Respectful Insolence

When religion interferes with medical education

I’ve often written about the intersection of medicine and religion. Most commonly, I’ve lamented how the faithful advocate inappropriately injecting religion into the doctor-patient relationship in a manner that risks imposing the religion of the health care practitioner on the patient, sometimes through physicians feeling no obligation to inform patients of therapeutic options that violate their religious beliefs or pharmacists refusing to dispense medications that (they claim) violate their beliefs. Another common thread running through this blog is criticism of religion when it leads people to reject scientific medicine, be it religious communities that refuse to vaccinate, Jehovah’s Witnesses who refuse blood transfusion based on a tortured interpretation of a single Old Testament passage even if it means their deaths, or parents who think that Jesus will do a better job of taking care of diabetic ketoacidosis than insulin and copious amounts of intravenous fluids. Finally, I’ve always been very skeptical of claims that religion or intercessory prayer somehow helps disease or makes people healthier, when there is no good evidence that it does.

I hadn’t considered how fundamentalist religion might affect medical education until now. Maurice Bernstein notified me of this possibility:

I teach first and second year medical students how to relate to patients, take a medical history and perform the physical examination. My medical school, as do all medical schools in the United States accept students from all different cultures and religions. There are various issues involved in teaching students which arise and need to be resolved despite they have already been accepted to medical school and have begun their studies. I have recently been made aware of medical student issues that happen to be related to students of Muslim culture and religion. The issues do not arise with every Muslim student as far as I know but it has arisen and I really don’t know what the issues represent and how to deal with them yet meet my responsibility to develop a professionally competent physician.

And:

The BMA said it had received reports of Muslim students who did not want to learn anything about alcohol or the effects of overconsumption. “They are so opposed to the consumption of it they don’t want to learn anything about it,” said a spokesman.

The GMC said it had received requests for guidance over whether students could “omit parts of the medical curriculum and yet still be allowed to graduate”. Professor Peter Rubin, chairman of the GMC’s education committee, said: “Examples have included a refusal to see patients who are affected by diseases caused by alcohol or sexual activity, or a refusal to examine patients of a particular gender.”

I don’t deal nearly as much with medical students, although I do frequently deal with residents. I’ve dealt with residents of many races, creeds, and colors, including a number of Muslim and Arab physicians, but have not heard of this problem before. Of course, anyone who successfully competes for residency slots in a quality general surgery program would be unlikely to have done anything that resulted in black marks on his or her record in medical school, otherwise they wouldn’t have been accepted. In any case Dr. Bernstein cites an article from the Times last year, which describes the problem in the U.K.:

Some Muslim medical students are refusing to attend lectures or answer exam questions on alcohol-related or sexually transmitted diseases because they claim it offends their religious beliefs.

Some trainee doctors say learning to treat the diseases conflicts with their faith, which states that Muslims should not drink alcohol and rejects sexual promiscuity.

A small number of Muslim medical students have even refused to treat patients of the opposite sex. One male student was prepared to fail his final exams rather than carry out a basic examination of a female patient.

What I can’t figure out is why this was even allowed to be an issue To me it’s quite cut and dried. Physicians must be trained and competent to take care of all patients. If a medical student refuses to examine or treat a female patient, he should be told quite firmly that he either does what his training requires or he’ll be kicked out of medical school. Then the medical school should have the intestinal fortitude to actually kick him out if he refuses. It is the same thing with regard to alcohol-related or sexually transmitted diseases. Medical school exists to impart a basic set of medical knowledge and skills that all physicians should have. All physicians. Some of those skills may be considered unnecessary in many specialties, but it is important that all physicians at least be exposed to them. Moreover, a major tenet of medical bioethics is that all patients deserve our best effort. While we can make some decisions based on the allocation of scarce resources (for example, refusing to do a liver transplant on an alcoholic with end stage liver disease unless he stops drinking because utilizing that scarce resource to treat someone who’s likely to destroy it by continuing to drink is hard to justify morally or economically), those decisions cannot include the refusal to treat the patient because our religion objects to his or her lifestyle. The same thing would apply to a physician refusing to treat a prostitute because he disapproves of prostitution. The basic principle is that we do not pass moral judgment on our patients, nor do we base our treatment decisions on our approval or disapproval of a patient’s morals.

I wouldn’t hesitate. Any student who refused to learn about alcohol related diseases would still be responsible for the information covered in class and would still have to be tested on it. If he couldn’t answer the questions on the exam, he would flunk that section of the class. Any student who refused to examine a female patient would flunk his physical diagnosis class. It’s just that simple. A person’s religion does not give him the right to pick and choose which parts of the medical curriculum he will study. Part of being a competent general physician is knowing both male and female anatomy and treating both male and female. If he cannot do what is required of him by a medical school to learn good patient diagnosis and care because his religion doesn’t permit it, he should then find another line of work.

What’s interesting to note is that mainstream Muslim organizations reject this line of thinking, although I’m not sure I like the reasoning:

“It is obligatory for Muslim doctors and students to learn about everything. The prophet said, ‘Learn about witchcraft, but don’t practise it’.”

Why he would equate examining female patients or learning about alcohol-induced diseases to witchcraft, I’m not sure. I realize the idea is that both are considered evil apparently, but why on earth would it be evil to learn the basic and clinical science of alcohol damage to the liver or why it would be evil to relieve the suffering of an alcoholic. The only explanation I can think is that it’s the same explanation that fundamentalists use for demonizing people whom they consider immoral: That the alcoholic with cirrhosis deserves his fate and is being punished by God for his immorality.

None of this is to say that a patient doesn’t have the right to choose her medical practitioner. If a woman wants a woman physician, she should be accommodated with in reason. (By “within reason,” I mean that if there’s no female physician around, for example, it’s not necessary to call one in just because the patient wants one.) The point is that the physician doesn’t get to choose that he or she won’t take care of patients of the opposite sex, at least not during training, and the doctor’s employer is under no obligation to retain such a recalcitrant employee. The same thing goes for Muslim women who refuse to wash their hands properly because it necessitates baring their arms above the wrists.

