Understanding patients' personal beliefs is an essential part of good medical practice. Patients' healthcare beliefs may either be knowledge or value based. When patients with intact mental capacity hold cognitive beliefs that are factually inaccurate or illogical because of their failure to understand medical information, this is resolved by educating them in a language and manner which they can understand. This is essentially a knowledge or comprehension issue. Doctors should be mindful to communicate at the patient's level and avoid technical jargon. It is good practice to use visual aids to assist understanding and to follow up with open-ended questions to check that the patient has understood.
The Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines states, "If patients continue to refuse necessary treatment despite your explanations, you must respect their decisions" In such situations, doctors are dealing with a different type of refusal. It is a value-based refusal that is influenced by personal, religious or cultural beliefs. The natural tendency is to switch to the explanation and persuasion mode to continue to convince patients and their surrogates on the benefits of treatment. However, a more effective approach is to explore further with patients their reasons for refusal. Patients' beliefs are influenced by illness interpretation and their priorities (ie, what is of importance to them, such as life goals, values and needs). It behoves doctors to understand what their patients' beliefs are, and utilise their medical knowledge to guide them on what treatment will best serve their goals and needs. Competent patients' treatment refusals that are made with genuine understanding should be respected by healthcare professionals. This is the cornerstone of respect for persons and autonomy. Although autonomy extends to accepting the patient's right to decline beneficial medical treatment, it does not carry any obligations for doctors to accede to demands for treatment that are not medically appropriate.
Doctors' personal beliefs
It is equally important to recognise the importance of the doctor's personal beliefs and these impact on clinical decision-making. Personal beliefs should not be confused with controversies that exist in the scientific basis of medical knowledge or judgement calls in clinical practice. The SMC Handbook of Medical Ethics (HME) defines personal beliefs as those held by the doctor on a personal basis, such as a set of religious or philosophical beliefs, and not the sort of beliefs that generally guide patient management.1
Patients rely on doctors for their expertise and treatment. This creates an inherent power imbalance in the doctor-patient relationship and patients are in a position of vulnerability. Patients may feel obligated to listen to doctors or feel constrained and intimidated in expressing differing beliefs. Patients may align their beliefs to suit their doctors' values inadvertently. Doctors should have the awareness and not foist their beliefs – whether consciously or unintentionally – on patients. This is reiterated in the SMC HME, "Patients will have their own beliefs, faith or spiritual concerns in addressing issues of illness, suffering, debilitation and dying. If you have a different set of beliefs from your patients, you ought not to try to change their beliefs or impose your own beliefs on them."1
Impact on clinical management
Personal beliefs and values by their nature tend to be strongly held by an individual, and doctors are no exception. There may be occasions when a doctor's beliefs prevent him/ her from offering certain treatment or procedures. Termination of pregnancy is one such example. If a doctor exercises conscientious objection, he/she is to explain his/her reasons clearly to the patient while respecting the patient's perspective. The doctor should refer the patient to alternative medical providers if she seeks treatment in this aspect. However, beliefs should not be used to discriminate against any individual or group of individuals on the basis of personal bias. Offering termination of pregnancy to one group of patients while declining in another group based on discriminatory factors is not acceptable. If a clinician has a personal belief against a procedure, all patients who seek that procedure for medically appropriate reasons should be referred on to other doctors.
Religious and spiritual beliefs
When doctors and patients share similar faiths or spiritual perspectives, doctors need to be prudent in supporting patients through religion. There is a risk of loss of objectivity, and of compromising clinical judgement and professionalism. However, patients also want empathy and compassion from their physicians, and religion forms a central part of how patients cope with illness and suffering. Any engagement should only be done with the expressed consent of the patient and the boundaries of professional relationship should be made clear.
Importance of self-awareness
The personal beliefs of doctors can subtly influence the medical opinions they give to patients and their decisions are not always free from bias. The safeguard against these influences affecting medical objectivity is awareness and a willingness to seek the input of others. With deliberate practice, doctors must learn to recognise situations where there is bias and take steps to prevent those biases from influencing clinical decision-making.