Doctors are often faced with ethical decisions in the course of patient care. These decisions may be emotionally wrenching, and can have an impact on a patient's life, and affect a doctor's career and wellbeing. Before COVID-19 changed medical practice Medscape UK surveyed 1355 doctors to find out how they felt about key ethical issues. In part 1 we looked at life and death issues, and the results of additional polling on coronavirus. Here we look at issues around money, romance, and patients. Totals may not equal 100% due to rounding. According to Medscape UK's Sexual Harassment of Doctors survey in 2019, 3% of doctors told us they'd experienced some form of sexual harassment at work in the previous 3 years. Our 2020 ethics survey finds most doctors would report another doctor they saw bullying or carrying out sexual harassment. It seems there are some ethical grey areas though, with 16% saying 'it depends', while 2% would not make a report. Comments from those who wouldn't make a report included: "Whistleblowing NEVER ends well for the whistleblower." "I have raised concerns about bullying previously and have been punished as a result." "We are in a blame culture and the, I believe, personal repercussions are too great. I have also not reported doctors who have sexually harassed me." "Consultants can unfortunately still get away with inappropriate behaviour and instead it will be taken out on me or the person being harassed." In 2019, a report by the British Medical Association (BMA) found widespread sexism still present in medicine and 'a lingering 'old boys' club' culture. So how many of our respondents have witnessed sexism at work in the NHS? More than half (55%) said they had. However, there was a notable gender difference with 74% of female doctors saying 'yes' compared with 44% of males. Under 45s were slightly more likely (61%) to say yes than over 45s (53%). Would respondents go as far as to say there's institutional sexism in the NHS? More than half (56%) said there is. Again, there were age and gender differences, with 72% of female doctors agreeing compared with 46% of males. Among over 45s, 54% agreed, compared with 64% of under 45s. In 2020, a special issue of the BMJ reported on racism and discrimination faced by black and minority ethnic (BAME) doctors in the UK. In 2019, A BMA survey found that BAME doctors are more likely to be bullied and scapegoated than their white counterparts. Would our respondents say the NHS is institutionally racist? Nearly 6 out of 10 agreed. More women (66%) than men (56%) agreed, and more under 45s (66%) than over 45s (58%) agreed. Just over half of our survey respondents (51%) had witnessed racism in the NHS. A further 41%, hadn't, while 8% preferred not to answer. When reports are drawn up into medical scandals, they often conclude that someone must have known what was going on but didn't report it. Or, if they did report it, no action was taken. Such was the conclusion into the rogue breast surgeon Ian Paterson, for example. We asked: Would you inform a patient if you knew they were going to have a procedure performed by a doctor with a substandard ability to perform it? This test of ethics found fewer than a third (31%) would speak up. The scale of the ethical grey area was pronounced, with 47% saying 'it depends', while 23% would not say anything. Males (34%) were more likely to say they would tell compared to females (25%). Many said they'd report the colleague through proper channels rather than warning the patient. Comments from those who wouldn't tell the patient include: "Happens everyday. Would be telling too many patients if I had to do that." "This is not the way to address substandard performance. This should be addressed before the patient reaches that stage. Some patients love their crap doctors because their criteria are different from ours." "Scary. I was in that situation for many years. I went to the medical director but he was the mate of the incompetent doctor." Nearly three quarters (74%) of respondents said they'd report a doctor friend, or colleague, who occasionally seemed impaired by drugs, alcohol, or illness. The ethical grey area accounted for nearly a quarter (23%), who said 'it depends', while 3% would keep quiet. Many said they'd talk to the colleague first. Comments from those who said 'it depends' included: "I would get them some help! Medics need support not reporting!" "Just about every single doctor or nurse has been impaired as a result of a night out..." "I would fear being victimised by the authority as foreign medical graduate if I were reporting a white British colleague." "All humans are occasionally impaired by illness and if none of us worked if we were only at 99% capacity due to a minor illness, and the drugs you had been given to treat it, the health service would collapse." In our 2018 UK Doctors' Burnout and Lifestyle survey, 1% of doctors admitted to using cannabis, or other 'recreational' drugs. We asked: Should recreational use of cannabis by adults be legalised? More than a third thought it should but over half said not. It was a grey area for 1 in 10. Specialists (36%) were more in favour of legalisation than GPs (27%). Men (39%) were more in favour than women (29%). Comments from those in favour of legalisation included: "If