Friday, February 15, 2008

Doing God's Work

In response to outbreaks of MRSA and c.difficile, hospitals in England have instituted various hygiene policies, including the need for medical staff to have bare arms, which they must wash to the elbows. Muslim female medical students are refusing, on grounds of immodesty inconsistent with Muslim law. When mentioned on the website Pharyngula, among the comments thereon was this:

Many moons ago I lived with a Bedouin hill tribe near Petra in Jordan. One winter I got terribly sick with pneumonia and had to receive treatment by a Muslim doctor in Petra. Whilst he was a lovely man and their training is first rate he still had to adhere to the silly requirements of his religion. As such, sick as a dog, I could only be examined from the other side of a sheet held up by his two giggling nurses. I explained that it didn't worry me to be examined and to go ahead, lift up my top and listen to my lungs, but no, still had to have that damn sheet. I was in that clinic for a week and all I remember in my delerium is that...sheet.

Some time ago, in another context I wrote about the very regal and imposing matriarch of an immigrant Muslim family on whom I operated. Seeing her in my office, I was forbidden, in no uncertain terms, from exposing her in any way when I examined her; I thumped, prodded and auscultated through her black coverings. When she came for surgery we brought her fully clothed in her religious garb into the OR, and I left it on during the whole operation, sliding it up (while keeping her lower body covered) only after she was asleep. Both the office exam and the OR proceedings broke a few rules of thoroughness, but I really didn't have a problem with it. I made some non-critical compromises to accommodate her beliefs; I assume (but don't know) that under other circumstances -- like evaluating her in critical shape after a car wreck -- her family would have allowed whatever uncovering was necessary.

In refusing for religious reasons to allow a full exam, my patient was the one taking the risk, however small, of forcing me to be incomplete: her religion, her problem. Had I thought it dangerous, I'd either have insisted otherwise, or if unsuccessful, I suppose, refused to provide care (since it was elective.) But the situation in England (and in Petra, for that matter) is different: in following their covenants the medics are putting others at risk. People have right to practice their religion freely (in most Western countries, anyway.) But isn't a line being crossed here? If your religion prohibits you from doing certain things, professionally, that are in the interest of others, ought you not opt out of that particular profession?

Well, of course. And in the US, there are pharmacists who refuse to dispense "morning after" pills for similar reasons. What's next? Young-earth firefighters not rescuing a married gay couple?


gay CME guy said...

I concur. If one's belief system (whether based on religious or other reasons) 'prohibits' one from doing the job that is required (or expected), then that person needs to choose another profession that accomodates their belief system.

rlbates said...

Very nicely said, both your post and gay cme guy's comment.

Anonymous said...

I don't disagree with you. But unqualified agreement is boring, yes?

The Muslim physician at Petra doesn't have a problem with his co-religionists--he wants them covered, they want to be covered. No problem. The difficulty comes in a pluralistic environment with heterogeneous value sets.
eg in England where the Muslim female med students say they value modesty more than infection control policies. Not only do different religions vary in how well they play with others, there is enormous variation in interpretation within each religion. I think some of the problem is solvable if only we could have a sense of humor and will to creative cooperation. (Disposable sleeves, paid for by a Muslim student association fundraiser?)

One more thought--I don't think your firefighters are logically analogous.


Anonymous said...

Ooh, sorry. It sounds a little like I thought the previous commenters were boring; I don't--apologies. I just think a little debate is fun. I'm fond of taking the middle position so I can ge tomato on both sides of my head.

Sid Schwab said...

dr bean: no problem. But I do think the firefighter analogy appropriate, and only differs in degree from examples at hand: if your religious beliefs allow you to refuse help to a woman in distress and, conceivably (pun), force her to become pregnant unwantedly, then it's only a little further to say that because you consider homosexuality an abomination in the eyes of God you'll not touch or help them. Likewise the arm-exposure: my beliefs trump your health. The solution of sterile sleeves, which are in fact readily available, is a good one: but the refusniks hadn't proposed it, at least not in the article; and such solutions aren't available in all situations: the pharmacist can't cover his head while handing over the pills. He simply refuses, and (happily) lets the patient go to hell.

Anonymous said...

Great post Dr. Schwab and congratulations on reaching 1/2 a million page views!

(For the record, the article initially cited did state the following:

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.")

Not Important said...

Dr. Schwab,

You've already seen my experience (he says, whoring his blog). The conflict between religious beliefs and doing one's job is alive and well here in the good ol' US of A.

The people who are working to chip away or outright knock down the wall betwixt church and state must be either willfully ignorant or outright dissemblers when they claim that our society wouldn't suffer. Neither option speaks well of them or their goals.


Anonymous said...

I thought firefighters were not analogous at first because saving life is not a religiously forbidden action like uncovering one's arms. But on reflection the real problem here is an attitude of "I'm more interested in making a point about what I won't do than in figuring out a way to help you." You are exactly right that people with this sort of attitude are the ones who would (in the logical extreme) leave people in a burning building if they thought they were "bad" people.