I’m very strongly in favor of freedom of religion or freedom from religion. It’s one of the founding tenets of our great nation. However freedom of religion does not imply that accommodations have to be made for religious belief if they conflict with good patient care. It doesn’t matter if it’s Muslims refusing to learn about diseases whose causes are related to behavior they consider immoral or Christian physicians refusing to disclose all science-based legal treatment options because the conflict with their religion. In medicine, the patient must come first. Medicine is a profession, and professionalism demands it. If a person’s religion will not let him or her do what the profession requires, then that person should not be a physician.

It comes down to is a small number of highly religious people who, rather than accommodating themselves to the rest of society, demand that society accommodates them. It’s not a bad thing for society to make reasonable accommodations, but the key word is “reasonable.” It’s not reasonable to change the standards of medical education or care just because a few fundamentalists object.

Comments

  1. #1 Aaron Golas
    September 12, 2008

    Why he would equate examining female patients or learning about alcohol-induced diseases to witchcraft, I’m not sure. I realize the idea is that both are considered evil apparently, but why on earth would it be evil to learn the basic and clinical science of alcohol damage to the liver or why it would be evil to relieve the suffering of an alcoholic.

    Well, there are two issues being conflated here: learning how to treat, and actually employing that knowledge to treat.

    They’re saying that witchcraft, alcohol, sex, and women are all evil, but it’s still okay to learn about them. Fine. But that then leads us to the next concern: even if they learn how to treat cirrhosis, etc, WILL they? What does the prophet say about healing witches? And is it even possible to learn such things in med school without getting involved with real patients? (That last one isn’t a hypothetical… I don’t know med school. :-P)

    Based on that, it sounds rather like the advice is to keep quiet, do your homework, and don’t raise a fuss until you’re higher on the food chain and harder to get rid of.

  2. #2 Pseudonym
    September 12, 2008

    Finally, I’ve always been very skeptical of claims that religion or intercessory prayer somehow helps disease or makes people healthier, when there is no good evidence that it does.

    Quite right, too. However, it does one important thing which shouldn’t be underestimated: It gives religious patients a tangible sense that their loved ones give a damn about them. You don’t need prayer for that, but it can’t possibly hurt.

    Anyway… apart from the four stray words at the end of the article, very well put.

  3. #3 Oldfart
    September 12, 2008

    What I can’t figure out is why this was even allowed to be an issue To me it’s quite cut and dried. Physicians must be trained and competent to take care of all patients. If a medical student refuses to examine or treat a female patient, he should be told quite firmly that he either does what his training requires or he’ll be kicked out of medical school. Then the medical school should have the intestinal fortitude to actually kick him out if he refuses.

    The crux of the matter. Fear of lawsuits. But, if they tough it out and deal with an initial spate of lawsuits which they should eventually win, the lawsuits will die off and we will all have been better served by the production of generations of medical students dedicated to medicine rather than YAHWEH or “da prophet”.

  4. #4 D. C. Sessions
    September 12, 2008

    Why he would equate examining female patients or learning about alcohol-induced diseases to witchcraft, I’m not sure. I realize the idea is that both are considered evil apparently, but why on earth would it be evil to learn the basic and clinical science of alcohol damage to the liver or why it would be evil to relieve the suffering of an alcoholic.

    Chill, Doc. It’s not (quite) like that.

    The Latin term in law is a fortiori — basically, “even more so.” If an argument applies to an extreme case, then (so it goes) it applies to all less extreme cases.

    In the instant case, if witchcraft is an absolute, total, burn-before-even-thinking-about-it no-no with no redeeming value whatever then it follows that those things that are less objectionable (not necessarily even “evil”) are covered .

    Thus the cases: consumption of alcohol is forbidden, but that doesn’t bar learning how it affects those who consume it. Another argument that could be used is that assault is also forbidden but that is no bar to learning how to treat its victims.

    The sex issue is different, in that Muslim men actually are forbidden from contact with women other than their wives. It’s not a matter of “learning witchcraft,” but of actually practicing a forbidden act. There, it really is a clear-cut dichotomy. The alternative is the kind of insanity that has been reported from parts of the Middle East, where the physician (no practicing women, of course) would examine the patient’s husband, who would in turn query his wife.

    Madness, but then I suppose it’s not like there’s much downside — at worst, a mere woman suffers. However, I don’t see that alternative as one that Western culture should be forced to accept, so those students who can’t accept the requirements of the program should consider studying elsewhere. I believe that there are medical schools in the Islamic Republic of Iran.

  5. #5 D. C. Sessions
    September 12, 2008

    And is it even possible to learn such things in med school without getting involved with real patients? (That last one isn’t a hypothetical… I don’t know med school. :-P)

    A good breakpoint is cadaver studies. I doubt that med students get a choice of gender in their cadavers (and I hope that those with “issues” don’t get special treatment.) Which would be a quick filter, perhaps.

    As for cadavers, I will note that there are a lot of quite Orthodox Jewish physicians named “Cohen.” Somehow they made it through cadaver studies. Make of that what you will.

  6. #6 Rev. BigDumbChimp, KoT
    September 12, 2008

    I’m very strongly in favor of freedom of religion or freedom from religion. It’s one of the founding tenets of our great nation. However freedom of religion does not imply that accommodations have to be made for religious belief if they conflict with good patient care.

    I have a problem with any job having to reduce an employee’s responsibilities (beyond an occasional holiday) because of his/her chosen faith. If you chose to be a member of a faith then you are the one taking on that faith, not the rest of the world around you. If you want to be employed you should have to do the job you are hired for. Period. IF you can not fill the responsibilities of that position then you should find a different position. With health care it’s even more important.

  7. #7 william e emba
    September 12, 2008
    “It is obligatory for Muslim doctors and students to learn about everything. The prophet said, ‘Learn about witchcraft, but don’t practise it’.”

    Why he would equate examining female patients or learning about alcohol-induced diseases to witchcraft, I’m not sure.

    It’s possible the speaker was equating the unwanted medical knowledge with witchcraft, but without further information, it’s not clear. The quote might very well mean that since even in something so extreme as witchcraft one seeks knowledge, the lesser sin of alcohol consumption is obviously open for learning about.

    I have no idea how the quotation connects with unwanted medical practice, like examining female patients. (For that matter, I’m not sure if the speaker or you made that connection.) We’re talking about a religion where people made sure women and girls were locked in a building where a fire broke out, rather than take the chance improper mixing of the sexes might occur in public while the firemen did their work. That it wasn’t quick enough for their lives to be saved was just written off as their bad karma.

