Relevant HPCSA Guidelines

Booklet 1, paragraph 5.1.5

Booklet 1, paragraph 5.1.6

Contents

• Patients’ personal beliefs
• Where patients ask for a procedure to be performed for mainly religious or cultural reasons
• Where patients refuse treatment which the healthcare practitioner assesses would be of overall benefit to the patient
• Judgment of patients’ values or behaviour
• Where practitioners feel that patients’ actions have contributed to their condition
• Discussing actions of the patient which could have clinical implications
• Obtaining advice on religious or cultural requirements
• Talking to patients about religious beliefs
• Standards applicable to procedures for religious or cultural reasons

Discussion

Patients’ personal beliefs

There are two situations which are particularly relevant when considering the effect which patients’ personal beliefs may have on proposed treatment.

The first of these relates to circumstances where patients request a procedure for mainly religious, cultural or social reasons.

The second situation which generally arises is where patients refuse treatment which the healthcare practitioner assesses would be of overall benefit to the patient.

Where patients ask for a procedure to be performed for mainly religious or cultural reasons

If patients ask for a procedure to be performed for mainly religious or cultural reasons, practitioners should discuss with the patient the benefits, risks and side-effects of the procedure.

In assessing what is of overall benefit to adult patients, practitioners must take into account their cultural, religious or other beliefs and values.

Practitioners should usually provide procedures that patients request and that they assess to be of overall benefit to the patient.

Where patients refuse treatment which the healthcare practitioner assesses would be of overall benefit to the patient

Practitioners should respect a patient with capacity’s decision to refuse an investigation or treatment, even if they disagree with the decision or think it is irrational.^[1]

Practitioners can advise the patient of their clinical opinion, but should not put pressure on the patient to accept the advice given by the practitioner.^[2]

Practitioners should be careful to ensure that their words and actions do not imply judgement of the patient or their beliefs and values.^[3]

Judgment of patients’ values or behaviour

A particular aspect for healthcare practitioners to be wary of is making a negative judgment or comment about their patients’ values and behaviour. Healthcare practitioners should therefore avoid sharing their personal beliefs and opinions with patients, unless the patient expressly asks that such information be shared.

The need for honest and open communication with patients does not mean that healthcare practitioners should offer opinions about their own moral or personal views. We live in a multicultural society, in which all people are entitled to certain fundamental freedoms. Within that context, we are all entitled to exercise a wide degree of choice regarding our personal beliefs and lifestyle. It is inappropriate for any person, including a healthcare practitioner, to undermine the enjoyment of those rights.

For this reason, healthcare practitioners should also be wary of the inclination to use prayer or religious comment to support or guide patients. Where this is not requested, the healthcare practitioner will potentially fall foul of the HPCSA guidelines relating to the imposition of personal beliefs.

Where practitioners feel that patients’ actions have contributed to their condition

A challenge can arise when healthcare practitioners form the view that the patient’s own actions have contributed to their condition. In these circumstances, healthcare practitioners must be careful not to moralise by making comments or lecturing the patient. Healthcare practitioners must also ensure that their views in this regard do not delay or in any other way affect treatment which is provided to the patient.

Examples of circumstances in which this can arise is through the abuse of drugs or alcohol, smoking, pregnancy or other sexual activity, or other perceived inappropriate lifestyle choices or conduct.

Discussing actions of the patient which could have clinical implications

In certain circumstances, the actions of patients can have clinical implications for the effectiveness of proposed treatments. In these circumstances, the facts need to be honestly and frankly discussed with the patient in a non-judgmental manner, as part of the process of providing sufficient information for the patient to make an informed decision.

Where it is necessary to discuss such issues with patients, healthcare practitioners must be careful not to imply discrimination, through language or conduct. In particular, gratuitous comments about the patients’ lifestyle must be guarded against; these statements are not conducive to the establishment of a relationship of trust between healthcare practitioner and patients.

