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Medical Ethics: Abortion, Referral and Autonomy

Welcome back – It is May, and this month we are going to focus on Women’s Health – the O & the G, pregnancy, family planning and preventative care for the ladies.

I am going to be brave and open a discussion on Abortion [I may regret this].  I do not wish to alienate anybody or sensationalise this issue – I do believe that it is an important discussion to be had between peers of different persuasions.

This is where I see the current state of play for abortion in Australia. I work in an area where I deal with abortion as a routine part of my practice.

  • Termination of pregnancy is a reality of modern medicine.
  • I know that the medical community is clearly split – those who do and those who do not.
  • Women [in most developed countries] have the right to choose and control their own bodies.
  • We – the medical profession, have a duty to provide this care in a safe and unimpeded manner.
  • I am a pragmatist and strongly believe in harm minimisation. (most of the women I anaesthetise for a TOP also agree to an implantable, longer term contraceptive device)
  • For me a TOP is a symptom – of poor sexual health education, often a relationship under strain, and a woman at risk of other problems – STIs etc.  This is an opportunity to intervene and make a difference, rather than an end in itself.

This story caught my eye this week – it was a piece in “The Telegraph” out of Sydney.  Link is HERE.

Essentially it is a story about a GP who refused to refer a woman (couple ) to a Gynecologist for a termination of pregnancy.  The GP is openly anti-abortion and has run for a political party on this platform.  However, in this case he refused to refer as he believed the couple were planning to terminate in order to achieve “gender selection” – i.e they did not wish to have daughter.

So I am going to go beyond the usual abortion debate – I am NOT asking if you feel it is right or wrong.  That debate has been well documented over many years.  I am going to ask a few more practical questions.  Imagine that you are a GP, take your own ethics into the room when your next patient requests a termination referral….

The Pinnion poll below includes 3 questions.  Feel free to answer them or not – you can select multiple options on the last question.

Or leave a comment on this topic – the story above and let me know what you think.

Lots of Women’s health coming up in the next few weeks – will be significantly less controversial I promise!

Oh, the last Ethics poll on post-mortem intubation is completed – check out the results on that post.

Casey

PS: A quick look at the spread of opinion on the 3 question in the poll ths far.  Small numbers – but a definite spread of opinion on the practical side of abortion referral in our readers.
abortion q3

abortion q2

Abortion q1

Comments

  1. Wow, Casey. What a curly one!

    Like you, I’m generally very pragmatic about these things. Apart from the fact that I don’t philosophically or spiritually object to termination per se, I also feel it’s important to support my patients in whatever difficult circumstances they find themselves in. I like to think that my consulting room is a “judgment free zone” and that my patients can be as open and honest as they like without receiving any negative reaction from me. However, if I’m REALLY honest with myself I realise that there are things that I am sometimes negatively judgmental about, eg refusal to vaccinate, choosing to home birth despite significant risk factors or even refusal to make positive health choices, but I try to still be respectful of patients’ rights to health autonomy. I’m glad I don’t, but If I did object to termination on religious grounds and needed to refer on I feel like it would potentially damage my rapport with my patients. However, I respect individual doctor’s right to refuse to refer for specific treatments as long as they refer to a colleague. If a doctor refused to make an alternative referral then I think that would be a fundamental violation of the trust within the doctor-patient relationship.

    That doesn’t meant that there aren’t some things which make me very uncomfortable. Request for termination at 19 weeks after gender identification goes firmly against the grain for me, as does termination for multiples (especially as I am a twin myself!). But I can see the argument for reducing multiples when they are higher order to reduce the significant health risks to both mum and babies. Terminating for various chromosomal abnormalities is a spectrum of grey and I still feel very mixed about it. On one hand I think terminating for universally fatal abnormalities is humane, but terminating for conditions likely to cause less profound disabilities is much much trickier. I really can’t even imagine how I would feel if I was pregnant with a child with a diagnosed chromosomal abnormality. It depends so much on the social, psychological and emotional state of the entire family at the time and in the end it really isn’t the place of outsiders (medical or otherwise) to judge the overall impact of that decision on all the other lives that will be affected.

    Look forward to reading others’ responses!

