Tuesday, 13 September 2016

Eugenics – could NIPT for Down’s Syndrome bring us full-circle?

Is it wrong to kill disabled people if caring for them costs more than identifying and destroying them?

The Nazis believed killing in these circumstances was not only right but a public duty and the German public was softened up to accept it through a skilful propaganda campaign which began in the classroom.

Leo Alexander, an American psychiatrist who gave evidence at the Nuremberg trials, described the process in his classic article ‘Medical Science under dictatorship’, published in the New England Journal of Medicine in 1949:

‘Acceptance of this ideology was implanted even in the children. A widely used high-school mathematics text, "Mathematics in the Service of National Political Education," includes problems stated in distorted terms of the cost of caring for and rehabilitating the chronically sick and crippled. One of the problems asked, for instance, how many new housing units could be built and how many marriage-allowance loans could be given to newly married couples for the amount of money it cost the state to care for the “crippled, the criminal and the insane”’

In a seminal article in the 1996 British Medical Journal, ‘Not a slippery slope or sudden subversion: German medicine and National Socialism in 1933’, Hartmut Hanauske-Abel outlined just how meticulously they went about it:

‘The 70 273 futile or terminal patients "disinfected" (murdered) in German killing hospitals up to 1 September 1941 are calculated to free up "4 781 339.72 kg of bread, 19 754 325.27 kg of potatoes . . .," a total of "33 733 003.40 kg" of 17 categories of food, plus "2 124 568 eggs." Projected over 10 years, these savings are predicted to amount to "400 244 520 kg" of 20 categories of food worth "141 775 573.80 Reichsmarks." Removal of these patients from the wards saves estimated hospital expenses of "245 955.50 Reichsmarks per day," or "88 543 980.00 Reichsmarks per year.’

We are shocked by the shameful cold-bloodedness of these calculations and the deliberate way in which the ‘disinfecting’ was carried out. We are thankful we have learnt the lessons of history. But have we?

There is evidence that these kinds of cost-benefit decisions might be creeping back. In the 1990s, the past-president of the European Bank for Reconstruction and Development, Jacques Attali, made the following pronouncement in L'Avenir de la vie:

'As soon as he goes beyond 60-65 years of age man lives beyond his capacity to produce, and he costs society a lot of money... euthanasia will be one of the essential instruments of our future societies.'

But the area where ‘cost-benefit’ calculations are most evident, and discussed quite shamelessly in the medical literature, is prenatal diagnosis and abortion for congenital abnormalities.

About 1% of all abortions in Britain are performed under Ground D of the Abortion Act 1967, effectively for fetal illness or disability. And one of the commonest causes, accounting for about one in three of all these abortions, is chromosomal abnormality. The most common cause of this is trisomy 21 (T21) or Down’s Syndrome. Currently about 90% of all babies with Down's Syndrome detected before birth are 'terminated'.

We don’t hear people openly saying that we should kill babies with Down’s Syndrome before birth because of the burden they create for society. We don’t use that language. But the sentiments are strongly and deeply felt and the issue has been debated in medical journals for many years. Most recently we see it in evidence given by medical bodies to the UK National Screening Committee’s (UKNSC) recent consultation on screening for fetal DNA (cfDNA) in pregnancy.

The NHS is close to introducing a new test for pregnant women that will make it much easier to detect and search out any babies with Down's Syndrome (DS) (see previous CMF blog posts here and here).

The new test, NIPT (non-invasive prenatal screening), involves taking a sample of blood from the pregnant woman which is then examined for abnormal fetal DNA. It is called 'non-invasive' because it doesn't involve 'invading' the mother's womb, as chorion villus screening and amniocentesis do. It, therefore, carries no risk of miscarrying a 'normal' pregnancy.

In their evidence to the consultation the Royal College of Obstetricians and Gynaecologists (RCOG) addressed the cost-benefit issue as follows (emphasis mine):

‘The UKNSC is consulting on offering cfDNA testing to women with a 1 in 150 or greater risk of trisomy. The decision NOT to offer cfDNA testing to all women (primary screen) is based upon the cost (“the UKNSC were concerned that this represented a large opportunity cost and that these resources might be better used by the NHS”). If the decision has been made primarily on cost grounds, then a more rigorous economic analysis has to be made that includes the lifetime costs of caring for children and adults with Down’s syndrome (bearing in mind that cfDNA testing as a primary screen test will identify approximately 289 more babies with trisomies). Such an economic analysis may (or may not) suggest that cfDNA testing for all is cost-effective.’

