To Practice Medicine According to My Conscience

Filed on 20 January 2009 in Food For Thought category. Print This Page

Abstract: The freedom to practice medicine according to our conscience is under threat.

There are those that actively promote the view that doctors not prepared to offer legally permitted care because it conflicts with their values should not be doctors.

But the real threat is that such a situation will come about by default through being un-insurable and un-registrable without such a policy ever having been adopted.

There is a need to actively defend the integrity and independence of the medical profession.

To practice medicine according to my conscience.

Written into the Declaration of Geneva formulated and adopted by the WMA in 2006 and ratified by the AMA also in 2006 is the statement:
I will practise my profession with conscience and dignity;
I will maintain, by all the means in my power, the honour and the noble traditions of the medical profession
I will maintain the utmost respect for human life

The Hippocratic Oath likewise states:
I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

As you know it goes on to say – immediately after:
I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion.

And in the final section from Medicine with Morality – a Manifesto of Human Life for the 21st Century that Australian doctors can sign into:
We affirm our right – and indeed obligation – to speak for the future of our society. We assert that ‘natural’ Law is present in the heart of mankind; that this law exhorts us to protect the innocent and helpless and to uphold the sanctity, preciousness and intrinsic value of life at all stages. We further assert that these are eternal and immutable principles.
We assert our right and obligation to practice medicine according to our conscience. We will not engage in or facilitate procedures or practices that we believe are inconsistent with the above manifesto.

To practice medicine according to my conscience. Is there ever any room for watering down of this fundamental principle? Medicine without morality?

But the practice of medicine and ethical medical science is under attack as never before. This is recognised by the profession in Australia. In the media release of September 2006 announcing the adoption of the Declaration of Geneva the AMA President said he was
confident that Australian doctors would welcome the Declaration at a time when there are great challenges to the integrity and independence of the medical profession… It reinforces the independence of the medical profession and it spells out clearly our duty and dedication to our patients and our respect for all human life.

MWM was formed in March 2006 in response to the argument put forward in the RU-486 debate that any decision regarding the clinical use of RU-486 must only be made on the grounds of Evidence Based Medicine (EBM) and not on grounds of religion. The argument was that EBM would support that RU486 was as safe as surgical abortion and therefore should be available. But this approach totally ignores the ethics of outcomes.
The application of EBM without consideration of intended outcome is ipso facto bad medicine and could be used to consider euthanasia techniques or even the transplanting of organs from clones bred for that purpose. How to do it ‘best’ and ‘legal’ is not all that matters.

Transplanting of organs? Yes, this has been suggested by Prof Julian Savulescu, an expatriate Aussie at Oxford University:
“Indeed, it is not merely morally permissible but morally required that we employ cloning to produce embryos or fetuses for the sake of providing cells, tissues or even organs for therapy” Journal of Medical Ethics 25.2 (April 1999): p87.

So yes, organs for therapy. So, lets not limit ourselves to 14 days – let’s grow these babies till we have formed organs – why fiddle with stem cells to grow organs when we can have the real thing. Some women will make the sacrifice of offering their uterus for this procedure either altruistically for a relative or friend who is otherwise going to die or be rewarded in some other way or we can use the organs of Down’s Syndrome babies that are going to be discarded anyway. Impossible? The history of the last 4 years shows us that which was once unthinkable or not morally acceptable (according to one of our senators) becomes thinkable and acceptable very quickly.

Now this same Professor Julian Savulescu who is the Director of the Oxford Uehiro Centre for Practical Ethics has also said
“If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors” (BMJ 2006;332:294-297 February 4).

Did you hear that? “…legally permitted and beneficial”. How to do it “best and legal”. And if we are not prepared to do it “best and legal” we should not be doctors. There is now no place for the ordinary doctor to stay out of the debate – our ability to practice medicine according to our conscience is under threat.

But the mind-set that Savulescu exemplifies has an even broader significance for the future of medicine.

It would lend legitimacy to the exclusion from O&G training places doctors who refuse to do abortions. If euthanasia became legal – or infanticide of premature newborns – it would lend legitimacy to the exclusion from anaesthesia training places doctors who refuse to participate in these procedures.