recreational drugs are legalised and managed I believe the frequency of serious crimes will fall. Secrecy and clandestine activities will no longer be necessary." "Treat it like alcohol & tobacco - standardise it & tax it." We asked: Is it ever acceptable to breach patient confidentiality if you know that a patient's health status (eg, communicable disease) could harm others? The GMC says, "Confidentiality is an important legal and ethical duty but it is not absolute." Yes, said nearly 7 out of 10 respondents. One in 10 said not, while it was a grey area for a fifth. Comments from those who would break confidentiality included: "The physician's duty of confidentiality may be overridden by a more powerful duty to other members of society." "There is a rule of preventing greater harm and harm to others." GMC guidance bans sexual or improper emotional relationships with current patients. But there's more leeway with former patients, especially after an unspecified period of time has passed. Breaching the rules sees doctors hauled before medical tribunals and jobs have been lost. We asked: Is it ever acceptable to become involved in a romantic/sexual relationship with a patient in your care? Most (64%) agreed it was unacceptable, but it was OK for 1%. With former patients 19% said it was OK provided at least 6 months had passed. However, it was a grey area for 16%. Comments from doctors who said relationships were OK with current patients included: "A genuine relationship should not be a crime." "Yes but they must stop being your patient immediately." "In general the answer is no. But 'is it ever' means you are looking for the one case in a million that makes this allowable. If you were the only GP (with good teeth) on a remote Scottish island and the only dentist (in good health) on the island and you were each others patients it seems unfair to deny you both a bit of fun after the annual island healthcare Xmas party when you are the only two attendees." If a drug rep buys you lunch, or you get paid by pharma as a speaker, does it influence your prescribing? Nearly 6 out of 10 (57%) said they could accept food or money without influence. Nearly a third (32%) believed there was influence, while it was a grey area for 11%. GPs (39%) were more likely than specialists (31%) to say payments and lunches could affect prescribing. More women (36%) than men (30%) thought similar. Comments from those who said they wouldn't be influenced included: "With appropriate disclosures. Often done. That said in my mind even if done with highest probity the waters are muddy." "Am I that cheap that I will be influenced by free food? No definitely not." "I don't see any harm - drug reps are often the source of useful information. But it would probably have an unconscious effect though." "I have never been corrupted by a few sandwiches." "I frequently speak for a company who introduced a procedure that we no longer provide, I switched to a cheaper alternative despite my professional relationship with the company." "Just take a free lunch for what it is, a free lunch. You don't have to be a fool as well." "Doctors are well paid individuals - a free lunch or occasional speaker fee would not influence them." In our 2019 Global Doctors' Burnout and Lifestyle Comparisons report, UK doctors were least likely (jointly with France) to hold religious or spiritual beliefs. But for the 52% that do have such beliefs, have they ever influenced clinical decision-making? Of all our respondents, more than 8 out of 10 said beliefs had not affected decisions. GPs (27%) were more likely to have been influenced than specialists (18%). Under 45s (15%) were less likely to have been influenced than over 45s (20%). The case of Dr Hadiza Bawa-Garba focused attention on pressures faced by doctors in the NHS system, and sparked debate about work pressures, and public protection against negligence. She was prosecuted for manslaughter over the death of a boy under her care despite being under extreme pressure and caring for too many patients. She was nearly struck off, too. We asked: Is it right to blame doctors for the systemic staffing or resources failures of the NHS? The vast majority said it was not. Before COVID-19, seasonal flu was one of the biggest risks to NHS resources and capacity. However, flu jab uptake amongst healthcare workers in England with direct patient care is less than three-quarters (72.4%), according to Public Health England. So, should healthcare professionals who have patient contact be required to have an annual flu jab? Yes, said nearly half of respondents (46%). Just under a third said no (29%), and it was a grey area for 24%. Under 45s (52% 'yes') took a harder line than over 45s (45%). Having more than a quarter of the healthcare workforce in England not having annual flu jabs may show some mistrust of vaccination. But if this went further to actually discouraging immunisation in general, should doctors who do so face penalties from the GMC? Yes, said 56%, no said 20%. It was a grey area for 25%. GPs (60%) were more likely than specialists (55%) to favour penalties. Under 45s (64%) also took a harder line than over 45s (54%). We asked for any additional thoughts on flu vaccination refusal penalties. Here are some of them: "Such behaviour is against all