  8. #8 Snarly Old Fart
    September 12, 2008

    Twenty-five years ago we would never have believed anything like this could happen. A med student who failed to complete his work, for whatever reason, would flunk out.

    Lately, the religious have been testing the limits of civilized people, getting away with more and more, in more and more areas, going after more and more aspects. We have Christians who are refusing to administer drugs to people they consider immoral. What’s next, a Christian Scientist paramedic who refuses to treat anyone medically but will happily pray for them instead? How about an Islamic firefighter who will insist that sinful houses burn to the ground?

    This is what happens when somebody who is practicing elective insanity insists that we treat him with respect and we don’t immediately slap him silly. It was always a mistake to let Christians get away with things simply because they had a ‘respectable’ kind of craziness. (Such as churchbells Sunday morning waking the shift workers who just got to sleep a few hours earlier.)

    What’s making the problem so insidious and superbly resistant to correction is that the right wing crazies have been packing the courts with fellow fascist Christians — starting with the first Nixon administration — so the courts are heavily biases in favor of the side of wrong.

  9. #9 dee
    September 12, 2008

    “A small number of Muslim medical students have even refused to treat patients of the opposite sex. One male student was prepared to fail his final exams rather than carry out a basic examination of a female patient.”

    This student failed his final exams, was kicked out and is unable to practice as a doctor. Quite right too.

    The UK’s regugulatory body has this to say:

    “You must not allow any personal views that you hold about patients to prejudice your assessment of their clinical needs or delay or restrict their access to care. This includes your view about a patient’s age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation, or social or economic status.

    You should not normally discuss your personal beliefs with patients unless those beliefs are directly relevant to the patient’s care. You must not impose your beliefs on patients, or cause distress by the inappropriate or insensitive expression of religious, political or other beliefs or views. Equally, you must not put pressure on patients to discuss or justify their beliefs (or the absence of them).”

    http://www.gmc-uk.org/guidance/ethical_guidance/personal_beliefs/personal_beliefs.asp – Paragraphs 18+19:

    Let us be quite clear – there is no evidence that practising Muslim doctors are abusing their power in this way. If they were they would run the risk of being struck off.

    I’m not saying that there shouldn’t be concern about the personal beliefs of any Doctors overriding the rights of their patients – but this concern doesn’t only apply to Muslims. I know lots of Christian medics who have issues around abortion for example. I think all of as us medical practitioners face the issue of our beliefs conflicting with that of our patients. The important thing is not what we believe, but whether we can fulfil our professional duties.

    “These issues do not arise with every Muslim student”

    Oh come on, these issues only arise with a vanishingly small number of Muslim students! I’m studying in a Medical school in the UK where there are a large number of Muslim students. I’ve not seen anything like this happen. It looks like fearmongering and jives rather too well with this right wing nuttery about the UK becoming an Islamic state and all that nonsense.

  10. #10 Dunc
    September 12, 2008

    This is possibly the stupidest thing I’ve heard all week. Can (or indeed, should) someone training to be a trauma surgeon or ICU nurse refuse to treat gunshot victims because they don’t believe in shooting people? Stupid, stupid, stupid… On so many levels.

  11. #11 Melissa G
    September 12, 2008

    Finally, I’ve always been very skeptical of claims that religion or intercessory prayer somehow helps disease or makes people healthier, when there is no good evidence that it does.

    This reminded me of an issue which confronted my (then two-year-old) son and me. It is far less serious and far-reaching than the issues brought up in this post and the comments thus far, but it really upset me at the time.

    I wish all hospitals, bar none, in the US, would have the option of putting a sign on the door OUTSIDE the room saying “No Chaplain.” What happened to us was that my boy needed dental surgery, and my husband’s family has demonstrated a history of sensitivity to anaesthesia, so I was WORRIED SICK. Of course I was trying my best to be calm and soothing for my child, who wasn’t old enough to understand what was going on, and was kind of weirded out by the hospital environment, etc.

    There was a knock on the door, and a sweet little old lady came in asking if we minded if she left us some literature and would we like for her to pray with us.

    I didn’t want to cause a scene in front of my son, which would have upset him greatly. I took the literature and told her I would very much appreciate it if she prayed for us in private. She stayed and chatted a bit, then left, and it would have been a lovely visit if there hadn’t been the LOOMING SPECTRE of ‘Oh gawd is she going to pray at us? That’s ALL my kid needs to prove to him something is REALLY out of the ordinary, aieeeeeee!!!’

    I recognize now that the whole matter isn’t that big a deal– I said no, she respected that. But my emotional state was already so heightened, so on edge, that it really kicked my fight-or-flight response into gear. My heart was racing and it took me a long time to calm down (while of course having to feign serenity the whole time). Isn’t there some easy way of not having to subject parents to that? A “Privacy Please” doorknob sign like in hotels so that Chaplains will know that their presence will be actively harmful and to please stay out?

    Ok, loser-length rant over. ;)

  12. #12 Nick Gardner
    September 12, 2008

    It seems like this post had more to say…

    “It comes down to”

  13. #13 Natalie
    September 12, 2008

    It comes down to what? I must know!

    Dee, I didn’t get the impression from Orac’s post that he thought this was a common occurrence, or somehow limited to Muslims. It’s just another example of some people asking that their religion excuse them from performing important aspects of their job, and a quite good one as one of the things that a few people are asking for is being excused from washing their hands properly. We don’t even have to take their position to its logical extreme to illustrate it’s folly – they’ve already done that for us!

  14. #14 Internist
    September 12, 2008

    Having been in medical education (and practice of medicine) and involved with the training of hundreds of medical students and medical residents over the past several years, I feel compelled to comment.

    What separates the profession of medicine from all others in the entire universe is the art and knowledge of learning how to heal another human just like us based on the best sound medical research available to date at any given time. This includes treating a patient who may not be at his/her best behavior at the time or well dressed or well groomed but definitely needs me as their physician. He/She may be completely a different individual if I met them at a mall or elsewhere. The person (my patient) may have acted in a very inappropriate manner in past (unknown to him/her that I am aware of this) or be in a prison (having murdered a ‘bunch of people’), or drunk, or high on cocaine. I write this because all these circumstances have really occurred in my experience.