In other words, the RCOG thinks NIPT will be cost-effective if it costs less to detect and kill babies with Down’s Syndrome than it does to provide them with a lifetime of care and support.

In a similar vein, the British Maternal & Fetal Medicine Society (BMFMS) asks (p20), ‘Why isn’t the cost of caring for a child with T21 included in the analysis?’

One might argue that these doctors' groups are different from the Nazis - they are not dragging adults and children with Down’s Syndrome to the gas chamber - and clearly that is true.

But my point is that their reasoning is the same reasoning that the Nazis used – that if the cost of care is higher than the cost of killing then homicide is justifiable on economic grounds.

Why do they fail to see this more clearly? I wonder if it is because these doctors (the leaders of the RCOG and Fetal Medicine Society) attribute little if any value to life before birth. In other words, they view a baby in the womb in a similar way to how Hitler viewed Jewish people; as a drain on resources and surplus to requirement. Not real people. So, they reason that if we have the technology, and can make it safe for the mother - and she wants it - then what’s wrong with it? The baby’s life has no moral value but it does nevertheless carry an economic cost.

Autonomy says ‘we can choose’. Technology says ‘we can do it’. Moral relativism says ‘why not?’

The ‘Don’t screen us out’ campaign (DSUO) is trying to change these perceptions. DSUO describes itself ‘as a grass-roots initiative supported by a collection of people with Down’s syndrome, families and Down’s Syndrome advocate groups led by Saving Downs Syndrome’.

They argue that NIPT does harm to babies with Down’s syndrome and the Down’s syndrome community, violates the Convention of the rights of persons with disabilities and enables eugenic discrimination.

These are strong charges indeed. But if we look at it logically – their argument does make sense. Why are attitudes to disabled people outside the womb so different to the attitudes (expressed above) to those inside the womb?

The key question is this - should the weak be sacrificed for the strong or should the strong make sacrifices for the weak? The Christian answer is clear - bearing one another's burdens is at the very heart of the Gospel. We walk in the steps of the all-powerful creator who laid aside everything and entered this world at great personal cost to rescue, care and serve.

There is no doubt that providing life-time support for people with Down's Syndrome can be costly in emotional and economic terms - but many families will testify that there are great rewards too and that they have much to teach us.

If we are going to talk about cost, then the cost of bringing up a so-called 'average' child in the UK (in goods, university, school and preschool fees, lost parental earnings etc) is around £230,000. Yet no one is seriously suggesting that we apply the economic argument to 'average' children.

So what does this tell us about our attitudes to people with Down's Syndrome? Why are we not up in arms against these doctors who seem to value these people's lives so cheaply? Is it perhaps that it is not just the doctors who are making these assessments? And yet is not the real measure of what kind of a society we are seen in the way we treat those with special needs?  

Monday, 12 September 2016

Is Professor Basky Thilaganathan deliberately misleading parliament over the results of NIPT for Down’s syndrome?

Here's a new story involving disabled people, taxpayers' money, apparent scientific deception, a biotechnology company looking for profits and the NHS.

The NHS is close to introducing a new test for pregnant women that will make it much easier to detect and search out any babies with Down's Syndrome (DS) (see previous CMF blog posts here and here).

Jeremy Hunt, the Health Secretary, is expected to respond to a recommendation from the National Screening Committee for the roll-out of non-invasive prenatal testing (NIPT) any time now. NIPT involves taking a sample of blood from the pregnant woman which is then examined for abnormal fetal DNA. It is called 'non-invasive' because it doesn't involve 'invading' the mother's womb, as chorion villus screening and amniocentesis do. It therefore carries no risk of miscarrying a 'normal' pregnancy.

The Nuffield Council of Bioethics is also expected to publish a report on the new technology this autumn (see CMF's submissions to both Nuffield and the UK National Screening Committee).

The move to make NIPT available on the NHS is extremely controversial and has led to the launch of the ‘Don’t screen us out’ campaign (DSUO). DSUO describes itself ‘as a grass-roots initiative supported by a collection of people with Down’s syndrome, families and Down’s Syndrome advocate groups led by Saving Downs Syndrome’.

They argue that the result will be ‘a profound increase in the number of children with Down’s syndrome screened out by termination’.

They say that, given the fact that 90% of babies who are prenatally diagnosed with Down’s syndrome are currently aborted, making the test available on the NHS is projected to lead to 92 more babies with Down’s syndrome being aborted each year (90% of the 102 more children with Down’s syndrome who would be detected annually by NIPT according to the National Institute for Health and Research RAPID evaluation study  projections).

