Increasing survival of extremely premature babies again raises questions about upper abortion limits

The increasing survival of extremely premature babies is again raising serious questions about the 24 week upper limit for social abortion.

Tonight, 6 March, Inside Out on BBC One in the East Midlands related how new treatments - including some trialled in Nottingham and Leicester - are helping to limit disabilities and boost life expectancy in premature babies weighing as little as one pound (450g).

Last week, under the headline “extremely premature baby saved by groundbreaking NHS surgical team”, the Guardian reported on the astounding case of Abiageal Peters who last year became the youngest baby ever to survive major abdominal surgery.

Abiageal was born three months premature in October 2016 at St Peter’s hospital, Chertsey after a gestation of only 23 weeks.

Her parents were warned at her birth that she had very little chance of surviving a severe gut condition known as perforated necrotising enterocolitis.

But thanks to the surgical team led by consultant Zahid Mukhta, Abiageal made an extraordinary recovery. ‘Any patient that comes into our system gets the best we can do for them’, Mukhta said.

Yesterday, the Sunday Times (£) reported that survival rates for babies born at 23 weeks’ gestation are now so high that up to 70% are being saved at some hospitals:

At University College London Hospitals, one of Britain’s leading trusts, the figures show that in the past five years, 22 out of 30 babies born after 23 weeks in the womb survived, according to new figures obtained under Freedom of Information laws.

At Leeds Teaching Hospitals NHS Trust, 16 out of 25 babies born at 23 weeks between 2011 and 2016 survived, and at East Kent Hospitals University NHS Foundation Trust, 9 of the 18 babies born at 23 weeks between 2012 and 2016 survived.

These figures are strongly at odds with those from the last national study, Epicure 2, which looked at babies born in 2006, and found survival of babies at 23 weeks of just 19%.

The best survival rates, not surprisingly, come from centres with expert levels of neonatal intensive care, but lower survivals elsewhere are nonetheless something of a self-fulfilling prophecy.

Although there has been no comparable national study since Epicure 2 to assess how survival rates are improving, many units are still being guided in their treatment decisions by these antiquated figures.

Lower survival of premature babies in some parts of the country is not surprising when, backed by the RCOG and BMA,  neonatal units apply blanket rulings on resuscitation based on a simplistic assessment of gestational age – which is often inaccurate – and fail to treat each baby as an individual in her or his own right.

This means effectively that that some babies that could be saved are dying from neglect.

There is an excellent article on this in the CMF journal Triple Helix by Professor John Wyatt which makes these points in greater detail.

These latest figures from centres of excellence demonstrate dramatically what can be achieved with a proactive approach and skilled staff and they highlight an unacceptable postcode lottery of care.

Every extremely pre-term baby deserves the chance to be considered for treatment and, even if curative treatment is not possible, to be given the best possible palliative care.

If there is a realistic chance that a particular baby can survive without overwhelming and catastrophic injury, then surely as a wealthy country we owe it to each child to give them a chance of life.

In this situation it is best to start ‘provisional intensive care’, giving the baby the initial benefit of the doubt, and taking each day as it comes.

But these latest figures will also fuel calls for the Abortion Act upper limit for able-bodied babies of 24 weeks to be revised (abortion is of course currently legal up until full term (40 weeks) for disabled babies, a situation which Lord Shinkwin is currently attempting to change with his abortion (disability equality) bill).

It is utterly incongruous that on the one hand we are aborting babies at a gestation when others are surviving with good neonatal care. Abortion at this gestation is tantamount to infanticide.

When this issue was last debated in Parliament, in 2008, MPs voted by a narrow margin not to lower the upper limit from 24 weeks to either 20 or 22 weeks. I argued back then (and again here) that it was time for change. 

But since this time survival rates have improved yet further and the composition of Parliament has also changed. At the last vote Labour government MPs were informally whipped to vote against any lowering of limits.

Were the issue to be revisited now there’s a good chance of a very different result.

A lowering of the upper abortion limit to 20 weeks would save more than 3,000 babies a year.

That may be a small start when we consider that there are around 200,000 abortions a year in Britain. However, for those 3,000 it would represent every difference in the world.

Ultimately each society will be judged on the basis of how it treats its weakest members. Neonatal centres of excellence in Britain are already demonstrating how worthwhile it is to make sacrifices for these most vulnerable of human beings.