    Now where do I draw the line. At alcohol, smoking, weight gain, promiscuity, manslaughter, murder, rape….. The fact remains that when I am taking care of this individual, he/she is a patient and I am his/her physician. At the time, I am NOT a Christian or Muslim or Budhist, or Hindu, or …… first a physician. And individuals who cannot comprehend this important fact and the enormous responsibility that comes along to serve a fellow human being probably can never be a good Christian, or good Muslim, or good Budhist, etc. Thus, they MUST be offered a fair opportunity to explore other avenues and professions where they may shine with their apparent set of ‘values’ which would now be ‘their old values minus caring for fellow human beings under any circumstances’.

    Just recently, a patient came to me very upset from seeing another colleague of mine. The reason: he was prescribed prayers and God from this MD rather than what he had come for. Now, I don’t care how religious one may be, but in practice, we should be careful not to alienate our patients because of our religiousity. That kind of defeats the purpose in the first place.

  15. #15 Hesitant Iconoclast
    September 12, 2008

    You may want to take a look at this, Orac. A recent-ish story.

  16. #16 Calli Arcale
    September 12, 2008

    Snarly Old Fart:

    It was always a mistake to let Christians get away with things simply because they had a ‘respectable’ kind of craziness. (Such as churchbells Sunday morning waking the shift workers who just got to sleep a few hours earlier.)

    In defense of churchbells on Sunday morning, I would think they’d be acceptable for the same reason that it is acceptable to use a chainsaw to cut down an unwanted tree on your property on Sunday morning. Yeah, some folks are trying to sleep, but the world can’t go silent all the time. It’s one of the unfortunate truths of the world that late shift workers will have to sleep while most of their neighbors are up and about.

    Heh; I remember when I was in college, and they were digging a foundation for the new student center. St Olaf College is built on a limestone hill, and they didn’t want to risk blasting, so they were using a wrecking ball to basically smash through the limestone, the fragments of which could be hauled out by front-end loaders. They’d start at 7AM sharp every weekday. The entire hill would reverberate; there was no sleeping through that!

  17. #17 dee
    September 12, 2008

    Natalie: Point taken, I guess I’m reacting more to the Times article which I found a bit hysterical tbh.

    HI: Very interesting. Not sure what I would do if a patient asked me to pray with them. I wouldn’t want to negatively affect a therapeutic relationship but wouldn’t want to give a false impression about my beliefs (agnostic). I’d probably bow my head or something and feel awkward (how English is that).

  18. #18 Marcus Ranum
    September 12, 2008

    This isn’t a “freedom of religion” or a “freedom from religion” issue. It’s a question of “are you getting the best possible medical care for your money?”

    If the answer is that your medical practitioner is basing – IN ANY WAY – their treatment or diagnosis on medieval delusions of a magical sky-being, rather than science and evidence, you ARE NOT getting the best possible care. You are, in fact, being treated by a self-confessed incompetent.

    So what if it’s politically correct; get religion (and if it means it, religious people, too) completely out of medicine. You’re a smart guy, Orac, and I’ve seen you railing about the influx of woowoo into medicine. Don’t you see that the two are connected? By tolerating and nodding politely to religious bullshit you’re opening the door to all the other magical thinking you despise so much.

    If I am to have someone cut my body open or feed me chemical cocktails, I do not want to hear him/her PRAYING under their breath for help. I want them to have the knowledge and self-confidence to a) know that prayer doesn’t matter and b) – more importantly – that it’s not necessary because they know what they are doing and understand that the intercession of sky-daddy isn’t part of my treatment.

  19. #19 Bill the Cat
    September 12, 2008

    In related news, a Hassidic community wants to get rid of bike lanes because riders are immodest.

    http://www.nypost.com/seven/09122008/news/regionalnews/hasid_lust_cause_128750.htm

  20. #20 Scott
    September 12, 2008

    If you want to get really scared, consider the fact that many religious fundamentalists insist that the rest of the world has to follow their rules. Now imagine the implications of applying that reasoning to these issues:

    – Nobody could get treatment for STDs.
    – Nobody could get transfusions.
    – etc.

    Or if you think of antivaxers, then consider having all vaccination banned!

  21. #21 Scott
    September 12, 2008

    Heh – and as I’m posting, Bill posts a perfect example of what I’m talking about.

  22. #22 Marcus Ranum
    September 12, 2008

    Internist writes:
    Just recently, a patient came to me very upset from seeing another colleague of mine. The reason: he was prescribed prayers and God from this MD rather than what he had come for.

    Horrifying. Sounds like great grounds for a malpractice suit. The hospital should have immediately disciplined the MD to control their liability.

  23. #23 Terrie
    September 12, 2008

    I got the feeling that the witchcraftt comment meant “Learn about the results of immoral behavior, but don’t practice immoral behavior.” That is, learn about treating alcoholics, but don’t go out and start drinking.

  24. #24 Marcus Ranum
    September 12, 2008

    a Hassidic community wants to get rid of bike lanes because riders are immodest.

    It’s just a matter of degree from the current modesty taboos that insist that women’s breasts (teh horror! teh grossness!) and everyone’s external genitalia need to be covered all the time. We either need to deal with no such taboos or ‘respect’ all of them.

    The problem with goofy taboos, of course, is coming up with a reasonable intersection (picture the venn diagram) of taboos. So complex! And it’s Ok to pick your nose if you’re a toddler but not a president… It’s Ok to go topless if you’re a girl until you’re (?years old) or over (?years old) etc etc.

    Personally, I consider wearing underpants to be taboo. Underwear is to be worn on the head, to honor the great sky fairy. Why is my taboo less respected than that that old bungholer yahweh doesn’t like the girls’ tits that he created? Oh, yeah, and it’s also taboo to pronounce “nuclear” “nukular” – in my religion we have to respectfully raise our middle fingers at anyone who does that. And it’s Ok to ride bicycles in tight spandex but only if you’re listening to Spinal Tap or Queen… Boy this religion racket is fun! I see why L Ron had such a good time with it…

  25. #25 Interrobang
    September 12, 2008

    This issue has already come up, with no Muslims involved, at least in Canada. What usually happens is that you get people who are anti-abortion for religious reasons who are going into general practice who refuse to learn how to perform abortions. As well as I understand, abortions are something many Canadian general practitioners do; I don’t necessarily think that you need a referral to an OB-GYN. (At least, neither my mother nor I have ever seen an OB-GYN for routine things, up to and including pap smears and birthing a baby.)