The same RAPID study also predicts that 25 miscarriages would be prevented by implementation of the technology because fewer women would go on to undergo more invasive chorion villus sampling (CVS ) or amniocentesis in order to diagnose the condition. So it is a trade-off of 25 'normal' babies saved for 92 babies with Down's syndrome aborted.

Don’t Screen us Out have launched an open letter to Jeremy Hunt demanding that his department stop ignoring the concerns of people with Down’s syndrome, their families and the wider community and start consulting them on the proposals. But thus far the health minister has not responded.

The move to introduce NIPT into the NHS is backed by powerful commercial interests. In March 2015 the St George’s University Hospitals NHS Foundation Trust revealed that it was joining forces with the British firm, Premaitha Health to bring in this new screening test. Clearly, if the health secretary gives the green light to pay for this new test to be rolled out on the NHS, then Premaitha, which describes the test as its ‘flagship product’, along with its shareholders, stands to make a lot of money. Millions in fact.

Premaitha admitted this much in a press release earlier this year: 'Premaitha anticipates that the endorsement by the NHS will accelerate private payer market growth in the UK'. More importantly, it will put them in pole position to pitch for NHS hospital tenders. 

Understandably, St Georges, which has a commercial relationship with Premaitha, is defending the test. Earlier this summer, Professor Basky Thilaganathan (pictured), head of the fetal medicine unit at the trust, said: ‘NIPT screening is an absolute sea change in how we have been doing things in the last 50 years. It has the potential to virtually eradicate invasive testing.’

According to the Evening Standard on 12 August, he dismissed claims from DSUO that extending the test would lead to an increase in abortions and claimed that more than 300 miscarriages a year could be prevented if the NIPT (non-invasive prenatal test) was used across the NHS. 

But DSUO have been questioning the evidence for his claims. And a new study published in the British Medical Journal on 4 July 2016 backs up their concerns.

The new BMJ study evaluates the outcomes and costs of implementing NIPT for Down’s syndrome into NHS maternity care and covers eight diverse maternity units. The lead author is Lyn Chitty, Professor of Genetics and Genomic Medicine, UCL Institute of Child Health, London.

Chitty and her colleagues calculate that in an annual screening population of 698,500, offering NIPT (as a contingent test to women with a Down’s syndrome screening risk of at least 1/150) would increase detection by 195 cases with 3,368 fewer invasive tests and, crucially, only 17 fewer procedure related miscarriages (not 300!).

Chitty’s projected decrease in miscarriages (17) is very close to the figure given by the RAPID study (25), and the difference is not statistically significant. But both figures are a far cry from Basky Thilaganathan’s 300, a number almost 20 times higher.

Furthermore, if rolling out NIPT will result in 195 more babies with Down’s syndrome being detected (Chitty), then assuming that 90% will then be aborted (the standard quoted figure), that means almost 180 more abortions for Down’s syndrome each year. Even if the percentage is only ~70% going on to abort, as Chitty suggests for the group having NIPT, we are still talking about over 130 more abortions each year of these affected babies.

DSUO argue that this does harm to babies with Down’s syndrome and the Down’s syndrome community, violates the Convention of the rights of persons with disabilities and enables eugenic discrimination. These are strong charges.

It is quite extraordinary, in the face of the facts just presented, that Prof Thilaganathan can both deny that the test will result in more deaths of babies with Down’s syndrome, and claim that the miscarriages prevented will be almost 20 times higher than the RAPID and Chitty studies predict.

Does he know something we don’t, or is he deliberately misleading the public and parliament in order to advance an ideological and commercial agenda?

The burden of proof is upon Thilaganathan and St Georges to reveal the scientific evidence supporting his claims, or if there actually isn’t any, publically to apologise to DSUO, the public, people with Down’s syndrome and their families and parliament itself for telling lies. 

At very least these latest developments should lead Jeremy Hunt to reflect more on the concerns raised by DSUO and the communities of Down's syndrome families they represent before deciding to invest scarce health service resources on this new venture. More questions need answering and more public scrutiny is required.

Meanwhile I'll be taking a closer look at some of the commercial interests and ideological drivers behind the scenes driving these new tests. Watch this space.

Friday, 5 August 2016

How should Christians respond to new biotechnologies?

In recent years we have seen an explosion of new biotechnologies bursting on the scene, with promise (or threat) of much more.

In vitro fertilisation (IVF) has opened the door to embryo experimentation, egg and sperm donation, surrogacy, embryo selection, pre-implantation genetic diagnosis, embryonic cloning, animal human hybrids, mitochondrial replacement and now gene editing.