Nearly two thirds of the public and more than three-quarters of women support a reduction in the 24-week upper age limit. 

76% of the public think that aborting a baby at six months is cruel. Furthermore, a 2007 poll by Marie Stopes International found that two thirds of GPs wanted a reduction from 24 weeks (more similar figures here). 

It’s time now for Parliament again to ask serious questions about late abortion.

My speech to the New Zealand Parliament Health Select Committee on Assisted Suicide

I have just given oral evidence on behalf of Care Not Killing to the New Zealand Parliament’s Health Select Committee on assisted suicide.

The committee has received a petition requesting, ‘That the House of Representatives investigate fully public attitudes towards the introduction of legislation which would permit medically-assisted dying in the event of a terminal illness or an irreversible condition which makes life unbearable.’

The petition asks for a change to existing law. Therefore the committee is undertaking an investigation into ending one’s life in New Zealand focusing on four main questions:

1. The factors that contribute to the desire to end one’s life.

2. The effectiveness of services and support available to those who desire to end their own lives.

3. The attitudes of New Zealanders towards the ending of one's life and the current legal situation.

4. International experiences. The committee will seek to hear from all interested groups and individuals.

Here is what I said:

Thank you for this opportunity to give evidence to the select committee.

I represent Care Not Killing which is a UK alliance of about 40 organisations spanning healthcare, law, disability rights, education and faith groups which in turn represent several hundred thousand people. We were established in 2005 and seek to promote better palliative care and ensure that existing laws against euthanasia and assisted suicide are not weakened or repealed.

I’m a New Zealand citizen but have lived in the UK for 28 years.

I trained in medicine in Auckland and specialised in general surgery and my day job here is as the chief executive of one of CNK’s 40 member groups, the Christian Medical Fellowship, which itself has over 5,000 medically qualified members.

I’ve been campaigning against the legalisation of assisted suicide and euthanasia for 12 years during which time we’ve had 10 attempts to change the law through British Parliaments all of which have failed.

I’ve also got skin in the game. My grandfather died from an aggressive cancer with spinal secondaries with pain that was very difficult to control and my father died from a very rapidly progressive dementia, both in Auckland. I’ve just been back to NZ with my wife over Christmas to place her elderly parents, both retired doctors aged 91 and 89, with dementia and Parkinson’s respectively, into an excellent private hospital in Auckland.

So my interest is professional and political but also personal.

The most recent attempt to change the law in Britain was in September 2015, when the Marris Bill, which attempted to legalise assisted suicide for the terminally ill, was defeated in the House of Commons by a 3 to 1 margin - 330 votes to 118.

MPs dealt the bill a resounding defeat largely driven by concerns about the risks it posed to vulnerable people who would have felt under pressure to end their lives.

A majority of both Conservative and Labour MPs voted against the bill. This is hugely significant as it signals that assisted suicide is not a simple left/right political issue here. In fact suicide prevention and protection of vulnerable people from exploitation and abuse resonate strongly with left of centre politicians because of their concern for disabled people’s groups and for those less able to access good healthcare.

Our case against the legalisation of assisted suicide and euthanasia is that it is dangerous, uncontrollable and unnecessary.

It’s dangerous because any law allowing it will inevitably place pressure on vulnerable people to end their lives in fear of being a burden upon relatives, carers or a state that is short of resources. 

Especially vulnerable are those who are elderly, disabled, sick or mentally ill. The right to die can so easily become the duty to die.

It’s uncontrollable because any law allowing it will be subject to incremental extension. We’ve seen in jurisdictions like Belgium and the Netherlands that over time you see a shift from terminal conditions to chronic conditions, from physical illnesses to mental illnesses and from adults to children.

The essential problem is that the two major arguments for euthanasia - that is, autonomy and compassion - can be applied to a very wide range of people. This means that any law which attempts to limit it, for arguments sake to mentally competent people who are terminally ill, will in time be open to challenge under equality legislation.

It is unnecessary because requests for euthanasia or assisted suicide are extremely rare when people’s physical, social, psychological and spiritual needs are adequately met. In other words, you should kill the pain not the patient. Britain was recently ranked number one in palliative care in the Economist magazine. But we still have some way to go in making this high-quality palliative care fully accessible to all.

