Previous research indicates the need both internationally and in Australia to address the medical profession’s lack of knowledge and training in relation to domestic violence. The American Medical Association's Council on Ethical and Judicial Affairs concludes that:
The medical profession must demonstrate a greater commitment to ending domestic violence and helping its victims. Medical societies should work collaboratively with established services for those who are abused. Training should include education about the dynamics of abuse as well as presentation of diagnosis and management
protocols… Comprehensive training on domestic violence should be required in medical school curricula and in residency programmes for specialities in which domestic violence is likely to be encountered (Council on Ethical and Judicial Affairs 1992).
Other research has found that in the absence of appropriate training in relation to domestic violence, service providers such as the medical profession assume the broader community's values and tend to interpret violence as the result of the woman's failure to meet domestic demands or maintain family stability. Their responses are seen as ‘overwhelmingly negative, at best ambivalent or detached (Easteal 1988). Research also indicates that a belief in the privacy of the family impedes doctors' responses to domestic violence. According to Dr. N. Jecker of the University of
Washington's Department of Medical History and Ethics:
Privacy beliefs…obfuscate the ethical analysis of physicians' duties to intervene on behalf of battered patients (Jecker 1993).
In a survey in America which asked 1000 abused women to rate the effectiveness of the intervention of various professionals, health care
professionals had the lowest rating behind women’s shelters, lawyers, social service workers, police and clergy (Bowker & Maurer 1987). Powerful medical institutions such as the American Medical Association have brought to the attention of their medical community the need for doctors to address the issue as it presents to them in their practices (Sasseti 1993). Sasseti finds that:
Domestic violence is an enormous health care issue that primary care physicians are powerfully suited to address. Battered women and their children are regularly and routinely presenting for primary health care (Sasseti 1993).
Australian research has also found that doctors are well-placed to effectively intervene when women present as victims of domestic violence because they often visit doctors for their injuries and other symptoms related to their abuse (Burge 1989; Mazza, Dennerstein & Ryan 1996; Taft 2002). Women present with a variety of medical complaints; these include headaches, sleep
disorders and abdominal complaints. They also present at emergency departments as emergency psychiatric patients, and to gynaecologists and obstetricians. Sasseti found doctors are in a unique and critical position to ‘break the silence’ that surrounds domestic violence and to ‘profoundly impact the health and wellbeing of their patients, their communities and the nation at large’ (Sasseti 1993). Other research suggests that the medical ethical
principle of beneficence requires doctors to intervene in cases of domestic violence. In their research, bioethicists Pellegrino and Thomasma refer to this ethic of beneficence in considering a doctor's duties as being more than addressing physical injuries:
The aim of medicine is to address not only the bodily assault that disease or injury inflicts but also the psychological, social, even
spiritual dimensions of this assault. To heal is to make whole or sound, to help a person reconvene the powers of the self and return as far as possible to (their) conception of a normal life (Pellegrino & Thomasma 1988).
The medical profession’s ethical principle of nonmaleficence also directs doctors to effectively intervene with women experiencing domestic violence in order to avoid harmful or inappropriate therapies. Previous research indicates that failure to diagnose abuse results in inappropriately prescribed
medications and an increase in women’s sense of powerlessness (Kurz & Stark 1988; Margolin, Sibner & Gleberman 1988). This includes the prescribing of medications, including anti-depressants, which are
contraindicated for victims of domestic violence where possible increased risks may exist for suicide and drug and alcohol abuse (Margolin, Sibner & Gleberman, in Council on Ethical and Judicial Affairs 1992). For example, research in the US found that doctors often prescribed drugs instead of exploring with women the problems in their lives and supporting women’s efforts to change their situations:
Doctors who feel unable to alter women’s social situations may prescribe drugs for women in an attempt to alleviate the ‘symptoms’ that result from their experiences of violence. (Harper 1996, cited in Hodges 1997: 23)
According to Hodges, women are often not provided with adequate
information to support them in making informed decisions about their health (Hodges 1997: 23).