Nanotechnology opens the possibility of ‘engineering’ minute biochemical systems at an atomic level.

Cybernetics merges human tissue with mechanical or electrical devices in order to restore lost function or enhance human abilities. With retinal implants, cyborgs – part human, part machine – may be just around the corner.

New drug treatments and enhancements are taking human performance to new levels: viagra to enhance sexual performance and modafanil to heighten concentration and memory.  

Humanoid Japanese robots can blink, smile, walk, talk, express anger, sing and provide healthcare.

Most of these so-called ‘advances’ have been justified on the grounds that they will prevent human suffering or lead to new treatments. Undoubtedly many will. But what biblical principles should we use to evaluate these diverse new biotechnologies from a Christian perspective?

First, as Christians, we must pray to be like the ‘Men of Issachar’ (1 Chronicles 12:32) who both ‘understood the times’ and ‘knew what to do’. John Stott popularised the principle of double-listening saying that as Christians we must approach the world with the Bible in one hand and the newspaper in the other – listening both to God’s Word and God’s World.

Second, we must realise that ethical approaches based on a secular worldview are inadequate for dealing with these dilemmas. We cannot simply rely on uncritically accepting the world’s principles. It’s not enough, as some moral philosophers are saying today, to say that we should just do good, respect choice and act fairly. How are we to define ‘good’, ‘bad’ or justice without any agreed moral framework? What do when choice and justice conflict? And what is it that defines a person to whom we owe these responsibilities? Are humans with severe dementia ‘persons’ with right? Are fetuses? Are embryos? These key questions need to be answered from a biblical perspective first.

Third, we need to embrace a biblical view of humanity.  Thomas Sydenham taught that human beings have dignity because they are created in the image of God and because the Son of God became a man. We are not just the product of matter, chance and time in a godless and purposeless universe, but the product of intelligent divine design. We are godlike beings made for the purpose of knowing, loving and serving our creator forever.

Fourth we need to understand that there are limits to what we can legitimately do technologically to human beings. Professor of Neonatology John Wyatt has described human beings as ‘flawed masterpieces’. On the one hand, we are masterpieces made in the image of almighty God – analogous to the creation of a great painter or sculptor. On the other hand, we have become cracked and flawed over time – needing restoration and ultimately re-creation. In attempting to restore the human body we must be guided by the creator’s intentions. There is a difference between restoration and enhancement and there are also limits to our powers of restoration.

Fifth, we must keep an eternal perspective. The ultimate goal of the secular transhumanists is immortality and the elimination of disease. The most extreme amongst them believe that perfect health and unlimited lifespans are within our grasp using some of these new tools.  But as Christians, whilst we value the blessings of medicine, we look forward ultimately to the resurrection rather than the genetic revolution or cybernetics for our restored bodies. We need to be good stewards of technology but we should not seek to ‘build heaven on earth’.

Sixth, we must learn to embrace a wider love. Jesus told the parable of the Good Samaritan in response to the question ‘Who is my neighbour?’ In telling the parable he taught the expert in the law who asked it what was he needed to do actually to be a neighbour even to those with whom he felt no human bond, regardless of age, size or degree of deformity.  The baby with special needs trapped inside a non-functioning and dying body is as valuable as the greatest athlete. The embryo in the petri dish is as important as the colleague in the laboratory who lends us a pencil. The child scraping an existence on a rubbish heap is as important as a world famous scientist.

Seventh, we must keep ends and means in balance. In God’s economy, the end never justifies the means – we must do God’s work God’s way. It can be very tempting to dispense with biblical principles such as the sanctity of life or the purity of the marriage bond in finding solutions to some of the vexing challenges in medicine and society. But we can’t justify breaking God’s commands in pursuit of some perceived greater good. This principle has profound implications for what we do with fetuses and embryos in particular.

Finally, in all this, we must keep the cross of Christ central – being prepared to follow in the footsteps that Jesus himself walked. Carrying the cross means two things. First, it calls us to stand up for the truth whatever the world may throw at us – to risk reputation, credibility and career if the situation calls for it. But carrying the cross also involves being part of the solution. Jesus did not live in blissful disengagement from the world, like the Buddha. By contrast, his life was one of painful engagement and involvement. He became part of the solution – and this must surely mean that we must be committed as his followers to fulfilling our role as God’s stewards, to use our God-govern gifts and abilities in God’s way to help provide just and compassionate solutions for human suffering whatever it may cost. That is our mission. 

Tuesday, 2 August 2016

High Court rules in favour of NHS providing 'HIV prevention drug' but big questions remain

The High Court has today ruled that the NHS in England can fund a drug that can reduce the chance of people catching HIV whilst engaging in high-risk sexual activities.

