Scenario 1: You are a GP (general practitioner or ‘family doctor’). A patient you’ve known for several years walks into your consulting-room and reveals s/he has suicidal thoughts, and matters have come to such a head that s/he has made elaborate plans to act upon those thoughts later that day. S/he listens to all your advice, but is unmoved in his/her decision, and swears you to secrecy, entreating that you do not contact the mental health support network. What do you do?
This was a common scenario presented to those of us appearing for our MRCGP (Membership of the Royal College of General Practitioners) qualifying exam, either as a written essay, or an OSCE (Objective Structured Clinical Examination), with an actor role-playing the part of the patient. It was meant to test whether the candidate could recognise the conflict between the doctor’s legal and ethical duty of confidentiality to the patient, but also a duty of care to that patient if his/her life is at risk, even if a self-inflicted one. The challenge is to negotiate a path, bearing these in mind, without loss of life or trust from one’s patient.
Scenario 2: You are a Catholic priest, and the same person, your long-standing parishioner, comes to you for confession, and tells you the same thing. What do you do?
I’m not a priest, of course (although I did think seriously about it in my boyhood years, but that’s another matter altogether), so I can pass on that one.
I happened to watch an episode of the six-part television drama series ‘Broken’ where scenario 2 unfolds. The actor Sean Bean plays a Roman Catholic priest Fr Michael Kerrigan in an unspecified northern English city who struggles with his own inner turmoil while still trying to counsel his flock. The series skilfully brings together themes of religion, social unrest and mental health, making for powerful, thought-provoking TV drama.
In this episode, Roz, a parishioner, is driven to the brink after being caught out embezzling money running into hundreds of thousands of pounds from her workplace to fuel a gambling addiction.
It turned out to be gripping, nail-biting drama, with the tension ratcheted to almost breaking point. I won’t spoil it for you (in case you manage to catch a repeat broadcast) by revealing more, but suffice it to say that when it first aired in 2017, it left viewers deeply moved and brought to the fore issues around both mental health and gambling addiction, something we can relate to very much in the sordid casino city that Goa has degenerated into.
You could dismiss it as “just television”, but the screenplay pulls no punches in unmasking the evils of gambling. “If you’d have told me 10 years ago that I’d end up here, I’d have laughed in your face,” Roz tells Father Michael. “I suppose everybody has their thing, where they want to feel nothing, to disappear…… Those machines were my thing, and if my boss hadn’t found out, they’d still be my thing.”
Do we even know what toll the gambling industry has had on our own social fabric, what it has done to individuals and families that have fallen prey to it? How many unbiased, comprehensive wide-ranging epidemiological studies have even explored this? There are statutory health warnings on tobacco products, and it is impossible to watch even a fleeting shot of a character smoking, on film or television, without this warning appearing as well, and quite rightly so.
There is exhaustive clinical evidence demonstrating the hugely addictive potential of gambling and its deleterious effects on individual, family and community health and well-being.
The DSM-5 (Diagnostic and Statistic Manual of Mental Disorders, Fifth edition) has reclassified ludomania (also termed compulsive or problem gambling, or gambling addition) as an addictive disorder, with sufferers exhibiting many similarities to those who have substance addictions. Studies have compared pathological gamblers to substance addicts (comparable to such highly addictive substances such as cocaine) concluding that addicted gamblers display more physical symptoms during withdrawal. A common feature shared by people who suffer from gambling addiction is impulsivity. Problem gambling is an addictive behaviour with a high comorbidity with alcohol problems and other addictive drugs. Problem gambling is often associated with increased suicidal ideation and attempts compared to the general population. Early onset of problem gambling increases the lifetime risk of suicide.
And just in case one thinks, “Oh, that’s just those with a gambling problem, it doesn’t apply to me”, the slope from casual to problem gambling is a very slippery one indeed. This is why Roz’s character in ‘Broken’ rang so true.
Why isn’t it mandatory for such health warnings to be issued in the public interest on every hoarding and advertisement for a casino, at the very minimum?
Back in the early 1990s, I made a trip to Kathmandu, which then (as now?) was notorious for its gambling industry. My travel companions wanted to have the casino experience, and I went along with them. They lost all their money, and had to borrow from me for the rest of our trip. A wise man learns from the experience of others. I haven’t been inside a casino in Goa, and plan to keep it that way.
The ‘Broken’ episode also took me back to my GP years in England. For the most part, the practice would see a seemingly-endless procession of coughs, colds, and other minor illness and requests for repeat prescriptions. But there would also be a sizeable number of patients who “just wanted to have a chat”; the receptionists would tell us this with some eye-rolling, as if to say “another time-waster.”
However, on “just having a chat”, one would often unearth issues that strayed into the realm of the moral and ethical, which strictly speaking are outside the remit of a medical consultation.
Infidelity in marriage or other relationships; probity in professional and public life: can a physician really weigh in on a patient’s decision-making, apart from lending a sympathetic ear and offering symptom-directed support? But you’d be surprised how often a GP is put in such a position, or the number of times a home visit is requested, on some contrived ailment, because the often-elderly or incapacitated patient is just lonely and wants someone to talk to and who will just listen to them.
It struck me then, and I was reminded again of it, that the traumatic experience and disillusionment of two World Wars seemed to have taken Britain and a lot of Europe away from God and religion, and quite often the GP (and the psychologist and psychiatrist) in the consulting room was taking the place of the priest in the confessional. I don’t wish to apply any equivalence to these situations, but am merely making the observation. I don’t remember who it was that coined the phrase ‘Pills, Prayers and Promises’ to describe the medical profession, but the parallels between priest and physician are many: both relationships are built on faith and have a duty of confidentiality enshrined in them.