GPs and conscientious objection to treatments

Doug Hendrie

28/11/2018 3:06:56 PM

With abortion newly legal in Queensland and voluntary assisted dying to be accessible in Victoria from mid-2019, many practitioners may be unsure with how to proceed in the event there is a conflict between their personal views and treatment sought by patients.

GPs may object to certain procedures but have the obligation to refer patients to practitioners who are willing to perform those procedures.
GPs may object to certain procedures but have the obligation to refer patients to practitioners who are willing to perform those procedures.

Under the Medical Board of Australia’s Good Medical Practice: A Code of Conduct, doctors have a duty to make the care of patients their first concern and to practise medicine safely and effectively. 
The code of conduct includes ensuring that personal views do not adversely affect patient care. Doctors’ decisions about patents’ access to medical care needs to be free from bias and discrimination. 
Doctors are not expected or required to provide or directly participate in treatments to which they conscientiously object; however, they cannot allow their objection to impede or deny access to legally available treatments. 
It is important for doctors to communicate their conscientious objection with patients and colleagues, and refer patients in a timely and effective manner to another doctor who they reasonably believe can provide the medical care sought by a patient.

newsGP spoke with Dr Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), about GPs and conscientious objection.

In your opinion, what are the common issues that might make a GP a conscientious objector? 
Conscientious objection is an issue, particularly as termination of pregnancy for medical reasons is something that trained GPs with adequate connections with gynaecological departments can undertake.
One critical determinant on whether or not to support physician assisted dying is the impact on physicians involved and the pressures they will face from family members and patients themselves.
Sometimes patients ask GPs to collude in unethical or illegal things, which is another minefield. Everything from sick notes to getting their licenses to continue.
We navigate moral difficulties all the time. If you stick to the high moral ground and a very strict following of legal principles, you can stay out of trouble. Certainly there are pressures on GPs to go beyond their comfort zone.
Injecting rooms and assisting people with substance-abuse disorders, assisting patients who are taking advice from naturopaths and complementary and alternative medicine providers. That’s all part of the grey zones GPs have to navigate with patients.
What approach do you think GPs should take if a patient requests something they do not want to do? 
The guidance available suggests GPs should not be denying access [to legally available care]. For legal reasons on issues such as termination of pregnancy, GPs have a duty of care not to put barriers in the way of patient care.
There are two components [to dealing with a request].
The first is a GP should be non-judgemental, empathic and sensitive with good communication. You want this person on side and to remain on side so the therapeutic relationship can be maintained, whether or not you’re actively involved.
The second is if you are uncomfortable directly being involved in care, you have a duty to direct the patient to a provider of services. It’s probably good for GPs to know colleagues who will provide advice to patients for areas they are uncomfortable providing advice themselves. For seamless transfer of care, ideally it would be one of the other GPs in the practice. But it might be outside.

Mark2-Morgan-hero-(1).jpgDr Mark Morgan says good communication and a non-judgemental approach are essential for managing difficult patient requests.
What phrasing would you use to decline a request? 
In order to be non-judgemental, you have to understand the patient perspective.
You can certainly ask questions about why the request is coming, where the patient stands, what’s happening in their life – you can take an effective history first up.
After that, you can say, ‘This is not something that I personally can directly be involved in, but here’s my colleague who will take it from here, if you are willing for me to facilitate that’.
Ideally, for frequent requests it might be useful for leaflets or practice websites to specify if doctors have particular restrictions, so patients have the chance [to find out] before the expense and time of making an appointment.
What about scenarios where GPs are unsure the legalities of treatment? 
You have to be able to switch off your own views on what’s morally acceptable when you’re seeing patients.
Imagine looking after someone using anabolic steroids for bodybuilding. You can give very clear advice on potential harms, because your duty of care is to their health. But you want to be looking after that patient, not washing your hands of them and their health  

In your opinion, what is the most challenging issue for a GP?
Euthanasia. There’s a clash between the wish to assist a patient to die at a time that suits them, with all the caveats about extreme need, versus years of medical training to never cause harm or actively kill someone.
Mixed in with that is the real and perceived pressures from longstanding patients and their families, who might be very keen – with a sense of some urgency – to head in one direction or another.
I think euthanasia will be the big one. That’s one of the reasons it’s controversial, to consider legalisation of physician assisted dying, when the alternative – high-quality palliative care – has major capacity and access problems at the moment.
There will be a strong need for training for GPs to understand the legal situation, to find out who are eligible, what are the alternatives, what are the steps to go through.
I suspect it will be something that happens slowly.

More information
Factual guidance for GPs can be found in the Medical Board of Australia’s Code of Conduct.  
In addition, the RACGP curriculum emphasises key skills, behaviours and attitudes, including empathy and sensitivity, respect, non-judgemental, and cultural competency.

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Elias   30/11/2018 8:10:55 AM

I think decision to kill someone should be handled by the courts or judges who made the legislation in the first place and not made by general practitioners. if judges/ lawyers make the legislation they should take responsibility for the killing and potential harm that their legislation causes for doctors , patients and their families. I still won’t break the Hippocratic oath when I first joined medicine of Doctors are to do no harm. All good GPS know good quality palliative care to prevent suffering. Instead of assisted killing why not give interested doctors free access to training in palliative care and improve funding for doctors providing palliative care which can be very time consuming. Why not make palliative care acesss easier for people who need it. Call me cynical, but it’s clear lawyers want to generate as much grey zones as possible in medicine and by extension increase business for themselves at the expense of GPS and the blood of patients.

MT   30/11/2018 8:59:34 AM

I object to the Code's assertion that a conscientious objector is obliged to make a referral.
Referring doctors do not give a referral so the patient goes away... no, it is a part of the patient's ongoing care with the referrer as the initial and final point of care following treatment with the other practitioner.
Nothing is done in isolation. If an objector makes a referral they have thus started the process, and have therefore not exercised their right to objection

Dr Roslyn Doyle   30/11/2018 9:04:26 AM

Well said.

Simon Holliday   1/12/2018 10:12:44 AM

In NSW the HCCC is disinterested in doctors refusing treatments. I asked for their opinion about a practice owner who refused to allow an employed doctor take over the methadone prescribing for a current patient. They said a doctor was entitled to refuse treatments.