Introduction
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Freedom of conscience for health professionals working in health care must be protected.
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Freedom of conscience is vital for health professionals’ personal integrity and for their ability to care for patients honestly.
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The freedom to be a conscientious objector applies to everyone who is a health professional eg nurses, doctors and pharmacists.
The New Zealand Context:
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In New Zealand, health practitioners have a lawful right to conscientious objection. This applies explicitly to requests for reproductive health services including advice.
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An example of such a request would be for referral for consideration for an abortion.
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A health practitioner can conscientiously object to the provision of such a request in accordance with S174 of the Health Practitioners Competence Assurance Act 2003.
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In this setting, the health practitioner has a duty to inform the person that to obtain that service they can see another health practitioner or attend a family planning clinic. That is the maximum obligation.
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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.
How to Answer Critics:
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Many people oppose the idea that health practitioners should be allowed to follow their conscience when doing their work.
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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.
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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?”
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Opponents of freedom of conscience must be confronted with this question. It should remain the focus for serious discussion.
Key Issues to consider:
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Correct science provides the indispensable basis for moral or ethical decision making;
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Science may determine what it is possible to do, but cannot establish what ought to be done or what ought not to be done;
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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;
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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;
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Belief may be religious (man is the image of God) or non-religious (man is a rational being);
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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:
The 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. I
I - 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. I
I - 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.
I - Has she had a previous termination of pregnancy? If so, how was that for her?
I - 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?
I - Who are her key supports? Is she alone in this situation?
I - Does she have false beliefs leading her to this choice? Often perceived difficulties are much less significant when explored together.
I - 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.
I - 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 Crisis Pregnancy 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.
Role Play
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 crisis pregnancy support centre in your patients area visit our Post Abortive Support section.
Best Practice: A Case Study – Crisis Pregnancy Support Service, Nelson
Our frontline team of health professionals, working in a General Practice setting, donate their time to any woman who would like to explore alternatives to a termination of pregnancy. This is a free service. Every care coordinator offers this service because of their belief in the uniqueness of each woman. They recognise that when a woman faces a crisis pregnancy there is no “quick fix” for her.
Every member of the team wants to see the woman empowered to make good choices. Time is required to allow a woman to overcome the state of shock that she may feel. Being in a crisis affects every woman differently. Her state of shock is unique but it typically includes an inability to sleep, an altered appetite and impaired decision-making. A woman in a crisis can be reassured to learn that it is usual to feel tearful, fearful, stressed, trapped, and overwhelmed.
A window of time
We recommend a window of time to allow a woman to realise that it’s very difficult to make an informed decision while under this degree of stress. It is helpful for her to speak with someone she trusts. We recommend allowing time for her sleep patterns and eating habits to settle and for her emotional equilibrium to improve.
From this platform, the woman can explore her current support and the various options before her. Our service has a Trust to access funds if a woman is experiencing hardship. The Crisis Pregnancy Support Service focuses on empowering women to draw on their own resourcefulness and to access other resources if needed.
In an overwhelming crisis, a stressor such as the breakdown of a car can feel like the ‘last straw.’ The Trust can access funds to assist with car repairs, for example. Although such financial help cannot remove the larger crisis, it provides a way to get one aspect of life into order permitting the woman to address bigger issues before her.
The Trust may also apply for funds to assist a woman to learn to drive to enable more independence and to help her to feel better about her future. For some women a crisis pregnancy poses a threat to relationships. It may cause a change in living arrangements. The pregnancy may threaten her career, her study and her very sense of self.
Most women are aware that they have three options:
- Continuation of the pregnancy with support.
- Consideration of termination of the pregnancy.
- Continuation of the pregnancy and offering the baby for adoption.
To have one’s sense of self threatened, can be overwhelming. Just as there are unwanted pregnancies there are also many unwanted terminations. It is always a delicate role to be a care coordinator for our Crisis Pregnancy Service (CPS).
We are non-judgemental and supportive. We let a woman know that she is safe to explore options freely. We recognise that we cannot make a decision on behalf of another. However, we can share her load and reassure the woman that we do care genuinely about her situation.
The majority of women who attend our service continue their pregnancy with support. Some of these women will choose to adopt. We have very helpful “Adoption Option” DVD’s available. These provide up-to-date factual information plus personal stories. The DVD presenters include Dr Sue Bagshaw among others.
Women who attend our service but who go elsewhere for a termination can return to the Counselling Service if support is required. Such a person may admit that she had felt so overwhelmed at discovering she was pregnant – perhaps because her partner had threatened to leave her – that she had not really connected with her emotions. She may say that after the abortion she had felt some relief initially but then, her “defensive shield” evaporated and she was left with a deep sense of pain and loss.
The woman may be angry towards her partner for not caring about her desires. She may also admit that hadn’t really voiced what she was feeling. At a sub-conscious level she had craved for her partner’s support for both herself and the baby. There may be intrusive thoughts, depression, panic attacks and anxiety. Relationship problems, alcohol and drug abuse and depression can result. Our Service has access to specialised help so that such women can be referred to Post Abortion Trauma Healing Services (PATHS) or to Rachel’s Vineyard Retreats if they want specialised help.
Many GPs and other health professionals think that if they refer a woman quickly for a termination of pregnancy this haste will help relieve her distress. Sadly, on asking about what happened to her prior to a termination, a woman will often say that she felt as if she was on a “conveyor belt of non-decisions”. Again, this comment reinforces our opinion that women need a window of time to discern and explore the issues. For example if a woman is 6 weeks pregnant she may decide that she will give herself 2 or 3 weeks to make this decision. This will help relieve her overwhelming sense of distress, by helping her to formulate a plan and regain a sense of control.
It is not easy sitting with someone in a crisis. However, over time, we have gained more confidence in the process and we are experiencing many positive outcomes. As stated earlier, there are three choices that face a woman in a crisis pregnancy. They are not easy choices. We will support the woman to make positive choices at this time
For those who continue with the pregnancy there is often great joy at the birth and the evolving journey that follows. Our role as a CPS coordinator does not stop at delivery. It is imperative that a woman is well networked into post natal support services that she and her baby will require. For women who choose to adopt there is great sacrifice, but also a sense of empowerment in making a positive choice for herself and the baby. There is much joy in an open adoption and an on-going relationship with the child can unfold bringing pleasure to all the parties involved.
Cushla Hassan BN Registered Nurse
Dr Joseph Hassan MBChB DCH Dip Obstetrics MRCGP FRNZCGP