British Medical Journal's 'Lobbywatch' puts the UK Islamic Medical Association under the microscope.

Last month the BMJ ran a rather damning expose of the Christian Medical Fellowship (an organisation which appears to have been hijacked by conservative Christians and used as a vehicle for pushing their increasingly extreme points of view on medical matters). This month it targets the UK's Islamic Medical Association who have equally wacky ideas on issues like vaccination. Their spokesman states:

...that he wants to promote a debate on the practice of vaccination in general. He has also urged British Muslims not to give their children vaccines such as that for measles, mumps, and rubella (MMR), because they contain substances that make them un-Islamic. He alleged that almost all vaccines contain “haraam” (forbidden) derivatives of animal or human tissue and that Muslim parents were better off letting children’s immune systems develop on their own.

Other medical practices are apparently not to be encouraged by Muslim doctors, such as giving condoms to unmarried persons, and the organisation sees its mandates as "joining actively the Pro-life campaign in Britain" and "Joining the campaign against the adding of Fluoride to our drinking water" (see http://www.islamicmedicine.org/imaUK.doc). 

The article notes that the British Medical Association and GMC have learned of Muslim students who are refusing to learn about alcohol related illness or sexually transmitted disease as it offends their religious beliefs and that "A small number were also reported to be refusing to treat patients of the opposite sex."

I guess that would at least shorten ward rounds by about half. Makes the Christian Medical Fellowship look almost moderate in its views. (OK, not really).

Where next for the anti-abortion brigade?

With the defeat of Nadine Dorries' abortion amendment in the House of Commons by 368 votes to 118, where can the UK anti-abortion lobby go now? The amendment had attempted to get 'independent' (read: 'faith-based') groups into pre-abortion counselling, with the aim of increasing the wait to abortion and applying pressure on those with unwanted pregnancies.

Well, the anti-choice lobby can take some comfort in the comments by the Under-Secretary for public health, Anne Milton, who was said that the Government was:

...supportive of the spirit of these amendments and we intend to bring forward proposals for regulations accordingly, but after consultation. Primary legislation is not only unnecessary but would deprive parliament of the opportunity to consider the detail of how this service would develop and evolve.

Ann Milton, Parliamentary Under Secretary of State for Public Health, and a supporter of 'the spirit' of Nadine Dorries' amendments

Milton has fallen for Dorries' trap, that there is a problem here that somehow needs correcting; that counselling services for women considering abortion are somehow currently skewed or inadequate (a contention for which not one jot of evidence exists). Dorries' (or 'Mad Nad' as Private Eye magazine now dub her) amendment was described by Diane Abbot (the shadow public health minister) as "a shoddy, ill-conceived attempt to promote non-facts to make a non-case".

That, however, is precisely the kind of strategy the anti-abortion lobby must now pursue. With no case to make for a comprehensive review of abortion law, they must concentrate on building up straw men using anecdotes, irrelevant facts, and presuming causation where there exists only correlation. Oh, and getting funding from US anti-abortion campaigners, who are suspected of bankrolling the 'Right to Know' campaign spearheaded by Dorries and her parliamentary colleague Frank Field. The anti-abortion campaigners must concentrate on peripheral or nonsensical arguments, such as the supposed mental health consequences of abortion, or the tiny proportion of late term abortions, in order to chip away steadily at the notion that universal access to abortion in the UK represents a huge advance in healthcare and reproductive ethics. Or, a new favourite, is to play the victim card: that people are conspiring against you (or even blackmailing others) or that you are the victim of censorship. And whatever happens, rule number one is always to use smokescreen arguments and to NEVER mention that you really object to abortion because you believe there exists a text which is actually the transcribed thoughts of a deity who wasn't too keen on female reproductive choice. And you think that this deity's writings should be forced upon other people who don't hold that belief.

Find out how your MP voted on the amendment here.

