Doctors should not be forced to provide emergency contraception if they have an ethical objection to it

The Independent has run the story of a ‘Christian-run NHS GP surgery’ which has apparently ‘attracted criticism for posting a notice warning that some of its doctors refuse to prescribe the morning-after pill to patients on grounds of conscience’.

The message on the door of The Links Medical Practice in Mottingham, south London advises patients that if ‘a consenting doctor is not available’ to prescribe contraception they should contact a local clinic or chemist.

One of the practice’s patients was apparently so outraged by this that she opted to leave the practice and Audrey Simpson, chief executive of the Family Planning Association, has said that other women should also think about leaving the surgery in response to the notice.

She is reported as saying: ‘Leaving will send out a message to them that women have the right to access emergency contraception.’

Women can of course legally access ‘emergency contraception’ in the UK and can buy the ‘morning-after pill’ levonelle over the counter without prescription from most pharmacies as well as accessing it free on prescription, from sexual health clinics and from NHS walk in centres.

But according to General Medical Council guidelines published just recently (see my full review of them here), doctors can also refuse to prescribe certain treatments as a matter of conscience.

The Guidance ‘Personal Beliefs and Medical Practice’ states:

‘You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients.’

It goes on to describe how this is to be done:

‘If, having taken account of your legal and ethical obligations, you wish to exercise a conscientious objection to particular services or procedures, you must do your best to make sure that patients who may consult you about it are aware of your objection in advance. You can do this by making sure that any printed material about your practice and the services you provide explains if there are any services you will not normally provide because of a conscientious objection.’

This seems to be exactly what these doctors have done.

The guidance adds that doctors who do not provide a certain treatment should ‘tell the patient’, tell them ‘that they have a right to discuss their condition and the options for treatment with another practitioner’ and ‘make sure that the patient has enough information to arrange to see another doctor who does not hold the same objection as you’.

Why might doctors have an objection to prescribing ‘emergency contraception’?

There are three main reasons.

Some doctors may have an objection to prescribing contraception in principle. Many Catholics take this view.

Some doctors object to prescribing a drug which might in some circumstances act by preventing an early embryo from implanting in the womb as they see this as an early form of abortion. Although there is not firm proof that levonelle acts in this way there is at very least a degree of uncertainty and no absolute proof that it does not (more on this here – note levonelle in the UK is the same drug as Plan B in the US).

Finally some object because they are unconvinced that levonelle is an effective intervention. Its success rate is relatively low (95% within 24 hours of sexual intercourse, 85% from 25-48 hours and 58% from 49-72 hours).  Also in clinical trials its ready availability has been shown not to reduce pregnancy rates in a population and actually to raise rates of sexually transmitted diseases. 

This is thought to be due to the phenomenon of ‘risk compensation’ – people taking more risks because they believe there is a safety net.

But regardless of the reasons for a given doctor’s objection to prescribing ‘emergency contraception’, the fact that a patient can legally access it does not mean that every doctor thereby has a legal or ethical duty to supply it.

Doctors should not be forced to provide treatments or interventions that they believe are unethical, ineffective or inappropriate. To force them to do so would be to undermine their professional integrity. They are not simply rubber stamps.

Instead reasonable accommodation should be made. And thankfully both the law and the GMC guidance currently allow for that. 

As the recent CMF File on the doctor's conscience concludes: 

The right of conscientious objection is not a minor or peripheral issue. It goes to the heart of medical practice as a moral activity....  The right of conscience helps to preserve the moral integrity of the individual clinician, preserves the distinctive characteristics and reputation of medicine as a profession, acts as a safeguard against coercive state power, and provides protection from discrimination for those with minority ethical beliefs.

(Listen to my BBC London Interview with Vanessa Phelps here)

Man in active homosexual relationship who wants to become priest takes bishop to human rights tribunal for ‘discrimination’

New Zealand became the 13^th country to legalise same sex marriage two weeks ago.

This week the Anglican Bishop of Auckland is being taken to the Human Rights Tribunal over allegations he is discriminating against a gay man who wants to become a priest.

