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The Challenges of being a General Practitioner Committed to an Ethical Practice of Medicine

Dr Paula Cummings

B Pharm MBChB FRNZCGP

Adapted from a presentation given to students and young-professionals in December 2012.

Thank you for this opportunity to speak on aspects of general practice that challenge my professional medical ethics but that lie at the very heart of why I chose medicine as a career.

I started practising medicine 16 years ago. Today, I expect of myself a consistent ethical practice, based on the Hippocratic Oath. This Oath from the Father of Medicine, Hippocrates, was protected and passed on from teaching physician to pupil over and over the millennia until this modern age. My training at Otago Medical School in Dunedin was during the mid-1990s. As at the majority of medical schools then the teaching reflected a diluted Hippocratic tradition.

Abortion was a not uncommon surgical procedure, during my time working in Obstetrics & Gynaecology. I chose to decline to be involved in any patient’s admission for an induced abortion during those days of training. Fortunately, I did not feel prejudice from the Department. Today, abortion has been described as the most common surgical procedure in the world. Later at this workshop my colleague Dr Naomi Bell will speak from a younger graduate doctor’s perspective on this subject.

New Zealand’s Abortion Law, as we know it, was passed in 1977.  Legal protection for doctors, nurses and midwives who hold a conscientious objection to abortion, exists in the New Zealand Bill of Rights Act 1990, the Contraception, Sterilisation & Abortion Act 1977 and The Health Practitioner’s Competence Assurance Act 2003.

Dr Joseph Hassan stood out in my early career as a doctor and leader who made prolife practising decisions that the media exposed and interrogated widely in print, on radio and on television. I thank Joseph for his unintentional but very public demonstration of his conviction and commitment to the truth.

As recently as 2010, Dr Catherine Hallagan of Wellington, a charismatic, inspiring GP and friend, initiated a landmark court case in the High Court of NZ. The case centred on the nature of a health practitioner’s right to conscientious objection around the provision of abortion & other reproductive health services. Dr Hallagan, as first plaintiff, and the New Zealand Health Professionals Alliance as second plaintiff sought a Judicial Review of a draft document prepared by the medical profession’s regulatory body, the Medical Council of New Zealand. The Judge ruled in favour of Dr Hallagan & the NZHPA. He agreed that the draft statement on ‘Beliefs & Medical Practice’ if published unchanged would contravene a health practitioner’s lawful right to conscientious objection. Consequently the draft document was dropped by the Medical Council and it was not published. This result was a monumental achievement for the protection of freedom of conscience for health professionals working in today’s challenging environment.

For my talk today I would like to consider three issues with you. They provide me with principles for a consistent pro-life ethic which I find valuable in reasoning my position within a medical culture that is increasingly open to a culture of death.

  1. What is the Unborn?
  2. What is the difference between an authentic right and a liberty right?
  3. How can one ethically help the woman with a reproductive health issue?

In medicine there are multiple life-threatening issues such as abortion, eugenics and euthanasia. These assaults on life are enormously complicated and deserve individual treatment. I don’t propose to review all this today! However, these life-threatening issues must be recognised as a degradation of an attitude in society around the unique dignity and sacredness of all human life from conception to natural death.

When human life under any circumstance is not held as sacred in society, all human life in that society is threatened. “When it is held as sacred in all circumstances, all human life is protected “(The Seamless Garment  Joseph L. Bernardin 2008).

I will begin with “What is the Unborn?” This summary is courtesy of Dr Michael Bryant, a Radiation Oncologist, from Southern Colorado, USA.  I met Michael in 2010, while he was taking his sabbatical in Christchurch.

In popular culture some draw a line between nonpersons and persons at birth, others at conception and others at various stages in between. In reproductive research, embryos are not granted human being status because of the potential for identical twinning to occur before implantation in the womb. In response to pro-abortionists’ attempts to justify abortion by defining the unborn out of the class of humanity or persons, one should ask what is the unborn before it is human and personal?

  • If the unborn is not a unique human person, then there is no objection to abortion and all arguments go away.

  • If the unborn is a unique human person, then killing him or her is wrong.

  • What proof is there that the unborn is a unique human person from the moment of conception? Scientific and Philosophical arguments can be used in this proof.

Pro-abortionists argue on:

  • Choice

  • Privacy

  • Mental stress ; economic hardship, inconvenient

  • Back alley abortion

What is the unborn?

  • A unique human person from the moment of conception

  • Zygote, blastocyst, embryo (organs forming), foetus (organs maturing)

  • 38 weeks onwards full term birth

What is an abortion?

