By Zeshan Qureshi and Mehrunisha Suleman.
(As a medical professional, I will: Make the care of patients my first concern.)
Doctors are trusted to make life-saving healthcare decisions. As a result, a duty of care towards patients must be a priority; no doctor should ever make a professional decision without appropriate consideration of the impact on patient care. This principle is embedded in General Medical Council’s (GMC) Good Medical Practice (GMP). However, we object to GMP establishing it as a doctor’s first concern, at the apex of a doctor’s responsibilities.
We argue that the duty to patients ought to be framed as a relative rather than an absolute duty. GMP needs to recognise that sometimes other concerns may take priority. This does not mean neglecting patients. Rather, we argue that a duty to patient care should not be instrumentalised to justify violation of other rights. GMP creates a hierarchy of rights, enabling employers to force doctors to always put ‘duty of care’ ahead of anything else. This undermines the rights of doctors. We will examine the intersection between the rights of patients and doctors, arguing that they are at least equally important, and that in many ways, upholding the rights of doctors benefits patients in the long term. We will demonstrate this both in principal and in current practice.
The right for all people to have access to at least a reasonable standard of healthcare is enshrined in the National Health Service and the World Health Organisation, including for doctors. In general, a patient’s right to healthcare is served by supporting a doctor’s right to health. A healthy workforce is required to deliver optimal care.
Practising medicine in and of itself is a risk to a doctor’s health, particularly in the contexts of infectious diseases and mental health. Regulation around rest periods and limitations around contracted hours of work help reduce risk of burnout. Guidelines around Personal Protective Equipment (PPE) reduce risk of exposure to infectious diseases. Both are at tension with making our duty of care to patients our first concern. In the context of COVID-19, guidelines suggested that even in the case of cardiac arrest, CPR was not to be started until appropriate PPE was donned. Delayed CPR in this context is putting the rights of HCPs above that of the patient, at least in the short term.
Other doctor’s rights directly conflict with any duty of care to patients, but are nonetheless important. During the pandemic, HCP were in such short supply that medical students started working and retired doctors were asked to come back to work. Yet, parental leave was still automatically accepted for those that wanted it. The same went for bereavement leave or a doctor needing to attend to their sick child. These processes prioritised a doctor’s right to a family life over a duty of care to patients. Similarly, every doctor has the right be treated with dignity. When patients are abusive to doctors, unless they are seriously ill, HCP have a right to decline care. A doctor being racially abused by a patient they are cannulating for intravenous antibiotics is having their dignity compromised. Here, the right to dignity trumps the patient’s right to care.
The first commandment of GMP gives primacy to the rights of patients over doctors. In practice, there is not a hierarchy of duties, and this ought to be better reflected in GMC guidance.
Being a doctor involves sacrifices, some of which are unavoidable. Some people need to work night shifts, despite the inevitable detrimental effect on health. There will always be a degree of risk in being around patients with infectious diseases for a doctor treating them. Working beyond contracted hours, although it can be reimbursed or paid back in time off, is sometimes inevitable in the context of an extremely unstable patient.
However, doing what’s best for the patient, whilst central to the role of doctor, as has been shown by examples above, is not an absolute duty. The sicker a patient is, the higher they ought to be prioritised, but we must recognise that if there is a conflict with the rights of doctors, the two sets of rights must be carefully balanced. More generally, the precedent of putting patients first leads to erosion of the basic needs of doctors. It has no doubt contributed to accepting poor doctor to patient staff ratios, pay erosion, and a mental health crisis amongst doctors.
We need to change the language of the GMC guidance. “Make the care of patients my first concern” inevitably demotes the rights of doctors to a secondary consideration. Instead, let’s move towards a conceptualisation of valuing both patient and doctor’s rights, and a nuanced discussion when they conflict. Such language recognises the importance of patient care to a doctor’s duties, whilst also giving room to uphold the rights of doctors more fairly. Such leadership, appropriately valuing doctors, may improve staff wellbeing, retention and recruitment.
Authors: Zeshan Qureshi and Mehrunisha Suleman
Affiliations: ZQ: Department of History and Philosophy of Science, University of Cambridge London School of Paediatrics; MS: Ethox Centre, Nuffield Department of Population Health, University of Oxford I have no competing interests.
Competing interests: None declared