It would lend legitimacy to government setting ethical standards for the practice of medicine with the risk of de-registration of doctors not prepared to carry out procedures prescribed by the law e.g. an anaesthetist not prepared to give anaesthetic to a prisoner being executed.

It then becomes possible for doctors to suffer disciplinary action – including deregistration – not for taking life but for not taking it or even for not suggesting how it might be taken.

Remember the Hippocratic oath “nor suggest any such counsel”? You think this cannot happen?

Written up in Australian Doctor 20 July 07 was a case in which a lady attended the GP after a condom broke the night before and she sued the doctor for not prescribing the morning-after pill. The Medical Defence Organisation (MDO) acting on behalf of the doctor actually settled out of court. Now there were some complexities in that case and dispute as to whether she actually did ask for the morning-after pill. As far as the GP was concerned the patient came in requesting a Depo-provera injection for future contraception but in the write-up in Australian Doctor the two doctors giving opinions on the case both said the GP should have discussed and offered emergency contraception.

Now the morning-after pill is easily available now (even if it required a prescription at the time of this case) and is public knowledge – will it be obligatory for GPs to say that it is available down the road? Just because the morning-after pill is acceptable practice for some doctors does it mean that others should go against their conscience and offer the same? Does it mean that at some future time it will be obligatory to say that Dr Nitschke’s website has detail on how to terminate a person’s life as an available option – even for a depressed teenager?

Faced with a possible adverse finding the MDO settled out of court – a practical economic solution that may have been justified by the other complexities. But will this mean that MDOs in their practical seminars on avoiding litigation will counsel doctors to offer all that is seen to be “best and legal” and indeed seek undertakings that doctors will in fact do this – and even refuse insurance to those that object on grounds of conscience? Will then Medical Boards refuse to register doctors who refuse such undertaking? Will Savulescu’s principle that such “should not be doctors” then become Savulescu’s Rule?

Yes, it is then possible for doctors to suffer disciplinary action – including deregistration – not for taking life but for not taking it – or even for not suggesting how it might be taken.

Now it is bad enough when ethical standards slip because of a deteriorating moral culture but there is a real danger when we may be forced to because of court determinations. If Medical Boards uphold such determinations what chance do we have to uphold respect for life?

There will be at some time a need for MDOs to defend in court the principle that a doctor cannot violate his or her conscience. Otherwise we are on a one-way trip to the medicine of Nazi Germany. And there is a challenge here for medical professional associations to band together in defence of conscience.

If abortion becomes totally “legal” – as per the bill before the Victorian Parliament – then will GPs be sued for not suggesting abortion – for not suggesting any such counsel?

Will “should not be doctors” become “will not be doctors” because they will be barred from practice by medical boards and by ultimately being un-insurable by medical defence organisations?

All this makes those concluding few lines from Medicine with Morality even more relevant
We assert our right and obligation to practice medicine according to our conscience. We will not engage in or facilitate procedures or practices that we believe are inconsistent with the above manifesto.

As reported in Australian Doctor 17 Nov 2006 in South Australia a doctor has come under attack for requiring that women seeking an abortion sign what was described as being an “unbalanced” summary of the procedure’s risks. In that report was the statement from the Medical Board of SA that “investigation (of the doctor) would be warranted if patients were being given information that was not objective or was not supported by evidence-based medicine.”

Now I do not know whether the doctor’s summary of risks was unbalanced or not. What I do know is that the evidence regarding breast cancer and abortion is hotly disputed and that those who deny such an association do everything they can to discredit evidence for the association and that any inclusion of the risk would be “unbalanced”.

But what is significant here is what the Medical Board is alleged to have said: “not supported by evidence-based medicine.” What about Post-Abortion Syndrome? It has been denied for years and short surveys (in terms of years), redolent with reporting bias by both patient and investigator, tend to support such denial – but we all know it is real.

Every counselling doctor knows the agony felt and expressed by women many years after abortion when permission to feel is finally given. Such is not readily assessable by EBM. Denial can be a life-saving defence mechanism and to let down this barrier is only possible given ideal conditions e.g. a long-time caring GP who is available for such times and facilitates such expression in a safe place.

