Case Title: Samantha Broughton – Term 2
|Describe the case as concisely as possible.
|Samantha is a 15 year old school student with a previous history of miscarriage. She is in a sexual relationship with Tom who is 17 years old and has been prescribed oral contraceptives as a method of birth control. After failing to take the contraceptive as directed Samantha discovers she is pregnant. Samantha seeks help and advice from her GP (Dr Hannah Jenkins). At this consultation Samantha indicates to Dr Jenkins that she has discussed the pregnancy with her boyfriend Tom but not with her parents as they would not approve. Samantha tells Dr Jenkins that she knows she can have an abortion without her parent’s knowledge. It is at this point in the consultation that Dr Jenkins informs Samantha that she has a conscientious objection to abortion. She then tells Samantha that if this is her decision then she would have to be referred to a colleague, however, the only other female GP within the practice also has the same conscientious objection. Samantha is then told the names of external clinics and advised to come back in one weeks’ time with her mother if possible.
|Summarize the ethical issue(s) raised by the case.
|The main ethical issues within the aforementioned case include; medical practioners having a conscientious objection to abortion and requests for abortions in under 16s.
|Provide a critical discussion of these issues. Ensure the discussion is balanced and relevant.
|There are few medical procedures as argumentative and politically charged as the termination of pregnancy (BMA, 2014). Abortion is legal in England, Scotland and Wales (E, S & W) as long as the provided criteria are met and is governed by the Abortion Act (1987). Unless an abortion is necessary to save a woman’s life, doctors in E, S & W have a right of conscientious objection under the aforementioned Abortion Act (Department of Health, 2014). At the same time, patients have the right to receive objective and non-judgemental care (GMC, 2013). GPs are for many the first point of contact for individuals seeking advice and support. In this case Samantha appears to be a capable and competent young women who has sought the help and advice from her GP regarding her current pregnancy. What is less apparent is whether the issues that arose due Samantha’s consultation with her GP could have had a positive or negative effect on Samantha and her decision to go ahead with either an abortion or to proceed with the pregnancy. The following considerations will be looked at: – Dr Jenkins behaviour in relation to General Medical Council (GMC) guidelines on conscientious objection – Whether Dr Jenkins conscientious objection had the potential to cause undue stress for Samantha – What the legal position on providing an abortion or abortion advice to girls under 16 years are The GMC sets out clear guidelines for doctors who have a conscientious objection to providing particular treatments because of personal beliefs or values (GMC, 2013). Upon Samantha indicating that she was considering an abortion Dr Jenkins did explain that she had a conscientious objection to this procedure and indicated that she would have to be referred to a colleague. Further to this she also indicated that her female colleague within the practice also had a conscientious objection to abortion. Whilst this does follow GMC guidelines Dr Jenkins failed to provide Samantha with enough information to arrange to see another doctor who did not hold the same objection. She advised of the names of several clinics without providing a named individual whom Samantha could speak to or to provide written information regarding these clinics with which Samantha could take away. The level of anxiety and stress that Samantha may have been experiencing during this consultation should also be taken into account and may have affected the spoken information which was retained (Kessels, 2003). Further to this the British Medical Association indicates that it is “not sufficient to simply tell the patient to seek views elsewhere” (BMA 2013) and as such it may have been more practical for Dr Jenkins to aid Samantha in arranging to see another named doctor. Dr Jenkins also deferred any referral process by asking Samantha to return in a week which could be construed as a further contradiction to the GMC guidelines which state that “arrangements should be made without delay” (GMC, 2013). During this consultation there was the potential to cause a level of undue stress to Samantha. She had approached Dr Jenkins for advice and left the consultation with no measures put in place to assist her. Although Dr Jenkins may have not construed her actions as undue stress and may have felt that asking Samantha to come back would allow her additional time to process her decision. Dr Jenkins did note that she appeared to have very limited support but advised Samantha to come back with her mother whom she had already noted would not approve. Whilst it is recognised that a level of support is required both before and after an abortion, Dr Jenkins should have also recognised that support can be given from whoever the patient feels