Medical practice today is based on a trusting, effective partnership between a doctor and a patient. The doctor must enable the patient to have the information and support they need to make their own, autonomous decisions and to actively participate in their own care. Defining a patient's ideas, concerns and expectations is essential to making a clinical decision which takes account of the patient's values.
Consider the case of Miss B, a student with acne which became suddenly worse during her exams. Her GP advised a long-term course of antibiotics as a step-up from topical treatments. Miss A said she did not want antibiotics, as she believed these to be bad for her health.
Rather than simply accepting the patient's reluctance for the treatment suggested, the GP explored the reasons behind her reluctance. Miss B said she had read that antibiotics caused toxicity in the gut, and that using these would also contribute to global antibiotic resistance. The doctor discussed the side effects and likely effectiveness of the antibiotics he had in mind, the issue of antibiotic resistance and the other treatment options available. He also informed the patient of the potential risks and disadvantages of choosing a treatment. Having had the opportunity to discuss Miss B's concerns and views on the use of antibiotics, they chose an option which the patient was happy to try.
Values and culture underlie a person's beliefs, feelings, fears and expectations of life. In turn, beliefs and expectations – in particular about illness, medical procedures and healthcare – can have a major impact on health behaviour and on a patient's healthcare decisions. Taking the time to explore these beliefs with patients and their families can help to make clinical decisions which are truly patient-centred and which, by maximising patient adherence to treatment, will also make the best use of precious healthcare resources.
What about your own values?
As a doctor you will have your own in-built attitudes, moral values and personal beliefs, influenced by your family background, culture and upbringing. These personal feelings could influence your attitudes and behaviour towards patients, often at a subconscious level. These hidden values might have harmful effects on health outcomes for the patient.
Mrs C was diagnosed with tonsillar cancer. Her oncologist knew of an experimental drug being developed for the malignancy. Because Mrs C's English language ability was poor, the oncologist thought she would have difficulty understanding and complying with the requirements of the clinical trial. As a result, she was excluded from consideration for the trial.
Mrs C's chances of surviving her cancer could have been adversely affected by the doctor's subconscious stereotyping and bias, linking her ethnicity with assumptions about language ability and educational attainment. Use of an interpreter could have bypassed the communication difficulty.
Restrictions on the time available to spend with patients often mean that clinicians rely on conscious or subconscious assumptions or attitudes about patients, despite the best of intentions. Your awareness of your own values and recognition of how these might influence a patient's care is of crucial importance in ensuring ethical medical practice.
Who else's values are relevant?
The law represents those values in society which are considered to be fundamentally important to that society. For example, the need to obtain a patient's consent for treatment is based on Article 8 of the European Convention on Human Rights, which provides the right to respect for one's bodily integrity, as well as common law. Compliance with these 'societal' values, with the law, is an essential part of being a good doctor.
The law underlies another set of important values – the General Medical Council (GMC) codes of conduct. The GMC codes of conduct are essentially professional values which the GMC has published as standards for professional behaviour, and to which doctors are expected to adhere.
Remember Miss B? The GMC would expect her GP to take account of psychological, spiritual, social and cultural factors, her views and values and respect her decision to refuse treatment without being judgemental of her.1
Of course, the GP would also be expected to to give the patient enough information to understand the potential risks and disadvantages of choosing a treatment that might not be the best clinical option, even if it is more aligned with the patient's views and values.
In Mrs C's case, professional values require that the oncologist does not unfairly discriminate against her; that she is not excluded from the benefits of research; is given information in a way that she can understand, and arrangements are made to meet her language and communication needs.
There are other values which are of potential relevance to a clinical consultation. Government policy sets out governmental values and expectations, such as in the NHS Code of Practice on Confidentiality. Clinical guidelines from the National Institute for Health and Care Excellence could be seen as 'values', guiding safe and effective clinical care in the context of optimal use of healthcare resources.
An employer will also have values which influence what a doctor does. These might be stated in your contract or presented to you in the form of a protocol – for example, the hospital or practice complaints protocol or whistleblowing policy, or the local prescribing formulary. An Occupational Health physician or an army doctor might have specific expectations set by their employer, amounting to corporate values, which they will need to take into account in decision-making.
Awareness of the values relevant to a clinical consultation, including self-awareness of your own values, will enable you as a doctor to identify the key considerations involved in making a clinical decision that you can justify based on ethical, professional and legal grounds and that fits with the expectations of patients and families.
FOOTNOTES
1Personal beliefs and medical practice (2013) paragraph 24
Dr Helen Manson
Medico-legal adviser
Dr Helen Manson
Medico-legal adviser
MBChB MRCGP
Helen is a medico-legal adviser at the MDU. Helen has worked in a variety of roles as a GP, and has a Fellowship in Medical Ethics from Harvard Medical School and an academic background in medical ethics education, designing and teaching ethics and law programmes both for the East of Scotland GP Deanery and Dundee Medical School. She also developed a new framework for assessing complex ethical cases for medical and nursing students, now also used in GP training.
See more by Dr Helen Manson