College climbs down over ban on Christian doctors and nurses training in sexual and reproductive health

Doctors and nurses wishing to practise in sexual and reproductive health have been granted more liberty to exercise freedom of conscience under new guidelines published earlier this year.

The Faculty of Sexual and Reproductive Healthcare (FSRH), a faculty of the Royal College of Obstetricians and Gynaecologists (RCOG), has relaxed its stance on conscience in new guidelines issued in April so that those with an ethical objection to certain procedures can now obtain qualifications which they were previously excluded from.

Christian doctors and nurses in the UK are practising in an environment that is increasingly hostile to their beliefs and values. We have accordingly come to expect new constraints on our freedom of conscience almost as a matter of course. So this is a refreshing backtrack by the College.

In April 2014 I highlighted the fact that the FRSH was barring doctors and nurses with pro-life views from receiving its degrees and diplomas and may also be breaking the law (see also here). The story was later picked up by the Telegraph.

Under the previous guidelines, now removed from the FSRH website but still accessible in the Telegraph, doctors and nurses who had a moral objection to prescribing ‘contraceptives’ which can act by killing human embryos (levonelle, ellaOne, IUCDs etc) were barred from receiving diplomas in sexual and reproductive health even if they undertook the necessary training.

The wording was as follows (emphasis mine):

‘Completing the syllabus means willingness during training to prescribe all forms of hormonal contraception, including emergency, and willingness to counsel and refer, if appropriate, for all intrauterine methods…Failure to complete the syllabus renders candidates ineligible for the award of a FSRH Diploma.’

It added:

‘Doctors who hold moral or religious reservations about any contraceptive methods will be unable to fulfil the syllabus for the membership … or speciality training…This will render them ineligible for the award of the examination or completion of training certificates.’

However, the new guidance grants much more freedom.

It begins by underlining the faculty’s commitment to diversity:

‘The FSRH welcomes and values having a diverse membership, representing a wide range of personal, religious and non-religious views and beliefs.’

It then underlines the fact that there is already statutory protection for healthcare professionals (HCPs) to opt out of abortions and procedures authorised under the Human Fertilisation and Embryology Act (HFEA):

‘There are currently two specific statutory protections for HCPs who have a conscientious objection 1) to participating in abortion (Abortion Act 1967, s.4) 2) to technological procedures to achieve conception and pregnancy (Human Fertilisation and Embryology Act 1990, s.38) .’  

But it also recognises that both the Human Rights Act 1998 and Equality Act 2010 offer some conscience protection in areas other than abortion and IVF:

‘The Human Rights Act 1998 incorporates the European Convention on Human Rights (ECHR) into UK law. Article 9 of the ECHR protects “the freedom of thought, conscience and religion; this right includes … to manifest his religion or belief, in worship, teaching, practice and observance.”’

‘Part 5 of the Equality Act 2010 sets out provisions for non-discrimination in employment. Specifically, s.39 prohibits employers from discriminating against individuals on the basis of “protected characteristics” (of which religious belief is one) and places an obligation on employers to make ‘reasonable adjustments’ to accommodate religious beliefs.’

The guidance recognises that the rights to ‘freedom of thought, conscience and religion’ and to ‘religious beliefs’ are not absolute, but qualified, and also that NHS employers may interpret these in different ways than the faculty, but this is nonetheless a significant step forward.

The guidance says that it applies to all FSRH qualifications and training, but a closer reading suggests that those seeking to sit the membership examination of the Faculty of Sexual & Reproductive Healthcare (MFSRH) will need to undergo ‘practical assessment of the provision of contraception (all methods including emergency contraception)’ and those seeking a Letter of Competence in Intrauterine Techniques (LoC IUT) will need to demonstrate ‘practical competence in the relevant live procedures’.

However, with respect to the Diploma of the Faculty of Sexual & Reproductive Healthcare (DFSRH and NDFSRH), holder must simply be ‘competent and willing to advise on all forms of contraception and manage SRH consultations, including providing evidence-based information on the options for unplanned pregnancy’. But there is no duty actually to provide all treatments.