comfortable with (GMC, 2013), giving consideration for both safeguarding issues and family dynamics within a given situation. The GMC sets out guidance for the advice and treatment of an abortion to those aged under 16 years without parental knowledge or consent (GMC, 2013). In the case of Samantha although she has not been provided with all the relevant information regarding an abortion it is reasonable to assume that she would be able to understand the risks and possible side effects of the procedure as she has already been deemed a competent minor (BMA, 2014) by Dr Jenkins. She has also been advised to speak to her parents although it may also be in her best interest to receive advice and treatment without fulfilling this criteria. Regardless of age, minors who can be deemed competent have the right to make choices regarding their health including their sexual health (Department of Health, 2004). Case law has been laid down most notable by Gillick (1986) and most recently by Axon (2006) which strengthens the argument for competent minors to be treated as autonomous individuals. It is important to note that as a doctor you do have the right to have your own personal beliefs as having true integrity is fundamental in your role (BMA, 2014). A doctors beliefs to having a conscientious objection to abortions must not however impact on the medical advice and treatment given to the patient (GMC, 2014). Whilst there is a conscientious objection clause in Section 4 of the Abortion Act (1967) for refusal of participation past case law (Janaway, 1989 and Doogan & Wood, 2014) have questioned what the meaning of the words “participate” and “treatment” actually mean. The result of the case of Janaway infers that GPs cannot reasonably claim exemption for putting in place any necessary processes or providing advice to women who wish to undergo a termination. With the result from Doogan and Wood inferring that the scope of the word “treatment” is defined as direct involvement rather than the broad scope of any involvement. Conscientious objections must therefore not impinge upon the reproductive rights of women.
|Indicate what you would have done/recommend and why. Provide reasons to support your position.
|From the evidence presented I would not have acted in the same way as Dr Jenkins during this consultation. Although Samantha has been deemed a competent young woman, vulnerability associated with such a young age should always be remembered. I would initially ask her why she would be reluctant to visit a male GP and explain that he would be able to assist her fully regardless of his gender. If she still wished to see a female GP I would regardless of my own personal beliefs speak through all the relevant information regarding abortion including any risks and side effects with her and made sure that she had further information to take away. I would also ensure that Samantha was referred to a named individual who could provide further advice. My conscientious objection to abortion should not stop me from providing information and referral for abortion as I am neither participating nor being directly involved in the termination. I would then explain that as her GP I would be there for all her other healthcare needs. I would have further discussed any other support networks that she may have other than simply parental support and I would have ensured that she left with a plan of where her situation was going and what help we as healthcare professionals could provide her with. By doing this I feel I would have fulfilled the criteria set out by the GMC in relation to both conscientious objections and abortion advice in under 16s.
|References: Abortion Act 1967. British Medical Association (2014). Expression of doctors’ beliefs https://bma.org.uk/practical-support-at-work/ethics/expressions-of-doctors-beliefs [Accessed 13/2/2015] Department of Health (2004) Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health, DH, London. Department of Health (2014) Guidance in Relation to the Requirements of the Abortion Act 1967: For all those responsible for commissioning, providing and managing service provision, DH, London. www.gov.uk/government/uploads/system/uploads/attachment_data/file/31 3459/20140509_-Abortion_Guidance_Document.pdf [Accessed 13/2/2015] Doogan & Wood vs Greater Glasgow and Clyde  General Medical Council (2013). 0-18 year’s guidance: Contraception, abortion and sexually transmitted infections (STIs). https://www.gmc-uk.org/guidance/ethical_guidance/children_guidance_70_71_contraception.asp [Accessed 13/2/2015] General Medical Council (2013). Conscientious objection. https://www.gmc-uk.org/guidance/ethical_guidance/21177.asp [Accessed 13/2/2015] General Medical Council (2013) Good Medical Practice, GMC, London. General Medical Council (2013). Personal beliefs and medical practice. https://www.gmc-uk.org/ guidance [Accessed 13/2/2015] Gillick v West Norfolk & Wisbech Area Health Authority . Janaway v Salford Health Authority . Kessels RPC. Patient’s memory for medical information. J R Soc Med 2003; 96 (5): 219-222. R (Axon) v Secretary of State for Health .
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