When religion interferes with medical education

I’ve often written about the intersection of medicine and religion. Most commonly, I’ve lamented how the faithful advocate inappropriately injecting religion into the doctor-patient relationship in a manner that risks imposing the religion of the health care practitioner on the patient, sometimes through physicians feeling no obligation to inform patients of therapeutic options that violate their religious beliefs or pharmacists refusing to dispense medications that (they claim) violate their beliefs. Another common thread running through this blog is criticism of religion when it leads people to reject scientific medicine, be it religious communities that refuse to vaccinate, Jehovah’s Witnesses who refuse blood transfusion based on a tortured interpretation of a single Old Testament passage even if it means their deaths, or parents who think that Jesus will do a better job of taking care of diabetic ketoacidosis than insulin and copious amounts of intravenous fluids. Finally, I’ve always been very skeptical of claims that religion or intercessory prayer somehow helps disease or makes people healthier, when there is no good evidence that it does.

I hadn’t considered how fundamentalist religion might affect medical education until now. Maurice Bernstein notified me of this possibility:

I teach first and second year medical students how to relate to patients, take a medical history and perform the physical examination. My medical school, as do all medical schools in the United States accept students from all different cultures and religions. There are various issues involved in teaching students which arise and need to be resolved despite they have already been accepted to medical school and have begun their studies. I have recently been made aware of medical student issues that happen to be related to students of Muslim culture and religion. The issues do not arise with every Muslim student as far as I know but it has arisen and I really don’t know what the issues represent and how to deal with them yet meet my responsibility to develop a professionally competent physician.

And:

The BMA said it had received reports of Muslim students who did not want to learn anything about alcohol or the effects of overconsumption. “They are so opposed to the consumption of it they don’t want to learn anything about it,” said a spokesman.

The GMC said it had received requests for guidance over whether students could “omit parts of the medical curriculum and yet still be allowed to graduate”. Professor Peter Rubin, chairman of the GMC’s education committee, said: “Examples have included a refusal to see patients who are affected by diseases caused by alcohol or sexual activity, or a refusal to examine patients of a particular gender.”

I don’t deal nearly as much with medical students, although I do frequently deal with residents. I’ve dealt with residents of many races, creeds, and colors, including a number of Muslim and Arab physicians, but have not heard of this problem before. Of course, anyone who successfully competes for residency slots in a quality general surgery program would be unlikely to have done anything that resulted in black marks on his or her record in medical school, otherwise they wouldn’t have been accepted. In any case Dr. Bernstein cites an article from the Times last year, which describes the problem in the U.K.:

Some Muslim medical students are refusing to attend lectures or answer exam questions on alcohol-related or sexually transmitted diseases because they claim it offends their religious beliefs.

Some trainee doctors say learning to treat the diseases conflicts with their faith, which states that Muslims should not drink alcohol and rejects sexual promiscuity.

A small number of Muslim medical students have even refused to treat patients of the opposite sex. One male student was prepared to fail his final exams rather than carry out a basic examination of a female patient.

What I can’t figure out is why this was even allowed to be an issue To me it’s quite cut and dried. Physicians must be trained and competent to take care of all patients. If a medical student refuses to examine or treat a female patient, he should be told quite firmly that he either does what his training requires or he’ll be kicked out of medical school. Then the medical school should have the intestinal fortitude to actually kick him out if he refuses. It is the same thing with regard to alcohol-related or sexually transmitted diseases. Medical school exists to impart a basic set of medical knowledge and skills that all physicians should have. All physicians. Some of those skills may be considered unnecessary in many specialties, but it is important that all physicians at least be exposed to them. Moreover, a major tenet of medical bioethics is that all patients deserve our best effort. While we can make some decisions based on the allocation of scarce resources (for example, refusing to do a liver transplant on an alcoholic with end stage liver disease unless he stops drinking because utilizing that scarce resource to treat someone who’s likely to destroy it by continuing to drink is hard to justify morally or economically), those decisions cannot include the refusal to treat the patient because our religion objects to his or her lifestyle. The same thing would apply to a physician refusing to treat a prostitute because he disapproves of prostitution. The basic principle is that we do not pass moral judgment on our patients, nor do we base our treatment decisions on our approval or disapproval of a patient’s morals.

I wouldn’t hesitate. Any student who refused to learn about alcohol related diseases would still be responsible for the information covered in class and would still have to be tested on it. If he couldn’t answer the questions on the exam, he would flunk that section of the class. Any student who refused to examine a female patient would flunk his physical diagnosis class. It’s just that simple. A person’s religion does not give him the right to pick and choose which parts of the medical curriculum he will study. Part of being a competent general physician is knowing both male and female anatomy and treating both male and female. If he cannot do what is required of him by a medical school to learn good patient diagnosis and care because his religion doesn’t permit it, he should then find another line of work.

What’s interesting to note is that mainstream Muslim organizations reject this line of thinking, although I’m not sure I like the reasoning:

“It is obligatory for Muslim doctors and students to learn about everything. The prophet said, ‘Learn about witchcraft, but don’t practise it’.”

Why he would equate examining female patients or learning about alcohol-induced diseases to witchcraft, I’m not sure. I realize the idea is that both are considered evil apparently, but why on earth would it be evil to learn the basic and clinical science of alcohol damage to the liver or why it would be evil to relieve the suffering of an alcoholic. The only explanation I can think is that it’s the same explanation that fundamentalists use for demonizing people whom they consider immoral: That the alcoholic with cirrhosis deserves his fate and is being punished by God for his immorality.

None of this is to say that a patient doesn’t have the right to choose her medical practitioner. If a woman wants a woman physician, she should be accommodated with in reason. (By “within reason,” I mean that if there’s no female physician around, for example, it’s not necessary to call one in just because the patient wants one.) The point is that the physician doesn’t get to choose that he or she won’t take care of patients of the opposite sex, at least not during training, and the doctor’s employer is under no obligation to retain such a recalcitrant employee. The same thing goes for Muslim women who refuse to wash their hands properly because it necessitates baring their arms above the wrists.

I’m very strongly in favor of freedom of religion or freedom from religion. It’s one of the founding tenets of our great nation. However freedom of religion does not imply that accommodations have to be made for religious belief if they conflict with good patient care. It doesn’t matter if it’s Muslims refusing to learn about diseases whose causes are related to behavior they consider immoral or Christian physicians refusing to disclose all science-based legal treatment options because the conflict with their religion. In medicine, the patient must come first. Medicine is a profession, and professionalism demands it. If a person’s religion will not let him or her do what the profession requires, then that person should not be a physician.

It comes down to is a small number of highly religious people who, rather than accommodating themselves to the rest of society, demand that society accommodates them. It’s not a bad thing for society to make reasonable accommodations, but the key word is “reasonable.” It’s not reasonable to change the standards of medical education or care just because a few fundamentalists object.