Friday, 3 August 2007


I was chatting with Martha the other day; she mentioned that she was planning to stay in a cottage on holiday so with a twinkle in my eye I asked her whether she was going cottaging. From her puzzled expression it was clear she didn't know that this is slang for casual gay sex in public lavatories. I explained this and also described the art of promenading, by which gay men can identify each other in the street. I knew this from reading the excellent columns written by Matthew Parris rather than from personal experience. On the spectrum of sexuality I am pretty near the heterosexual end. I regard homosexuality rather like football: I can understand the attraction but it doesn't do anything for me. Having said that I did once watch Swindon Town play, but I don't want to stretch the analogy too far!

I mention this because some ten to fifteen years ago we had a reputation of being a “gay-friendly” practice. In fact we weren't gay-friendly at all, we were simply gay-neutral at a time when many practices were, rightly or wrongly, perceived as being gay-hostile. When I started in practice I was still a rather sheltered middle-class boy, and I learned so many things about my patients' lives that were completely outside my experience that the fact that some of them were gay seemed unexceptional. A GP's surgery is like the old slogan for the News of the World, “all human life is there”.

I very much hope that we are no longer considered gay-friendly, but for the good reason that other practices are no longer seen as gay-hostile. But we still have a large number of gay patients who come to see us, the women mostly seeing Martha and the men mostly seeing me. When a patient talks about their “partner” my ears prick up, waiting to see whether the partner will be referred to as he/his or she/her. If the plural they/their is used then clearly the patient is trying to hide the partner's sex, and I try to indicate by using the appropriate singular form that I realise that they are a same-sex couple but it's no big deal.

Because it is no big deal. I generally take my patients as they are, and accede to their requests as long as they don't appear harmful. But for a long time I worried that my tolerance meant that I was morally lax. Was I simply afraid of saying “no” or causing an upset? Some of my partners who have strong Christian faith suggested to me that I wasn't strict enough when seeing women who requested terminations. This upset me as I am a Christian myself, although not a very good one. I didn't feel able to recommend my personal moral choices to others, and saw this as weakness rather than a virtue.

More recently I was worried about the GMC's edict that doctors should not impose their morality on their patients. This was ironic since the GMC was only forbidding something that I had never done, but there is a difference between a personal decision and being told what to do. I tend to catastrophise in my thinking, and somehow I supposed the GMC were saying that our surgeries should be a morality-free zone, and that if a patient expressed a wish to murder his neighbour we should merely advise on the risk of arrest and conviction rather than suggesting that he ought not to do it. I worried about future social cohesion if doctors were not allowed to promote any form of moral structure, particularly among patients whose lives are disorganised. Reflecting on this post has made me realise that we are still allowed, and indeed encouraged, to promote moral principles such as honesty, tolerance, concern for others, and “do as you would be done by”; by inference and example as much as by exhortation. What the GMC don't want us to do is to promote (subtly, or not so subtly) moral or ethical systems which are peculiar to just part of society.

I don't try to hide my religious beliefs, but I never mention them unless asked directly. I remember at the end of one consultation, during which nothing religious or moral had been discussed, a patient asked me “are you a Christian?” When I said yes she replied “I thought so” in a friendly way. In retrospect I think that was high praise. If only I could live up to that standard most of the time!


The Shrink said...

Morality, a curious one, that.

Prejudice, that's straight forward. I'd hope none of our medical colleagues would be allowing personal prejudice to colour clinical decision making.

As you say, morality would impact on negative life choices (like suicide or homicide) and it would seem non-sensical and unethical to countenance such actions since they're autonomous patients and such choices are outwith the medical counsel we should proffer.

We often have a range of options to put before a patient, to choose from. I am sure that although I don't consciously attempt to, I must use language and communication that favours the less destructive and what I'd see as the most favourable intervention to try first.

I guess I would see this as beneficence and thus a form of morality.

D'you reckon the GMC will come knocking?

Anonymous said...

The GMC:
I guess if you can show you keep your e-copy of Good Medical Practice open and refer to it on a regular basis you will gather up the odd credit with the GMC.

Morality and prejudice:
The thing is not to expect to have no personal moral framweork or prejudices but to recognise and acknowledge them so that you can take into consideration in the consultation your own characteristics as well as those of the patients.

Anonymous said...

In the psychotherapeutic setting - in my case a classic "talking cure" - I have been exposed by my shrink, a psychiatrist and psychotherapist, to morals and an outlook on spirituality that could be considered non-mainstream and therefore "peculiar to just part of society."

I wasn't perturbed by this because there was a) a link to the issues we were working through at the time and b) he knew me well enough to be confident that I could form my own decision and draw my own conclusions on his views and opinions and wouldn't regard them as gospel.

I was very glad he did this because I believe that in a healthy, longstanding therapeutic relationship it is important that the patient should know what the therapist is about, not just the other way round. Successful psychotherapy is a two-way street.

In my opinion, a GP who presents himself/herself to the patient as a person with a defining sense of integrity without forcing his specific beliefs on the patient must be doing everything right, edict notwithstanding.

Dr Andrew Brown said...

The Shrink: Quite often we will recommend (overtly or covertly) one course of action over another. It's benificence as long as we do so because we think it's better for the patient and not because it benefits ourselves in some way.

Anonymous: Perhaps I should work through the Duties of a Doctor one by one? Yesterday I showed how I listen to patients and respect their views. Tomorrow I shall demonstrate giving patients information in a way they can understand. But today we have naming of parts.

You're right about recognising our own prejudices. A certain regional sub-group of the British irritate me for no rational reason, and I have to bear this in mind whenever I see such a patient.

Orchidea: I guess that the GMC would be concerned about two situations. First, where the doctor attempts to impose his beliefs on his patient. It sounds as though your therapist did not do so. Presumably it would be just as wrong to pretend that one did not hold one's beliefs. The other is where the doctor's beliefs prejudice the patient's care.

It's another matter whether the patient believes the doctor is unprejudiced. "Good evening, I've got a little free time before I go off to chair the Catholic Pro-Life committee meeting, now do come in and tell me about your unwanted pregnancy."