There is then a potential for EBM wrongly applied to be used as a “stick” to threaten good practice. Conscientious counselling in particular cannot always be judged by whoever and whatever body might decide (inappropriately) is EBM.

How serious is this? The future of medicine is at stake – the ethics of procedures, the ethics of research, the ethics of using materials gained from unethical research, the ethics of organ transfer. What will we teach? Will we use EBM to decide and then teach the best means of euthanasia? Will we exclude conscientious doctors with a high view of the intrinsic value of all human life from obstetrics and anaesthesia? Will we exclude from psychiatry those doctors who will categorically refuse to entertain a recommendation for euthanasia?

Will “should not be doctors” become “will not be doctors”?

Applying this to the situation before us now, if abortion becomes totally unrestricted and “legal” – as per the bill before the Victorian Parliament – then will GPs be sued for not even suggesting abortion as being a solution to an unwanted pregnancy?

Now I’d like to make some further comments on the culture of denial that touches so much on these matters and on what it means to be human.

If we thought the old argument that the conceptus – in itself a sweet word masking the truth – was only a clump of cells was out of fashion, we were wrong. One only has to look at the Lockhart Report to see attempts to disguise the truth:
> The Committee was told: “it was not clear that an SCNT clone should be called an ’embryo’. If it were not defined as an embryo, there would not be a problem with creating one. (!) (p97)
> …a human embryo clone created to extract stem cells is created as a cellular extension of the original subject. (p170)
> …SCNT only aims to copy a person’s cells; therefore… there is no objection to this (p171)

However we hear from the abortion lobby that every woman having an abortion knows what she is doing and has to face the agony of this. Really? Then why do we have such a hard battle not to turn the ultrasound away? This has raged for years and is clearly designed to hide the fact that a real live human baby is present in the safe-house womb – or what should be a safe house.

Now that recommendation was one of many in the trashed NHMRC report of 1995 on Services for the Termination of Pregnancy in Australia. That report also recommended the D&X procedure – Dilatation & Extraction but better known as Partial Birth Abortion – as the termination procedure of choice in 3rd trimester. Interestingly, just the use of the term D&X in this report once again highlighted the emphasis on clinical technique rather than the killing of a baby and nowhere in that report did it actually define what the D&X procedure was.

Now the report said that the D&X procedure had the “advantage of producing a dead baby”. Unbelievable! Why? The report did not say why but clearly the advantage would be that the mother did not have to face the agony of whether or not to keep or kill that baby. There was no longer any ethical dilemma. The job was done by the procedure that was medically necessary for the delivery i.e. to deliver the head through a not-fully-dilated cervix.

I am sure you all know what the D&X procedure is but I am going to tell you what was said in the US Supreme Court that ultimately upheld the congressional ban on partial birth abortion by a 5-4 margin in April this year.
The abortionist (his assistant reported) “delivered the baby’s body and arms — everything but the head.” At that point, “The baby’s little fingers were clasping and unclasping, and his little feet were kicking. Then the doctor stuck the scissors in the back of his head, and the baby’s arms jerked out. … The doctor opened up the scissors, stuck a high-powered suction tube into the opening, and sucked the baby’s brains out.”

I think that sometimes we have failed to speak out for fear of upsetting people or offending people. Now the truth may cause offence but not to tell becomes an offence in itself. Over the years I have deliberately avoided in public the description of D&X because I knew what reaction would come and that some would be genuinely distressed and suffer that distress for a long time. But it has often been the haunting pictures of suffering and war that have galvanised action and ultimately led to change and it seems that the evidence given to the US Supreme Court on D&X was at least partly helpful in swinging the decision to ban it.

I also think that many people have not wanted to know and shut their ears – like some of the German people who, when confronted during Hitler’s regime about what was going on in concentration camps, said no, no, we would never do such things; that is not possible – we are German. Or like others who did realise but shrank into their sanctuaries of private virtuousness that Dietrich Bonhoeffer talked about. Bonhoeffer also talked about the silent church that denied responsibility and the confessing church that took the risk and spoke out against the evil of the time. In our present time in Australia praise is due to our church leaders that have spoken out so clearly and courageously. May we never be a silent people.