evidence base, endangers not only the individual patient, but also population including those who cannot be vaccinated due to medical conditions." "The benefits of most vaccines have been proved by clinical trials, and doctors must base their practice on that evidence rather than on their prejudices." "These are clearly proven lifesaving therapies, its unethical and unprofessional to promote a personal view over a scientific evidence base." "They should not be licensed to practice at all, as this is likely to be an indication of a wide range of irrational medical practice behaviours." "Punitive regulation is bad regulation." "Vaccination should be voluntary and doctors should be able to voice an opinion without penalty." "Herd immunity is being jeopardised." "Where do you draw the line?..... medical dictatorship..this will create non- thinking clones.......evidence is often flawed and should be open to peer and public discussion and more research so it becomes even more compelling so no one would question it!" Last year, the UK lost its measles-free status. So should MMR vaccination be compulsory for all children before they start school? Nearly three quarters (74%) said it should. No, said 15%, and it was a grey area for 11%. This was a "no brainer," and the "only way to ensure keeping UK measles free, doctors told us. But for others, "We need to educate not regulate," and "The state should not bully people, it should educate." Other comments: "Absolutely not. It is the right of parents to accept or decline vaccinations for their children. The idea of the state imposing this on children is terrifying." "This will validate conspiracy theories and hamper the future. This needs a lot of hard work and conversations with individuals addressing fear and misinformation with truth and facts and methods to allow an individual to learn themselves, really the answer is education, education, education." Would you ever recommend or provide life-sustaining therapy if you believed it would ultimately be futile? This was a grey area for nearly 4 in 10 (39%). Yes, said 21%, no said 40%. GPs (25%) were more likely than specialists (21%) to agree with providing ultimately futile measures. We asked for your additional comments: "Sometimes if relatives are on their way it can be kinder to prolong life a little bit." "I'm an oncologist. All treatments I give palliatively are ultimately futile in that they don't cure; my patients will still die." "No point in providing false hope - that's cruel." "The Hippocratic Oath requires us to do everything legally possible to preserve life." "I don't believe in whimsical hope." "All life-sustaining therapy is ultimately futile." "Prolonging suffering is wrong." "Futility is hard to predict." Looking at difficult treatment decisions from another angle, we asked: Would you go against a family's wishes to stop treatment, and continue treating a patient whom you felt had a chance to recover? Nearly half (49%) would, only 10% wouldn't. But it was a grey area for 41%. Men (53%) were more likely to support continuing treatment than women (43%). We asked for your additional comments: "The patient is my concern, the family may have ulterior motives for refusing the treatment. A family should not be allowed to prevent appropriate therapy." "Did once when we had the distinct feeling the family were quite keen for the patient to die. We did not feel that the family were making the request in the patient's best interest." "I witnessed a situation with a young child who needed life-sustaining transfusion. The parents refused. Hospital took legal advice and provided life-sustaining transfusion. Child lived and eventually became well enough to go home. Child went into care." "Families cannot understand medicine, so why do they get a say?" "Family are not competent to make medical decisions and may have ulterior motives like inheritance influencing such decision." Around 1 in 4 women and 1 in 7 men in the UK are estimated to have experienced domestic abuse, according to the Office for National Statistics. Doctors have a duty to look out for signs of domestic abuse. We asked: Have you ever suspected that a patient is a victim of domestic abuse but failed to report it or investigate further? Most report their suspicions (84%) but 12% don't always do so. It was a grey area for 4%. GPs (17%) were more likely to fail to make a report than specialists (11%). It was also more of a grey area for GPs (7%) than specialists (3%). We asked for your additional comments: "I think I have made errors of judgement at times." "Yes because I didn't feel it was my place." "In the face of denial by an adult it is difficult to progress your concerns." Fifty-nine percent of survey respondents were male, 36% female, while 5% preferred not to say. 21% of respondents were under 45, the rest 45 and over. For ethnicity, 52% described themselves as white, whilst BAME accounted for 36%, and 11% preferred not to answer. In line with the relative populations of the UK nations, 83% were practising in England, 8% in Scotland, 5% in Wales, 3% in Northern Ireland, and 1% other UK. Hospitals were the most common workplace for our respondents (67%). GP settings accounted for 12% of work settings, with 1% in single-handed practice, and 11% in a group practice. Source
