Religion vs. public health redux

I mentioned previously a clash between religion and public health, where a Liberian immigrant was jailed for importing bushmeat. She argued that infringing upon her religious freedom in this manner was unconstitutional; authorities argued that she couldn't put others at risk because of her religious beliefs. Another clash where religious beliefs are at odds with public health is simmering in the U.K.; more after the jump.

Women training in several hospitals in England have raised objections to removing their arm coverings in theatre and to rolling up their sleeves when washing their hands, because it is regarded as immodest in Islam.

Universities and NHS trusts fear many more will refuse to co-operate with new Department of Health guidance, introduced this month, which stipulates that all doctors must be "bare below the elbow".

The measure is deemed necessary to stop the spread of infections such as MRSA and Clostridium difficile, which have killed hundreds.

Reactions from other doctors and infectious disease specialists quoted in the story are harsh--justifiably, in my opinion--and they note that some trainees have indeed quit the program rather than expose their arms.

A possible compromise?

Dr Majid Katme, the association spokesman, said: "Exposed arms can pick up germs and there is a lot of evidence to suggest skin is safer to the patient if covered. One idea might be to produce long, sterile, disposable gloves which go up to the elbows."

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How about not compromising? Just say, "If you can't perform the requirements of this job, then get a different job." Really, I'm so sick of caving in to stupid religious superstitions.

I say F*&k 'em if they can't do the job. I also am sick of caving.

I often support appeals to conscience by healthcare professionals because it is frequently possible to accommodate those appeals while still providing medically indicated care. I think this is probably one of those cases, since disposable gloves should do the trick.

By bob koepp (not verified) on 05 Feb 2008 #permalink

It's a difficult situation. The UK educates plenty of doctors and nurses but lots of them go into private practice or quit after only a few years. The British government has come under a lot of criticism for recruiting medical professionals from African countries and so they are trying harder to recruit from under-represented groups in Britain. And, if different beliefs can be accommodated without putting the patients at risk or too much additional cost (longer sterile gloves) then why not?

If it doesn't require a lot of effort to find a reasonable and safe solution, why bother fighting about it? We shouldn't cave on things that are truly crucial, like fully informing patients of their options, when religious beliefs come into play, but this is not one of those.

Why bother fighting about it when there's an easy solution?

You see, what's best for the patient should take absolute priority and not spreading superbugs is the primary thing here. Public health and safety should take precedence over personal beliefs anyday - especially when it is dealing with the likes of MRSA, which is already a considerable problem in hospitals.

Because of the old saying about inches and miles. Does this accommodation open the door for the trainees to not participate in procedures that violate their religious beliefs? Besides which, it seems unethical to subject patients to what amounts to an experimental alteration of the standard of care (long gloves vs. scrubbing) that has the potential to impact the outcome of their surgery if the glove option turns out not to be as effective in creating a sterile field. I could get behind the reasonable accommodation of screening the scrub area to allow privacy while preparing, but altering evidence-based process to accommodate? Sorry, no.

So far as inches and miles are concerned, it's not the distance that matters but the warrant, or lack thereof. Give and inch, or a mile, when it's warranted. Don't give an inch, or a mile, if it's not warranted.

Regarding warrant, I urge everyone addressing issues of this sort to not lose sight of tried and true liberal principles such as freedom of conscience. Living in a society where that freedom is respected will benefit all of us.

By bob koepp (not verified) on 05 Feb 2008 #permalink

Let them quit. I don't want an idiot like that working on me.

This isn't about beliefs, it's about behavior. I don't care that someone has a sincerely-held religious belief that involves eating animals from an African jungle or not exposing their arms or not using birth control or orally removing the blood from a circumcised male infant and I have no interest in impinging on their freedom of conscience. I do have a very strong opinion about the public health effects of:

No one is suggesting that any of these people change their beliefs - they have (and should have) complete freedom of conscience. However (aside from the herpetic mohels) they are all voluntarily engaging in illegal and/or unprofessional behavior and using their sincerely-held beliefs as a cheap excuse for putting others at risk.

In the same way that slaughterhouses should not have to cease operations to accommodate vegetarian employees, neither should we let our public health systems be held hostage by tiny, extremist unprofessional minorities - religious or otherwise. In the (horrible, tragic) case of the mohel, an infant has no more religious belief than a goldfish, so regardless of the religious identification of the parents, the child's health should be protected. Most sects have modified their practice to safeguard the health of the child except for a few (surprise!) orthodox sects. So it's more than possible to simultaneously change behavior and maintain strongly-held beliefs if a group really wants to.

It's not a matter of conscience, it's a matter of public health - if people voluntarily put others at undue risk as a direct result of their behavior, they need to be stopped. Why should the rest of society pay for accommodating their callous, selfish, dangerous behavior?

And yes, I very much enjoyed using the phrase "herpetic mohel" :P

Regarding warrant, I urge everyone addressing issues of this sort to not lose sight of tried and true liberal principles such as freedom of conscience.

