Ethics and Aboriginal and Torres Strait Islander Patients

Discussion of health and Aboriginal and Torres Strait Islander people in Australia tends to focus on closing the gap in on the social and health disadvantages – the comparatively poor life expectancy and the disproportionately high burden of chronic illness such as cardiovascular disease, diabetes and chronic respiratory diseases.
Discussion of ethics and Aboriginal health has frequently focused on research that has confirmed these disadvantages and burdens but, until recently, has failed to identify effective methods for reducing these. By contrast, there has been less discussion of the ethical dimensions of individual consultations between non-Aboriginal health professionals and Aboriginal patients.
Aboriginality and ethics
An Aboriginal person is one who is a descendant of an indigenous inhabitant of Australia, identifies as an Aboriginal and is recognised as Aboriginal by members of the community in which the person lives. This reveals the fact that Aboriginality exists within a web of relationships that extends from the reciprocal relationships in current communities into ancestral times. In addition, Aboriginal relationships to land or country can be as significant to their well-being as those with other community members. The ethical principle of respect that is central to doctor-patient relationships needs to recognise that these relationships are fundamental to Aboriginal life and well-being.

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“If the Australian healthcare system is to effectively close the gap, consultations between health professionals and Aboriginal patients need to be respectful to be effective.”
COLIN THOMPSON

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Ethics in Aboriginal health care
The establishment and extension of Aboriginal Medical Services is based on the premise that Aboriginal people should control, manage and deliver healthcare services for Aboriginals. In this context, there is more commonly an ethical recognition of the cultural factors that affect patients’ conditions and how to meet their healthcare needs.
By contrast, where Aboriginal patients seek health care provided in the conventional Western mode, there are many elements that are foreign. Important among these are assumptions that:

• based on ideas of individual autonomy, patients can make decisions for themselves and by themselves;


• such decisions can be made in the short time of a consultation with a general practitioner


• the authority and scientific base of Western medical advice is accepted,


• that patients trust and rely on advice and treatment and,


• the context of the engagement promotes in patients a sense of cultural safety.

Communication and Decision-making with Aboriginal Patients
Aboriginal culture is distinctive in its practices of oral communication: of listening and talking and silence. Communication is complex and often enveloped in narratives and discursive accounts of events. A situation that is unsympathetic to such forms of communication is unlikely to promote effective communication. Accordingly, it will be important for health professionals not to assume that they will receive direct responses to specific questions and to be willing and patient to listen with care in order to understand what is being conveyed in indirect and discursive accounts of illness.
Communication among Aboriginal people takes time – time is respectful of others and necessary for effective outcomes. Decisions made in limited time with minimal conversation are not likely to be realistic or reliable.
The Aboriginal cultural emphasis on community means that decision making is reached communally, whether among family members or wider groups of relationship, and rarely by individuals alone. Further, the relationships that are accepted as contributing to decisions may not be those that Western culture would assume, for example, the view of older members of families may be influential. Accordingly, Aboriginal patients are likely to find difficulty in reaching decisions alone, without company and support of family or community members and being away from country.
The history of medical research involving Aboriginal and Torres Strait Islander people has left little basis for them to trust in Western medicine. Further, Aboriginal culture often explains illness by reference to different sources and causes than Western medicine now ascribes. As a result, especially where Western medicine offers only one course of action, premised on its scientific basis, a willingness to conform to a treatment regime might be unlikely.
Resources
If the Australian healthcare system is to effectively close the gap, consultations between health professionals and Aboriginal patients need to be respectful to be effective. A thorough understanding of Aboriginal culture and communication remains intrinsic to ensuring health professionals can develop effective practices informed by the extrinsic features of that culture. Among the many available resources to assist in this important responsibility are the following:
www.healthinfonet.ecu.edu.au
www.racgp.org.au/afp/2014/ January february/aboriginal-cultural mentors/
www.nmml.org.au/page/Programs/Aboriginal_health/Health_professionals_working_with_Aboriginal_people/
www.greaterhealth.org/educationtraining/indigenoushealth/practicaladvice/
www.snaicc.org.au/_uploads/rsfil/02497.pdf
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.