So, in summary the best law is one like New Zealand and Britain’s current law,  that gives blanket prohibition on all assisted suicide and euthanasia. This will deter exploitation and abuse through the penalties that it holds in reserve, but at the same time give some discretion to prosecutors and judges to temper justice with mercy in hard cases. The current law has both a stern face and a kind heart and does not need changing. We have an aphorism in surgery, if it ain’t broke, don’t fix it.

Leaving the law as it is will mean that some people who desperately wish help to end their lives will not have access to such a service. But part of living in a free democratic society is that we recognise that personal autonomy is not absolute. That’s precisely why we have laws. We must not allow so-called freedoms which will at the same time undermine or endanger the reasonable freedoms of others. And one of the primary roles of government is to protect the most vulnerable even sometimes at the expense of not giving liberties to the desperate.

I wanted, finally, to make some brief comments about the four questions raised by the consultation.

First, on factors that contribute to the desire to end one’s life, we know that 90% of those who commit suicide suffer from some form of mental illness including depression, bipolar disorder, 

borderline personality disorder and alcohol and drug misuse. We know that in Oregon, in 2013 despite 26% of assisted suicide cases meeting the clinical criteria for depression, less than 3% of them had a psychiatric assessment.

But even more striking was the fact that most people making use of Oregon’s death with dignity act in 2016 - the figures came out just three weeks ago - cited existential or spiritual symptoms as their reason. 89.5% cited loss of autonomy, an identical percentage cited being less able to engage in activities making life enjoyable and 65% loss of dignity. Pain, or even concern about it, did not feature in the top five.

More worryingly 48.9% cited being a burden on family, friends or caregivers. The equivalent figure in neighbouring Washington state the year before was 52%. I would submit that it is an abuse of medicine to treat fear of the future or loss of meaning and hope with lethal injections or draughts of barbiturates. The best response to existential suffering is to do all we can to restore hope and allay fear by caring for the needs of the whole person.

Second, in terms of the effectiveness of services and support available to those who might wish to end their own lives, people contemplating death from a progressive terminal illness will understandably experience fear and anxiety and may in rare cases consider suicide.

These fears can be heightened by high-profile media cases, especially those involving celebrities – we call it suicide contagion or the Werther effect. But we know that only a very tiny minority have persistent ongoing death requests once they have experienced what proper support and good palliative care can offer. Rob George, former president of the Association for palliative medicine in Britain said that after a lifetime of managing over 20,000 dying patients, he could count on the fingers of one hand those who still wanted assisted suicide or euthanasia after receiving good palliative care.

This is why every Royal Medical College in Britain along with the British Medical Association is opposed to any change in the law. And those who are closest to the dying patient, namely geriatricians and those in palliative medicine, are most opposed for two main reasons. They know how to treat the symptoms of dying people effectively, and they understand the vulnerability of dying patients better than anyone else.

Third, with respect to the attitude of New Zealanders to change the law, in most Western countries approximately three out of four will be in favour of legalisation in opinion polls depending on how the question is framed. However, these opinions tend to be reflex rather than considered and largely uninformed about the complexities involved. Our experience in Britain has been that when legislators have been able to consider the arguments carefully they have invariably opted not to legalise.

Strikingly, when ordinary people are given the arguments against they too will change their minds. In 2014, 73% of the general public was supportive of Lord Falconer’s assisted dying bill. However, this reduced to 43% once they heard the five major arguments against it. These were:

1. people may feel pressurised to end their life so as not to burden loved ones
2. there’s been a steady rise in assisted suicide in places where it has been legalised
3. end-of-life care may worsen, given its cost, as against of lethal drugs
4. major disability rights groups oppose a change in the law
5. the majority of doctors oppose it including the BMA and Royal College of GPs

Finally, with respect to international experiences of legalisation the frightening consequences in Belgium and the Netherlands are well-publicised and well known and played a major role in convincing British legislators. Every year, with each new report from Belgium or Holland, our job gets easier. The recent story of a female Dutch doctor drugging the coffee of a patient with dementia and then asking her family to hold her down as she fought while being given a lethal injection, is a poignant case in point.