Now looking at some of the situations where D&X might be considered e.g. foetal abnormality. What if a mistake is made in diagnosis or at least the severity of abnormality as might have been the case with baby Jessica that Andrew Bolt wrote about so forcefully in The Herald Sun on July 25th. It has been said that “banning infanticide unfairly discriminates against the normal child by forcing a late stage abortion” and that if infanticide for abnormality was legal then we could allow the baby to be born before making that decision and what’s more do that painlessly with appropriate anaesthesia – requiring of course a doctor willing to do that work

Which bring us to the problem of foetal pain – another sphere of denial.

When does a baby feel pain? It was reported last year that British researchers concluded that premature babies around 20 weeks did actually feel pain when withdrawing their feet with heel prick rather than this just being a reflex action. Before this the withdrawal was just regarded by some as being reflex. How did we even think they might not feel pain? Nerve pathways are being laid down from around 7 weeks. When does an unborn infant feel pain as we do? We do not know and to pretend that a 32-week unborn infant does not feel that stab of the scissors in the back of the neck prior to its brain being scrambled and then sucked out is mind-boggling in its denial. In that sense also infanticide discriminates against the unborn. Let’s at least be consistent and say that painless infanticide after adequate assessment of all the facts makes more sense – but there would be no room for denial then would there? The mother and the father and the doctors could no longer pretend this wasn’t a real baby. While it’s in the womb at least we can pretend its not really human.

Now I don’t know whether hypertonic salt solutions are still used for abortion but these cause scalding – internal and external – in the process of poisoning the baby. Why was even the possibility that such pain might be felt hidden from the mother?

Which brings us to the problem of eugenic selection.

Which lives should be terminated? And what does our answer say about our view of the disabled in our world? What does it mean to have a world free of ‘imperfection’ whatever that might mean to a particular generation or government? What implications does this have re cost to the community and distribution of scarce funds? Already parents refusing termination are being labelled as ‘genetic outlaws’ for bringing this ‘financial impost on the community’. We are practicing eugenic purification without calling it that.

Now if we introduced totally unrestricted abortion I suppose it could be logically argued there is no dilemma. Mothers could demand termination for any reason and argue against refusal on the grounds of discrimination with predictably the eventual backing of the courts upholding that which is legal – oh dear, we’re back to that again. Consider:
“Well doctor, if you will terminate for Down’s Syndrome then it would be discriminatory for you not to terminate for this cleft lip.”
“Well doctor, if you terminate at 24 weeks – as in the case of my friend – it would be discriminatory for you not to terminate at 32 weeks for me.”
“Well doctor, my two-year-old has just been diagnosed with autism and I am pregnant with a male baby and autism is more likely to be passed through the male – if you will terminate male babies at 12 weeks in these instances it would be discriminatory for you not to terminate mine at 36 weeks.”

I can hear the cries already “no, no, that would not be morally permissible – it is disingenuous to suggest that approving this will open the door to further killing of living human beings.” Well, we all know how disingenuous – or insincere – that statement was in retrospect having witnessed in just 4 short years the reversal of the cloning ban.

These are some of the matters concerning the value of human life that impact when consideration is given to legalising abortion through to term. Those of the personal choice and autonomy mindset will continue to deny the reality of what is at stake both now and in the future but the threat to our society consequent upon the real devaluation of human life is too great for us to ignore.

The drift is further illustrated by the work of prominent bio-ethicists who argue for delayed personhood on the basis of self-awareness. This philosophy then legitimises all destructive embryo research, abortion and is extended to infanticide. This definition of personhood – and its absence – can also be used to legitimise euthanasia.

It is very easy for doctors on the frontline of practical medical care to become weary. Sadly it is often ethicists and philosophers and doctors away from that frontline who sometimes set the tone in medical ethics and who have the platform to deliver their message. Similarly it seems that doctors are losing control over self-regulation and education as was lamented recently in a Medical Journal of Australia editorial (Vol 186/3, 5 Feb 2007) by Dr Martin B Van Der Weyden The Absence of Many Voices in Protest in which he describes the take-over of regulation by committees in which doctors will have less influence. He questions whether doctors have become fatigued by their never-ending tussles to maintain self-governance and “the absence of many voices in protest may well seal the fate of the profession’s independence.”