‘The FSRH requires all Diplomates to provide patients with the full range of contraception choices, including emergency contraception and support of a woman with an unplanned pregnancy and appropriate onward referral. HCPs who plan to opt out of providing aspects of care because of their personal beliefs may still be awarded the Diploma, or recertified, if they can demonstrate commitment in their practice to the principles of care in section 5 of this document. For example, if a HCP chooses not to prescribe emergency contraception because of their personal beliefs, she/he has a personal responsibility to ensure that arrangements are made for a prescription to be issued by a colleague without delay, ensuring that the care and outcomes of the patient are never compromised or delayed.’

Although some would see referral to another doctor or nurse as a form of complicity, this is nonetheless a big improvement on the previous guidance.

Previously doctors or nurses who refused to fit coils or prescribe the morning after pill (MAP) were also barred from receiving the diploma signifying expertise in the management of infertility, cervical cancer or sexually transmitted infections. This effectively meant that many thousands of doctors and nurses were not able to obtain qualifications to pursue a career in gynaecology and sexual health.

This is no longer the case.

Quite why the faculty has relaxed its guidance is not clear, but I wonder if they have been conferring with the General Pharmaceutical Council (GPhC) who also similarly relaxed their guidance on dispensing drugs after receiving submissions from Christian Medical Fellowship and the Christian Institute earlier this year.

The GPhC’s attention was drawn to the fact that their proposed new guidance might well be illegal under Equality legislation (I made the same point about the FSRH in 2014).

The GPhC backtracked after the Christian Institute made it clear, in pre-action legal correspondence exchanged with the Council’s lawyers, that they ‘were fully prepared to litigate’.

Perhaps the FSRH also, on reflection, thought it wise to protect themselves by erring on the side of caution and taking themselves out of the legal firing line.

However, whatever the reason, the climb down is most welcome and will enable many more doctors and nurses to obtain diplomas in sexual and reproductive health. That can only be good for patient care. 

Boots chemist should not have capitulated to pressure from BPAS over emergency contraception

Last night I waded into the debate on whether Boots should reduce the price of the so-called ‘morning-after pill’ and criticised the high street chemist for ‘capitulating in the face of political pressure’. 

Let me explain why.

Boots had originally defied calls to slash the price of ‘emergency contraception’ – with its chief pharmacist saying it did not want to ‘incentivise inappropriate use’.

But late on Friday night Boots released a statement to say it was ‘truly sorry’ about its ‘poor choice of words’, and was looking at cheaper alternatives (see here, here, here, here and here).

The about-face was the result of a high-level campaign on social media by abortion provider BPAS and a group of 35 Labour women MPs.

It all began when BPAS (the British Pregnancy Advisory Service) wrote to Boots’ head pharmacist, Marc Donovan, pointing out that generic versions of the Levonelle brand of emergency hormonal contraception can be bought cheaply by pharmacies and can retail for as little as £5.50 in France. By comparison, Boots charges £26.75 for its own version.

Mr Donovan wrote back to say that if Boots did make the pill cheap it could be ‘accused of incentivising inappropriate use’.

This led to an explosion on social media from Labour women MPs calling for women to boycott the chemist and forcing Boots to back down.

I have three main concerns about this whole furore.

First, public policy decisions about women’s health should not be made on the hoof after twitter rants especially when these are strongly ideologically motivated. They should rather be made after proper and robust debate on the facts. The knee-jerk assumption of most people is that making emergency contraception readily available either free or cheap over the counter without prescription will reduce unplanned pregnancies and safeguard women’s health. In fact there is no evidence to suggest that this is actually true (see below).

This latest broadside needs to be seen for what it is – part of a high level campaign by  abortion industry leader BPAS – which receives £30miliion of taxpayers money annually – to advance its agenda of abortion on demand up to birth and free contraception for all. They are prepared to bully, blackmail and boycott to achieve their agenda and sadly few are willing to stand up to them. If MPs wish to influence pharmacy practice they should raise it in the House of Commons in a responsible way, not form a social media lynch mob.