  2. I had a debate out this article after your twitter post today, and found the whole process very enlightening. I’ll cut and paste my thoughts to avoid people having to click through.

    _Ethics of refusing to provide non-emergent medical care_

    After a couple of hours of debate, for me, it has come down to ‘I don’t have enough information’.

    – I think that demanding people to act in, what they believe to be, a morally reprehensible way is not a good idea (TM).
    – I think the idea of providing a referal if you are not willing to provide a certain treatment is good in theory, but it is (very slightly) a step too far in prescribing the actions of doctors.
    – I think that mandating that doctors provide information that what the patient is looking for is not available here and may be found elsewhere allows conscientious objection without forcing abetment and is enough to morally and ethically discharge a minimal duty of care.
    – I think it would be morally reprehensible and ethically unconscionable to deliberately obfuscate access to medical care.

    I do not have access to enough facts to know if this doctors actions are ethically right or wrong (at least by my standards outlined above).

    I also do not have enough legal knowledge to hold an informed opinion on *all* the relevant laws, or if the quoted law in the article is taken out of context/paraphrased/expanded on in another section/etc, to know if this doctors actions are legally right or wrong.

    As to what the doctor was actually objecting too, that is irrelevant. He could have been objecting to giving children vaccines for all that it matters to a debate on the ethics of refusing to provide non-emergent medical care.

  3. I think professional autonomy trumps patient autonomy in this case.

    Autonomy is a two way street – the patient has the right to autonomy over their own body, and the doctor has the right to autonomy over their own practice. If a doctor feels that a particular treatment is not in the patient’s best interests, they are not obliged to provide it.

    If, however, a treatment is the standard of care, then you have a professional obligation to refer if you cannot or will not provide it.

    We are not technicians, to provide operations or medications on demand. I would not provide opioids on demand, or an amputation on demand, so why would I provide a TOP on demand (if I were trained to do them)?

    In this case, Dr Hobart missed a trick, which would have been to refer to a clinic that he knew refused to terminate for sex selection, and to make his opinion on that known.

    This is one reason I oppose taking abortion crimes off the books – there is a public interest in TOP being performed by medical practitioners, and the Tegan Simone Leach case in Queensland demonstrates why it should not be fully legalised in this day and age of purchasing drugs on the internet. Instead, a broad interpretation of health-and-wellbeing-of-the-mother permits our current system.

    As an analogous quuestion:
    – a patient comes in asking for a referral to a plastic surgeon for a perceived cosmetic defect with their ears. You suspect a degree of body dysmorphic disorder. Do you refer?

  4. doctor says:

    How about adding a few extra options on question 3-
    “psychological distress of the mother-to-be”
    “lethal disease that would likely result in death of fetus in utero”
    “in my opinion there are no reasonable medical grounds to terminate”

  5. Yes, a doctor should be able to refuse to refer for abortions. However, in this situation I’d also hope the doctor would tell the patient why they’ve made that choice – that it’s against their personal belief – and tell them that other doctors may not hold the same view. Otherwise, are you misleading a patient who might take your refusal to mean, “It’s not possible/I can’t get it done”? By doing so, you’re causing harm – and wasn’t there some oath you took about that?

    Like the others, I’m very pragmatic on abortion, and I personally fall very much on the mother’s right to decide, whatever the circumstances. I happen to work in VIC, where we see more doctors / Marie Stopes etc willing to perform quite late term abortions for medical and psychological reasons. This is so refreshing after previously working in QLD. The Gynae team was often fraught with medical professional distress about legalities, even with serious fatal malformations like anencephaly – just because a pregnancy was second trimester. I knew a intern in QLD who was asked to prescribe and administer mifepristone (early term), because none of the 6 registrars or consultants on that day were comfortable doing it, and they cited both religious and legal reasons.

    While we certainly shouldn’t force doctors to perform things they don’t feel comfortable doing, it would go a long way to improving the availability and access to appropriate medical care if we reviewed the archane and common-law-peppered anti-abortion legislation around the country and dragged it into the twenty-first century.

    Phew, had my rant 🙂

  6. Hello, I read your blogs regularly. Your writing style is witty, keep
    doing what you’re doing!

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