Cover up

Muslim women may wish to work while wearing a hijab or even a full facial veil. How can governments and hospitals avoid religious discrimination while ensuring that patients receive effectively communicated care? Karen Hebert discusses

Widening participation has become the buzzword of medical education today. Governments, deans, doctors and students recognise that for far too long medicine has been a profession of middle and upper class men.¹ To this end, the UK government pledged £9m ($16m; €14m) toward schemes that would encourage a wider range of young people into the healthcare professions.²

Clearly much is being done to make the medical profession a more diverse sector. But the situation is not so simple. We may be encouraging a more diverse profession, but are we tolerant of our resulting differences?

From 2 December 2003, it became unlawful to discriminate against workers because of religion or similar belief in the United Kingdom, excluding Northern Ireland.² The ruling also applies to providers of vocational training. So it would be direct discrimination for a medical school or NHS trust to reject an applicant on the basis of their religious beliefs. This scenario may seem unlikely, but there are more subtle religious issues. Medical schools are becoming increasingly tolerant of differences.² But do these differences become less tolerated once we enter the wards?³

Hijab in the UK

Miriam is a Muslim medical student at Manchester University. She describes some difficulties that have arisen for her and some of her colleagues. "One major problem is the dress code in theatre. Muslim girls would like to keep their head, neck, breasts, and arms covered in theatre. I have been told at the hospital that I need to either cover all of my scarf with a surgical cap or that I should not wear it. I have therefore, used a surgeon's cap, the big ones, to cover my headscarf, and I wear a theatre gown to cover my arms. It does seem to work although it makes me feel awkward, but the problem in Manchester seems to be that every hospital has its own rules and some say definitely ‘no' to headscarves. This is what I have gathered from other Muslim girls that I have talked to. Some girls even take a washed headscarf to theatre or buy a new one especially for theatre. The problem seems to be that there is no consistency in what we should be doing."

The surgical scrubbing-up is also a problem. "The thing is that Muslim girls do not expose their arms, etc, in front of men, so scrubbing-up has been an issue for them. Some girls take it as an exception and scrub-up quickly, and some don't wear their headscarf in theatre. Some girls are happy wearing scrubs that have short sleeves; others, like me, wear a theatre gown over it. What most girls say is that for those who don't want to make an exception because of their beliefs there should be alternative ways—I don't know what these may be."

ANJA NIEDRINGHAUS/AP/EMPICS

Iraqi doctors preparing medication for children

Although no one is deliberately obstructive or discriminatory against such students, there is a tension between the needs of the students, the expectations of the medical profession, and the needs and expectations of the patients. As Miriam said, one big problem is the variability between hospitals and clinicians, and guidance is needed in this area.

The situation in Bahrain

Selina is a medical student in Bahrain, a traditionally Muslim country. Many women in Bahrain wear a hijab, the idea of which is to cover all body parts except for the face and hands. Clothes should not show or give an exact outline of the body, so they should not be tight nor transparent. Selina explains, "There is no trouble whatsoever in wearing the hijab in governmental places in Bahrain. To the extent, that in the surgical theatre—where one should wear only totally sterile clothes—there are sterile scarves for women who wear hijab."

It also appears that students who are not Muslim are not discriminated against. "Bahrain is a very tolerant country, and is a metropolitan country. Therefore, there is no discrimination against those of other religions or Muslim women who do not wear scarves. There is a small minority of non-Muslim students in my college, but they are treated just like anyone else. A big proportion of the faculty is non-Muslim, and they are all treated with respect."

Veils

Most Muslim women today do not wear a full face veil. It is more common to see women in hijab, loose clothing topped by a type of scarf worn around the head and under the chin. Women don't share a common style nor have the same reasons for wearing hijab. For many it reflects the belief that they are following God's commandments, are dressing according to "the correct standard of modesty," or simply are wearing the type of traditional clothes they feel comfortable in.⁴

The problem for some Muslim women in the UK comes with the tradition of covering all the face apart from the eyes. Aideen Silke, policy officer for the Council of Heads of Medical Schools, explained that this would not be possible during clinical time as a medical student. "Most schools would expect students' faces to be visible at all times. When this was discussed by the council's education subcommittee, it was believed that covering the face while meeting a patient is unacceptable as it breaches the duty ‘to make the care of the patient your first concern' and to ‘make sure your personal beliefs do not prejudice your patient's care.' There was general agreement that many patients would be upset by meeting a student or doctor who insisted on keeping their face covered. Equally, there are issues of entry to the hospital, school, or examination. The key point here is that students can believe what they wish so long as they conform to the GMC standards of Duties of a Doctor and Good Medical Practice."

Selina commented on this issue too. "Working women in Bahrain hospitals are not allowed to cover their face or wear veils in work. This created a bit of a hassle for female students from other countries who wear veils, but a decision was made to allow only non-Bahraini medical students to wear veils in the hospital; this was due to cultural reasons. It is considered a traditional thing for women to cover their faces in those countries but not in Bahrain."

The GMC statement on this issue reads, "The GMC have not published any guidance which specifically addresses the issue of medical students or doctors wearing face veils. We do have a policy to promote equality and value diversity. We do not set out guidelines about the dress that medical students should or should not wear. The GMC say that graduates can obtain registration with us provided that they can meet the outcomes set out in Tomorrow's Doctors and are fit to practise to the standards set in Good Medical Practice. We do not consider that wearing a face veil, in and of itself, necessarily has any effect on a doctor's ability to practise medicine. However, good communication between patients and doctors is essential to effective care and relationships of trust, and patients may find that a face veil presents an obstacle to effective communication."