NHS England had previously argued that local councils should provide PrEP ('pre-exposure prophylaxis') as 'health prevention' is their responsibility.

But Mr Justice Green said that NHS England had ‘erred’ and that both it and the local authorities were able to fund the drugs. Summing up, he said:

‘No one doubts that preventative medicine makes powerful sense. But one governmental body says it has no power to provide the service and the local authorities say that they have no money. The clamant [the National Aids Trust] is caught between the two and the potential victims of this disagreement are those who will contract HIV/Aids but who would not were the preventative policy to be fully implemented.’

The ruling has understandably evoked praise from gay rights campaigners and AIDS charities but consternation from NHS England which intends to appeal the decision. They are concerned about the effectiveness of the strategy, the precedent it creates for funding other 'disease prevention' measures and the way resources might be drawn from other health priorities were it to get the go-ahead.

The once a day pill known as PrEP, trade-named Truvada, consists of two antiretroviral medications used for the treatment of HIV/AIDS (tenofovir and emtricitabine or TDF-FTC) and costs £400 a month per person. The total cost to the health service could be in the order of £10-20m.

It is currently used in the US, Canada, Australia and France to help protect the most at-risk gay men.

According to the CDC (Centers for Disease Control) PrEP is for people who do not have HIV but who are at substantial risk of getting it.  It should be used in combination with other 'HIV prevention' methods, such as condoms, but even in these circumstances is not foolproof.

The CDC reports studies have shown PrEP reduces the risk of getting HIV from sex by more than 90% when used consistently. Among people who inject drugs, PrEP reduces the risk of getting HIV by more than 70% when used consistently.

But these figures are what is achievable with good adherence (consistent use), and many of those most at risk are very likely not to adhere with taking the pills regularly.

An authoritative Cochrane review is far less reassuring. Overall, results from four trials (Baeten 2012Van Damme 2012Grant 2010Thigpen 2012) that compared TDF-FTC versus placebo showed a reduction in the risk of acquiring HIV infection by about 51%.

Marked differences between the studies were attributed to differences in levels of adherence.

As one major review has concluded:

‘The efficacy of PrEP is dependent on adherence, and adherence to PrEP medications in efficacy studies has been variable, raising questions about whether persons who are prescribed PrEP in clinical settings will be adherent enough to derive protection.’

Furthermore the drug’s use may in fact lead to a paradoxical increase in other sexually transmitted infections (gonorrhoea, chlamydia etc) by encouraging more high risk behaviour from those who have been lulled into a false sense of security.

This well-known phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’.

I have previously blogged on the fact, surprising to some, that morning-after pills don’t actually cut teen pregnancy rates and instead increase the incidence of sexually transmitted infections (see also here). 

The term ‘risk compensation’ has also been applied to the fact that the wearing of seatbelts does not decrease the level of some forms of road traffic injuries since drivers, feeling more secure, are thereby encouraged to drive more recklessly.

In the same way making PrEP freely available to already promiscuous homosexuals could well encourage more sexual risk-taking and more sexually transmitted disease as a result. Any effect on decreasing HIV transmission rates is then cancelled out by rising levels of promiscuity.

Many will be shocked at the levels of promiscuity reported in these high-risk groups. In one study in the Cochrane database, during screening, participants reported an average of 12 coital acts per week with an average of 21 sexual partners in the previous 30 days.

It is only when these facts are known that the highly addictive nature of high-risk sexual activity, especially amongst male homosexuals, becomes evident. PrEP is not a prevention strategy at all. It is rather a harm reduction strategy aimed at lessening the damage that people addicted to high-risk sexual behaviours are doing to themselves. More akin to clean needles for drug addicts, filter cigarettes for smokers, protective gloves for compulsive burglars or seatbelts for habitual joy-riders.

As has been recently argued with respect to PrEP for drug addicts, 'PrEP is not ready for our community and our community is not ready for PrEP'. We need instead to address the underlying structural drivers and social context of the HIV epidemic and ask what it is that actually leads people to behave in this way. 

PrEP may reduce the risk of HIV transmission significantly but it does not eradicate it. That is because it is not actually a 'prevention' strategy at all but a 'harm reduction' strategy. And lack of adherence and ‘risk displacement’ simply add to the problem. This means that those who rely on PrEP for protection against HIV are still effectively playing Russian roulette, with the willing assistance and collaboration of health professionals.