The American Council on Ethical and Judicial Affairs also found that a number of studies show:
…physicians often fail to diagnose abuse when signs and symptoms are present…emergency department physicians identified one in 35 of their female patients as battered, while a review of their medical charts indicated that one in four were likely to have been battered (Council on Ethical and Judicial Affairs 1992).
They found studies showing physicians' discharge diagnoses correctly indicate domestic violence in only eight per cent of cases where explicit information or strong indications of same were noted on the medical chart (Council on Ethical and Judicial Affairs 1992). Research suggests that if
doctors fail to effectively intervene when a women is assaulted by a male partner the violence is most likely to continue and possibly escalate. One study found that one in five women experiencing domestic violence who seek help from doctors have sought medical attention for injuries from the violence, on eleven previous occasions (Council on Ethical and Judicial Affairs 1992).
Jecker’s research suggests an ethical analysis of a doctor's duties should be widened to incorporate the principle of justice:
Ethical principles of beneficence and nonmaleficence have been invoked to justify physicians' duties to abused patients; however the principle of justice has not been invoked (Jecker 1993).
Establishing conditions favourable for self respect was seen as a requirement of justice, with the intervention chosen by doctors having important
ramifications for supporting women's self respect and dignity (Jecker 1993). Jecker states:
If justice forms part of the ethical foundation for physician intervention in domestic violence mandatory steps that do not transgress the confidentiality of the physician-patient relationship or infringe the patient's autonomy should be taken such as requiring domestic violence training in medical education and following treatment plans and protocols to identify abuse and provide assistance to battered patients (Jecker 1993).
Australian research indicates that women experiencing domestic violence, who present to doctors, express dissatisfaction with the attitudes and interventions received (Head & Taft 1995). Their research recommends domestic violence education for doctors at undergraduate, postgraduate and continuing education levels. However, they state that:
This research suggests that the beliefs a general practitioner holds are not the most important determinant of whether a general practitioner fulfils their role or not (Head & Taft 1995).
They suggest that knowledge and skills are the most important determinant after their research attempted to examine whether beliefs are indicative of a general practitioner’s reported behaviour, which beliefs lead to better
behaviours and which lead to less useful behaviour. They note:
...from discussions with these GPs about their beliefs, it is difficult to make generalisations about their belief systems (Head & Taft 1995).
However, their findings indicate they did identify some individual beliefs that clearly did lead to differences in reported behaviour and impacted on the effectiveness of intervention.
The evaluation of the Australian Women and Violence training manual also raises the issue of doctors’ attitudes. The manual states:
You must be aware that your attitude to violence, male-female
relationships and the role of women in society affects how you ‘hear’ a woman’s story (RACGP 1994).
The evaluation notes that: the educational intervention changed general practitioners’ knowledge in the area of domestic violence; general
practitioners reported an increased number of domestic violence cases in their practice; and general practitioners reported an increase in the number of strategies used to identify victims (RACGP 1994). However, it found:
...global questions dealing with complex issues do not lend themselves to simple categorising of right and wrong. GPs may require much more than a two hour session to change their response to questions which might be part of their belief system rather than something learned previously from coursework or texts…Perhaps changes in attitudes, confidence and motivation are required to elicit changes in behaviour, even in GPs who have substantial pre-existing knowledge of the topic area ( RACGP 1994: 53).
Flitcraft suggests that while knowledge, skills and attitudes are necessary for effective practice, ‘attitudes can be at odds with practice skills and knowledge’ (Flitcraft 1992: 3 195). She suggests:
…knowledge transforms behaviour only when appropriate skills and values converge in the right political climate. Deep ambiguities persist on the societal and community levels regarding the difference
between…legitimate authority and abusive behaviour (Flitcraft 1992: 3 195).
These findings reflect concerns that in the absence of appropriate education and training, responses to domestic violence, including from doctors, will tend to reflect community attitudes. This has been supported by more recent
research (Patton 1997; Taft 2002; Taft 2003) suggesting doctors’ attitudes are
a significant factor in an effective response to women assaulted by a male partner. They suggest that training for attitudinal change should begin in undergraduate education and continue through ongoing education.