Right Reverend Ross Bay (pictured) has been accused of preventing a gay man entering the Anglican Church's training or discernment programme for priests because he is unmarried and in a sexual relationship with his male partner.

Bay denies the allegation.

The complainant, who cannot be named for legal reasons, said he had been signalling his desire to train for the priesthood since 2006, but had never been accepted into the programme (but see follow up here).

Bay, who approves entrants to the Anglican Church's clergy training programme, has been the Bishop of Auckland since 2010.

The Human Rights Act 1993 allows exceptions to some discrimination laws, including where organised religions are following their doctrine.

The Bishop said, ultimately, church rules determine who can be ordained, and he refused the man entry ‘by reason of the defendant not being chaste in terms of canons of the Anglican Church’.

He added that anyone in a sexual relationship outside of marriage would not be accepted to train as a priest.

The case is illustrative of the sort of litigation that will become commonplace once same sex marriage is legalised.

At the end of the day this is not about ‘legal equality’ – already granted by civil partnerships – or ‘love’ – nothing currently stands in the way of such relationships.

It is largely about the desire for affirmation and recognition.

What infuriates and drives some sections of the gay rights lobby is the fact that some other members of society - in this case leaders in the Anglican church - refuse to accept, affirm and celebrate their sexual relationships.

And so in complete disregard of the directive of Jesus and Paul not to take fellow Christians to court (Matthew 18:15-17; 1 Corinthians 6:5-7) they end up doing just that – thus underlining the key issue at stake in this debate – a disregard for biblical authority.

The Bible is very clear that the only context for sexual intercourse is within a lifelong heterosexual marriage relationship.

If this aspiring priest wishes to be ordained he needs to acknowledge and respect that by giving up his claim to ordination or by becoming celibate. He can't have it both ways. 

Even if he is successful in challenging the rules in a human court he will not be successful when he attempts to justify himself before God who set the rules in the first place. 

See also 'New Zealand anti-gay marriage group to lose charity status')

NB: The Human Rights Tribunal later dismissed this case in October 2013

58 premature babies in England and Wales every year develop cerebral palsy because their mothers had previous abortions

Almost 60 premature babies are born with cerebral palsy in England and Wales every year because their mothers had previous abortions. 

This is because 15% of babies born before 28 weeks develop cerebral palsy and 400 premature births before 28 weeks each year are attributable to abortion. 15% of 400 is 60.  This calculation is based on the studies below.

It is well known that women who have abortions are more likely to suffer from pre-term births in subsequent pregnancies.

I have blogged previously  on the scientific evidence for this link. There are now at least 119 articles in the world literature attesting to the association, and very few indeed that contest it (see review).

A new Finnish study published just last month has further confirmed the link.  It showed that prior induced abortions (IAs) result in a 28% higher risk of an extremely preterm birth (< 28 weeks' gestation).

Another landmark study from Finland last year analysed data from 300,858 first-time mothers between 1996 and 2008. It showed that women were three times more likely to have a very premature baby, born before 28 weeks, if they had had three or more abortions.

Overall the paper showed three babies born before 28 weeks for every 1,000 women who had never had an abortion, four per 1,000 who had had one abortion, six in those who had had two abortions and 11 if the woman had had three or more abortions.

One of the more serious consequences of premature birth is cerebral palsy.

A major meta-analysis (study of studies) by Eveline Himpens et al published in 2008 quantified this risk (See ‘Prevalence, type, distribution, and severity of cerebral palsy in relation to gestational age: a meta-analytic review’). Twenty-six articles met the inclusion criteria.

The prevalence of cerebral palsy was found to decrease significantly with increasing gestational age as follows: 14.6% at 22 to 27 weeks' gestation, 6.2% at 28 to 31 weeks, 0.7% at 32 to 36 weeks, and 0.1% in term infants.

In other words babies born before 28 weeks have 146 times the chance of having cerebral palsy of those born at term.

So how much cerebral palsy in very preterm babies can be attributed to previous abortions?

There are about 4,000 babies under 28 weeks born in England and Wales each year (there were 4,150 in 2005/6).