NHS England is right to challenge this judgement. We will need much more evidence that PrEP is truly effective in practice before embarking on this strategy, which brings us back to the bottom line in all this: The only way of preventing HIV infections, as opposed to reducing the chance of catching them, is by avoiding the high-risk sexual behaviours that lead to them.

Friday, 22 July 2016

New parliamentary report on conscientious objection to abortion calls for widespread changes

A new parliamentary report has found that there is ‘widespread and increasing pressure’ on healthcare professionals to participate in abortions which is ‘in large part due to inadequate observance of the current legislation’.

‘Freedom of Conscience in Abortion Provision’, which was published on 21 July, is the culmination of a four-week consultation and makes nine key recommendations. In total 150 witnesses contributed to the inquiry, of whom nearly a third were current or former healthcare professionals or healthcare bodies.

Notable amongst these was the British Medical Association (BMA), the doctors’ trade union, which spoke of doctors ‘being harassed and discriminated against because of their conscientious objection to abortion’.

The inquiry, carried out by the All Party Parliamentary Prolife Group (APPG), sought to assess the extent to which the Conscience Clause provides adequate protection for doctors and other health professionals who do not wish to participate in abortion, directly or indirectly, and to examine how freedom of conscience in the law and professional guidance can be developed. It is the first parliamentary inquiry into this subject and is long overdue.

The 37 page report, calls on both Government and NHS governing bodies to ensure that the legal right of healthcare professionals to conscientious objection is properly protected and makes specific practical suggestions about how this can be achieved.

AGGP chair Fiona Bruce MP (pictured with five other MPs from the APPG)  concluded, ‘Freedom of conscience is a key part of living in a diverse and democratic society. It is vital that conscientious health professionals who do not wish to participate in abortion can be confident in their right to opt-out of doing so without fear of censure, discrimination or abuse. It is essential that our hardworking doctors, nurses and midwives are given the protection the law requires if they do not want to participate in abortions.’

She said that while the Inquiry received some examples of good practice, it also received accounts from nurses, midwives and doctors who had been pressured and discriminated against despite their right to conscientious objection, often seeing their career or training options limited.

The report makes clear that, whilst there is legal protection for healthcare professionals who have a conscientious objection to participating in abortion, this is not being properly observed in practise.

Section 4 of the Abortion Act (1967) requires that ‘no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this Act to which he has a conscientious objection’.

Commonly known as the ‘Conscience Clause’, the purpose of this section of the 1967 legislation was to enable men and women with conscientious objections to abortion to remain fully engaged in providing healthcare without being compelled to participate in the provision of abortion.

The report, which is well worth reading in its entirety, expresses deep concern about the way the conscience clause has been both interpreted and applied and reserves specific criticism for the Royal College of Obstetricians and Gynaecologists, which refused to give evidence to the inquiry, and the Vice President of the Supreme Court, Lady Hale, who in a recent judgement, narrowed the scope of the conscience clause so that it applied only to staff directly involved in abortion provision.

It also recommends that the Government conduct a review into the training of medical students, and calls for the principle of ‘reasonable accommodation’ to be introduced into legislation in this country. The report calls specifically on the Royal College of Obstetrics and Gynaecologists to publish a statement clarifying its position on this issue.

‘Freedom of Conscience in Abortion Provision’ makes nine practical recommendations to strengthen provision of the protection which Parliament intended for healthcare professionals with a conscientious objection to abortion:

1.      A cross-party Parliamentary Commission should be established to examine the role of conscience in the context of ‘British Values’ and any new ‘British Bill of Rights’.

2.      The Government should commission a full review into the training given to healthcare students to ensure that they are given full information about their right to conscientiously object.

3.      The General Medical Council should maintain their current guidelines ensuring that no doctor who has a conscientious objection to abortion should be required to refer a patient to another practitioner.

4.      All professional healthcare bodies should adopt the wording of the current GMC guidelines ensuring that no healthcare professional who has a conscientious objection to abortion is required to refer a patient to another practitioner (Recent Royal College of Midwives (RCM) guidance makes referral mandatory).

5.      The Royal College of Obstetricians and Gynaecologists (RCOG) is requested to publish a statement in response to this Inquiry to clarify their view on career progression for healthcare professionals who conscientiously object to abortion.

6.      Government and NHS governing bodies should ensure that an appropriate appeal system for those who believe they have been discriminated against because of their conscientious objection is set up.

7.      New guidelines for managers must state how those with a conscientious objection to a procedure should be fairly and respectfully treated and also propose solutions for how employers can accommodate practitioners with a conscientious objection.

8.      The Government should consider the feasibility of extending conscientious objection to indirect participation in abortion by authorising trials in several hospital departments and clinics across the country.

