Good Medical Practice - A Draft for Consultation
Response to the General Medical Council from the Christian Medical
30 November, 2005
Christian Medical Fellowship (United
Reproduced with permission
When may a general practitioner refuse to accept a patient?
We quote this excerpt from the GMCs Contractual arrangements in
health care: professional responsibilities in relation to the clinical needs
of patients (May 1992, paragraphs 15 - 17):
'(15) â€¦ Since the NHS began a few general
practitioners have used their right to remove patients from their lists for
reasons which have included, for example, old age, severe disability or drug
addiction, on the grounds that such patients are costly in terms of time and
effort needed to provide care. â€¦ (16) â€¦ The general position is worth
re-stating. Patients have a right, enshrined in law, to choose their family
doctor. Doctors have a parallel right to refuse to accept patients,
or to remove them from their lists, with no formal obligation to give
reasons for their decision. These rights flow from the belief that
a satisfactory relationship between patient and doctor will arise only where
each is committed to it; consequently, if either party believes that the
relationship has failed, they have a right to end it. â€¦
(17) â€¦ Given this, family doctors, as the professionals involved, have
special responsibilities for making the relationship work. In particular, it
is unacceptable to abuse the right to refuse to accept patients by applying
criteria of access to the practice list which discriminate against groups of
patients on grounds of their age, sex, sexual orientation, race, colour,
religious belief, perceived economic worth or the amount of work they are
likely to generate by virtue of their clinical condition.'
We have particular concerns about the issues relating to conscientious
objection. Currently this mainly operates in relation to abortion, although
there is also a clause in the HFE Act, and if assisted dying is legalised in
the UK we expect another similar conscience clause. Some doctors will have
issues of conscience for example if asked to sign off a 'welfare of child
assessment' for a lesbian couple to have IVF treatment, or perhaps to refer
some couples or single patients for infertility treatment. Many doctors will
struggle to maintain a clear conscience while prescribing contraceptives for
teenagers, or counselling a 12 year old who is seeking an abortion and
refuses to have her parents consulted.
It is increasingly important to our members that the laws which define
acceptable medical practice do not also force them to provide to patients
whatever is deemed 'acceptable' within the law.
We therefore feel it is important that the freedom of doctors to take a
patient off their list is retained and emphasised. We have concerns about
the activism expressed by certain groups to 'out' doctors with conscientious
objection. We are also aware of other groups that may tend towards
activist approaches in their campaigning. In light of this we feel it is
important that doctors should be able to remove someone from their list if
they feel threatened in this way, or judge that they may frequently be
unable to meet the patients' treatment requests.
31. Is it clear this paragraph relates to doctors' beliefs about
procedures and not their beliefs about their patients?
However, regarding referral, we are concerned that this might have the
effect of requiring a doctor who had a conscientious objection to abortion
to refer a patient requesting abortion to a doctor who would have no such
qualms. We believe that as a matter of law such a requirement would fall
foul of the conscientious objection clause in the 1967 Abortion Act. To
refer is certainly to participate in abortion. To say otherwise is to assert
that referral is a merely administrative act - a conclusion which would have
worrying ramifications for general practitioners and hospital clinicians
alike: it would imply that the GP was simply a post-box and that hospitals
could ignore as unconsidered what the GP said. Further, to require such
involvement in abortion would be to breach the doctor's right under Article
9 of the ECHR. A guideline imposing such a requirement would accordingly be
unlawful and susceptible to judicial review.
Comments on other paragraphs
Paragraph 27: Maintaining trust in the
profession / expressing personal beliefs
Paragraph 27 is open to broad interpretation, and needs
to be clarified. The way we express beliefs in everyday life can be
perceived in many different ways. A belief expressed in one way may be
perceived by one listener as not distressing, and another as distressing.
Our knowledge of the person concerned may allow us to predict the response,
but we can often be wrong. The same applies to doctor patient interactions.
Instead of using the phrase 'in ways which are likely', which is open to
interpretation, motivation should be used: 'You must not use your
professional position to express personal beliefs in a way motivated by a
desire to cause distress or exploit the patients vulnerability.'
It may be further problematic, as sometimes patients need to hear
comments that they may initially find distressing but which are for their
ultimate good. For example, asking 'Do you think it is good for your health
to be sleeping with so many partners?', and expressing an opinion on that
topic (see our above response to Questions 3-8 / Paragraph 5).
Some might see discussion of faith issues in the course of a consultation
as likely to cause distress, as it inherently introduces ways of looking at
the world that may be new, unfamiliar and challenging to the patient.
However, this may ultimately work for the patient's well being if it
encourages them to think through their lifestyle choices more, or gives them
opportunity to investigate a helpful faith perspective that they may not
otherwise have had. There is abundant medical literature now on the clear
link between faith, lifestyle and good health; and the sensitive and
appropriate use of discussion about spiritual values and faith perspectives
may well provide benefits for the patient.
We are concerned that the case for being 'vulnerable' could apply to any
doctor-patient relationship and so might be used to outlaw any mention of
spiritual matters or faith perspectives in the clinical setting.
Quoting from the GMC's Annual Report (1993:4) regarding Doctors' use
of professional standing to promote personal interests or beliefs:
'The Committee's attention was drawn to the activities
of a very small number of doctors who use their professional position to
proselytise patients, or who offer diagnoses based on spiritual, rather than
medical, grounds. The Council has hitherto taken the view that the
profession of personal opinions or faith is not of itself improper and that
the Council could intervene only where there was evidence that a doctor had
failed to provide an adequate standard of care. The Committee supported that
policy and concluded that it would not be right to prevent doctors from
expressing their personal religious, political, or other views to patients.
It was agreed, however, that doctors who caused patients distress by the
inappropriate or insensitive expression of their personal views would not be
providing the considerate care that patients are entitled to expect.'
This statement affirms that discussion of personal religious, political
or other views by the doctor to the patient is admissible provided that it
is done in a way that is both appropriate and sensitive. We recommend that
this statement, or words to the same effect be incorporated into the
guidance so that the situation is further clarified. It is important that
the doctor as an individual, with all that s/he brings to
the consultation, is recognised and upheld in the Good Medical Practice
document as an autonomous being who is free to express opinion and belief.