  26. #26 Barbara
    September 12, 2008

    You might enjoy responding to this post:
    http://fatdoctor.blogspot.com/2008/09/belief-systems.html.

  27. #27 Marcus Ranum
    September 12, 2008

    I got the feeling that the witchcraftt comment meant “Learn about the results of immoral behavior, but don’t practice immoral behavior.”

    Yep. Drinking is a personal choice and can be a very entertaining way of spending one’s time on earth. Exactly how is it a doctor’s business to judge it as immoral?

    I can see it’s entirely appropriate for a medical professional to identify too much (or too little) drinking as a possible health risk, and to counsel accordingly – that’s their job. But the notion of “drinking is immoral” is rooted in judeo-christian-muslim religious notions that have absolutely no grounding whatsoever in objective reality. How can a medical professional guarantee the best possible treatment if they are implicitly disrespectful of their patient by assuming they lack moral fibre, or whatever? It’s exactly that kind of rotten logic that leads to the earlier example of an MD “prescribing” prayer and god to a patient.

  28. #28 gimpy
    September 12, 2008

    Orac, I think you’re guilty of under-researching this.

    I tracked down the source of the quote you refer to

    What’s interesting to note is that mainstream Muslim organizations reject this line of thinking, although I’m not sure I like the reasoning:

    “It is obligatory for Muslim doctors and students to learn about everything. The prophet said, ‘Learn about witchcraft, but don’t practise it’.”

    as coming from the Islamic Medicine Association. Does their website look mainstream and respectable to you?

    I notice that your links are to The Times and The Telegraph, these are right-wing papers that are far from impartial on the subject of Muslims in the UK. As Dee pointed out this is a non-issue.

    Anyway in the UK muslims whose families were originally from the Indian sub-continent tend to over-perform compared to other groups and are well-represented within the medical profession. If being a Muslim was a problem, it would have been heard about long before now.

  29. #29 TheOtherOne
    September 12, 2008

    So, you want to be a doctor, but you refuse to learn the symptoms of (much less how to treat) alcohol-related illnesses?

    Excuse me, you think you’re going to be able to limit your practice to observant Muslims?

    And, um, can’t you get cirhosis in other ways? Only these doctors wouldn’t be able to diagnose it due to their prejudice against it’s best-known cause.

    Willfully refusing to learn about *any* illness should be grounds for preventing any would-be doctor from entering the profession.

  30. #30 Melissa (oddharmonic)
    September 12, 2008

    Marcus wrote:
    The hospital should have immediately disciplined the MD to control their liability.

    Good luck with that ever happening.

    Nine years ago, an OB/GYN dismissed concerns that I might be pregnant as “all in my head” (they were aware that I have major depressive disorder) and told me to pray and go to church. I got a second opinion, turned out to be 12 weeks pregnant, and filed a complaint about the first doctor with my insurance company and the state medical board.

    The takeaway lesson for me is to ask every medical professional seen for my family’s medical care since if their religious beliefs contraindicate sharing all medically valid treatment options even if they find them morally distasteful. If their religious beliefs trump patient care, I’m not going to waste my time or theirs. They can cater to patients to who share those beliefs and I’ll take my family’s health care needs elsewhere.

  31. #31 Natalie
    September 12, 2008

    By tolerating and nodding politely to religious bullshit you’re opening the door to all the other magical thinking you despise so much.

    Marcus, did you read the previous posts that were linked in the opening paragraph? Where are you seeing “nodding politely” to religion?

    Dee, fair point. From what I understand the Times is usually more rational but I can see where you would read the article as alarmist.

  32. #32 Joshua Zelinsky
    September 12, 2008

    D. C. Sessions, in regard to people named “Cohen” there is very little correlation between having that last name and being a Cohen(or Kohain) in the technical sense. Moreover, Judaism has much more willingness to set aside prohibitions to save lives. Indeed, even Shabbat is set aside by Orthodox Jews to save lives.

    The question of Kohanim is more complicated. In particular, training is not directly saving a life so it isn’t clear that one can set aside the prohibition on a kohain coming in contact with a dead body. In general, Conservative and Reform kohanim are willing to become doctors. Most Orthodox Kohanim simply don’t become doctors under the logic that someone else will be just as qualified and we have a limited number of slots for medical schools and such anyways. I’ve never heard of a Kohain going to medschool and then skipping the problematic parts. It is idiotic. Of course, Kohanim are only a small fraction of the total Jewish population, so it isn’t really a similar situation. If hypothetically one had 90% of the Jewish population as Kohanim this might look equally ridiculous.

  33. #33 leigh
    September 12, 2008

    if you want to opt out of medical training for whatever reason you present, you clearly do not want to be a doctor. i also take tremendous issue with the sanctimonious pricks out there who are for whatever reason too good to treat REAL people. you know, the ones who drink and smoke and shoot up and fight and oh heavens, have sex for reasons other than producing children and even outside of marriage!

    i have a good friend who went in for an annual checkup, and was briskly told three things before the doctor even introduced herself:
    1. she would not prescribe contraceptives because she “didn’t believe in promiscuity”
    2. she would not order STD panels because there was no reason a single, abstinent person should need them
    3. if that was a problem, my friend was free to walk out the door.

    as a nurse at another facility under the same administration, she was too intimidated to file a complaint. but she was greatly upset by this experience. these types of people should either find a specialty where regular everyday people won’t affect their little superior religiuos bubble, or find something else to do with their lives.

    you can’t expect to retain a job where you can’t perform the full range of duties. period.

  34. #34 Danio
    September 12, 2008

    This is reminiscent of the horrifying HHS legislation in play that’s designed to shield religious health care workers who refuse to provide reproductive health services that conflict with their particular beliefs. The penalty for taking any punitive action against an employee acting in this manner is the loss of Federal funding.