Second, all the evidence suggests that ready availability of emergency contraception does nothing to reduce abortion rates and actually increases rates of sexually transmitted diseases.

For a start levonelle is not 100% effective in any given case.  Its success rate is relatively low (95% within 24 hours of sexual intercourse, 85% from 25-48 hours and 58% from 49-72 hours). 

A 2012 study in Washington State showed that free access to emergency contraception caused a statistically significant increase in STI rates (specifically gonorrhoea rates) and no change in birth and abortion rates.

The results were almost identical to those of a British study published in the Journal of Health Economics (full text) in December 2010 and reported in the Daily Telegraph in January 2011. (See my previous blogs on this here and here).  The researchers found that rates of pregnancy among girls under 16 remained the same, but that rates of sexually transmitted infections increased by 12%.

In fact, in a systematic review published in 2007, twenty-three studies published between 1998 and 2006 measured the effect of increased EC access on EC use, unintended pregnancy, and abortion. Not a single study among the 23 found a reduction in unintended pregnancies or abortions following increased access to emergency contraception (see also fact sheet here).

The phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’. The term has been applied to the fact that the wearing of seatbelts does not decrease the frequency of some forms of road traffic injuries since drivers are thereby encouraged to drive more recklessly. In the same way ready access to emergency contraception encourages young people to take more risks and can also be used as a tool by abusers to negotiate for sex.

In 2015 the total number of new STI diagnoses in England was 434,456. This included more than 129,000 diagnoses of chlamydia (a major cause of infertility) in 15-24-year-olds.  Young females are more at risk of a diagnosis than young males. The male diagnosis rate among 15 to 19-year olds was 824.4 per 100,000 population and 1,693.8 among 20-24-year-olds compared to 2,436.8 among 15 to 19-year-old females and 2,557 among females aged 20-24. Gonorrhoea is also most common among the 20-24 age group, with a rate of 269.5 per 100,000 population.

So making the emergency contraceptive pill available over the counter free or cheap, without prescription, is sadly an ill-conceived knee-jerk response to Britain’s spiralling epidemic of unplanned pregnancy, abortion and sexually transmitted disease amongst teenagers. It is also not evidence-based.

Third, the emergency contraceptive levonelle is already available free from Brook centres, some pharmacies , most sexual health clinics, most NHS walk-in centres,  most GP surgeries and some hospital accident and emergency (A&E) departments. For pharmacies it is a free market. Boots’ own  price tag was based on the cost of the medicine and the regulated mandatory consultation with the pharmacist. It is surely only fair that as a retail pharmacy they don’t compromise or undervalue this professional service.

It is regrettable that Boots has capitulated in the face of political pressure and failed to support its chief UK pharmacist in his legitimate concerns over incentivising the inappropriate use of emergency contraception. It is settled science that making so-called emergency contraception more easily available does not reduce pregnancy rates in a population and actually raises rates of sexually transmitted diseases. 

By appeasing this cartel of radical feminist MPs Boots is encouraging more reckless sexual behaviour and thereby exposing young people to an increased risk of sexually transmitted infections. They are also encouraging MPs and sections of the media to force changes in medical practice through bullying, name calling and blackmail rather than sound evidenced-based argument. The same campaign is going to target Lloyd’s Pharmacy next. This is bad medicine, bad leadership and bad public policy.

But perhaps the most frightening aspect of this whole episode is the deafening silence of other sitting MPs at Westminster who by their failure to speak out have signalled complicity with both process and practice.

The best way to counter the epidemic of unplanned pregnancy and sexually transmitted disease is to promote real behaviour change. The government would be well advised to enter into dialogue with leaders of communities in Britain where rates of sexually transmitted diseases and unplanned pregnancy are low, especially Christian faith communities, to learn about what actually works.

Church-based programmes such as Love for Life (Northern Ireland), Love2last (Sheffield), Challenge Team, Romance Academy or Lovewise (Newcastle) are getting great results and have much wisdom to pass on.