Anonymous said...

Pharmacists who won't dispense the morning after pill really bother me, as do the corporate giants that hire them and permit this. I've always wondered about following this line of thinking to its logical extreme...what if you had a pharmacist who was a Christian Scientist and refused to dispense any medication whatsoever?

Anonymous said...

Dr. Schwab - You are right on target about the ridiculous nature of these Muslim women's objections. I made similar remarks on my blog.

Howeve, I have to object to your fireman analogy. No serious Christian evangelicals that I know of would suggest such a thing, and any who do would be universally decried as a lunatic fringe by the rest of the Christian community. The difference is that these Muslims who are trying to risk their patients' lives are being supported by their religious community. Conservative Christianity and conservative Islam are not identical, and do not deserve to be tarred with the same brush.

Sid Schwab said...

OK, then what about the pharmacists? Their view is that a pill which blocks FERTILIZATION is sinful. And they're entirely supported by Christian evangelicals. Like the Muslim women, they are using a religious belief to trump the needs of women who have lawfully been given a prescription for a lawful drug. In doing so, they override the patient's physician, and her well-being, only for religious reasons. Like the Muslim women willing to spread infection to innocents. The facts are different: the ethics aren't. They're entitled to their beliefs. But they're in the wrong profession.

Joan K said...

When I was young and foolish I was a nun - think floor length habit and veil - nun. I was very ill and had major surgery. I had no problem with exams or anything necessary to treat me but the doctors I had insisted on examining me with the habit on and were a bit freaked by the idea of my removing it. One did a complete pelvic exam w/ the habit on. This was in New York City 10 years ago.

I thought it was rather silly to be so upset by such things. I guess it shows that religious sensibilities are a problem on both sides.

I an no longer a nun or even a Christian.

I think that those Muslim women who will not wash properly need to follow the washing rules or get into a different profession.

Ones religious sensibilities should not interfere with effective, safe treatment for all.

Joan K said...

And to make my comment even odder I should add that now that I am an out and married lesbian. I have never experienced discrimination from the medical community. A few doctors have been puzzled by "my wife" (its legal where I live) but once they know the relationship they have no problem with it. Of course I live in a very liberal state (Massachusetts)

I am more concerned with medical care somewhere where same sex marriage is not legal. We have the appropriate legal documents and aren't afraid to use them.

Anonymous said...

I agree with the idea that if someones religious beliefs are harming patients they should probably either change jobs or find a way around it. But I think we need to step back and look at this in perspective. I work as a doctor in hospital where most staff wear long sleeves and wear watches. These probably spread MRSA and other infections, however the staff know that it probably isnt significantly contributing to mortality to do something about it, because really infection control staff and their directives are unrealistic. In this blog previously there was a post about surgical prep and how it is sometimes overly done. Now I think the muslim students are probably aware that this new policy is probably not goin to benefit patients all that much, just as Sid Schwab knows that a patient doenst need to be covered in skin prep from head to toe. I think if it was a more serious issue at hand there would be less resistance. And I am certain most non-muslim staff in these British hospitals dont follow this policy at all times.

If I could also make a comment about the issue of uncovering of female patients. I know many strict muslim doctors who are fine with uncovering female patients. And the religion also allows for compromise of all its rules when it is a issue of life and death. For example eating pig and drinking alcohol are prohibited, but both are allowed if it is necessary for survival. Another example is if someone threatens a muslim with torture or death if they dont renounce their faith, that muslim is allowed to verbally renounce their faith to escape such punishment without any religious consequences.

Sid Schwab said...

yt: I never said skin prep was unimportant; in fact, I said it was the most important thing we do. What I said was that there's some silliness in that the prep often (until I intervened) would extend only a couple of inches from the incision on one side and a couple of feet on the other. Nor do I accept that the Muslim students "know" it makes no difference. It most assuredly does.

It's good that compromise is allowed when one's OWN health is at stake. So why not when another's is? Now THAT would be a breath of fresh air!

Bongi said...

there was an arguement about this very topic on rantings of an arab chick.
as far as i can tell she is muslin. so even muslims (some) disagree with this selfish insanity.

i can't help wondering if these short sighted students belong in medicine at all. if their god places their honour or whatever they call it above the lives of their patients???? sayus something about their god maybe??

Anonymous said...

Well i think my pleas for perspective on this issue were probably not heard.

But in any case these are students, and if they werent rebelling against one cause they would be against another, it comes with being a certain age and being at university.

I feel a lot of the discourse that has occurred in this debate is more anti-religion than anything. Its a common occurrence that if someones beliefs are quite different from ones own that they find points of disharmony in the opposing view points and emphasize them. This reassures us how right we are and how wrong the other is, and makes us feel better, makes us feel superior. But at the end of the day it breeds hate and conflict which is unhealthy. Sure muslims are wrong about some things, and sometimes very very wrong. But these wrongs occur because of some deviation from the religion, and because of cultural (not religious) practices, political instability or social disadvantage. So dont asssume everything done in the name of a religion is a true reflection of that religion. The true nature of ones motives may be masked by religion but may be something entirely different. In this case it could just be that these are university students finding a cause to protest against.

