Why religious belief should be declared as a competing interest
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1456 (Published 12 April 2018) Cite this as: BMJ 2018;361:k1456
All rapid responses
We are grateful for responses to our article.
We started our article by stating that if in doubt whether to declare a conflict of interest, you should declare it. This applies to all conflicts of interest, but we were asked to write only about religious conflicts of interest. Other articles in the BMJ discussed other non-financial conflicts.
We have declared conflicts of interest of suffering from reflux when writing an article on the subject (JB) (1) and of the recent death of a pet rabbit when writing an editorial on animal experimentation (RS).(2)
One of us (RS) coauthored an article on the fallacy of impartiality in which he and others concluded: “Our message is simple: we must recognize that we are all conflicted and declare accordingly.”(3) In particular the article argued that academics without financial links with for-profit companies were wrong to think that they had no conflicts.
Nature interestingly has recently decided to tighten its rules on non-financial conflicts of interest. (4)
There is obviously a problem with declaring what you are not: it could be a very long list. But we agree with the point of many respondents that if writing on a subject where religious belief is important then it would be wise to declare an absence of faith. That’s what Smith did with our article. Perhaps it should become routine in articles on issues like abortion and assisted suicide, where religious belief is relevant.
We think as well that it would be wise to declare your type of faith and perhaps explain the line that strict adherents to the faith would take on the issue.
Woody Caan argues that it would be a sad day if people had to declare “the nine characteristics protected under the Equality Act 2010,” but there is a big difference between discrimination and declaring conflicts of interest in an article. The point of declaring conflicts of interest is to give readers information that will help them evaluate an article.
Nowhere in our article did we suggest that people of faith are irrational. We do not believe so, and such a belief would undermine our article in that one of us does have a faith. The point of our article was not in any way to suggest that the views of those with faith are “somehow less credible, less worthy of consideration.”
We continue to be convinced that when relevant religious faith should be declared, as should its absence.
1. Blazeby J, Barham P, Donovan J. Commentary: Randomised trials of surgical and non-surgical treatment: a role model for the future. BMJ 2008; 337:a2747
2. Smith R. Animal research: the need for a middle ground. BMJ 2001; 322 :248
3. Anonymous. Outside interests. Nature 2018; 554: 6.
4. Smith R, Feachem R, Feachem NS, Koehlmoos TP, Kinlaw H. The fallacy of impartiality: competing interest bias in academic publications. J R Soc Med 102(2): 44-45; doi:10.1258/jrsm.2009.080400
Competing interests: RS has no religious faith but respects those who do. JB has a religious faith and respects those who do not.
I believe Richard Smith and Jane Blazeby to have raised an interesting issue as to whether medical practitioners should declare religious belief. Whereas, the article sought to set out a balanced view of the argument, I believe the authors only raised one substantive point against disclosure, namely that religious observance is a private matter.
In my view, such privacy might just be enough. It is a reality that discrimination on the basis of protected characteristics is commonplace and although the authors allude to this, I would be concerned that doctors may risk being entirely defined by their religion so that the public may not be convinced that they could hold anything but 'the party line' . Furthermore, why ask doctors alone to expose themselves to discrimination when other professional groups involved in public life may be at risk of demonstrating similar religious conflicts of interest in the course of their work? Indeed, should doctors go further and disclose other characteristics that might influence their views, such as sexual orientation?
The impact of religious observance on practice is moreover likely to be dependent upon factors which require exacting or impractical detail in any disclosure e.g. nominal to substantive practice of any religion; or communication of the relevant core beliefs of any religious grouping - Roman Catholics and Presbyterians within Christianity may have significantly different views on social issues.
Do we not have currently in Good Medical Practice, a guide which is sufficient to balance the needs and care of patients with doctors personal religious views?
Competing interests: No competing interests
We need more focus not less on institutional and financial conflict - this article is a distraction.
Competing interests: No competing interests
1. It matters not what your nominal religion is.
Example. Back in the 1970s, before Mrs Barbara Castle brought in Free Contraception for ALL (dressed up as Family Planning), there were some GPs here who did NOT agree to give contraceptive advice or devices to thei own patients. These patients went instead to the Family Planning Clinics.
However, when “fee for family planning” came in, gradually, all these GPs opted to provide the service - even if the actual insertion of the intrauterine device, for example, was carried out by an assistant or a partner.
So, pounds sterling trumped the religious doctrine.
2. In 1962, I was admitted to a hospital in the English Midlands. The ward sister asked me what my religion was. I replied “None”. But she said, “But you must have been baptised in to SOME religion.” I said I said I wasn’t baptised. All right, she said, she would put down FREE CHURCH. Anxious as I was to lie down on a bed, I agreed - even though Free Church really is a Christian term in this country.
The “ ministers” of various denominations visited the ward every day. They had all known me for a year and a half and we always had had chats. But when I lay in my hospital bed, only the Methodist minister would pop in and say hello and ask how I was feeling.
I would have been glad of a chat with the others too. I was not lonely - the nurses, other housemen, my consultants all dropped in. And since I was in my own ward (in a side-room, the only side-room free at the time in the hospital) all the nurses, cadets, night sisters would give me a cheery wave in passing.
3. In the same hospital, the consultant OB-Gyn, nominally belonged to a religious sect which did not believe in termination of pregnancy. However, this consultant DID terminate pregnancies for medical reasons. Then he would be assisted by a theatre nurse who belonged to a different branch of the religion. Curious it might seem but there was never any rancour between the staff on this score.
Suggestion: Forget “religious belief”. Just talk about your “conscience at the moment”.
