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Duty of care or respecting belief?
Whilst working within the Hospital Eye Service, I came across several cases that I shall never forget – some funny, some sad and some just downright strange. However there is this one particular case I recall during my pre-registration year that I was reminded of today when a colleague called to discuss a similar case that she had recently seen. Both cases were quite different in clinical presentation but what was similar was the dilemma of the onward management. Both patients were refusing further treatment on the grounds of belief.
So the question is, where does our ‘duty of care’ end when our code of ethics conflicts with our patient’s moral or religious belief?
The case I recall was of a middle-aged gentleman, well dressed, well spoken and very well educated, who was suffering from primary open angle glaucoma. Over the years, he had continued attending his hospital appointments despite refusing all forms of treatment, on the grounds of religious belief. At that time, his sight had almost completely gone, yet he was continuing to work within the legal profession, and at a pretty high level. It was his understanding that very soon, according to his belief, his sight would soon be restored. The consultant, following several long discussions with the patient, allowed the patient to make his own decision and agreed to merely monitor the condition.
There were a few of us at the time who raised an eyebrow. Whilst we had no difficulty in respecting another man’s moral or religious belief, we were uneasy with the added fact that the patient believed that he was the Messiah.
My colleague today mentioned that she had come across a sight threatening and possible life threatening condition which warranted prompt referral to a neurologist via the GP. However, the patient is currently refusing referral and was indeed insisting that the GP was not informed of the finding. Her faith healer would be taking on the case. Understandably, my colleague is more than a little perplexed.
As practitioners we have a code of ethics that we stand by. Our own personal moral or religious beliefs should not stand in the way of our duty of care to the patients who seek our advice. However, where do we draw that line? Should our second case be referred into the hospital system?
Whilst still wishing to respect our patient’s belief, where do we stand legally if we do not refer?
Peter Chapman // Jun 16, 2007 at 2:29 am
A similar incident happened with me. It always seems odd that patients refuse medical help but I personally think a lot is due to psychology of patients and fear of bad news.
After much legislation reading, it seems that patient confidentiality always takes precedence. The Opticians Act 1989 and GOC Rules Relating to Injury Or Disease Of The Eye 1999 both clearly state that the Optometrist or Dispensing Optician shall only refer with the consent of the patient. If this consent is not given then this reason why shall be noted of the record card.
In recent advice given by the AOP, a letter should be given to the patient and explanation of the nature and necessity of the referral given to enable self-referral at a later date. This has then discharged the duty of care from the Optometrist.
With regard to referral to a non-medical practitioner, this is possible as long as the optometrist/dispensing optician feels that the person to whom the referral is to has the necessary qualifications and expertise to manage the condition. This is one of the many grey area’s in practice as do we think a faith healer has the necessary expertise/qualifications. I am not commenting either way!
Grey areas are present in all aspects of optometry. When deciding on what action to take, I think it is always worthwhile thinking about how you are judged in disciplinary hearing, that is: have you done what competent and like minded professionals would do to the best of your ability?
Links
Revised advise on referrals by optometrists:
http://www.assoc-optometrists.org/uploaded_files/referral_advice.pdf
THE RULES RELATING TO INJURY OR DISEASE OF THE EYE 1999
http://www.optical.org/index_files/legislation/disease1999.pdf
Priya Morjaria // Jun 17, 2007 at 4:28 am
Having been faced with the situation that Jane has mentioned, I feel it has left me questioning ‘my duty of care’.
Peter says there are a lot of grey areas and that you have to think ‘have you done what competent and like minded professionals would do to the best of your ability?’
My point is what if you have done all that is necessary and that the next step a competent professional would do is to refer the patient as they could potentionally lose their sight. So where does that leave me?
When I raised this question with other colleagues who are in a position to advise me I felt the main concern was ‘the repuation of the company you work for’.
You cannot force a patient to be referred if they refuse to be seen. But what is to say that the same patient realises the urgency of the situation too late, does that mean as a practitioner you failed to ‘convince’ the patient?
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