9.      Consideration be given to the introduction of the principle of ‘Reasonable Accommodation’ into legislation in this country, in the form of an amendment to the Equality Act 2010.

This inquiry has done a great service to the healthcare professions and NHS, not simply in its detailed and helpful analysis of current practice, but also in making specific achievable suggestions about how the problems with the conscience clause can be addressed. Doctors and other health professionals must now press the relevant authorities, not least parliament itself, to implement its recommendations.

It is particularly striking that all the witnesses who submitted evidence to the inquiry stressed the importance of conscience, regardless of their beliefs on the substantive issue of abortion. 

As the report concludes, ‘Conscience plays a crucial part in the dignity and morality of each individual. Any downplaying of conscience in public life is to the great detriment of society and individuals.’

Further Reading

Sunday, 3 July 2016

When the foundations are being destroyed – Christian reflections on Broken Britain

'When the foundations are being destroyed what can the righteous do?’[i]

We live in times when the very foundations of our civilisation are being destroyed: the NHS with its burgeoning needs and shrinking budgets, mounting national debt, political and economic uncertainty following ‘Brexit’, the threat of Islamic fundamentalism, creeping atheism and secular humanism.

The mountains of our culture, those institutions which shape its trajectory: our parliaments, courts, universities, medical institutions and the worlds of art, media and entertainment, seem increasingly to be run by people who do not share our Christian beliefs and values.

Daily in our GP surgeries and hospitals we see the fruit of a society which has turned its back on God: family breakdown, educational failure, economic dependence, indebtedness and drug and alcohol addiction. Marriage and the family are threatened by same-sex unions, ‘gender fluidity’, internet pornography, gene editing, abortion and euthanasia.

Broken families, broken communities, broken institutions, a broken country. 

The Psalmist, seeing the foundations being destroyed, is taunted by his accusers: ‘Flee like a bird to your mountain. For look, the wicked bend their bows; they set their arrows against the strings to shoot from the shadows at the upright in heart.’[ii]

But instead of succumbing to the very real threats about him and withdrawing to safety he declares: ‘In the Lord I take refuge…. The Lord is in his holy temple; the Lord is on his heavenly throne.’[iii]

He takes himself in hand and remembers that he serves the ruler of the universe, the judge before whom every knee shall one day bow, who ’is righteous’, ‘loves justice’ and ‘observes everyone on earth’. He reminds himself that ‘the upright’, those who he has justified by faith, will one day ‘see his face’.[iv]

Jesus who announced the coming of his Kingdom in the Nazareth synagogue as coming with preaching, healing, deliverance and justice[v] later commissioned his disciples with the words, ‘as the Father has sent me, I am sending you.’[vi] But he also promised them his power, presence and the gift of prayer. ‘Come to me, all you who are weary and burdened, and I will give you rest….  For my yoke is easy and my burden is light’.[vii] ‘Ask the Lord of the harvest, therefore, to send out workers into his harvest field.’[viii] ‘You will receive power when the Holy Spirit comes on you; and you will be my witnesses’.[ix]  ‘Surely I am with you always, to the very end of the age’.[x]

We are not called to escapism, retreating to our Christian ghettos. Nor are we called to assimilation, merely blending in with the world around us.

Instead we are called, like Babylon’s exiles, both to moral distinctiveness – ‘shining like stars’[xi] - and to courageous and compassionate engagement with society – ‘seeking the peace and prosperity of the city’.[xii] We are to be ‘in the world’ but ‘not of the world’.[xiii]

The social reformer William Wilberforce, whom God used to end the British slave trade in the early 19th century, spoke of his Christian calling in this way: ‘God almighty set before me two great objects, the suppression of the slave trade and the reformation of morals and manners.’

But in reforming ‘moral and manners’ he was not advocating a mere fleshly legalism. He understood that it was the ‘peculiar doctrines’ of Christianity (salvation by grace through faith in Christ’s death and resurrection) which led to ‘true affections’ (a changed heart), then to personal transformation’ (an obedient life) and ultimately ‘political reformation’ (a renewed society).[xiv]  

UK Prime Minister David Cameron resigned after the Brexit vote on 24 June without ever fulfilling his dream of a ‘big society’. And yet, since he first came to power in 2010, we have ironically seen an explosion of Christian social initiatives in Britain – food banks, debt counselling, street pastors, drug and alcohol rehabilitation, parenting classes, crisis pregnancy counselling. Churches are touching the heart of our broken society’s need.