On the basis of the Finnish study quoted above I have previously calculated that 10% of these premature births - about 400 - are attributable to abortion.

If 14.6% of these 400 babies had cerebral palsy (Himpens’ figures), that would make 58 babies born each year in Britain who have cerebral palsy attributable to premature birth as a result of abortion. 

A report last year showed that the NHS paid out £3.1bn in damages over a decade to babies and mothers injured as a result of staff errors during childbirth.  Of this £3.1bn a total of 542 claims for cerebral palsy cost the NHS some £1.3bn alone.

But what about injuries which happen as a result of premature births which in turn have occurred as a result of abortion?

I wonder if those women who have a baby with cerebral palsy as a result of a premature birth attributable to a previous abortion might have a claim against those doctors who performed those abortions.

It’s an interesting question. 

Several leading bioethicists defend the practice of infanticide this week in leading medical journal

In February 2012 two bioethicists provoked international outrage with an article advocating infanticide.

Writing in the Journal of Medical Ethics (JME), Alberto Giubilini and Francesca Minerva argued in ‘After-birth abortion: why should the baby live?’,   that foetuses and newborns ‘do not have the same moral status as actual persons’.

They concluded that ‘after birth abortion (killing a newborn) should be permissible in all the cases where abortion is, including cases where the newborn is not disabled’.

The same journal (JME) has this week responded to the crisis with a special issue containing 31 commentaries from a range of ethicists, some of whom have argued for years that infanticide can be a moral action; others who believe that even suggesting it is a vile stain on academic integrity.

Editor Julian Savulescu introduces the issue with these words:

‘Infanticide is an important issue and one worthy of scholarly attention because it touches on an area of concern that few societies have had the courage to tackle honestly and openly: euthanasia. We hope that the papers in this issue will stimulate ethical reflection on practices of euthanasia that are occurring and its proper justification and limits.’

Savulescu claims to be ‘strongly opposed to the legalisation of infanticide along the lines discussed by Giubilini and Minerva’ but says that they are not alone in advocating it.

Infanticide is already practised openly and legally in the Netherlands under the ‘Groningen Protocol’ which allows doctors to end the life of neonates at the request of their parents if the infant is experiencing ‘hopeless and unbearable suffering’.

In addition some of the world's most famous living philosophers have written about its merits and justification over the last 40 years, including Michael Tooley, Jonathan Glover, Peter Singer, Jeff McMahan and John Harris.

Four of these five have contributed to this issue of JME and the full text of their articles is currently available on line.

McMahan argues that the permissibility of infanticide in some circumstances is not only implied by certain theories, but by beliefs that are widely held and difficult to reject.

Michael Tooley's book is entitled Abortion and infanticide.

Peter Singer wrote a book in 1985 with Helga Kuhse called Should the baby live?

Jonathan Glover's landmark Causing death and saving lives notes that ‘Dr Francis Crick (the Nobel Laureate who discovered DNA with Jim Watson in 1956) once proposed a two-day period for detecting abnormalities, after which infanticide would not be permissible’.

Many will be shocked by what these philosophers are saying but Savulescu argues that the issue throws up a broad range of ethical questions fundamental to medical ethics.

What constitutes a person with rights? Is there a moral difference between killing a baby of the same gestation inside and outside the womb? Is there a moral difference between euthanasia and withdrawal of treatment and/or sedation with the explicit intention that the baby will die? In what circumstance is ‘letting die’ morally different from killing?

These are all serious questions which many people, including many doctors, have not carefully thought through.

As I have previously argued these bioethicists have actually done us a service. If we don’t like their conclusions, then it should actually lead us to question the premises from which they logically flow.

Philosophers like Peter Singer believe that it is the qualities of rationality, self-consciousness and communication that make human beings special. What follows from this is those humans with less of these qualities are of less value and can, in some circumstances, be disposed of.

By contrast this Christian view of the sanctity of life, which Singer and others reject, is that human beings have value not because of any ‘intrinsic’ qualities, but for two main ‘extrinsic’ reasons. First, that they are made in the image of God for an eternal relationship with him, and second because God himself became a human being in the person of Jesus Christ and thereby bestowed unique dignity on the human race.