Why have things gone so drastically wrong? Yes, of course there are doctors and scientists who will deliberately go down a track that they know to be wrong but for the majority of the medical profession it has been a matter of misplaced compassion – pity if you like, and there is a big difference between pity and love as any parent knows.

Pity is not enough. Real compassion is the mix of love and mercy with justice and truth.

But we had pity on the university students when they found they were pregnant and on the mother with four children who found herself pregnant again. In their anguish, shock and grief we had pity and decided we could fix this, turn back the clock, denying the truth that they were ever pregnant and get rid of the “products of conception”. But denial is never a solution for grief. Accidents happen. People make mistakes. Risky behaviour has consequences. How did we ever think that taking a life would ever be a solution for misery? And, of course, that is not true anyway – people do suffer consequences from abortion as we all know.

The plea from others – both distant and significant – “she’s only a girl, have pity”; “she has difficulty coping, show pity” swayed the doctor’s judgment and yes, we turned the ultrasound away and said “yes, we’ll turn back the clock and we won’t tell a soul and you won’t have to worry about a thing” and we said to ourselves that these bits of tissues were just products of conception.

Thou shalt not kill. Killing is not an option. Pity is not enough.
First, do no harm (Hippocrates: Primum non Nocere).
To cure sometimes, to relieve often, to comfort always (said to be 15th century proverb).

I am a doctor! I inform and educate every day of my working life. It is my pleasure to inform and help people by partnering with them in wholistic management. I want the opportunity to fully inform and empower. I demand the right not to facilitate by referral any procedure that I regard as being unethical nor suggest any such counsel.

I am a doctor! In the best traditions of ethical medicine I seek to cure sometimes, to relieve often, to comfort always, to do no harm, to uphold respect for life and to practise medicine according to my conscience.

Lachlan Dunjey MBBS FRACGP DObstRCOG
4 August 2007. Right to Life Australia Conference, Melbourne.
Delivered under title The Proper Role of a Doctor – Upholding Respect for Life.
AMA Adopts WMA Declaration of Geneva Date released: 28/09/2006

The AMA has adopted the World Medical Association’s (WMA) Declaration of Geneva as a contemporary companion to the 2,500-year-old Hippocratic Oath for doctors to declare their commitment to their profession, their patients, and humanity.

The AMA Executive Council has formally embraced the Declaration as AMA policy, with the new voluntary vow setting ‘guiding principles around becoming a medical practitioner’.

AMA President Dr Mukesh Haikerwal said today he is confident that Australian doctors would welcome the Declaration at a time when there are great challenges to the integrity and independence of the medical profession.

“The Declaration is a short, sharp summary of all that is good about being a doctor in the 21st Century,” Dr Haikerwal said.

“It reinforces the independence of the medical profession and it spells out clearly our duty and dedication to our patients and our respect for all human life.

“While the Hippocratic Oath sets out the historical and philosophical roles of the medical profession, the WMA’s Declaration of Geneva encapsulates the basic noble principles and values of being a doctor.

“Together, they are a comprehensive affirmation of the value of our profession, and they complement the guidance on ethical standards and professionalism provided by the AMA’s Code of Ethics.”

Declaration of Geneva (WMA, 2006)

At the time of being admitted as a member of the medical profession:

I solemnly pledge to consecrate my life to the service of humanity;

I will give to my teachers the respect and gratitude that is their due;

I will practise my profession with conscience and dignity;

The health of my patient will be my first consideration;

I will respect the secrets that are confided in me, even after the patient has died;

I will maintain, by all the means in my power, the honour and the noble traditions of the medical profession;

My colleagues will be my sisters and brothers;

I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;

I will maintain the utmost respect for human life;

I will not use my medical knowledge to violate human rights and civil liberties, even under threat;

I make these promises solemnly, freely and upon my honour.

Share |