    Why is the field of medicine such fertile ground for this? Employees in other fields–even similarly lettered professional ones–refusing to perform services against their beliefs would be dismissed/sued before they knew what hit them. So why the extreme accommodation for those who have beliefs that clearly conflict with the full breadth of a health-related position, yet choose to do that job anyway and plead for special considerations?

  35. #35 Calli Arcale
    September 12, 2008

    Interrobang:

    As well as I understand, abortions are something many Canadian general practitioners do; I don’t necessarily think that you need a referral to an OB-GYN. (At least, neither my mother nor I have ever seen an OB-GYN for routine things, up to and including pap smears and birthing a baby.)

    IIRC, in the US one has to be certified to perform surgery in order to perform a surgical abortion. I’m not sure about RU-486; I know there is some sentiment that it should only be used in a setting where a surgical alternative is immediately available should things go badly.

    I also used a family practice doctor for my prenatal and postnatal care, though as both of my babies ended up being c-sections (not planned that way; it’s just how it ended up) and my doctor was not qualified to perform c-sections, the obstetrician on duty delivered both of my babies. My doctor did get to assist at least. She makes a point of assisting at the c-sections, reasoning that even if she can’t do the actual procedure, she has a professional obligation to be there for her patients (both mother and child — she’s also my children’s pediatrician).

  36. #36 Coriolis
    September 12, 2008

    Everytime this topic comes up, I wonder why the hindus who refuse to serve beef in mcdonalds don’t speak up.

    Oh right, they don’t exist.

  37. #37 Annie
    September 12, 2008

    From the next-door-to-medicine perspective of nursing.

    Savvy accredited colleges of nursing have students read, understand and sign contracts about the ethics of the profession and practice before students begin their clinical rotations and direct patient exposure. Dee’s above UK ethics statement is a pretty comprehensive one, in my view, and it could be used as a model.

    As an undergraduate nursing educator, I’ve had students question, but never resist or refuse the care of individual patients. I would use their questions and concerns as the basis for a clinical discussion about suspending personal value judgments and providing care even in the presence of cultural, religious or personal belief clashes.

    Without fail, all students would pipe up and contribute their own perspectives on how these affected them, and then we’d discuss strategies and resources they might use in professional practice for resolving them while assuring patient safety, advocacy and accepted standards of practice and care.

    If you can keep the aim ALWAYS on the desired patient outcomes WITHIN the accepted standard of practice and care, the conflict becomes moot. The provider is obligated to act, whether that be in delivering direct care, in delegating it within an acceptable time frame to another competent professional or in providing an acceptable and timely alternative means of care.

    For any student or licensed (the license means there’s a statutory obligation, too) professional to duck out is malpractice or at the very least, negligence, and no school should allow it under any circumstances.

  38. #38 ebohlman
    September 12, 2008

    Internist: I think you’ve touched on an issue that partially explains the popularity of “alternative” medicine. Much of that popularity is based on the fact that patients feel that “alternative” practitioners connect with them emotionally (“treat them as a whole person”) in a way that conventional practitioners don’t. Of course, what they’re really experiencing is just good sales skills, not a genuine connection. And here’s where your points come in: a genuine full interpersonal connection between patient and physician would likely be a case of “getting more than you wished for” precisely because both the patient’s and physicians most deeply personal values and beliefs, and any similarities/differences between them, would necessarily play a major role in such a connection. Proper medicine has to be somewhat impersonal in order to be egalitarian; I can see no way (other than faking it like the alties do) to “get personal” without treating some patients better than others.

  39. #39 anonymous
    September 12, 2008

    Orac, Jehovah’s Witnesses don’t rely on Old Testament regarding refusing blood. It’s Acts 15:29. These abstracts are off topic, but I couldn’t post it to your older blog about refusing blood transfusions.

    http://watchtower.org/e/vcae/article_01.htm The website includes video interviews with some surgeons who explain why they don’t mind operating on Jehovah’s Witneses.

    To me, evidence based medicine says that blood transfusions are not all they are cracked up to be. It’s not just about fear of HIV and Hepatitis and viruses that are not yet being tested for in the blood supply.

    The following are all from pubmed, but I’m only including the first URL. Of course, they don’t answer all the questions about blood transfusions and religious beliefs. What worries me is that people tend to trust that someone else’s blood is more or less a safe thing that increases oxygen carrying capacity and that’s it. Besides that, good look at the history of the behavior of blood banks is enough to make people think twice about blood transfusions.

    http://www.ncbi.nlm.nih.gov/pubmed/18784497?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
    Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery.

    “SUMMARY: The harms of RBC transfusion have potentially serious and long-term consequences for patients and are costly for health services. This evidence should shift clinicians’ equipoise towards more restrictive transfusion practice. The immediate aim should be to avoid transfusing small numbers of RBC units for general malaise attributed to anaemia, a practice which appears to occur in about 50% of transfused patients. Randomized trials comparing restrictive and liberal transfusion triggers are urgently needed to compare directly the balance of benefits and harms from RBC transfusion.”
    ———-

    Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.
    CONCLUSIONS: Red blood cell transfusion in patients having cardiac surgery is strongly associated with both infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital costs.
    —-

    Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient.

    CONCLUSIONS: Transfusion of packed red blood cells is associated with nosocomial infection. This association continues to exist when adjusted for probability of survival and age. In addition, mortality rates and length of intensive care unit and hospital stay are significantly increased in transfused patients.

    The silent risks of blood transfusion.
    Rawn J.

    Brigham and Women’s Hospital, Boston, Massachusetts, USA.

    PURPOSE OF REVIEW: Clinical research has identified blood transfusion as an independent risk factor for immediate and long-term adverse outcomes, including an increased risk of death, myocardial infarction, stroke, renal failure, infection and malignancy. New findings have called into question the traditional assumptions clinicians utilize in evaluating the risks and benefits of blood transfusion. Appreciation of newly recognized risks is important for conserving scarce resources and optimizing patient outcomes. RECENT FINDINGS: Recent clinical outcomes research has examined the impact of blood transfusion on critically ill patients, trauma patients, patients undergoing cardiac surgery, patients experiencing acute coronary syndromes, oncology patients and others. These studies provide additional evidence of adverse outcomes associated with blood transfusion in a wide variety of clinical contexts. SUMMARY: The benefits of blood transfusion have never been conclusively demonstrated, but evidence of transfusion-related harm continues to accumulate. Given the transfusion triggers that currently predominate in clinical practice it appears that clinical outcomes could improve significantly with more widespread adoption of restrictive transfusion strategies.
    —-
    Emerging viral threats to the Australian blood supply.

