The most hurtful thing someone said to me after my son died was: ‘Was it caused by all the medication you took when you were pregnant?’ (I suffered with appendicitis when 6 weeks pregnant, and I admit I did need analgesia to cope with the excruciating pain.) Why did my friend feel the need to assign blame to the cause of my son’s death? Why could she not accept that it was simply bad luck? My already disproportionate guilt was heightened by her comments and the dagger of grief in my chest had been twisted further.
I’ve since noticed this blame game is universal. It is not only commonly talked about for victims of crime (the rape victim who was wearing a short skirt), but also in the context of ill health (the patient with diabetes who is overweight). Although it might seem obvious to us as doctors to show compassion once people have developed an illness, we have to remember that this isn’t obvious to everyone else with whom our patients interact. For the most part, people try to ignore their vulnerability by feeding the self-belief that bad things can’t possibly happen to them. Assigning blame is psychological self-defence: ‘He only developed cancer because he smoked … I don’t smoke so it won’t happen to me.’
There is an argument, however, that people should bear a moral responsibility for their own health. If someone became seriously injured from making a conscious decision to drive after drinking alcohol, perhaps they are no longer an innocent victim. As doctors, is our role to employ a moral principle of ‘fairness/justice’ — in other words, should we be making sure the patient accepted responsibility for their downfall? — or, rather, simple benevolence — as surely it’s too late now and what will blame achieve? These conflicting moral responsibilities are an everyday issue within NHS doctoring, so perhaps we are already experts in deciding how we will behave to our patients. Or maybe it depends if the patient in front of us is the third or 30th of the day.
Health promotion is a particularly contentious area. It is habit (and recommended) for doctors to provide opportunistic health promotion advice. However, we may be causing more harm than good. There is certainly some evidence to suggest that emphasis by doctors on ‘unhealthy’ behaviours may deter patients from seeking medical care (for example, for chest pain due to the established links between heart disease and lifestyle factors). Patients not only blame themselves for their behaviour and ill health, but also believe they will be blamed by doctors.
This is particularly strong in those from more deprived socioeconomic groups.1 A particularly memorable piece of writing for me is from Emma Lewis in the BMJ:
‘I often try to avoid visiting a general practitioner. Almost every consultation I’ve ever had — about glandular fever, contraception, a sprained ankle — has included a conversation about my weight and that’s inevitably the conversation that destroys any rapport or trust that might have existed … When health professionals bring up my weight in a consultation, I don’t feel like they’re looking out for my health … they put me right back to where I was when I was a binging-fasting teenager: full of shame.’ 2
So how can we help our patients and help ourselves?
In my view, although some may feel a moral responsibility to ensure that people accept some liability, I think society does enough of that already. We can be happier doctors with happier patients if we leave that job to someone else. Furthermore, as well as not being a perpetrator of blame, I feel we have the power to help reduce destructive self-blame. Exploring blame is more than exploring ‘ICE’. People will be even more reluctant to share such thoughts as they will probably expect the doctor to blame them too. Showing kindness and developing trust as well as exploratory questioning are key to exposing such emotions. Oh, and please don’t tell them to lose weight again …
- © British Journal of General Practice 2018