Medical ethics and contraception

Medical ethics and contraception

What ethical issues do doctors or other medical professionals face when giving contraceptive advice?

Their primary concern should always be the welfare of the patient concerned.

This goes hand in hand with respecting the autonomy of the patient: the doctor must respect the patient's right to make their own decisions, which means the doctor should provide the method the patient prefers unless there is a medical reason not to do so.

The doctor should make sure the patient gets the information and advice they need to be able to choose wisely.

It's important to realise that the doctor has rights too. Organisations such as the British Medical Association recognise that a doctor has the right to claim a conscientious objection to prescribing contraception and emergency contraception. However in such a case the doctor should refer the patient to another source of treatment and advice.

Methods

The principle of informed consent requires a doctor to make sure that the patient is aware of, and has genuinely understood the hazards and benefits of various methods of contraception.

For each method of birth control the patient needs to know:

• Reliability of the method
• Ease of use of the method
• Potential side-effects
• Health risks

Doctors should explain the methods available, and help patients weigh the advantages and disadvantages of the methods so as to make the best choice for their situation.

Doctors must make sure that that patients are able to use the chosen method properly and can recognise and cope with side effects.

Doctors provide continuing support for their patients' birth control needs.

Doctors should outline the emergency contraception options that are available if there is a problem.

Where the method is sterilisation the doctor must ensure that the patient is aware that it is unlikely to be reversible.

Personal views

Where the doctor has strong ethical or religious views on birth control they have two choices:

• Make the patient aware of their views and give the patient an opportunity to consult someone else
• Disregard their own views and give unbiased medical advice

It is unethical for a practitioner to give medical advice influenced by a non-medical factor without disclosing this to the patient.

This poses problems not just for doctors who disapprove of contraception itself, but also for doctors who while willing to provide birth control to married couples, believe it is wrong to help unmarried people avoid the consequences of sexual immorality.

An additional moral issue for doctors is whether or not they need to warn patients seeking contraception outside marriage (or at least a settled relationship) of the dangers of sexually transmitted diseases.

Confidentiality

Doctors have an obligation to maintain patient confidentiality.

This has come under pressure in cases where teenagers seek help with contraception from a doctor and make it clear that they do not wish their parents to know about it.

A British Medical Association report recommended in December 2003

• that children of under 16 must be entitled to expect that both the existence and the content of a consultation in connection with pregnancy or contraception will normally remain secret
• that in the case of any departure from this rule doctors should be liable to justify their action.

In such cases:

• Doctors are advised to encourage young people to inform parents of the consultation and explore the reasons if the patient is unwilling to do so
• Doctors should take into account whether the patient is likely to have sexual intercourse without contraception
• Doctors should assess whether the patient's physical or mental health or both are likely to suffer if the patient does not receive contraceptive advice or supplies
• Doctors should consider whether the patient's best interests would require the provision of contraceptive advice or methods or both without parental consent
• If the doctor believes that colluding with the child in deceiving the parent would be unethical then the only moral course of action is to be open with the child, and if necessary to refer them to a clinic where confidentiality is a feature of the service offered. It would be unethical to promise confidentiality and then break it.

Guidelines from British medical and family planning organisations state:

• The duty of confidentiality owed to a person under 16 is as great as that owed to any other person.
  • Regardless of whether or not the requested treatment is given, the confidentiality of the consultation should still be respected, unless there are convincing reasons to the contrary.
• Any competent young person, regardless of age, can independently seek medical advice and give valid consent to medical treatment.
  • Competency is understood in terms of the patient's ability to understand the choices and their consequences, including the nature, purpose and possible risk of any treatment (or non-treatment).
• Parental consent to that treatment is not necessary.
• It is obviously preferable for young people to have their parents' support for important and potentially life-changing decisions. Often, however, young patients do not wish parents to be informed of a medical consultation or its outcome and the doctor should not override the patient's views.
• Establishing a trusting relationship between the patient and doctor at this stage will do more to promote health than if doctors refuse to see young patients without involving parents.

Can doctors ever break confidentiality over contraception?

Yes they can, but only in very limited circumstances.

In the UK all the following conditions must be met:

• the patient does not have sufficient understanding to appreciate what the advice or treatment being sought may involve
• the patient cannot be persuaded to involve an appropriate person in the consultation
• the doctor believes breaking confidentiality is essential to the best medical interests of the patient

There is one other situation in which confidentiality can be breached in this context, and this is where the health, safety or welfare of someone other than the patient would otherwise be at serious risk.

This is likely to arise in cases where the doctor suspects, with good reason, that the patient and other people may be suffering from sexual abuse or exploitation.

A doctor who does breach confidentiality must be prepared to justify his or her decision before the General Medical Council.