If we follow that view through to its logical conclusion it leads us to say that any human being, regardless of its age, appearance, degree of deformity or mental capacity, is worthy of the highest possible degree of protection, empathy, wonder and respect.

These bioethicists are arguing that infanticide is morally no different to abortion.

But we can draw one of two conclusions from that – either we should embrace infanticide or stop doing abortions.

But whatever view we opt for, we should have the courage of our convictions to draw out its full practical implications as these bioethicists have done.

Most people are just not that consistent. 

How to ask your MP to support a referendum on same sex marriage

Anne Main (also see here) (pictured) is my local MP. She has an excellent voting record on social issues (you can find out your own MP’s voting record here).

She voted against the redefinition of marriage in February and I have just asked her to co-sign an amendment (New Clause 9) to David Cameron’s same-sex marriage bill calling for a referendum on the issue.

My local Tory candidate for the local elections, Salih Gaygusuz, did not bother replying when I asked him his view on the issue, so I gave my vote to the UKIP candidate Philip Singleton who opposed the measure instead.

I have told my MP this and also that I will (reluctantly) vote for UKIP again in 2015 if the Tory Party continues to drift in its current direction.  

If you wish to write to your own local MP urging them to co-sign new clause 9 (which will increase its chance of being debated) you can do so very easily via the write to them website.

The more MPs who co-sign an amendment the more chance it has of being debated.

My letter to Anne is below.

My letter to Anne Main MP

Dear Anne,

As you will know MPs vote soon on amendments to the government's Marriage (Same Sex Couples) Bill.   

I am writing to urge you to co-sign the proposed amendment 'New Clause 9' to the bill which calls for a referendum on the issue.

It is not the government's job to redefine marriage and there is no mandate for this bill.

It didn't feature in any major party's manifesto and there is no public consensus for redefining marriage - many people are opposed to it.

Furthermore the government's consultation ignored half a million responses opposing the redefinition of marriage.

I'm deeply concerned about the bill and what it more widely represents - that the Tory Party leadership is no longer listening to social conservatives.

As a result for the first time I voted for UKIP in this week's local elections. 

Despite my longstanding personal support for you I will do so again, with considerable regret, in the next general election in 2015 if the Conservative party continues to drift in this direction.

Yours sincerely,

Peter

One in four 2010 Tories say gay marriage turning them off voting Conservative, according to new poll

From the Coalition for marriage and covered today by the Daily Telegraph and ITV

• Gay marriage will hit David Cameron hard in the local elections

• Pro traditional marriage UKIP surge to 22 per cent

• Lib Dems also losing votes over policy

David Cameron faces losing hundreds of county council seats this Thursday, because of his plans to redefine marriage, according to a major new poll of voters entitled to vote in this week’s local elections.

The survey carried out by ComRes ahead of the local elections reveals that one in four of those who helped put David Cameron into Downing Street say the policy is turning them off from voting Conservative.

Asked, "Does the Coalition Government's plans to legalise same sex marriage make you more or less likely to vote for each of these parties in next week's local elections?" one quarter, (26 per cent) of Conservative 2010 voters say less likely with fewer than one in 10 (nine per cent) saying more likely. 

The policy is costing the Conservatives three votes for every one gained.

Worryingly for Mr Cameron the poll, carried out between 24^th and 28^th April, found evidence that the policy was driving voters into the arms of the UK Independence Party, who have seen their poll rating surge in recent months.

Asked about voting intentions for Thursday, more than one in five of voters (22 per cent), said they were planning to vote for Nigel Farage's Party which opposes gay marriage. Amongst Conservative 2010 voters this rises to one in four (25 per cent) who say they will be voting UKIP on Thursday.  

Colin Hart Campaign Director for the Coalition for Marriage described the poll as a “real blow for the PM”.

“The Prime Minister has consistently backed the proposed changes to redefine marriage as part of the so called decontamination strategy, but it has not worked. Every section of the electorate are highly sceptical about his motives, believing he is pushing this policy in a cynical attempt to make his party look trendy and progressive. This is the ultimate failure of Blairite triangulation policy.

