Julian Sheather: Should doctors make moral judgments about their patients?

Thou shalt not judge. There are times when it feels like our eleventh commandment. In our liberal, offence-free world there are supposed to be no good and bad choices, no good or bad lives, only a plurality of equal lifestyles equally deserving of respect. Arguably, the charge of moralism is now more widely feared than the charge of immorality. By what right, we tend tremulously to ask, can I hold that one way of life is better than another? The difficulty though with “non-judgmentalism”—forgive the unwieldy word—is that we human beings just cannot keep ourselves from judging. We are evaluative creatures all the way down. Even the exhortation not to judge contains a judgment. Whenever we desire something we are evaluating it—and just try to stop yourself wanting things. Nor would many people consistently hold that Mother Theresa’s “lifestyle” choice is on a par with, say, Fred West’s. When very widely held beliefs are in violent contradiction with reality, when we say things that are wildly at odds with what we do, the result is either hypocrisy—if we know it—or neuroses and dysfunction where we don’t.

I bring this up because I was recently talking to a bunch of GP trainers about the problems some of their trainees experience when they first open their consulting room doors to the wide and unrelenting world. Among the problems in those early days are what can only be described as value shock. They talked of a trainee from a sheltered background sent reeling by provocatively dressed fourteen year old girls seeking contraception. Drug abuse, shattered families, violence and self-destruction: all in a day’s work for an inner city GP. And GPs are trained to respond to this without batting a moralising eyelid, trained to identify health problems and to provide treatment on the basis of need. They know that they must not, on pain of excommunication, pass judgment on the patients who come through their doors.

Medicine is a demanding and competitive profession. Students work hard to get to medical school, and have to work hard if they are to excel. I  have taught medical students and junior doctors for many years now. When I look at the classes I teach I invariably see as many, if not more, women than men. Ordinarily I will see students from a variety of ethnic backgrounds. But unless I am much mistaken, most of them will be middle class. And those who did not come from the middle class are by and large headed for it. I realise that class is an increasingly slippery concept—or at least the reality to which it points is increasingly slippery—but traditionally among the markers of the middle class have been certain values. These include thrift, hard work, investment in education and training, self-discipline, deferral of gratification, wealth accumulation and a certain emphasis on family and stability. These values—in themselves and in their parents—have no doubt helped students get to medical school. And these are the values that they will largely continue to hold dear as doctors. Any surprise then that a young trainee might suffer from disorientation when confronted with chaotic and self-destructive lives? Any surprise that doctors might at times be tempted to conclude that behind some of the health problems lie moral ones?

Temporarily setting aside the eleventh commandment, should doctors just go right ahead then and tell their patients what they think, in morals as well as medicine? Well no. Firstly because human beings are usually poor judges of others. In a complex world, under pressure of time we are likely to over rely on our prejudices, particularly when threatened (these judgments belong to the quicker half of Kahneman’s Thinking, Fast and Slow and are subject to innumerable irrational biases and interference effects.) Our knowledge of others, of what lies behind their choices can also be scanty:  I see this man’s fall but not his struggle as John Donne somewhere says. There are also the likely consequences of moralising. Patients will simply stop visiting their doctors if they are going to be preached at and invaluable opportunities to provide support can be lost. The bar on uninvited moral judgment is a good one.

But there is a big difference between making judgments and expressing them and problems can arise for doctors where they confuse the two. We make moral judgments—judgements about what is good for us and for others—almost as freely as we breathe. If we try and stop doing it we disfigure ourselves. And if we suppress our judgments, they are more likely to come out inadvertently, through all sorts of non-verbal give aways. Better by far to recognise that we are moral animals, that we have values, that we make judgments. If we know we are making them we can at least ask ourselves if they are reasonable. And where doctors are familiar with their own moral codes they are likely to be a little better placed to understand their impact on others. And, critically, in the consulting room, that little bit better able to draw a productive boundary between their private views and their professional obligations to patients.

Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.