"Independent" abortion counselling: a solution in search of a problem

Rules designed to restrict abortion choice look set to be introduced by the coalition Government in the UK. The rules, proposed as an amendment to the Health and Social Care Bill by Labour MP Frank Field and Conservative MP Nadine Dorries (both devout Christians), will remove the role of abortion providers such as BPAS and Marie Stopes in providing pre-abortion advice. Ms. Dorries and Mr. Field state that there is a financial conflict of interest of abortion providers in providing pre-abortion counselling. It is of course a ridiculous idea, effectively accusing medics and nurses working for such organisations of failing to obtain informed consent (the cornerstone of medical ethics) for abortion procedures. There is not one study or piece of evidence to support their claim. Imagine if you are thinking of having your gallbladder removed due to gallstones. The very idea that a surgeon could not tell you about the procedure or alternative options because he/she has a financial stake in carrying out the operation (is paid by the NHS to carry out such operations) is a ludicrous one. But that is the logic of Ms. Dorries.

The amendment is supported by the secretive 'Right to Know' campaign, which rebuts all questions about its funding. It is widely suspected that it is financed by US evangelical conservative Christian groups (see interview with Dr. Evan Harris here), and is part of the 'chipping away' strategy that Ms. Dorries is adopting at UK abortion law.

Whilst this is only tinkering (reducing the gestation limit at which abortion is available was roundly rejected by MPs in 2008), Ms. Dorries has admitted to being advised by Dr. Peter Saunders, who is CEO of the Christian Medical Fellowship (which appears to be an increasingly extreme organisation peddling increasingly wacky ideas). A look at the powerpoint slides of Dr. Saunders here lays bare the 'chipping away' strategy. Ms. Dorries has indeed concentrated on the potential reduction in numbers of abortions her amendment might produce (she states up to 60,000) a year). More pragmatic commentators have stated that numbers will probably not be reduced a great deal, but that referral to the 'independent' counsellors will cause delays in abortion meaning later term abortions, which will be a matter of regret not only to Christian and secular organisations, but particularly for patients.

Pre-abortion advice provided by non-mainstream organisations has been found severely wanting. As The Guardian reported this month:

A survey of 10 centres operated by Christian and anti-abortion organisations found evidence in most of them of poor practice and factually incorrect advice, while the quality of counselling differs widely. Advice ranged from scaremongering – linking abortion with breast cancer, for example – to actions apparently designed to steer women away from abortion, such as showing them baby clothes and talking about "the child"...At a Life centre in Covent Garden, London, the undercover researcher was given a leaflet entitled Abortions – How they're Done, which said incorrectly that 85% of abortions are carried out using vacuum aspiration. It stated that "the unborn child is sucked down the tube" and that "the woman should wear some protection. She has to dispose of the corpse [in the case of chemically induced abortion]."

Finally, Ms. Dorries cites support for her campaign from BACP, the British Association of Counselling and Psychotherapy. This rather conflicts with the reply from BACP to a question about its supposed support to which the answer came "BACP has never suggested or implied that organisations like BPAS and Marie Stopes International should stop providing abortion advice or any of their other ancillary services."

It's good to know that the Government is, in straightened times, thinking of introducing complex, unfeasible, unceccessary, and expensive legislation for which there is no need, merely at the whim of a couple of backbench MPs. The amendments will also use up valuable time for debating the major aspects of the Bill - most notably, that GPs will be given the majority of the NHS budget to commission services, and the stealth privatisation of the NHS. I urge you to lobby your MP about this issue before the 6th Sept (when the amendment is likely to be debated), which can be done easily at this link:

http://www.abortionrights.org.uk/component/option,com_frontpage/Itemid,1/

Catholic hospital may lose status over 'abortion' to save mother's life

From Medical News Today via RDFS

Bishop Thomas Olmsted sounds like a chap with his priorities in the right order. In response to a case of fetal termination to save a mothers life, Olmstead states that CHW's "actions communicate to me that [the hospital does] not respect my authority to authentically teach and interpret moral law in this diocese."

