Thou shalt not judge. A GP asked me recently whether he should sign patients off sick when he thought they were swinging the lead. I talk to a lot of GPs and I get asked a lot of difficult questions – it goes with the ethics territory – but this one looked like a no-brainer: if you’ve got good reasons to believe that someone is not sick, don’t sign them off. Why lend your hand to a fraud? I’ve also knocked around this territory long enough to know that, for good and ill, things are never, ever that straightforward. We were in a less than affluent part of Manchester. Outside high rises lowered over wind-scoured scraps of grass. Employment levels in the area were as low as the cloud cover. I know they’re trying it on, he said. They’re totally capable of working, but they can’t be bothered. Across the table a GP colleague – did it make a difference I wonder that she was, well, a she? – bristled very slightly. It’s not that straightforward, she said. Psychosocial burdens are as debilitating as physical ones. There is more to sickness than aberrant biology. I listened to them talk for a while and it was almost as if there were two different kinds of medicine in the room, two different versions of the GP’s job, two different takes on the human predicament. Are we the products of our environments or of our choices? Does medicine have a role in dealing with social as well as biological pathogens? I am not sure I have ever seen the struggle over the soul of medicine dramatised quite so urgently.
I have been brooding on that conversation ever since. The first doctor, let us call him Dr A, working, loosely speaking, on a biomedical model, seemed to be making the following assumptions:
- That a doctor’s primary role is to treat disease, defined as a more-or-less identifiable deviation from normal, ‘species-typical’ functioning that is usually betrayed by clear biological markers
- That medicine operates according to an objective standard that is unaffected by the environment
- That people are not determined by their environments but can make choices independent of them
- That “intuition” and inference are reliable indicators of whether someone who says he is sick is actually sick
- That a GP’s role is to help the sick, not pander to the undeserving well
- That GPs are at risk of being dragged into a lively fraud whereby the workshy bulk out their benefits by getting ‘on the sick.’
There is an attractive, almost Johnsonian common sense to much of this. It also appeals to our everyday self-understanding: mostly we know when we are sick; we know that we are capable of making choices; we know that ‘tis human to backslide, and rational to increase our income without increasing our labour.
Dr B however was singing from a very different, largely psychosocial hymn-sheet. Behind the individual patient loom the complex social drivers of pathology. So called free choices can carry a buckling load of social deprivation. Dr B’s assumptions seemed to include the following:
- That ill health is much broader than disease and is a complex category, a protean composite of biological and social pathogens
- That, like small boats on a turbulent sea, our apparently free choices are often compelled by deep-running social currents
- That medical instincts and intuitions are too often biased by our own values to be much help in assessing sickness – that everyone should be assessed by the same clinical standards and that every consultation should be a fresh consultation – this time the patient really could be sick
- That a GP’s role is to support her patients, not to act as agents of the state
I realise that there has been a great sea of ink spilt on the various models of ill health – biomedical, psychosocial, biopsychosocial – and I have no wish to reprise them here. Each has its appeal, each has its drawbacks. The first can make us too much the agent of our destiny, the second too little. We seem closer to complex reality when we try to pull the truth in each of them together. But in the midst of so much uncertainty, how, to return to the question, should the doctor act? Should he sign them off sick? Well no. In the face of irremediable complexity it can help to keep a few simple truths to hand. If the doctor has a reasonable belief that the patient is trying it on – and the reasons should of course be good ones – then he should decline. Politics is the proper response to social injustice, not fraud, and it scarcely needs saying that doctors should have nothing to do with fraud.
Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.
See also: Fit for work