A interesting note is here in australia, medical students are told to wear ties. Staff are encouraged to do so. Even though ties are probably the worst garment in terms of infection control. However I remember clearly one surgical professor (actually the head of surgery at the the hospital and the head of the clinical school) telling off a student for not wearing a tie when seeing a patient.

Sid Schwab said...

yt: I think we're arguing at cross-purposes. I don't at all see those students as "rebelling." They are toeing the party religious line. And of course what I said was anti-religious, in the sense that I object to people who allow religious dogma to lead them to ill-serve the people for whom they are to care. It's not anti all religion; nor is it relevant that people who so behave may or may not represent an entire religion. They represent their own view of religion, making no allowance for those who may believe differently, willingly subjecting them to harm, choosing their narrow views of purity, over the well-being of others. And I included not only Muslims.

I wrote about the necktie thing a while back. At least we're in agreement on that subject!

Anonymous said...

This is a fascinating discussion - as much for what it reveals about us - as it does about the op.

What would happen if a similar policy were implemented here in the US? Maybe banning long-sleeved shirts, neckties, and white coats, and tying compliance to Medicare reimbursement.

I think that some docs might readily comply, others might refuse to toss out generations worth of tradition, others still, perhaps the majority, might want to see the data and draw their own conclusions from it. There'd probably be a national public debate, and, ultimately, patients might choose to avoid non-compliant docs etc...

I guess my point is that there would be a measured, even nuanced, response.

It seems, however, that in today's social and political climate, all nuance is lost when when it comes to decisions made by people of faith, and in particular Muslims.

Bongi said...

i find it interesting that people think that muslims are being discriminated against here. the patients are the ones that will bear the septic brunt. in fact these students (who claim to be acting in the name of their religion) are discriminating against patients. the students are not the victims but the perpetrators.

Doctor David said...

I have complementary experience to yours, Sid, that I'd like to share. I am a part of the pediatric bone marrow transplant team at my hospital, and as such we have numerous patients who come from the Middle East. Interestingly, however "modest" the mothers are, I have never encountered ANY resistance to ANY medical procedure I have needed to do for the girls I care for. That includes looking for peri-rectal abscesses. Obviously, this is not a scientific study, but I think that it's interesting that women in burqas who will not even shake my hand will still allow their daughters to be stripped naked when they need to to get their necessary medical care.

Sid Schwab said...

doctor david: That is interesting. I don't think I have had a similar mother/daughter situation, and it's nice to hear of yours.

Anonymous said...

"Pharmacists who won't dispense the morning after pill really bother me, as do the corporate giants that hire them and permit this. I've always wondered about following this line of thinking to its logical extreme...what if you had a pharmacist who was a Christian Scientist and refused to dispense any medication whatsoever?"

I think that's simply between them and their employer. If an employee won't fulfill the requirements of their position, the employer should be under no obligation to hire them or maintain their position. I see no need for government intervention. The oft-proposed scenarios of "What if it's the only pharmacy in this small town, and she NEEDS Plan B?" are ridiculous. Should we then put pharmacies in every small town that doesn't have one, even if they couldn't support its existence?

Sid Schwab said...

Prowler: I don't think I agree. There are plenty of national scale employers who could easily make it a policy not to carry those drugs; in the same way that an individual pharmacist has an obligation to provide legally and properly prescribed drugs, so does a business that purports to serve that need. I think there are times when one's duty to others trumps one's religious beliefs, and if a person can't abide that, then they really need not to be in that line of work. A vegan wouldn't work in a meat packing plant; nor would a person whose religion forbids the touching of, say, pork. Ideally, all employers would either stipulate that employees dispense all legal and proper drugs, or provide another who would. But if they don't, given the needs of the public, I'd think laws would be proper. Even though I deplore the fact that such a thing would be necessary.

Anonymous said...

i am a female muslim surgeon living in a country with 50% professed muslim population. i wear scrubs and wash hands before and after every patient. it's second nature. it is what doctors do. my colleagues and patients wear the hijab. we have never had problems with physical examination or sterility.

Islam is based on hygiene. Our prophet's(PBUH) last act was ablution and brushing of teeth. that's how important hygiene is in Islam. Islam, like many other organised religion is heavily tinged with cultural dogma. it is from this that one hears stories/practices as narrated by the author and readers.

as entertaining as the anecdotes may be, they do not reflect the true nature of Islam, their doctors or patients in general.

i do however concur if one is stupid enough not to adhere to infection control standards, then they should not be in the medical profesion.

but then, we have bigoted priests/mullahs/rabbi running aroud too..

Sid Schwab said...

Indeed, we most certainly do!

Anonymous said...

This is a topic that we will be discussing in our Monthly physican staff meeting tonight.

One of our partners has decided for religious reasons to stop providing BCP for any reason.

Should be a lively, interesting discussion.



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