    Conclusion: Current interventions have proven extremely effective in minimising transfusion transmission in Australia of recognised viral pathogens. The threat posed by emerging viral pathogens to the safety of blood transfusion emphasises the need for global collaboration and consideration of further intervention strategies on a country by country basis including options such as nucleic acid testing and pathogen reduction technologies.

  40. #40 D. C. Sessions
    September 12, 2008

    D. C. Sessions, in regard to people named “Cohen” there is very little correlation between having that last name and being a Cohen(or Kohain) in the technical sense.

    Agreed — but the ones I’m thinking of are called up with the kohainim at shul.

    Moreover, Judaism has much more willingness to set aside prohibitions to save lives.

    Or for other necessary occasions. I’m thinking met mitzvah.

    Indeed, even Shabbat is set aside by Orthodox Jews to save lives.

    Precisely. In fact, my totally ignorant goyishe musing is that the mitzvah of pikuach nefesh enters in somehow.

    My more general point is exactly yours: the more extreme religiousity under discussion is quite likely a more about the individual than the religion itself.

  41. #41 Ancient Brit
    September 12, 2008

    My two cents, FWTW:

    In context, it might make sense to say “Learn about X, but don’t practice it” at a time (5th-6th century) when, if you chose to learn about something, you fully intended to practice what you’d learned. There would be no real reason to learn about something otherwise – it would be a waste of valuable time.

    It would thus make sense to distinguish between the two intentions.

    It would follow that it’s OK to learn about torture but not to practice it, to learn about child abuse but not to practice it, and so on. We’d probably take that for granted now, but 1500 years ago it wouldn’t necessarily be common sense.

  42. #42 PalMD
    September 12, 2008

    Quotemine of the week:

    I “do” frequently…residents…with residents of many races, creeds, and colors. If a medical student refuses [me]…he should be told quite firmly that he either does what his training requires or he’ll be kicked out of medical school….It is important that all physicians at least be exposed to sexually transmitted diseases.

    BTW, as someone who works with a high percentage of Muslim colleagues and residents, I’ve never had any problems/requests/complaints.

  43. #43 Melissa G
    September 12, 2008

    It is important that all physicians at least be exposed to sexually transmitted diseases.

    I got a chuckle from that line out of context!

  44. #44 daedalus2u
    September 12, 2008

    A question (not rhetorical, I don’t know the answer); what has been the response or non-response in India regarding caste issues? Are untouchables not treated by MDs of higher caste?

  45. #45 PalMD
    September 12, 2008

    Many of my residents and colleagues are Indian, and I’ve never heard of it. Many are required to serve in villages for a time after medical school.

    Most of the cultural issues ive run into have been more subtle…men who don’t relate well with women as equals, etc. I’ve never had to deal with people refusing to deal with others or to do basic medical procedures. If i did, i’d react much as Orac would, and as i’ve written before regarding conscience issues…you chose the profession and its consequences…do it or quit, and no whining.

  46. #46 Jerry Jones
    September 13, 2008

    SUMMARIES OF 1300 JEHOVAH’S WITNESSES MEDICAL LAWSUITS & OTHER COURT CASES

    The following website summarizes 850 court cases and lawsuits affecting children of Jehovah’s Witness Parents, including 400 cases where the JW Parents refused to consent to life-saving blood transfusions for their dying children:

    DIVORCE, BLOOD TRANSFUSIONS, AND OTHER LEGAL ISSUES AFFECTING CHILDREN OF JEHOVAH’S WITNESSES

    http://jwdivorces.bravehost.com

    The following website summarizes over 500 Jehovah’s Witnesses Employment related lawsuits, etc, including DOZENS of court cases in which JW Employees refused blood transfusions, and/or other cases involving Worker’s Comp, medical, health, and disability issues:

    EMPLOYMENT ISSUES UNIQUE TO JEHOVAH’S WITNESS EMPLOYEES

    http://jwemployees.bravehost.com

  47. #47 Hesitant Iconoclast
    September 13, 2008

    Heard about the Muslim radiographer who lost her job after refusing to bare her arms?

    There is something quite inane about losing gainful employment to protest (on religious grounds) about following basic hygiene rules. Bear in mind that the UK has some problems with MRSA and C-Dificile superbugs, which is why these rules were implemented in the first place.

    Also, all visitors to UK hospitals (medical professionals and visitors alike) are expected to rub/clean their hands fairly regularly with a special gel that is dispensed from special containers placed all around hospitals at easy intervals (you’re never too far away from one). As you can expect, Muslim medical professionals, med students and visitors sometimes refuse to follow this process of basic hygiene, because the gel is alcohol-based. The stupidity is amazingly hilarious if it wasn’t so tragic.

  48. #48 dee
    September 13, 2008

    HI: But the point is, surely, that she lost her job. Regulatory bodies and management are unequivocal on this issue – the patient’s safety comes first. And that case proves it.

    I have never seen my Muslim colleagues refuse to use the alcohol gels.

    I’m not saying it never happens but I don’t think it is at all widespread, and should of course be dealt with. The point is that we all have beliefs that might conflict with our patients. The mark of a competent dioctor is that this doesn’t affect your ability to deliver the best possible care.

  49. #49 D. C. Sessions
    September 13, 2008

    As you can expect, Muslim medical professionals, med students and visitors sometimes refuse to follow this process of basic hygiene, because the gel is alcohol-based.

    What’s even sillier is that the alcohol is not even drinking (or drinkable) alcohol. The Qu’ran doens’t get into chemistry, just refers to intoxicating drink.

  50. #50 Hesitant Iconoclast
    September 13, 2008

    Dee, agreed. :) I guess I was just sounding off a slight frustration about why beliefs even have to be part of the equation.

  51. #51 Tsu Dho Nimh
    September 13, 2008

    daedalus2u said:

    A question (not rhetorical, I don’t know the answer); what has been the response or non-response in India regarding caste issues? Are untouchables not treated by MDs of higher caste?

