NHS morality and care based on compassionate values

In December 2013, the Royal College of Psychiatrists published an occasional paper responding to the Francis report, OP92. ¹ In an editorial, John Cox and Alison Gray stridently criticise the document. ² By contrast, I believe that OP92 strikes exactly the right tone and that the actions it sets out should be strongly supported. All members of the College should read it (it is available at the College website: www.rcpsych.ac.uk/files/pdfversion/OP92.pdf). It succinctly relates principles to the actions that the College is taking.

I suspect that that the source of dissatisfaction for Cox & Gray lies in the following passages in the document: ‘Responses to inadequate or abusive practice tend to emphasise the practical, ethical or moral failings of individuals. These are relevant, but, alone, statements of the importance of compassion, patient-centred care and the duty of candour are unlikely to prevent further scandals. Inadequate and abusive care arises in response to situational forces and a variety of behavioural cues. […] We need to take on board the lessons of the Milligram (1974) and Zimbardo (Haney et al, 1973) experiments […] namely that ordinary, decent people will behave badly in environments that are not designed to help them to behave well’. ^{1(pp. 4–5)}

This touches on a systemic and empirical understanding of the problems in British healthcare delivery, which is exactly the appropriate approach for applied scientists to take. However, Cox & Gray seem to prefer a model of moral decay, which they want addressed through urgent dialogue between the College and the medical profession in general on the one hand, and religious leaders and thinkers on the other. They introduce this suggestion through the rhetorical device of an allegation that OP92 fails to address the inadequacies of the ‘business model’ in healthcare. This criticism is in any case inaccurate; OP92 includes an implicit critique of the entire system and the clinical environments it creates, as can be seen in the passages I have quoted.

It is disappointing that Cox & Gray declare no conflict of interest in their editorial. Four years ago, in a letter to this journal, ³ they supported a call by Robert Higgo and myself ⁴ for the College to establish a working party on psychiatry and religion. Their declaration of interest in that letter was as follows: ‘John Cox is a Christian from the Methodist Tradition. Alison Gray was recently ordained Deacon in the Church of England’, and their affiliation was stated as ‘Centre for Faith Science and Values in Healthcare, University of Gloucestershire’.

Cox & Gray’s religious faith may well help them to adhere to their own moral standards. They have every right to understand things that go wrong in the world in terms of morality and religious faith. These are personal matters. The suggestion that the Royal College of Psychiatrists should take such a position is wholly inappropriate and wrong. The College has important institutional roles concerning ethics and proper professional behaviour, which are part of its overall raison d’être: to maintain and improve standards of care for patients. These roles would be utterly compromised by dabbling in morality and religion. If the College were to take a position on individual morality informed by religious thinking, we would enter a morass of schism and conflict. This would do nothing to protect patients.

Three years ago, concern was raised that the ostensibly anodyne College position paper Recommendations for Psychiatrists on Spirituality and Religion would be taken as permission to breach professional boundaries with respect to religion. ⁵ The vast majority of psychiatrists successfully avoid inappropriate interdigitation of faith, belief and professional practice. It will not be just the atheists who will find Cox & Gray’s editorial worrying.