Isabelle is 40 years old, middle class and married with four children.
I have known her for four years, and she can be histrionic. She usually consults about PMS and depression, and has been treated with fluoxetine in the past.
This time she came with back pain, which for once seemed genuine. But she suddenly burst into tears and said she had been caught shoplifting.
She told me she had run up enormous debts and that her housekeeping went on paying off credit cards. She had been convicted of shoplifting before, and this time she had stolen a hat with the intention of claiming a refund.
She had been advised to obtain a character reference from me before appearing in court. She was afraid that, without the reference, she might receive a harsh sentence.I feel sympathy for her, but given her previous conviction, I am reluctant to become involved. What should I do?
A GP'S VIEW - DR JULIA MARKHAM, A GP IN SOLIHULL, WEST MIDLANDS
The dilemma is about needing to do what is ethically correct, while maintaining a good doctor-patient relationship. GPs get to know their patients very well over the years, and we can empathise with them and usually want to help them.
However, when a patient has done something that falls outside the law, they have to take the consequences like the rest of us.
I would try to be sympathetic to this lady and the predicament she finds herself in, and I would explore her current mental state. Is she clinically depressed, and is she having suicidal thoughts? I would offer regular support or refer her to a counsellor.
Contact details of a debt counselling service might prove helpful. I might also consider asking the opinion of my defence organisation.
I would not feel able to give her a character reference given that she has admitted to me that she has been involved in shoplifting on more than one occasion.
However, given her history of PMS and depression, a compromise might be to offer to provide her with a medical report or to release her medical notes to her solicitor.
I would explain that this report would only be prepared at the written request of a solicitor and with her written consent.
She might be angry with me, but I would try to preserve our doctor-patient relationship by asking her to come back to see me at a later date, so that I could ensure that she was coping and not becoming clinically depressed.
A PATIENT'S VIEW - TREVOR SEEMANN, A MEMBER OF THE PATIENT PARTNERSHIP GROUP
My initial reaction is that I do not believe that a GP should give a character reference every time a patient asks for one.
It cannot be the GP's responsibility to answer for the character of a patient except in exceptional or extenuating circumstances.
My concern here, however, is that these are far from normal circumstances.
You have listed Isabelle as suffering from PMS and depression.
Isabelle is a woman with serious personal problems that need handling with care and respect.
Although I am not a clinician, I would hope that if Isabelle were a member of my family she would receive less sympathy and more empathy.
I would like to see her receive an immediate referral for a psychiatric assessment. It would then be possible for her psychiatric specialist to provide an indicative report to the court, supported by a general medical report from you, highlighting her mental and physical problems.
These appraisals would serve her far better than a general character reference.
The next stage is for Isabelle to be referred to her local Citizens Advice Bureau (CAB) for immediate financial help and support, which would resonate well with the court.
Finally, she must be encouraged to gain the confidence of her family and friends.
With this strong package of support, Isabelle can be helped through what is a very difficult and stressful time and will give her hope for the future.
What this case does highlight is the necessity for GPs to enable their practices to reach out into the community and give all-round support.
There are good practices that involve and encourage organisations such as CABs to conduct outreach services within their surgeries.
A MEDICO-LEGAL OPINION - DR LYN GRIFFITHS, MEDICO-LEGAL ADVISER, MEDICAL PROTECTION SOCIETY
This is a complex issue. You will need tact and pragmatism to preserve the doctor-patient relationship while ensuring you are not compromised.
There is no obligation to provide any report for Isabelle.
Indeed you might be insufficiently familiar with her to feel qualified, let alone willing, to provide a supportive reference as to her good character.
A report outlining her current health status might, however, be both beneficial to the court and helpful to Isabelle.
Referral for specialist advice in order to ascertain whether or not her conduct and behaviour could be attributable to her physical or mental health problems may be helpful.
This opinion usually lies outside the field of expertise of a GP. If this is undertaken, the court should be informed because they might consider it to be appropriate to adjourn their deliberations.
Remember that any report produced to help the court should be accurate and complete. If Isabelle has voiced any concerns about her childcare situation, this might indicate that a health visitor should assess the home situation.
Also, you should not overlook her back pain.