I previously blogged on this case here.

The foetus cannot feel pain before 24 weeks

The peer-reviewed working party report by the Royal College of Obstetrics and Gynaecologists is here. The findings of the committee hinge on the following evidence:

1) That the foetus is not conscious by that time, being kept in a state of "a continuous sleep-like unconsciousness or sedation".

2) That the neural connections allowing the experience of pain (by relay of neural signals to the cortex) are not sufficiently developed.

Recently, UK parliamentarians (including the Prime Minister, David Cameron) have begun making noises about possible downwards review of the 24 week limit. This follows bills introduced by various US states to limit late term abortions on the basis of the putative ability of foetuses to feel pain, most notably that of Nebraska which has decreased the upper limit to 20 weeks. Another 29 states have bills scheduled for the 2010-2011 legislative seasons. Of course, none of those bills will now pass if the lawmakers are interested in scientific evidence (and, of course, the separation between church and state means that the lawmakers will most certainly not be considering any religious views!).

Justice John Paul Stevens — The Practice of Medicine and the Rule of Law

New England Journal of Medicine (free full text article) marks the retirement of Supreme Court Justice John Paul Stephens and his record of defending medicine against interference by government and other groups, including matters of abortion and assisted suicide:

Although it’s not a thought that has leapt to the minds of commentators, U.S. Supreme Court Justice John Paul Stevens will be missed by physicians and patients. Stevens believes that the Constitution prohibits government from interfering in personal decision making, including medical decisions that belong in the hands of physicians and their patients, not politicians and regulators; it was for this reason that he was Justice Harry Blackmun’s staunchest ally in upholding the Roe v. Wade abortion-rights decision.

What can be expected of his successor, Elena Kagan, here: Kagan Memos On Abortion Limits, Religious Rights

Nun excommunicated for allowing abortion

Various sources are reporting the excommunication of Sister Margaret McBride for allowing a fetus to be aborted which, if the termination had not taken place, would almost certainly have resulted in the deaths of both the mother and the fetus. Bishop Thomas J. Olmstead, after finding out about the abortion, ordered the excommuncation of Sister McBride, every Catholic involved with the decision and the procedure, and indeed the patient herself.

In decrying the doctrine of double effect (for which, ironically, we owe a debt to Catholic theology), Rev. John Ehrich, the medical ethics director for the Diocese of Phoenix stated: "She consented in the murder of an unborn child...There are some situations where the mother may in fact die along with her child. But — and this is the Catholic perspective — you can't do evil to bring about good. The end does not justify the means."

The notion of a medical ethics director abiding not by principles of medical ethics, but by substituting (or overlaying) his or her system informed by faith, is against all tradition of medicine as an activity designed to better the lot of the ill, rather than to better the lot of the decision-maker or his church. Decision-making in medical ethics should shun 'absolute' (deontological) approaches and instead adopt frameworks that help guide the clinician or other agent to the best possible outcome for the particular case being considered by incorporating a wide range of moral considerations. Such a system is exemplified by the decision-making approach from the University of British Colombia detailed here (PDF), or the 'Ethox structured approach' from the Ethox Centre at the University of Oxford, which I reproduce below:

Compare the principalist and reflective decision-making process depicted here which includes elements such as 'Does this option respect the persons involved', with the deontological approach used by Rev. John Ehrich in the case of Sister McBride. His ethics come from the Ethical and Religious Directives for Catholic Health Care Services, Fourth Edition, which states, for example:

Directive 36: Compassionate and understanding care should be given to a person who is the victim of sexual assault...It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum.

The difference between the two methods of decision-making, the Ethox approach designed to produce the best outcome for the patient, and the Catholic approach which will frequently have the opposite effect, is so stark as to negate the latter as a system of medical ethics; it is instead dogma, which should not be tolerated by medicine.

