Ethics in the country

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Colin Thomson discusses the educational challenges in professionalism for rural and regional health professionals.  

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Colin Thomson
BA, LLB, LLM (Sydney) www.ehealthinfo.gov.au
Colin Thomson, BA, LLM (Sydney) is Professor of Law at the University of Wollongong and Academic Leader for Health Law and Ethics in the Graduate School of Medicine. He also works as a consultant.
He was a member of the Medical Research Ethics Committee (1988-91) of the National Health and Medical Research Council and, from 1998-2002 a member, and from 2006-2009, chair of the Australian Health Ethics Committee. As a consultant, he has advised NHMRC, FaHCSIA, Health Departments of NSW, Qld and Vic and several universities. He is a Senior Consultant with Australasian Human Research Ethics Consultancy Services (www.ahrecs.com).
Colin has provided training to human research ethics committees, chairs the CSIRO Social Science HREC and is a member of HRECs at Department of Health and Ageing and University of Wollongong/Illawarra Shoalhaven LHD.
He is a joint author of Good Medical Practice: professionalism, ethics and law, 2010, Cambridge University Press.
There is little doubt that rural and regional areas of Australia are in need of more health professionals - not only general practitioners, but nurses and suitably trained allied health professionals. In relation to General Practitioners, the Commonwealth government has dedicated funds to be used by university medical schools to train general practitioners to meet the need.
A characteristic of the medical schools that are supported by these funds is that they have adopted a different curriculum structure from the long-standing six-year, undergraduate entry programs. These newer curricula compress the overall training program to, typically, four years and are only open to candidates with previous degrees. In addition, many of these schools add admission requirements that seek to address the need for relevant personal and professional experience that offers a sound basis for confidence that, as medical graduates, these students will have not only the essential intellectual achievement but the character and maturity that will equip them for rural and regional practice.
One other reason for seeking this further evidence is that these curricula expose students to clinical experience much earlier than traditional programs did. In the program with which this author is familiar, students begin clinical rotations in the second half of the second year and complete a full year clinical placement in a rural or regional general practice.
In preparing the students for both those placements and their continuing professional careers, the features of rural and regional Australia that are likely to present professional ethical difficulties need to be considered. Living and working in small, often close-knit communities where extended family members know much about the life and health and experience in the healthcare system of their relatives. Further, they are often comfortable discussing these, a frankness and degree of shared knowledge that can confront health practitioners with new contexts in which to address conventional professional ethical obligations. These obligations have a characteristically individualistic focus, for which a mutually agreed sharing of life experience can be a challenge.
The close-knit community that such a clinically placed student or new general practitioner is now part of may also be much more comfortable with giving and exchanging gifts in appreciation of services rendered than in urban and often less personal settings. Although these gifts may not be given with any intent of attracting preferential treatment, nonetheless a refusal to accept them may appear discourteous and inconsistent with the spirit in which they were intended and community practice and understanding.
It may also be the case that clinically placed students or newer general practitioners appear eligible partners for local residents. Negotiating the overlapping territories of professional obligation, personal courtesy and social life in such communities is likely to be difficult.
Realistic examples include:

• While visiting the local base hospital to see a patient, a doctor notices another, elderly, patient of whose admission the doctor was unaware, although the doctor has treated the patient for most of her adult life. Having quickly reviewed that elderly patient’s hospital file (without asking the patient), the doctor, as he is leaving the hospital, assures the elderly patient that he (the doctor) has checked the patient’s file and assures the patient that she is being well cared for.


• The doctor has, on several occasions, seen a patient, L, who has been demonstrating symptoms of depression, although usually has reasons why she is tired or run down. At the local hardware on a Saturday afternoon, the doctor sees L’s sister in-law (also a patient of the practice) who mentions that L and her husband are having relationship problems and that the family thinks she might be drinking heavily, depressed, and possibly pregnant to someone else.


• The doctor, single and recently arrived in a rural town, has been seeing one patient regularly from arrival. The patient has a minor muscular skeletal injury that requires frequent consultations. The doctor is attracted to the patient who has, subtly but apparently deliberately, indicated that the attraction is mutual. A local festival in support of a health related charity involves a dinner-dance to which the patient invites the doctor.


• A newly arrived doctor in a coastal town is a keen fisherperson and joins a local fishing club. One of the members, whose young children are frequent patients for treatment of asthma and allergies, begins to regularly drop by the doctor’s surgery with gifts of freshly caught fish.

Conventional responses to these situations emphasise that

• both the clinically placed student and a doctor have underlying obligations of confidentiality to patients and should not disclose information provided by patients to others;


• doctors should avoid relationships with patients that could compromise independent clinical judgment; and


• doctors should decline gifts that could influence independent clinical judgement in treating patients.

However, these responses now need to be considered in the light of the real processes of smaller community life. These include:

• the importance of being accepted by that community


• the maintenance of suitable courtesy


• living as an engaged community member, and


• showing respect for the genuine concern that family members have for others.

The Medical Board of Australia has developed a code of practice for medical practitioners - “Good medical practice” that was been developed by the Australian Medical Council:
http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx.
The Code offers nuanced and practical guidance that will assist in resolving many of these dilemmas and will be the source of guidance for practitioners. However, what will remain important is how to abide by this Code in the rural community context, where the modern challenges seem to far exceed those of nearly forty years ago, so memorably explored by John Berger in his “A Fortunate Man: The Story of a Country Doctor”.
In these situations, what are likely to be needed are readily available and experienced professionals to act as sounding boards for the discussion of situations that present practitioners new to rural and regional communities with these ethical challenges. Providing these sounding boards in sufficient number in Australia’s vast rural and regional communities continues to be a significant educational and professional development challenge.