Jane McCredie: Conscientious challenge

MANY years ago, a friend told me her GP, a man of strong religious beliefs, had repeatedly failed to act on her husband’s requests to be referred for a vasectomy.

The doctor never actually came out and said he wouldn’t do it. He just kept letting it slide.
    
Whatever you think of the vexed issue of health professionals allowing their personal views to influence the care they provide, it seems to me there is a problem if a doctor does not make his or her position clear.

At a minimum, a health professional who chooses not to provide particular services for ethical reasons needs to make a clear declaration of that fact — and preferably before a patient asks for the service (through prominent signs at the surgery, for example).

Similar issues arise when a pharmacy refuses to dispense contraception, as happened in Thurgoona near Albury in NSW a few years ago.

In that case, the pharmacists, a Catholic couple, were including a note with any contraceptive pills they dispensed.

“If your primary reason for taking this medicine is contraceptive then it would be appreciated that, in the future, you would respect our views and have your OCP (oral contraceptive pill) prescriptions filled elsewhere”, the note read.

More recently, website Mamamia published an article about a woman who was refused the morning-after pill by a pharmacist citing religious reasons.

In professional circles, the consensus has tended to be that health professionals should be able to refuse to supply a service for reasons of conscience, provided the patient can access that service from another provider.

But is it really that simple?

These stories often relate to reproductive issues but, as the woman featured in the Mamamia article asks, would it be acceptable for a pharmacist who was a scientologist to refuse to dispense antidepressants?

Even if the patient was referred to another pharmacy, you couldn’t guarantee they’d persevere in the face of a first refusal.

The same could well apply to some women seeking emergency contraception, especially if they were young and vulnerable.

And, of course, there’s the perennial question of what happens when the doctor or pharmacist is the only provider in a small country town.

In Italy, it has become increasingly difficult for women to access legal termination of pregnancy, with the percentage of gynaecologists who are conscientious objectors to the procedure now at nearly 70% (and as high as 80% in some regions).

Interestingly while the objection rate has risen among gynaecologists in recent years, it has declined among anaesthetists and auxiliary personnel.

In an article in the Journal of Medical Ethics, University of Melbourne ethicist Dr Francesca Minerva suggests not all the objections may be genuinely conscientious, with questions of professional advancement and the stigmatising of those who carry out the procedure possibly playing a role.

The country’s official abortion rates are low, but Dr Minerva suggests this may be because women travel to other countries for the procedure or turn to unauthorised providers.

I am not debating the rights and wrongs of abortion here (though, for the record, I believe the service should be safe and legal and that it is the woman’s right to choose).

Nor am I suggesting doctors should be forced to carry out the procedure if it is against their conscience.

Dr Minerva describes the question of health professionals’ right to conscientious objection as “one of the most puzzling and yet urgent topics” in bioethics. The AMA released a position paper last year that said conscientious objection might be exercised “in exceptional circumstances, and as a last resort”.

Balancing two conflicting rights is never easy, but it does seem to me the default position should be that anybody who chooses to work in, say, community pharmacy or reproductive health will be prepared to supply the full range of services allowed under our medical system.

A conscientious objection to doing that should be treated as a serious matter, perhaps requiring the approval of the appropriate professional board, and with strict guidelines around how the objection could be implemented.

Anything less would seem a failure of care.

Jane McCredie is a Sydney-based science and medicine writer.