But let us submit ourselves to dogma for a moment. We glance at Directive 47 of the above document:

Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

In light of such provision, the justice administered to Sister McBride appears rather summary and in stark contrast to the leniency shown to the paedophilic actions of thousands of priests.

Society for the Protection of Unborn Children: Incompetent or deceitful?

The cryptically named Society for the Protection of Unborn Children (can children be unborn?) has put out a press release in response to the announcement by Marie Stopes International that they will be running a TV campaign to raise awareness of abortion services.

The SPUC release states "Abortion is in English law a criminal offence. Advertising of a criminal offence is not permitted". According to SPUC, the NHS and several hundred thousand health professionals (including myself) were mistaken in our belief that abortion was legal under the 1967 Abortion Act.

So SPUC's statement is either: 

1) A genuine mistake on the part of SPUC. Are they thinking about the The Offenses Against the Person Act, 1861, s.58 under which procuring or supplying abortion was an offence? Is it possible that a group (one of whose expressed aims is "To examine existing or proposed laws, legislation or regulations relating to abortion") are so incompetent as to be one hundred and fifty years out of date in their research? (the act they seem to think is still operating also mandates life imprisonment for homosexuality). 

or:

2) A deliberate and grotesque attempt to mislead women at a vulnerable point in their lives.

I direct SPUC to the wording of the 1967 abortion act and presume that a further press release will follow shortly, admitting either 1) their incompetence; or 2) their willful deceit.

Oklahoma abortion laws: physicians doing harm

The recently enacted Oklahoma abortion laws have been delayed for 45 days whilst the state prepares its defence to a legal challenge. A quick recap on the substance of these laws:

Law 1) Before an abortion, the woman must have an ultrasound in which the monitor must be turned towards her so she can see the fetus, and the physician must describe the condition of the heart, limbs, and fetal organs. No exceptions for rape/incest victims.

Law 2) Any woman who has a disabled baby may not sue her physician who withheld information as to fetal deformity, even if that physician withheld the information to prevent the woman from having an abortion.

There are myriad arguments against these positions, which cannot be dealt with here. I simply wish to address the ethical implications for physicians complying with these laws, in relation of the four principles of medical ethics outlined by Beauchamp & Childress in 'Principles of Medical Ethics' (1979). These are 'non-maleficence', 'beneficence', 'respect for autonomy', and 'justice'.

Law 1) violates the principles of 'first do no harm' (non-maleficence) and 'do good' ('beneficence') if the description or visual image causes distress to the woman, as these are not required for discharging the physician's clinical duty. This indeed seems to be the case; Jennifer Mondino, a staff attorney for the Center for Reproductive Rights (who filed the suit against the enactment of the laws), stated “We have been in touch with our clients and they are telling us stories of having women break down into tears hearing the description of the ultrasound”. The law also violates the principle of 'respect for patient autonomy' if the woman does not wish for such information to be revealed.

Law 2) violates principle of 'respect for patient autonomy' as witholding information (or, indeed lying) limits options available to the patient (e.g. choosing to abort a deformed fetus), preparing her life to look after a disabled child etc. Also violates the principle of 'justice' as the physician's actions may bring a potentially unwanted child into the world who will likely be a heavy consumer of scare medical and social resources.

Counterarguments to these violations of standard ethical frameworks will likely appeal to ethical duties to 'potential persons' i.e. the fetus overriding those of the woman. These are dealt with well by Francesca Minerva at the Oxford Practical Ethics blog.

Physicians clearly have an obligation to obey the law, but they also have a duty to uphold the ethical principles of their profession. When a law clashes with those principles, it's a fairly good barometer that the law itself is ethically flawed, or designed to serve the concerns of a particular group of people or lobby whom are unlikely to find themselves falling under that law's ambit.

Update: Satire can pinpoint ethical unease with great precision. The Onion news network: New Law Requires Women To Name Baby, Paint Nursery Before Getting Abortion.