Sean Murphy – Administrator of the Protection of Conscience Project – www.consciencelaws.org Presented at the Obstetrics and Gynaecology Conference New Developments – New [...]
Freedom of conscience for health professionals working in health care must be protected.
Freedom of conscience is vital for health professionals’ personal integrity and for their ability to care for patients honestly. The freedom to be a conscientious objector applies to everyone who is a health professional eg nurses, doctors and pharmacists.
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The UK Context:
In the UK, health practitioners have a lawful right to conscientious objection. This applies explicitly to requests for reproductive health services including advice.
An example of such a request would be for referral for consideration for an abortion.
A health practitioner can conscientiously object to the provision of such a request in accordance with the Abortion Act 1967
The health practitioner does not have to write a referral, arrange transport or otherwise engage in the provision of the service if he or she holds a conscientious objection.
The 1967 Act provides as follows:
4. Conscientious objection to participation in treatment
- Subject to subsection (2) of this section, no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this Act to which he has a conscientious objection:Provided that in any legal proceedings the burden of proof of conscientious objection shall rest on the person claiming to rely on it.
- Nothing in subsection (1) of this section shall affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman.
- In any proceedings before a court in Scotland, a statement on oath by any person to the effect that he has a conscientious objection to participating in any treatment authorised by this Act shall be sufficient evidence for the purpose of discharging the burden of proof imposed upon him by subsection (1) of this section”.
How to Answer Critics:
Many people oppose the idea that health practitioners should be allowed to follow their conscience when doing their work.
They argue that a health professional’s moral code should be kept private at all times. They say that public, professional behaviour must differ from personal beliefs.
However, this raises a fundamental question:
“Upon what universally accepted principle should individuals be forced to give up their own convictions and be made to act upon the contrary moral beliefs of an employer, union, professional association or state?”
Opponents of freedom of conscience must be confronted with this question. It should remain the focus for serious discussion.
Key Issues to consider:
Correct science provides the indispensable basis for moral or ethical decision making;
Science may determine what it is possible to do, but cannot establish what ought to be done or what ought not to be done;
The decision that something ought to be done reflects a moral or ethical belief; that’s exactly the same kind of belief as a decision that it ought not to be done;
One cannot exclude belief from moral or ethical decision-making because all who exercise moral or ethical judgment are acting upon a belief of some sort;
Belief may be religious (man is the image of God) or non-religious (man is a rational being);
To claim that only non-religious belief is valid in moral or ethical decision making reflects anti-religious prejudice, not sound reasoning.
Best practice application example – GP consultation:
When a woman comes to talk about having a termination of her pregnancy, we face one of the most important and difficult consultations in General Practice.
This woman comes in a state of shock and extreme anxiety. The possible consequences from the consultation are extreme for this woman and the unborn baby she carries. It really is a matter of life and death. She wants a solution to her problem and she has to overcome embarrassment and anxiety to approach us for help. She is making a grim choice, often facing the conflicting alternatives of “death of self” or ending the unwanted pregnancy. She may be under duress from people who are not present at the consultation – her partner, her parents, her friends or others. She may have been threatened (the end of her relationship, being forced out of home etc,) or she may have imagined severe consequences which might never actually eventuate (“my parents would kill me”). She may feel very alone.
An abortion may seem like a simple, quick solution so that the woman’s life can go on as before, but it may very well not be a free choice or her preferred choice. Commonly women in this situation only hear negative opinions from others and they are waiting for just one person to sow a seed of hope and encouragement.
We have a vital part to play in helping women in this situation. It is important that we be empathetic and offer real hope for this woman. We should not underestimate our role just because we do not refer for abortion. The simpler consultation would be to refer the woman to a Gynaecology Clinic for consideration of an abortion. We could then hope that the hospital social worker will allow the woman to discuss alternatives to an abortion. However, as a Physician who respects life from conception, the pathway forward is more challenging and demands far greater skill than simply making a referral.
It is essential that we respect patient autonomy. Before proceeding further with the consultation we have to ensure the following:
- That the woman knows our genuine concern for her situation and desire to help her in any way we can.
- That she is informed clearly and early in the consultation that we do not refer women for termination of pregnancy owing to our personal and professional beliefs and that she has the option to leave the consultation to see another doctor or to attend a family planning clinic if she wishes. This should be done with humility and compassion, bearing in mind how difficult it has been for her to come.
- That we are happy to act as a sounding board and will not charge for our time if she wants to discuss the situation further and explore her options more fully.
If the woman then chooses to accept this invitation to continue the consultation, then the following advice may be helpful.
(Note: This consultation should be held at the woman’s pace. It may be inappropriate to cover all the points outlined below. Proceed gently.)
- Listen carefully to her history – as much as she will share. What things lead her to this position where she is faced with this difficult choice? Try to view things from her perspective and share her load.
- Has she had a previous termination of pregnancy? If so, how was that for her?
- Does she have any beliefs about abortion? I have often been surprised to learn that a woman in this situation may see abortion as wrong. Is she really making a free choice?
- Who are her key supports? Is she alone in this situation?
- Does she have false beliefs leading her to this choice? Often perceived difficulties are much less significant when explored together.
- There is no such thing as an easy solution to her situation. Explore with her how each of her options will feel for her today, in 6 months, in 1 year, in 5 years, at the end of her life, etc. She may not be aware of the development of her unborn baby at this gestation. She may not be aware that abortion can have severe adverse psychological effects.
- Offer her the option of discussing her situation further in more depth with a crisis pregnancy support worker. To locate a crisis pregnancy support centre in your patients’ area visit our Pregnancy Counselling and Support section*
*It is essential that the health professional has a working knowledge of what support is available for women who wish to explore alternatives to abortion. These resources will be regional and should be reliable, practical and sustained for as long as needed. The resources should adhere to accepted professional standards. If a support service like this is not available locally you may be able to help set one up. If you would like advice about resources please contact us.
This is a useful tool to help with the complexities of this consultation. We must approach the woman with empathy and with confidence. For many health professionals this consultation creates inner anxiety for the practitioner. This anxiety can potentially undermine one’s ability to offer hope. Ask one of your colleagues, family or a friend to take the position of a distressed woman seeking a termination of pregnancy. Have another person act as her advocate in the consultation. Practice how to show empathy, compassion and confidence to impart hope. Saying “no” to a referral for abortion is not saying “no” to helping this woman. You have a lot to offer. Swap roles. How did that feel for you? Continue to role play until you can undertake this kind of consultation with confidence and warmth.
Post Abortion Grief
Many patients suffer alone with long-term psychological problems from having had an abortion. These difficulties are often not shared, as the person may feel unable to raise her concerns with her doctor. Other medical professionals have agreed that abortion was her best option so she wonders why any doctor or practice nurse would understand her feelings of guilt, recurring nightmares and spiritual fears. Even if the health professional does understand, what can they really offer to the woman with post abortion distress?
The father of the baby or another close family member may also be suffering as a result of an abortion.
This patient may be living with severe anxiety, depression, nightmares, psychosomatic illness or substance abuse. It is important that we have a working knowledge of local resources to help with this clinical situation. To locate a support service in your patients area visit our Post-Abortion Support section.