But what if churches were to think even bigger like Wilberforce and his fellow Christian professionals from the ‘Clapham Sect’: Christian GP surgeries and hospitals, socially responsible businesses, legal advice and advocacy, schools and universities, serving in the political corridors of power? 

Might we, by God’s grace, take Britain back? That is our challenge.  

‘If my people, who are called by my name, will humble themselves and pray and seek my face and turn from their wicked ways, then I will hear from heaven, and I will forgive their sin and will heal their land.’[xv]

[i] Psalm 11:3
[ii] Psalm 11:2
[iii] Psalm 11:1,4
[iv] Psalm 11:4-7
[v] Luke 4:18,19
[vi] John 20:21
[vii] Matthew 11:28-30
[viii] Matthew 9:38
[ix] Acts 1:8
[x] Matthew 28:20
[xi] Philippians 2:15
[xii] Jeremiah 29:7
[xiii] John 17:14,15
[xv] 2 Chronicles 7:14

Tuesday, 21 June 2016

BMA rejects attempt to push it neutral on assisted suicide by 2 to 1 majority

Today the Annual Representative Meeting (ARM) of the British Medical Association (BMA) in Belfast voted against going neutral on assisted suicide by a two to one majority (see detail here).

Delegates rejected motion 80, ‘that this meeting believes that the BMA should adopt a neutral stance on assisted dying’, by 198 to 115 (63% to 37%).

The debate took place after a previous motion affirming that ‘it is not appropriate at this time to debate whether or not to change existing BMA policy’ was defeated by 164 to 160.

The BMA, the UK doctors’ trade union, has been opposed to the legalisation of assisted suicide and euthanasia for every year of its history with the exception of 2005-6 when it was neutral for just twelve months.

Fifteen doctors spoke during an impassioned debate on the two motions but the final vote was decisive, and reflected the 65% opposition to legalising assisted suicide shown in most opinion polls.

Dr Mark Porter, the Chair of BMA Council, noted that the debate marked the eighth time in 13 years that the BMA had considered the matter, and stated that ‘nobody can credibly say this issue has been suppressed or obfuscated’. Dr Andrew Mowat, who moved Motion 79, went further, describing the constant returns to the issue as a ‘neverendum’; Dr Gary Wannan simply mused, ‘we’ve been here before...’

The Royal College of Physicians, Royal College of General Practitioners and British Geriatrics Society are all officially opposed to a change in the law along with 82% of Association for Palliative Medicine members.  Amongst all doctors, this latter group carries the greatest weight in this debate due to their understanding of the vulnerability of dying patients and their knowledge of treatments to alleviate their symptoms.

British parliaments have consistently resisted any move to legalise any form of assisted suicide or euthanasia. There have been a dozen unsuccessful attempts in the last twelve years. Last year the Marris Bill in the House of Commons and the Harvie Bill in the Scottish Parliament were defeated by 330-118 and 82-36 respectively.

Assisted suicide and euthanasia are contrary to all historic codes of medical ethics, including the Hippocratic Oath, the Declaration of Geneva, the International Code of Medical Ethics and the Statement of Marbella.

Neutrality on this particular issue would have given assisted suicide a status that no other issue enjoys. Doctors, quite understandably, are strongly opinionated and also have a responsibility to lead. The BMA is a democratic body which takes clear positions on a whole variety of health and health-related issues.

Furthermore, to drop medical opposition to the legalisation of assisted suicide and euthanasia at a time of economic austerity would have been highly dangerous. Many families and the NHS itself are under huge financial strain and the pressure vulnerable people might face to end their lives so as not to be a financial (or emotional) burden on others is potentially immense.

In rejecting an attempt to move it neutral at its ARM in 2012 the BMA said that neutrality was the worst of all positions. This was based on bitter experience. When the BMA took a neutral position for a year in 2005/2006 we saw huge pressure to change the law by way of the Joffe Bill. Throughout that crucial debate, which had the potential of changing the shape of medicine in this country, the BMA was forced to remain silent and took no part in the debate. Were it to go neutral again it would be similarly gagged and doctors would have no collective voice.

Going neutral would also have played into the hands of 
a longstanding campaign led by a small pressure group with a strong political agenda. 

Healthcare Professionals for Assisted Dying (HPAD), which is affiliated to the pressure group ‘Dignity in Dying’ (formerly the Voluntary Euthanasia Society), at last count had just over 500 supporters, representing fewer than 0.25% of Britain’s 240,000 doctors.

Instead the BMA ARM wisely gave short shrift to this latest neutrality proposal and signalled by the margin of defeat that this matter should now be settled for the foreseeable future.