We have lately been asked for an opinion on whether doctors who may be exposed to the coronavirus are under an obligation to remove their beards—and, presumably, any other facial hair that may potentially impede the effectiveness of an FFP3 respirator. As with many an ethics question it is trickier than it looks.
First up is the question of proportionality. Is the removal of beards necessary? FFP3 masks are recommended to protect staff from aerosolised pathogens. They differ from those standard surgical masks increasingly seen on wary members of public, which are designed as a two-way barrier to droplets—and a handy way of stopping wearers touching their mouths. Not much good in a flu pandemic. FFP3 masks, in contrast, require a clean seal between mask and face. Although we have no RCT-buttressed evidence that FFP3 masks are effective, professional opinion supports their use.
When considering proportionality, we should identify relevant rights and consider how they can best be balanced. First comes patient safety. Primary is the right of patients accessing health services to be protected from avoidable harm—and from this everything else stems. If the wearing of beards presents a direct risk to patients, then a duty arises on behalf of the healthcare provider to ensure that patients are treated by health staff without beards.
Ethically twin to obligations to patients are employers’ obligations to protect staff. They have legal—and moral—duties to identify and control workplace risks that may harm their employees. This extends to consulting with staff, giving information about the risks, along with training and advice on how to manage them—including the removal of beards if required.
Employers must also deal with questions of fairness and equality within the workforce, balancing different impacts on different groups. For example, if doctors with beards refuse to remove them it may impose an unfair burden on women and beardless men. If covid-19 presents a serious risk to health, surely it would be unfair for those who prefer to wear a beard to forego treating patients who may be infected with it?
The short answer to that is yes—in so far as choosing to wear a beard is a sartorial preference. However, where doctors are under a religious duty to wear beards, requiring them to shave could risk claims of indirect religious discrimination. Once again though, things get tricky. Under the Equality Act 2010 a rule or policy that has a particularly negative impact on a group (Muslim or Sikh men, for example) can still be justified if it is a proportionate way of achieving a legitimate goal—in this case controlling the risks to patients and staff safety and, as far as possible, preventing the spread of the infection. For example, a few years ago a Christian nurse who was moved to a desk job after refusing to remove a visible crucifix at work, lost her case of religious discrimination. The UK courts and the European Court of Human Rights ruled that health and safety considerations justified the NHS dress code policy in that case.
What if a member of staff requests a religious exemption to shaving their beard? An employer would need to consider the impact on the individual of shaving and whether there are other effective means of meeting their clear obligation to provide a safe and effective service. Some employer policies, and the Health and Safety Executive, say that where there is a religious duty to wear a beard, there may be alternative respiratory protective equipment that does not require the tight fitting of an FPP3 mask—a powered air purifying respirator (PAPR) allied with a full head covering. This may though require additional training for staff to use, clean and re-use effectively.
If alternatives are not available, could the member of staff be exempted from treating patients infected with covid-19? The feasibility of this would depend in part on how many staff members are seeking to be exempted and the scale of the impact on healthcare provision and on other staff. It may be possible in the short term to excuse men who wear beards for religious reasons from treating covid-19 patients, but this may get harder if faced with a pandemic.
So, should shaving be enforced? Pragmatically, first steps must be voluntary—a request for doctors to remove beards, with the reasons for it, should be made, bearing in mind the issues of fairness and equality raised above. Practical solutions should be considered: is there alternative protective equipment available in sufficient supply for healthcare staff wearing beards for religious reasons and can staff be trained in time?
A point may come where it is impossible to provide safe cover to patients—without requesting all doctors with beards remove them. Here doctors would be under an ordinary obligation to remove their beards, although obviously they cannot be forced. If doctors who wear beards for religious reasons regard the removal of their beards as absolutely impermissible, we recommend legal advice is sought on how health and safety obligations interact with equality legislation in the facts of their particular case. It is very likely that a Tribunal would take into account the impact of a requirement to remove beards where an individual has demonstrated a deep and long-term commitment to such an obligation, and the removal of a beard would be an occasion for deep personal distress.
A colleague recently sent us a link to a BBC story about the Wuhan outbreak. It showed Chinese doctors shaving each other’s heads to prevent infection. We don’t know the backdrop to the story, but cultural differences are endlessly fascinating. At the risk of repetition though, where beard wearing is a sartorial preference, the interests of patients take priority. Where it is a religious obligation, all reasonable efforts to accommodate should be made. If those efforts have been made and things become more difficult, it will be harder to argue unlawful religious discrimination. However, legal advice should be sought on the application of such a policy to an individual for whom shaving would be completely impermissible, including the possible consequences for employment and professional practice.
See also: Sixty seconds on beards
Julian Sheather is ethics manager, BMA.
Sally Brett. Head of Equality, Inclusion and Culture, BMA.
The views expressed in this opinion pieces are entirely the authors’ own.
Competing interests: None declared.