DERMOT TAPLOW/PANOS

Keeping it covered

The French stance

In 1989, a French court ruled that the wearing of religious insignia in state schools was permissible as long as it was not done with the aim of "pressure, provocation, proselytism, or propaganda." Many Muslim girls have been expelled from French schools for wearing headscarves to school. In 2004, the French parliament voted to ban the wearing of overt religious symbols in schools. Polls suggested that 70% of the French public were in favour of this. The French government maintain that the law is not about suppressing religious freedom but rather about preventing the use of religious symbols to further political aims. The law has angered French Muslim, Christian, and Jewish groups, however, as it means that headscarves, crucifixes, and skullcaps are all banned in schools. These religious groups maintain that these symbols are apolitical and rather are about obeying their religion. Some people feel that the new law means having to make a choice between religion and education.

The United States

In contrast, the United States seems to be a country very open to difference. Douglas Olson is a medical student in the US. He describes the situation there, "We have our core holidays—winter break, that usually covers Christmas, Hanukkah [the Jewish festival of lights] and Kwaanza [an African American holiday celebrating new year and the history of black communities in the US]. Other than that, there is no religious preference given to students unless they attend a religious school. For example, if a Christian student wants Good Friday off, he can take it, but must make up the work and get the notes."

He adds, "If there's an exam they can reschedule, usually earlier. The same is true for a Jewish student who wants to celebrate Passover. I mention these two examples because they are examples that I know have occurred at my school. To be honest, the faculty seem pretty willing to accommodate religious freedoms whatever the faith or belief."

The situation is similar in the UK, but problems do arise combining religious practice with medical care. Sam Leinster, dean of the University of East Anglia's medical school, points out that there is a difficult balance that has to be kept. "In my view, freedom of religion and freedom of belief are fundamental human rights. So far as is possible, medical schools should not have regulations or compulsory activities that would create conflict for a student. For example, Muslim students should not be expected to sit examinations on a Friday and Jewish students should be able to have some time off for Yom Kippur. Equally, Christian students should not be required to attend compulsory activities on a Sunday."

He continues, "On the other hand, Duties of a Doctor, as laid down by the GMC, mean that when the student qualifies it will almost inevitably be necessary to put patient care before religious observance on occasion. At some point, therefore, the aspiring doctor has to choose to put their patients before their religious observance. Ultimately, patient care must come first and with this in mind we need to try and strike a delicate balance."

Karen Hebert, fourth year medical student, University of Bristol
Email: Kh9694@bristol.ac.uk


studentBMJ 2005;13:265-308 July ISSN 0966-6494

1. Fair admissions to higher education: recommendations for good practice. www.admissions-review.org.uk (accessed 14 Jun 2005).
2. Aim higher. www.aimhigher.ac.uk (accessed 14 Jun 2005).
3. BBC News. NHS "equality champion"appointed. http://news.bbc.co.uk/1/hi/health/3739096.stm (accessed 14 Jun2005).
4. Historical perspectives on Islamic dress.www.womeninworldhistory.com/essay-01.html (accessed 14 Jun 2005).

       

           

	LIFE Cover up       Karen Hebert (July 2005)
	Caroline Mann (July 25, 2005)       5th Year MBChB, University of Birmingham carolinemmann@yahoo.co.uk
	As a medical student in Birmingham, I regularly encounter students, doctors and patients of wide ranging religious beliefs. This includes many female Muslims wearing a head scarf and hijab. Based on my personal experience, neither of these items of clothing present any problem whatsoever to patient communication and good practice. In fact, as many non-Muslim female medical students wear low-cut or mid-rif baring tops, I can only see covering up as an advantage in maintaining a professional appearance on the wards. One of the main problems that I can see, as already mentioned in this article, involves theatre scrubs and scrubbing-up. There are already theatre caps that will adequately cover a head scarf, and it would seem a reasonably simple solution to have theatre scrubs that would cover more of the chest and arms. I'm sure many female medical students have gone to change into scrubs only to find XL is the only size left- and perhaps a little more revealing than they would have liked! The scrubbing-up problem may be more expensive to solve- building new female and male scrubbing areas may not be a realistic plan currently, especially in hospitals that are still struggling to have enough sinks on some wards. In the future however, this could surely be taken into account when building new theatre facilities, particularly in Birminghamwhere there are many Muslim medical students. One additional problem that I have noticed is that teaching is often scheduled during mid-day prayers. The student then has the choice of attending the teaching and missing prayers, or explaining the reason for their absence and missing out on the teaching. The student is at an obvious disadvantage whatever happens. I can vouch for the fact that requesting the teaching to be rescheduled would not make a student popular. Although there may be little deliberate discrimination, the lack of facilities or lack of guidance concerning these issues could perhaps be construed as indirect religious discrimination. Surely in Birmingham , one of the UK's most multi-cultural cities, in 2005, these issues should already have been addressed? Or is it the GMC's responsibility to ensure that medical students in the UK are not disadvantaged simply because of their religious beliefs?