered the excommuncation of Sister McBride, every Catholic involved with the decision and the procedure, and indeed the patient herself.

In decrying the doctrine of double effect (for which, ironically, we owe a debt to Catholic theology), Rev. John Ehrich, the medical ethics director for the Diocese of Phoenix stated: "She consented in the murder of an unborn child...There are some situations where the mother may in fact die along with her child. But — and this is the Catholic perspective — you can't do evil to bring about good. The end does not justify the means."

The notion of a medical ethics director abiding not by principles of medical ethics, but by substituting (or overlaying) his or her system informed by faith, is against all tradition of medicine as an activity designed to better the lot of the ill, rather than to better the lot of the decision-maker or his church. Decision-making in medical ethics should shun 'absolute' (deontological) approaches and instead adopt frameworks that help guide the clinician or other agent to the best possible outcome for the particular case being considered by incorporating a wide range of moral considerations. Such a system is exemplified by the decision-making approach from the University of British Colombia detailed here (PDF), or the 'Ethox structured approach' from the Ethox Centre at the University of Oxford, which I reproduce below:

Compare the principalist and reflective decision-making process depicted here which includes elements such as 'Does this option respect the persons involved', with the deontological approach used by Rev. John Ehrich in the case of Sister McBride. His ethics come from the Ethical and Religious Directives for Catholic Health Care Services, Fourth Edition, which states, for example:

Directive 36: Compassionate and understanding care should be given to a person who is the victim of sexual assault...It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum.

The difference between the two methods of decision-making, the Ethox approach designed to produce the best outcome for the patient, and the Catholic approach which will frequently have the opposite effect, is so stark as to negate the latter as a system of medical ethics; it is instead dogma, which should not be tolerated by medicine.

But let us submit ourselves to dogma for a moment. We glance at Directive 47 of the above document:

Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

In light of such provision, the justice administered to Sister McBride appears rather summary and in stark contrast to the leniency shown to the paedophilic actions of thousands of priests.