Competing interests: I am an atheist NOW. During my life-time I have had various “religious beliefs”.
The feature article (1) by Richard Smith and Jane Blazeby spoke passionately and clearly about declaring religious beliefs as a competing interest in clinical practice. Also, it was good to see that they made a declaration of their belief/non-belief. Did these fairly generic declarations seem in keeping with what they meant as the message of their paper? I was envisioning something more.
As practicing Intensivist, I come up against very difficult end-of-life issues daily. I routinely disclose my religious beliefs (Catholic) whenever we are discussing a clinical conundrum about which my faith might influence my own personal comments to them. Alongside such a disclosure, I then make it very clear that I am there to serve the patient and need to know his/her spiritual values and beliefs systems so that I can navigate our decisions.
Using the same rationale discussed about religion, do the authors feel that disclosure of other “isms” should be “essential” as well? For example, secularism, atheism, Marxism, Freudianism, scientism, and humanism are no less potent beliefs that serve to guide the ethics of those who affiliate with such groups. The difference merely lies in the object of the belief. As such, these other non-religious belief systems raise the exact same issues because they are clearly not neutral forms of belief. Shouldn’t such potent ideologies, using the same logic posed by the authors, be disclosed since they have every bit as much of a “profound effect on their views on matters such as assisted dying and abortion” as religious beliefs?
1. Smith, R and Blazeby J. Why religious beliefs should be declared as a competing interest. BMJ 2018; 361:k1456 doi: 10.1136/bmj.k1456 (Published 12 April 2018).
Competing interests: No competing interests
I come to respond to this thought provoking article finding that many have already done so, and that many of these contributions have articulated a good number of the impressions that I had myself.
I find myself uncomfortable with the implicit idea that a theistic view of the world can be classified as a “bias” while other philosophical underpinnings are regarded as the unbiased default. As others have pointed out, we all need to recognize that we approach ethical and value based issues with a raft of presuppositions and assumptions which have their routes in our fundamental world view, be that theistic or not. The “view from nowhere” does not exist, and while the authors correctly point out that religious belief often profoundly affects how we evaluate our decisions, to regard religious belief as a special category that should be specially declared while other belief systems need not, risks a dangerous and potentially discriminatory precedent.
Competing interests: I am a Christian.
Smith and Blazeby1 seem to be implying that only ‘religious’ people hold a faith position, whilst the rest of us approach difficult ethical issues with a cool, detached neutrality. Presumably these ‘religious beliefs’ need to be seen for what they are – unscientific, irrational and dangerous. However, it is a myth that only ‘religious people’ have a faith – we all have world view convictions – why we are here, where we are going, what we value, who we love and so on. As the GMC so succinctly states, ‘all doctors have personal values that affect their day-to-day practice’.2
The second myth perpetuated here is that ‘religious’ people smuggle these biases into their work, negatively impacting patient care. Polls on issues like abortion and euthanasia show that those adhering to a secular set of values (codeword: ‘faith’) will favour the autonomy of choice above all other moral foundations, including the sanctity of life. But this too will inevitably, in the authors’ words, ‘create a risk that professional judgement or actions…will be unduly influenced by a secondary interest.’ Of course, these views aren’t based on science, but on a way of seeing the world. As a case in point, the question of whether a 12-week old foetus is a ‘human life’ is no longer seriously in question. Why? Because of, among other things, the advances of science and imaging technology. The goalposts have therefore been shifted to the issue of personhood – the foetus may be human but isn’t a person - which seems to me to a moveable goalpost and arguably rather more un-scientific and irrational than a ‘traditional Christian view’.
We should all be aware of our personal beliefs that affect our medical practice. Perhaps the authors could reflect on their early statement that ‘hiding a competing interest hints at dishonesty, raising doubts about the integrity of what has been written or said’.
References
1. Smith R, Blazeby J. Why religious belief should be declared as a competing interest. BMJ. 2018; k1456.
2. GMC ‘Personal beliefs and medical practice’, 2013
Competing interests: No competing interests
Despite its respectful liturgy and doxology, religion is covert frustration and anger with God, who gave us just enough intelligence to understand life's dilemmas, but not enough intelligence to solve them.
Competing interests: No competing interests
The overwhelming impression left by this article is that not having a religious belief is a neutral position that does not, of itself, lead to similar competing interests imputed to those of us who have such a belief.
For some, lack of religious belief is a product of not wishing or bothering to think about such matters. Others positively deny belief in God, often failing or refusing to believe that, by doing so, they have espoused a world view (or 'faith') as powerful as the religions they reject. Such people are surely as liable to have competing interests as the religious person. For example, on p. 330 of the second edition of his book 'The Selfish Gene' (OUP 1989), Richard Dawkins, the high priest of the 'New Atheism', remarks that 'faith is a kind of mental illness' . This condescending view derives from his own beliefs as an atheist and, I suggest, could, in some contexts, lead to significant competing interests. In my opinion such competing interests are not sufficiently explicit in the 'non-financial' category posited by the authors. Thus if religious beliefs are to be declared surely all strongly held beliefs, be they religious or secular, should be explicitly included?
Competing interests: Practicing Christian
Re: Why religious belief should be declared as a competing interest
Thank you for an interesting and thought-provoking article. Although not explicitly stated, I presume the authors would also expect that those with any significant belief system shoud declare it. For example, members of the British Humanist Association or the National Secular Society often have strongly held beliefs, inevitably influenced by their belief system, and these influences need to be declared just as much as overt religious beliefs.
Declaration of interest - I am a Christian.
Competing interests: No competing interests