In a similar way, discussions with patients dealing with the practitioner’s conscientious objection to providing any particular treatment must be handled respectfully and sensitively, with care being taken not to imply discrimination.

Obtaining advice on religious or cultural requirements

Where practitioners carry out a procedure, for religious or cultural reasons, they should consider requesting the patient (or, in the case of children, their parents) about information as to how the procedure should be performed in order to meet the requirements of their faith or cultural beliefs. In appropriate cases, a religious adviser or cultural may be requested to give advice on how it should be performed to comply with religious or cultural requirements.

Talking to patients about religious beliefs

Healthcare practitioners are, of course, entitled to personal beliefs and opinions, but should not impose those beliefs on patients.

The concept that healthcare practitioners should not impose their beliefs or opinions on patients is founded on the provisions in the guidelines which require that practitioners should respect the privacy, confidentiality and dignity of patients; treat patients politely and with  consideration;  and listen to their patients and respect their opinions.^[4]

While practitioners may not impose their beliefs or views on their patients, where practitioners wish to find out about patients’ beliefs so that they can receive any religious or spiritual support which they require, the position is different. Particularly in the context of palliative care, it may be of great assistance in providing good quality care to know the individual views and requirements of patients. It may therefore be of assistance to take into account spiritual, religious, social, and cultural factors when assessing a patient’s condition and taking a history.

For these reasons, it may be appropriate to ask a patient about their personal beliefs. The determining factor is that the patient’s privacy, confidentiality and dignity must be respected. Where the patient’s views are of assistance in providing appropriate treatment and care, and provided that the manner in which the enquiries are made is made respectfully, then such enquiries will not contravene the provisions of the Guidelines.

A general approach which healthcare practitioners may find of assistance in implementing these principles is to keep discussions relevant to the patient’s care and treatment.

Care should be taken when disclosing any personal information to the patient, and the practitioner should be particularly aware in such circumstances of not crossing the professional boundary between the practitioner and the patient. At all times, practitioners should not impose their beliefs and values on patients, or cause patients to feel distressed or uncomfortable by providing inappropriate or insensitive information to patients.

Maintaining this boundary is an essential aspect of establishing and maintaining a relationship of trust with the patient, and is essential to the provision of professional healthcare services. Practitioners should therefore avoid talking about their own personal beliefs, unless the patient asks them directly about such beliefs or opinions, or the patient otherwise indicates that such a discussion would be welcome.

Standards applicable to procedures for religious or cultural reasons

Where practitioners agree to perform any procedure for religious or cultural reasons, they must meet the same standards of practice required for performing therapeutic procedures including:

1. having the necessary skills and experience to perform the procedure and use appropriate measures, including anaesthesia, to minimise pain and discomfort both during and after the procedure;
2. keeping their knowledge and skills up to date
3. ensuring conditions are hygienic; and
4. providing appropriate aftercare.

References

1. Addressing legal and policy barriers to male circumcision for adolescent boys in South Africa A E Strode, 1,2 LLM, PhD; J D Toohey, 2 LLB; C M Slack, 2 MA Clin Psyc, PhD;
2. Auvert B, Taljaard D, Lagarde E, et al. Correction: Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Med 2006;3(5):e226; ttp://dx.doi.org/10.1371/journal.pmed.0030226
3. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. AIDS 2000;14(15):2361-2370.
4. Talking to patients about religious beliefs BMJ 2015; 351 doi: https://doi.org/10.1136/sbmj.h4116 (Published 04 September 2015) Cite this as: BMJ 2015;351:h4116
5. C Ngwena, Conscientious objection and legal abortion in South Africa: delineating the parameters 2003 Journal for Juridical Science 28(1): 1-18 Journal of Medical Ethics 2016; 43 192-200 Published Online First: 03 Oct 2016. doi: 10.1136/medethics-2016-103476
6. BMJ 2015; 351 doi: https://doi.org/10.1136/sbmj.h4116 (Published 04 September 2015) Cite this as: BMJ 2015;351:h4116