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Chapter 5 - Morality and decency

The public has a high expectation of the moral standards that should be maintained by anyone who employs a position of trust in society. Morals are, essentially, guiding principles in relation to what is right and wrong, and they can apply to all kinds of behaviour. Moral actions and behaviour are virtuous, respectable and beyond reproach, so they clearly form an integral part of ethics.
The doctor–patient relationship is by no means the only area where questions of a doctor’s morality and/or decency might arise
The converse terms 'immoral’ or ‘immorality’ are, however, most often used to describe sexual misdemeanours, although this is actually only one aspect of immorality. The terms ‘indecent’ and ‘indecency’ have been similarly commandeered to signify something improper or obscene in a sexual sense, whereas ‘decency’ is essentially the quality of fairness, respectability and of upright and proper behaviour. Another important facet of morality relates to honesty, but this is discussed further in Chapter 6 – Honesty.

It is obvious that a doctor should avoid any situation where it might be suggested that s/he has acted in an immoral or indecent fashion in relation to a patient. Less obvious, perhaps, is the fact that the doctor–patient relationship is by no means the only area where questions of a doctor’s morality and/or decency might arise.

Regulatory bodies (Medical Councils and Medical Boards) have been known to view, with equal concern, allegations of inappropriate behaviour, especially of a sexual nature, involving staff members, or even situations arising in a doctor’s personal life.

The basis for this is that such behaviour can still suggest what is sometimes described as ‘moral turpitude’ – that is, deficiencies in a person’s moral standards – whether or not any patients are involved. There is also a potential for such behaviour to undermine public trust and confidence in the profession.

Allegations or convictions for indecent assault, or those which involve offensive behaviour of a sexual or immoral nature, such as rape or pornography (especially child pornography), are, therefore, likely to be viewed very seriously.

Regulatory bodies exist to protect the public and, in doing this, certain values and standards of personal behaviour are generally expected

Serious criminal offences aside, some might question what relevance some of these other offences could possibly have to one’s ability to practise medicine, and ask why a doctor is not entitled to a personal/private life like anyone else in society.

Such views are understandable, but regulatory bodies exist to protect the public and, in doing this, certain values and standards of personal behaviour are generally expected. They are considered to be a prerequisite for the relationship of trust and confidence that needs to exist between any healthcare provider and a patient.

It is the abuse of this trust that lies at the heart of cases where acts of immorality and indecency place a doctor’s professional career at risk. The higher the public’s expectation of morality and decency, the more severe any disciplinary sanction is likely to be. Here, as in many other areas, we find that the price of being a member of a respected profession is high.

Misunderstandings

Doctors regularly find themselves working in close physical proximity to patients, which creates a need for doctors to be mindful of how their actions may be perceived or interpreted, however innocent or well-intentioned they might be.

When dealing with a patient who is acutely anxious or distressed, it is a natural human reaction to help and support them, and to demonstrate care, concern and compassion. In some healthcare settings – such as when someone is being told that a close relative has died – this may well involve putting a reassuring arm around them, or touching/holding their hand.

Doctors need to be mindful of how their actions may be perceived or interpreted, however innocent or well-intentioned they might be

In the past, such acts on the part of a healthcare professional would rarely have raised any doubts or concerns, but the world is changing and one can find the most natural and innocent gestures being questioned.

Some individuals are instinctively tactile in their interpersonal communication, and because this is their natural style, it may not even cross their mind that it could be unwise to adopt the same approach when dealing with patients. Much depends upon the context, of course, and factors such as the age/sex/previous relationship between the parties are obviously relevant. But past experience suggests that male doctors need to be particularly cautious about any physical contact with female patients, however well-intentioned the motive.

Just as doctors are different, so are patients. Wide variations can be found between one patient and another, because of their own particular background, upbringing and style of communication. There are also important cultural variations to bear in mind. A reassuring and fleeting touch of the arm of one person may be welcomed, while another patient may find such a gesture quite alarming and offensive.

Whilst the doctor may be absolutely clear about why or how he is conducting a particular examination, this is not always obvious to the patient, who may misinterpret the doctor’s actions. The doctor should always preface an examination with an explanation as to what he is going to do and why. Even simple procedures such as fundoscopy may be open to misinterpretation. The patient needs to be told why the room is darkened and that the doctor’s face will be very close to the patient’s during the examination.
The doctor should always preface an examination with an explanation as to what he is going to do and why
Where doctors are found to have committed acts of indecency, or to have behaved immorally, this is such a fundamental breach of trust that the professional consequences are likely to be severe and regulatory bodies will strongly disapprove.