“As Lady Thatcher famously said, 'If you just set out to be liked, you would be prepared to compromise on anything at any time and you would achieve nothing'."

The poll makes grim reading for Mr Cameron's Coalition partners, the Lib Dems who see their electoral support plummet. In 2009 a quarter, (24.9 per cent) of those voting in the same local elections voted Lib Dem. Four years later this figure is set to halve to just over one in ten (12 per cent).

Twice as many Lib Dem 2010 voters say that gay marriage is making them less likely to vote for their party compared with more likely, (18 per cent and 9 per cent respectively). And one in five Lib Dem 2010 voters say they intend to vote Labour on Thursday.

The poll also found some evidence that this weekend’s attacks on UKIP have boosted support for Mr Farage to the tune of nearly five per cent.

Mr Hart continued: "No 10 will no doubt take comfort that his own performance is slightly less disastrous than Ed Miliband's, who polls under a quarter, (24 per cent), but this compares with less than one in nine people (12.7 per cent) who voted in the same elections in 2009. So these figures represent a significant improvement on where Labour was four years ago.”

The poll is the third blow to Mr Cameron’s gay marriage plan this week. Yesterday a national newspaper published a letter from the leaders of the UK biggest so-called black churches, which was highly critical of the plans.

Black church leader Rev Yemi Adedeji (whose group includes churches representing one million people) accused the PM of turning his back on traditional values to satisfy the demands of a “white, liberal elite” while ignoring the growing ethnic minority communities who might otherwise be part of their core vote.

The letter said that the Government had “no respect for democracy” and warned the Conservatives that the redefinition of marriage could cost them votes by rejecting “difference” and “a plural society”.

And yesterday the Northern Ireland Assembly firmly rejected a Sinn Fein backed proposal to rewrite the current definition of marriage by more 11 votes, an increased majority from when the assembly last voted on the issue.

Mr Hart concluded: “This latest poll is a real blow for the PM. It shows that ripping up the current definition of marriage is a real turn off. It is costing both the Conservative and Lib Dems massive amounts of votes and is significantly driving up support for UKIP.

“The legal safeguards have already started to unravel making much more likely cases like Adrian Smith, the Housing Manager demoted for saying on his personal facebook page that gay marriage in churches was an “equality too far”, or Rev Ross who was sacked because his belief in traditional marriage was “not compatible” with Strathclyde’s police equality policy.

“Now we find out that the leaders of Britain’s largest ethnic minority churches have been completely ignored, including their request for a meeting with the Secretary of State being rejected. Given that Black churches represent well over a million people it is astonishing that this important group would be so marginalised and ignored.”

Marie Fleming loses Supreme Court appeal challenging ban on assisted suicide

A 59-year-old Irish woman today lost her Supreme Court challenge to the ban on assisted suicide.

Marie Fleming (pictured) is a 59 year old former Irish lecturer who has multiple sclerosis and wanted her partner to be able to help her kill herself without risk of prosecution (See Irish Times and BBC Europe reports).

She had argued the ban on assisted suicide breached her Constitutional rights and discriminated against her as a disabled person.

This morning, however, the Supreme Court’s seven judges concluded that “there is no constitutional right to commit suicide or to arrange for the determination of one’s life at a time of one’s choosing”.

Fleming's landmark case in Ireland is very similar to that of Debbie Purdy in Britain, who won a case in 2009 forcing the Director of Public Prosecutions (DPP) to make public the criteria he used in deciding to bring a prosecution for assisting suicide. These criteria were published in February 2010 and have been the subject of some controversy.

What makes the Fleming case particularly interesting is that her partner who wishes to avoid prosecution is none other than Tom Curran, the Coordinator for Exit International Europe (EIE), a pro-euthanasia lobby group (EIE is part of Exit International, which is headed by controversial Australian euthanasia campaigner Philip Nitschke). 

Suicide was decriminalised in Ireland in 1993, but Section 2.2 of the Criminal Law Suicide Act 1993 makes it an offence to ‘aid, abet, counsel or procure’ a suicide. Those convicted under this law still face a custodial sentence of up to 14 years.

