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CoVid-19. To shave or not to shave

Editorial Staff

The British Medical Journal is the official publication - and mouthpiece - of the British Medical Association. As the CoVid-19 problem moves from epidemic to official pandemic according to the World Health Organisation, official advice is often drowned out by misinformation on social media. It's made worse by the fact that the problem has also become an opportunity for criminals - only this morning we received a spam claiming to advertise the only face-mask that offers protection against the virus. So, in this, the first of what will be a series of items on those parts of the authoritative news that doesn't reach the attention threshold of the superficial media, we look at what the BMA/BMJ says about beards in the healthcare sector.

Published 12 March, 2020, the BMA has issued guidance on a question that has been asked in the past but seems to have not had a definitive answer.

The question is this: are doctors who are exposed to CoVID-19 under an obligation to be clean shaven so that an FFP2 respirator gives maximum protection.

The answer is .. unclear.

First, the question applies to one specific form of mask "FFP3 masks are recommended to protect staff from aerosolised pathogens. They differ from those standard surgical masks increasingly seen on wary members of public, which are designed as a two-way barrier to droplets—and a handy way of stopping wearers touching their mouths. " So, we should all get those Fab-o FFP-3 masks, right?

Well, no: "Not much good in a flu pandemic. FFP3 masks, in contrast, require a clean seal between mask and face. Although we have no RCT-buttressed evidence that FFP3 masks are effective, professional opinion supports their use. "

So, not to put too fine a point on it, there's no science to say they will protect the wearer from others, or others from the wearer, but medics appear to think they will. Does that sound like what we hear on social media with such nonsense as "smoking will protect you against breathing in the virus." Arguably, yes it does. Unarguably, it won't..

So the BMA falls down to two things - ethics and questions as to liability.

Obligations to patients: "Primary is the right of patients accessing health services to be protected from avoidable harm—and from this everything else stems. If the wearing of beards presents a direct risk to patients, then a duty arises on behalf of the healthcare provider to ensure that patients are treated by health staff without beards."

Obligations to staff. Employers "have legal—and moral—duties to identify and control workplace risks that may harm their employees. This extends to consulting with staff, giving information about the risks, along with training and advice on how to manage them—including the removal of beards if required."

So that leads to a complex series of questions - if some men, for whatever reason be it vanity, culture or religion, refuse to remove their beards, should they be removed from duties where the wearing of such a mask is required, what happens next?

"Employers must also deal with questions of fairness and equality within the workforce, balancing different impacts on different groups. For example, if doctors with beards refuse to remove them it may impose an unfair burden on women and beardless men. If covid-19 presents a serious risk to health, surely it would be unfair for those who prefer to wear a beard to [avoid] treating patients who may be infected with it?"

And then comes the really big question - that of religion. This demonstrates the quandary that faces so many businesses which are not allowed to set their own rules as to conduct within their operations - the point where avoiding discrimination creates a situation which cannot be reconciled because of laws, rules and bad PR.

The BMA says "where doctors are under a religious duty to wear beards, requiring them to shave could risk claims of indirect religious discrimination. Once again though, things get tricky. Under the Equality Act 2010 a rule or policy that has a particularly negative impact on a group (Muslim or Sikh men, for example) can still be justified if it is a proportionate way of achieving a legitimate goal—in this case controlling the risks to patients and staff safety and, as far as possible, preventing the spread of the infection. For example, a few years ago a Christian nurse who was moved to a desk job after refusing to remove a visible crucifix at work, lost her case of religious discrimination. The UK courts and the European Court of Human Rights ruled that health and safety considerations justified the NHS dress code policy in that case. "

The extent to which the BMA has considered this problem is demonstrated by this paragraph: "What if a member of staff requests a religious exemption to shaving their beard? An employer would need to consider the impact on the individual of shaving and whether there are other effective means of meeting their [it is not clear who "their" relates to i.e. the employer or the employee] clear obligation to provide a safe and effective service. Some employer[s'] policies, and the Health and Safety Executive, say that where there is a religious duty to wear a beard, there may be alternative respiratory protective equipment that does not require the tight fitting of an FPP3 mask—a powered air purifying respirator (PAPR) allied with a full head covering. This may, though, require additional training for staff to use, clean and re-use effectively."

And then "A point may come where it is impossible to provide safe cover to patients—without requesting all doctors with beards remove them. Here doctors would be under an ordinary obligation to remove their beards, although obviously they cannot be forced. If doctors who wear beards for religious reasons regard the removal of their beards as absolutely impermissible, we recommend legal advice is sought on how health and safety obligations interact with equality legislation in the facts of their particular case. It is very likely that a Tribunal would take into account the impact of a requirement to remove beards where an individual has demonstrated a deep and long-term commitment to such an obligation, and the removal of a beard would be an occasion for deep personal distress. "

So, hospitals cannot refuse to engage those for whom a beard has a religious facet and it must allow them to avoid working in an environment where the wearing of a beard might put them or patients at risk, thus increasing the exposure of those who are clean shaven, including women.

The article concludes "At the risk of repetition though, where beard wearing is a sartorial preference, the interests of patients take priority. Where it is a religious obligation, all reasonable efforts to accommodate should be made. If those efforts have been made and things become more difficult, it will be harder to argue unlawful religious discrimination."

So, the answer is - no clear answer. Employers should take independent legal advice.

Julian Sheather is ethics manager, BMA.

Sally Brett. Head of Equality, Inclusion and Culture, BMA.

Full article: https://blogs.bmj.com/bmj/2020...