    Way back in the pre-BSI dark ages of the 1970s in the USA, one Indian surgery resident had to have his high-caste attitude adjusted. On his first day of solo rounds, he was ordering the nurses to remove dressings so he could inspect the wounds, leaving a mess behind him for them to clean up, and expecting them to re-do the dressings.

    I encountered his god-like ‘tude when I was collecting blood for lab tests about 7AM. He mucked about with the other patient, dropping a bunch of dirty dressings on the floor, and snapped, “Take care of this” on his way out the door. I called the head nurse and the pathologist. It took our pathologist less than 5 minutes to get there, get the chief of surgery there, and give the resident an attitude adjustment that lasted for his entire residency.

  52. #52 Leni
    September 13, 2008

    Leigh wrote:

    …as a nurse at another facility under the same administration, she was too intimidated to file a complaint.

    Is there some reason she can not file an anonymous complaint?

    I know this isn’t the best response, but I find myself feeling angry about her lack of spine. There is no excuse for letting this kind of negligence go unreported. At the very worst she’d have to find a job elsewhere, and while that’s not a desirable outcome it certainly isn’t the end of the world, given the availability of jobs in nursing.

    I find this article profoundly depressing. The message I get from these students’ behavior is that they think their patients aren’t worth treating, even when refusal to treat could lead to the patient’s death.

    I find the lack of compassion, coupled with the selfish disdain for the life and dignity of their patients incredibly upsetting. Why on earth would such a person even consider being a doctor? They’d make far better executioners.

    And while I’m glad it’s not very common, and that the Muslim Medical Association (or whatever it was) is not in favor of it, I am depressed by the mere fact that they need to address it. Any student who displayed this kind of dereliction should be booted out of med school without a second thought. I suppose one good thing about it is that their refusal to learn the curriculum gives us an easy way to identify them and an unambiguous reason to boot them out of med school.

  53. #53 dee
    September 13, 2008

    HI: Fair enough. Sorry I sound like a stuck record, but we all have beliefs that might conflict with our patients. It is how we act on them that matters.

    DC Sessions: The alcohol hand gel is eminently drinkable, as anyone who deals with a ward full of alcoholics is all too aware. Bitrex is nothing to those guys…

  54. #54 MBA
    September 14, 2008

    Earlier, someone asked about choice of cadavers during the dissection part of anatomy lab. Well, no, you have no choice. Furthermore, at my school, we rotate through the bodies, so that everyone works on several different bodies during the course. Can’t say how other schools do it. The bodies are placed randomly in the lab, so by chance alone the sex of the cadaver will change. I have never heard of a student who refused to dissect a particular sex, but I suppose we are not yet to the genital part of the course, so it’s possible that it could still come up. On the other hand, issues with one student do not necessarily become public knowledge, so if an issue like this came up and was handled quietly, I’d probably never hear about it.

  55. #55 dusonfnp
    September 14, 2008

    Annie had very good points. As doctors (PA’s, NP’s, RN’s, etc), if we don’t have a basic knowledge of, and some respect for, what our patients believe, we’re going to give crappy care. If our beliefs are going to interfere with our ability to give care, then we shouldn’t be in that particular aspect of the business. The “just bend your head and be awkwardly quiet” is actually an excellent solution – you aren’t praying, you’re just showing respect for their beliefs, and taking a moment of probably rare quiet to really think about what you’re doing for this patient. Being uncomfortable is one thing, but if you aren’t capable of showing respect for those beliefs, you’re just as bad as a Muslim doc who won’t treat women.

    Educating people to make sure they know that the best treatment really doesn’t conflict with their beliefs (i.e. Mirena IUD’s do not cause early abortions, they prevent ovulation and conception) is our job – not changing people’s beliefs. And make sure that they aren’t replacing medicine with religious beliefs: I get families of new-onset diabetic kids that want to “pray away diabetes” so I tell them they should pray thanks for the better meds available now; pray for the researchers; and pray for their families to deal with this new challenge.

    I don’t run into problems with the Muslim docs at the hospital where I work – they are quite capable of treating whoever walks in and needs help for whatever. But that’s just one person’s story – kind of like the anecdote about the woman who wouldn’t test for STD’s sounds pretty much anecdotal – on a science blog, you should know that one bad experience related by a friend is suspect. Also, I’m pretty sure that the “prayer doesn’t work” statement comes from a blinded research study about intercessory prayer, as opposed to someone praying specifically for themselves or a family member.

    Asking for privacy is quite reasonable, and should be respected. I’m here in the Bible Belt, and our chaplains only come when they are requested. Various churches send up visitors, and if they haven’t pre-arranged to come and are visiting only those who want to be visited, or aren’t coming specifically to visit someone from the congregation, we don’t let them into rooms.

    And finally, if you want to take religion out of medicine, you’re forgetting a lot of our history. Medicine has historically been a religious vocation; evidenced by the numbers of hospitals founded by the Catholic church and evidenced by the missionary hospitals in Africa and Korea.

  56. #56 dee
    September 14, 2008

    “The “just bend your head and be awkwardly quiet” is actually an excellent solution – you aren’t praying, you’re just showing respect for their beliefs, and taking a moment of probably rare quiet to really think about what you’re doing for this patient. ”

    What a lovely way to look at it. Thank you for that insightful point.

    dee

  57. #57 Reginald
    September 16, 2008

    This is honestly why I think PZ’s cracker desecration was so important. It highlighted for me just how silly it is to expect that other people treat your superstition with as much reverence as you do.

  58. #58 TheOtherOne
    September 16, 2008

    i have a good friend who went in for an annual checkup, and was briskly told three things before the doctor even introduced herself:
    1. she would not prescribe contraceptives because she “didn’t believe in promiscuity”
    2. she would not order STD panels because there was no reason a single, abstinent person should need them
    3. if that was a problem, my friend was free to walk out the door.

    Um, no. You want to give me this list when I call to set up an appointment? Fine! Thanks for saving me the waste of time.

    But let me take time off work, drive to your office, sit in your waiting room, and pay the co-pay, and THEN give me this little list? NOT COOL. It’s utterly unnecessary for you to see me in person to tell me about this very important restriction on your willingness to treat me, and given that I’m coming to you for treatment (and you’ve held yourself out as treating patients), I think the burden is on you to let me know in advance so that I don’t waste time and money.

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