I think you're missing something. Even according to the most liberal interpretation of liberal principles, your right to practice your religion stops where it intersects with my right to remain unharmed by your religious practice. (See also "Your right to swing your fist ends at my nose.")

If there is, in fact, significant risk caused by the religious objection here, there's no reason to accommodate it in that way. If there is a reasonable accommodation possible that does not compromise safety (such as what we had here in Canada where Sikh RCMP officers can now wear a duty-issue turban with their dress uniforms), go for it. Otherwise, no.

By Interrobang (not verified) on 06 Feb 2008 #permalink

I haven't missed anything that Interrobang has pointed out. I'm well aware of the traditional liberal position that freedom of conscience can be trumped by a compelling social need; i.e., if necessary for the maintenance of a well-ordered society (which requires a bit more nuance than fists and noses). Liberal minded people should be ready and willing to look for ways to accommodate conscience, and only overrule it when necessary. To do less is, well, illiberal.

By bob koepp (not verified) on 06 Feb 2008 #permalink

Regarding warrant, I urge everyone addressing issues of this sort to not lose sight of tried and true liberal principles such as freedom of conscience. Living in a society where that freedom is respected will benefit all of us.

So, you want to permit workers in a specialized environment to disregard established safety procedures according to the dictates of their own conscience at the risk of the health and life of a third party? I fail to see the benefit to anyone in this scenario, including the original worker whose act of conscience could directly contribute to the death of another person. They are not obligated to work in an operating theatre. Those who work in an operating room are obligated to follow the established rules to prevent life-threatening infection.

To use a far more trivial example, I'm hooked on modeling reality shows (America's Next Top Model, Make Me a Supermodel). In Cycle 1 of ANTM, I could see a fresh-faced young woman being shocked that she'd have to strip for a photo. Cycle 10 is about to start and, like every season, there's going to be drama when one of the contestants is told to get naked for a photo. This is the job. Anyone who'd watched any of the previous cycles (or had two grains of sense to rub together) would know this.

The moral is, if you don't want to strip naked in front of strangers, don't be a model. If you don't want to roll up your sleeves where you work, don't work in an operating theatre.

usagi - Just where did I say, or imply, that anybody should be allowed to put the health and life of anybody else at risk? In my very first comment I referred to the possibility of accommodating appeals to conscience while still providing medically indicated care. I assume that medically indicated care includes appropriate measures to maintain a sterile environment in the operating theatre.

So, do have anything to say about the issues that's actually relevant, or do you just feel the need to vent?

By bob koepp (not verified) on 06 Feb 2008 #permalink

You implied that others' health could be put at risk when you said that some medical staff could, on grounds of conscience, not follow the same rules on sterile operating conditions as others. Unintentionally, I'm sure, but you did, which is why usagi is objecting.

By Stephen Wells (not verified) on 07 Feb 2008 #permalink

Oh, and re. the OP: Saying that you object because X is considered immodest doesn't seem to me be a reasonable grounds for an exemption. Sticking your fingers up someone's butt is considered immodest in almost all cultures, and cutting holes in people with sharp implements is usually considered downright rude. This is medicine, dammit, and you can leave your modesty at the door, where it won't get in the way of survival.

By Stephen Wells (not verified) on 07 Feb 2008 #permalink

I'd really prefer to address contentful issues, but I'll settle for what's on the table.

Stephen, what you say was "implied" was not -- that would require an additional premise to the effect that those "same rules" were the only way to maintain a sterile environment. That premise is demonstrably false.

By bob koepp (not verified) on 07 Feb 2008 #permalink

I assume that medically indicated care includes appropriate measures to maintain a sterile environment in the operating theatre.

The stated standard is to roll up one's sleeves and scrub. Violating this procedure fails to meet the standard of care established by the hospital and should be grounds for termination. You don't get to ignore safety standards in the workplace because you think you have a better idea about something that'll work just as well.

[W]hat you say was "implied" was not -- that would require an additional premise to the effect that those "same rules" were the only way to maintain a sterile environment. That premise is demonstrably false.

Then the impacted workers should present the peer-reviewed research that supports this conclusion to the office or committee at the hospital responsible for establishing procedure in the OR. When the hospital has reviewed and vetted the procedure and determined that there is indeed equivalency between the established procedure of scrubbing and the revised procedure of using longer gloves without scrubbing the arms, the hospital administration may allow the alternate procedure to be used.

usagi - Has anybody claimed it's OK to ignore safety standards? Not me. I've assumed all along that maintaining a sterile surgical environment is necessary.

So... I don't think it's OK to ignore safety standards. Nor do I think it's OK to ignore appeals to conscience. I think it's obvious that a decent society will try to accommodate both.

By bob koepp (not verified) on 07 Feb 2008 #permalink

If research indicated that it would be best for doctors to operate in the nude, then that's what they should do. Any who couldn't deal with it would be indicting themselves. Nevertheless, the objection to arm exposure gives people a chance to think about it creatively. Maybe there's a win/win here. For instance, a comparative study of approaches could be carried out. Look at things a little more closely, but choose policy based on a rational assessment of outcomes.