Early on in my ‘career’ in ethics – I put the word in scare quotes not only because the idea that my rather shapeless crashing about should be dignified with the name ‘career’ makes me chuckle, but also because the idea of a career in ethics itself has always felt like a category error – I vividly recall a passionate young consultant explaining to me, with complete candour, how she had ignored a direct refusal of treatment by an obviously competent young man. The patient needed a tracheotomy – without one he would die – but he refused it. The doctor knew that at some point he would lapse into unconsciousness, and when he did, he would give him the tracheotomy. She could not, on principle, stand by and watch the young man die. This was many years ago now, but I was reminded of it by the recent media kerfuffle about a research article published in the Journal of Medical Ethics entitled ‘The role of doctors’ religious faith and ethnicity in taking ethically controversial decisions during end-of-life care.’ The findings were drawn from a survey of more than 8500 British doctors from a range of specialties designed to see what influence religious belief – or its absence – had on end of life care. The findings were controversial – it is not every day that the Journal of Medical Ethics gets such a media outing – with Sarah Bosely at The Guardian leading with “Atheist doctors ‘more likely to hasten death'” and Jenny Hope at The Daily Mail warning us that “Doctors without religious beliefs more likely to help patients to die”. Although none of these headlines are exactly untrue, they are an object lesson, should anyone still require it, of how newsworthiness can be the enemy of the truth, or at least of careful thought. Read by the unwary, these headlines suggest that atheist doctors are less likely to be on the side of the dying. But the article itself says something different:
“…being ‘very or extremely non-religious’ increases the odds of a doctor reporting sedation or a decision with some intent to end life. Palliative care doctors are particularly unlikely to report decisions with some intent to end life, regardless of the strength of their religious faith. The results also show that willingness to discuss with a competent patient a decision expected or partly intended to end life is less likely if a doctor is very or extremely religious, regardless of either specialty or ethnicity.”
Given that the interventions under consideration – deep sedation for example – are, where clinically indicated, an entirely legal option for end-of-life care, the article’s findings are some distance from the headlines. Do we really want to hear, in direct contravention of GMC guidance, that doctors who report themselves as ‘very or extremely religious’ are more likely to decline to discuss a range of appropriate end of life care options with competent patients than their secular colleagues?
Both the young consultant and the doctors surveyed in the research were clearly acting on the basis of strong principles. They were morally motivated. The difficulty of course is that they came up against, and in some circumstances violated, another very strong principle, one that it is now widely accepted should supervene, the principle of respect for the informed choices of others, often shortened to the principle of autonomy. In short they put their own version of the patients’ interests first.
Although by contemporary standards these doctors acted inappropriately, their actions nonetheless raise some interesting questions. While the non-religious – and also many of the religious – will probably find it easy to criticise a failure to discuss the full range of appropriate treatment with the dying, many more, I would imagine, would struggle if they found themselves in the consultant’s shoes. To stand by while a young man dies of an entirely preventable illness is unlikely to be easy. It is also worth pointing out in case of doubt that respecting a competent decision to refuse treatment in such a circumstance is not a value-neutral act, it is to put one value – a respect for self-determination – before another, let us call it beneficence. And this is where the problems arise. Medicine aspires to the dignity and objectivity of science. In doing so it lays claim to being, at least potentially, value free. The GMC’s guidance reflects this when it states that explicitly held religious values should not influence the provision of care. Such cases seem clear cut. But can medicine ever really absent itself from value claims about the world and about people’s choices? Is health not just too central to human wellbeing for doctors to be indifferent to any choice that a patient makes? Medicine, after all, will always be a tool held by a human hand, and human life cannot be free from moral evaluation. To muddy the water further, when the young man regained consciousness, complete with tracheotomy, he could not express his gratitude enough. Championing autonomy can also have a terrible human cost.
In the end if we are to accept, as I think we must, that medicine can never be entirely value free, then the best that we can hope for is that doctors be alert both to their own values, and to the impact they may have on their practice.
Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.