  • Termination of a pregnancy

  • Everyone on both sides of the argument agrees that abortion kills ‘something’

  • And only something alive can be killed

  • To kill is to deprive of life

  • To view images of the aborted foetus, it looks like a human person

  • If killing an innocent human person is wrong and an unborn foetus is an innocent human person, then abortion is wrong

The Scientific Proof

  • Alive & growing from conception,

  • Multiplying cells are developing,

  • Cells are metabolically active,

  • There is no period of non-life

  • Distinct individual being with his/her own unique DNA fingerprint (23 chromosomes from each parent;46 );

  • Already defined hair colour, facial features, gender, blood group

  • NOT Mother’s body

A Human Law of Biogenesis

  • Living creatures come from pre-existing creatures; not spontaneous generation and not starting from a clump of dirt

  • Each being produces after its own kind;

  • A human develops from a human

  • Mum & Dad do not produce a thing which becomes a person

The First ‘Test Tube’ Baby:

Dr Lundrum Shettles, the first scientist to achieve conception in a test tube, wrote that…

“Conception not only confers life, it defines life”

The Philosophical Argument:  Apply the S.L.E.D Test

  • Size

  • Level of Development

  • Environment

  • Dependency

Size:

  • Does how big you are dictate status as a human?

  • Was Mother Teresa less a human than Sir Edmund Hillary?

  • Is a 1yr old less a human than her mother?

Level of Development:

  • At what level of development do you become a human person?

  • Is a 16yr or 6mth old boy less a person than his father, grandfather?

  • Is a 25yr old living with Down Syndrome less a person than any other 25yr old?

  • Is an 8week old embryo less a person than a new born?

Environment:

  • Does where one is dictate who one is?

  • Is a 24 week old foetus less a human than a child born at 24 weeks lying in her mother’s arms?

Dependency:

  • Does the help one needs define whether or not they are a human person?

  • Does dependency on a respirator, pacemaker or insulin take away your humanity?

  • Is a one month old baby, who cannot survive alone, not a human person?

Conclusion

  • The unborn is a unique human person from the moment of conception

  • Therefore killing him or her is a terrible wrong

Authentic Rights vs Liberties

Robust debate exists on an individual’s freedom of choice and rights. Popular culture exalts the individual in an absolute way, even at the expense of solidarity of relationships within families, communities and our wider society. Individual rights ought to contribute to the common good of society.

Are all rights equal?

Individual rights should be for the common good of society.

To avoid disorder in society and to prevent becoming a culture highly permissive of death, it is necessary to distinguish a true claim right in the strict sense of the word versus a liberty right.

One problem in popular debate about rights is that the debate takes a two-term-way relationship between one person and one subject matter eg a smoker’s right to smoke, a worker’s right to a just wage, a woman’s right to abortion, and the unborn’s right to life.

A three-term-way relationship between two persons (or groups of persons) and one act of a specific type, differentiates a true claim right from a liberty right. With regard to abortion, the two person groups are the mother and the unborn child. The specified action in question is an act of the mother not of the unborn.

If we consider a woman’s alleged right to abortion, the woman has a liberty right relative to the unborn to intentionally abort it, if and only if, the unborn baby has no claim right that the woman should not abort it.

With regard to the unborn, we can say the unborn have a claim right to life if, and only if, the unborn have a right that their mothers and other persons have a duty to the unborn to not intentionally kill innocent human persons. Any liberal Western Democratic society also imposes a duty on all persons to not kill intentionally innocent human persons. Reproductive science shows that abortion is the intentional killing of an innocent human being.

The challenge for good policies in health and social justice today is to protect authentic claim rights whilst enabling liberty rights for the individual that are for the greater common good of society.

How to ethically help the woman on reproductive health issues

The woman or teenage girl who has an unplanned and/or unwanted pregnancy and who wishes to consider termination is a common consultation for General practitioners.

My experience is that the woman appears often to be overwhelmed, fearful, anxious and under pressure to deal with ‘the problem’ quickly, through abortion, and she then expects that the crisis will go away. The overall effect of this pressure is surely that it “shuts down” the space the pregnant patient needs in order to reflect in a considered way on what is happening to her/them. This ‘space’ is a basic requirement in order to act morally and ethically. Invariably, I perceive that my colleagues’ referrals for terminations of pregnancy are done expediently. Such referrals seem to be like a knee-jerk reaction, done presumably with well-meaning intentions, but reflecting a reactive response rather than the provision of permission for the woman to consider freely her options in a time-frame comfortable to herself (& her partner).

I believe good ethics in general practice requires us to create an ‘ethical space’ for our patient to consider in a measured way the choices she knows she can access. This I think is a more complete and fuller pro-choice approach to addressing lawfully my professional responsibility to my patient.

My personal approach to the desire or wish from a woman to consider a termination is to engage primarily with her in perhaps her greatest moment of fear, anxiety, and confusion. Far fewer in number are the women or teenage girls who are not like this and who act nonchalantly about termination as if it is an easy Band-Aid to their problem.

