Conscientious objections in the rural setting
BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS
What do you do when a patient or colleague asks you to do something that goes against your beliefs and principles?
It depends on the request and the strength of your conviction. A common example is termination of pregnancies – not a problem if you are all for it, quite a conundrum if you object on moral or religious grounds and cannot see yourself ever performing an abortion or even referring on to a colleague who does.
This would be a lose-lose situation – damned if you do, damned if you don’t. It is important to remember that you have rights and so does the patient. But will your rights or the patient’s rights be stepped on? The ideal outcome is that both the needs of the patient and the doctor are met.
In the urban setting, alternatives are available. You can make a direct or indirect referral. There are specialists in the Yellow Pages, and sexual health centres take calls, so indirectly you could respectfully refer the patient to do her own research. You could refer her to another GP colleague down the hall who does not have the same objection. This process keeps you one step removed from the act you conscientiously object to. Or, if you are comfortable, you can make a direct referral. This second type of referral takes you closer to the final termination. However you do this, your patient receives the care they need and you have not performed any actions contrary to your beliefs.
In the rural settings our options are not as broad. Often, we are the only medical resource; the timing of the pre-procedural investigations depend on us. We may need to sign the Patient Assisted Travel form that will ultimately lead to a medical act that we morally object to. We need to do the research to find the nearest provider. If you refuse, the patient meets hardship, and may have to travel far away to meet with another GP who may also have the same conscientious objection.
Time is of the essence. They are bewildered and stressed and so are you.
Can you be forced?
The Medical Board of Australia states we must not impede. Your actions cannot prevent the patient from getting the care she wishes. Our Association, the AMA, states that we need to inform the patient she can receive care elsewhere. Both organisations advocate transparency so that the patients and impacted doctors are aware of our stance.
Minor examples exist, such as a doctor who does not prescribe oral contraceptive pills, or doctors who refuse to do pap smears. This objection is not just preference or distaste, it is a deep seated religious or moral objection. In the city it is no big deal, alternative care is easily found elsewhere. Rurally, it is a big deal for a patient to have to travel to receive such routine medical care.
Another example, medically assisted dying, is just around the corner. When the legislation passes, of course you cannot be forced into action. However, what happens if you are the only doctor in a rural setting, and you DO believe in assisted euthanasia? The unintended consequence of your beliefs may cause your patients to feel uneasy and as such they may wish to get their care elsewhere. Unfortunately for many patients in rural and remote regions of Australia, there is often not much choice of doctors. This scenario has been already occurring in Canada.
Rural doctor, you know your own moral beliefs, you also know whether they deviate from the majority belief.
So arm yourself.
Find a pathway that will enshrine your needs while ensuring that rural patients receive the appropriate care. Prepare a phone list of known doctors you respect, who may or may not do as the patient wishes; find doctors who will help you keep your distance from the resulting consultation; offer telephone or telehealth consultations. The best thing you can do is get support before you need help with these difficult moral and ethical decisions.