The Irish Act is almost identical to the Suicide Act 1961 of England and Wales, with the exception that in the latter the words ‘aid, abet, counsel or procure’ were amended to ‘encourage or assist’ by the Coroners and Justice Act in 2009 in an attempt to make it easier to secure convictions in cases of internet suicide promotion where the guilty party did not personally know the victim.

In her case against Ireland, the Attorney General and Director of Public Prosecutions (DPP), Fleming claimed section 2.2 of the Criminal Law (Suicide) Act, which renders it an offence to aid, abet, counsel or procure the suicide of another, was unconstitutional on grounds that it breached her personal autonomy rights under the Constitution and European Convention on Human Rights (See more here)

Fleming argued that the absolute ban should and must be relaxed to meet her particular circumstances as a terminally ill person in severe pain who is mentally competent to decide when and how she wants to end her life but cannot do so without assistance. She claimed that the law discriminated against her as a disabled person who needed assistance to kill herself.

A three judge High Court ruled earlier that the absolute ban did not disproportionately infringe Ms Fleming's personal rights under the Constitution and was wholly justified in the public interest to protect vulnerable people.

The High Court also ruled that the Director of Public Prosecutions had no power to issue guidelines setting out what factors she would consider in deciding whether to prosecute cases of assisted suicide. However, the court was however ‘sure’ the Director would adopt a humane and sensitive approach to Ms Fleming's plight, Mr Justice Nicholas Kearns said.

Ms Fleming was not appealing against that aspect of the court's decision. Her appeal instead focussed on arguments that the absolute ban on assisted suicide breached her personal autonomy rights under the Constitution and European Convention on Human Rights and that, in her particular circumstances, this ban was not justified on public interest grounds but was disproportionate and discriminatory.

This claim has now failed, with the Supreme Court rejecting 'the submission that there exists a constitutional right for a limited class of persons, which would include the appellant. While it is clear that the appellant is in a most tragic situation, the Court has to find constitutional rights anchored in the Constitution... [and it] has not been the jurisprudence of the Constitution that rights be identified for a limited group of persons.'

Fleming’s case rested on the flawed assumption that, since suicide itself is not illegal, there is thereby a right to suicide. It is on this basis that she claimed that as a seriously disabled person she was being discriminated against for not being able to exercise that right, when able-bodied people can.

Dignity in Dying (the former British Voluntary Euthanasia Society) has used a similar line of argument.

However this is to misunderstand the basis and intention of the law.

When the British Parliament passed the Suicide Act in 1961 it was assured that the decriminalisation of suicide did not indicate any reduction of the seriousness with which either (a) suicide or (b) assisting suicide were viewed.

The Joint Under-Secretary of State for the Home Department, moving the Suicide Bill's Third Reading, said:

'Because we have taken the view, as Parliament and the Government have taken, that the treatment of people who attempt to commit suicide should no longer be through the criminal courts, it in no way lessens, nor should it lessen, the respect for the sanctity of life which we all share. It must not be thought that because we are changing the method of treatment for those unfortunate people, we seek to depreciate the gravity of the action of anyone who tries to commit suicide…..' (Hansard: HC Deb 28 July 1961 vol 645: 1961(a): Cols 822-823)

He went on:

'I should like to state as solemnly as I can….that we wish to give no encouragement whatever to suicide…..I hope that nothing that I have said will give the impression that the act of self-murder, of self-destruction, is regarded at all lightly by the Home Office or the Government.' (Hansard:HC Deb 19 July 1961 vol 644: Cols 1425-1426)

Fleming and others wish to argue that in some cases suicide is not serious and is in fact a morally good course of action. That is a position that needs to be strongly resisted at all costs.

It is one thing to argue that people who attempt suicide should be treated with mercy and compassion by the courts. But it is quite another to argue that committing suicide, taking one’s own life, is a moral good and thereby a right.

That would be a very dangerous precedent indeed, which once established would be used as a legal lever for more and more incremental extension.

Judgment Of the Supreme Court: Fleming v Ireland