I confirm the pregnancy & acknowledge her feelings towards her situation. All pregnant women acknowledge that keeping the pregnancy or adoption are choices available to her. I advise the woman early in the consultation that I do not do referrals for terminations of pregnancy however she may access that pathway through a colleague or Family Planning Clinic.

Providing the woman is not firmly requesting a referral for termination of pregnancy, I open up the consultation in any other avenue that I perceive she wants. Invariably the woman needs empathy and I offer her that as well as professional information on her pregnancy, counselling options, crisis pregnancy support. I also invite her to see me again, perhaps with her partner or other support person in a week or so, to facilitate her making a measured decision in a time-frame that she is comfortable with.  I tell the woman that no matter what decision she makes, I will always be happy to see her for any further care during this pregnancy or thereafter.

Increasingly, the health profession of medicine is assuming the values of a free market, to become service providers for a fee. There is a demand for abortion and so the free market model dictates that it should be supplied. Abortion laws state that there must be medical indications for the procedure but lack of any convincing medical indication seems irrelevant in practice. However, health practitioners do not have to embrace this consumerist approach to the provision of abortion.

The extraordinary achievement of mapping out the human genome and other research has been important advancement for understanding the physical human condition. Prudent therapeutic interventions aimed at correcting genetic diseases & preventing their occurrence are in principle good uses of genetic science & healthcare. The big problem now is that the pace of genetic knowledge and its use has transgressed therapeutic use. Genes have been identified that cause or confer predispositions to syndromes such as Down’s, Edward’s, Patau’s, Turner’s; to cystic fibrosis, dwarfism, haemachromatosis, haemophilia, Huntington’s chorea, muscular dystrophy, spina bifida, as well as more common conditions such as cardiovascular disease, Alzheimer’s, osteoporosis, epilepsy, asthma, diabetes, deafness and hypertension. Genes are being identified that are associated not only with physical diseases, but with physical features such as height, body shape, the colouring of skin, hair and eyes, gender, longevity and athletic and other physical potential. “Design a Baby 2012!” Within New Zealand, alongside ultrasound & other procedures, genetic technology is now being used to test the unborn for chromosomal and genetic abnormalities and traits. The truth is that this technology is being used to diagnose the unborn carrying some disease, condition, unwanted characteristic or imperfection and that unborn child’s life can be subsequently terminated.

The New Zealand Ministry of Health’s National Screening Unit has had an antenatal screening programme for some genetic conditions in place for several years. All doctors and midwives assessing the newly pregnant woman are obliged to advise the woman of this programme. Prenatal screening and testing are now routinely available in New Zealand.

However the health practitioner with a conscientious objection to the couple’s indication for antenatal screening does not have to order the tests.

The most common reason I believe as to why prospective parents have prenatal tests is that doctors tell their trusting patients that they need the tests.

The test is a screening test, using a laboratory computer software programme to give a risk estimate for there being a genetic condition (derived from a blood test measuring proteins in pregnancy, a radiographer’s assessment of neck skin fold thickness on an ultrasound of the baby, maternal age, ethnicity, body weight and foetal age).

The top 5% of values or risk estimates are sliced off as testing positive. Such a result has diagnosed nothing! It is a risk estimate and any risk >1:300 is considered a positive screening result.  The woman is then likely not free to jump off this obstetric treadmill because the positive test is likely to evoke natural disappointment, grief, shame or anger when a woman or couple is told her/ their unborn child carries a high risk of a genetic disorder.

Fear of social rejection in raising a different child, inexperience of what caring for a child with a disability might actually involve, information deficit or information overload limit ‘free’ and rational decision-making in a measured approach. Counselling will help to some degree.

Diagnostic tests for confirmation of genetic abnormalities need DNA. Of the top 5% of screening test positive results, more than 94 out of 100 women don’t have an abnormality proven on the best diagnostic tests. These rely on analysing the unborn child’s DNA detectable either through an invasive needle sampling of the placenta (CVS) or of aspirating some amniotic fluid containing foetal cells shed within the womb (amniocentesis). These invasive diagnostic tests carry a risk of harm to the unborn child (limbs, infection, prematurity, lung, cord damage) or of miscarriage alone (CVS 3%; Amniocentesis 1%).

In my practice, I inform the pregnant woman of the availability of antenatal screening. I explain what it involves and give her full and correct information. I also advise the woman that I do not do the referrals for antenatal screening and that she can access this from a colleague or a lead maternity caregiver.

Fortunately for health professionals like Dr Hassan, Dr Bell and me, we do still live in a democracy in New Zealand which honours the fact that we have the lawful right to absent ourselves from being involved in clinical activities which we believe to be unethical. There are laws to protect us in this regard and we are keen to see such legislation retained. That’s why we are supportive of the New Zealand Health Professionals Alliance which is committed to upholding freedom of conscience in the ethical practice of health care.