But I want to draw your attention to what’s happening in a jurisdiction with far more modest legislation. And to this end we will send you a copy of our brochure “don’t make Oregon’s mistake” as supplementary evidence.

·        In Oregon there’s been a steady increase in annual numbers of people undergoing assisted suicide -more than 500% over 19 years.

·        The Oregon health department is funding assisted suicide but not treatment for some cancer patients

·        Patients are living for in some cases many years after having been prescribed lethal drugs showing that the eligibility criteria for terminal illness are being stretched

·        the vast majority of those choosing to kill themselves are doing so for existential reasons large rather than on the basis of real medical symptoms

·        many give “fear of being a burden on others” as the reason for ending their lives

·        fewer than one in 20 patients are being referred for formal psychiatric or psychological evaluation

·        a substantial number of patients dying under the Oregon act do not have terminal illnesses

·        some doctors know the patient for less than a week before prescribing the lethal drugs.

We would urge the New Zealand Parliament if it comes to consider legislation on this issue, not to proceed with it but rather to focus on suicide prevention and on providing better care and support.

Thank you very much for your time.

Regulator’s proposal to remove pharmacists’ conscience rights is unethical, unnecessary and quite possibly illegal

Should pharmacists be forced to dispense drugs for what they consider to be unethical practices – like emergency contraception, gender reassignment, abortion and assisted suicide?

Or should they have the right to exercise freedom of conscience by either referring to a colleague or opting out?

The General Pharmaceutical Council (GPhC), the independent British regulator for pharmacists, pharmacy technicians and pharmacy premises, is proposing to replace the current ‘right to refer’ with a ‘duty to dispense’.

The Council calls this ‘person-centred’ care. 'Person-centred care' which puts the dignity and best interests of the client first is, of course, crucial and at the very heart of true professionalism.

But the Council then goes on to frame this care in terms of a universal right for clients to ‘access’ legally prescribed drugs and devices.  Pharmacists would thereby be pressured to comply or risk disciplinary procedures and/or possible loss of employment. Potential trainees could be dissuaded from pursuing a career in pharmacy altogether.

The consultation on the draft proposal is open until 7 March 2017 (background here; full consultation document here - the response form is on pages 23-30 and is summarised on p31).

Pharmacists who believe that human life should be respected from the time of fertilisation will generally object to dispensing potentially abortifacient drugs like levonelle and ellaOne.

Although marketed as ‘emergency contraception’ or the 'morning-after pill', these drugs are known in some cases to act by preventing the implantation of an early embryo and causing, in effect, an early abortion.

Currently pharmacists have a right to refer these cases to another pharmacy or colleague, but under the new draft guidance, which the GPhC admits represents ‘a significant change from the present position’ this right would be removed.

All health professionals are currently protected by a conscience clause in the Human Fertilisation Act 1990 from having to participate in ‘any activity’ governed by that Act. So, for example, if they have a moral objection to disposal of, or experimentation upon, human embryos, they do not have to take part.

But ironically, no such statutory conscience protection exists for those 'contraceptives' which act by killing embryos.

The Abortion Act 1967 has a conscience clause which allows health professionals to abstain from ‘participation’ in abortion. However, it also does not cover abortifacient contraceptives. Its scope has also recently been narrowed by a Supreme Court judgment so that it probably does not now protect pharmacists from being forced to supply drugs used in medical abortions either.

Highly contentious gender reassignment procedures, involving hormones to bock puberty in children, or to aid transsexuals to ‘transition’ to the opposite gender, are another area where the new regulations will put pharmacists under pressure to comply.

Assisted suicide and euthanasia are currently not legal in Britain, but were they to become so, this could be yet another situation where the new proposed guidance would leave pharmacists exposed.

Freedom of conscience has been a core ethical value, foundational to healthcare practice as a moral activity, from the Hippocratic Oath to the General Medical Council’s Good Medical Practice.

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

Most people can understand and respect the right of health professionals not to be involved in activities which they regard as abhorrent – obvious examples in other jurisdictions in which doctors have been complicit include female genital mutilation, punitive amputation, capital punishment or organ harvest from prisoners or street children.

But equally we need to recognise that many healthcare professionals in Britain regard such practices as abortion, assisted suicide, gender reassignment or embryo disposal or experimentation to be similarly morally wrong.

Pharmacists are healthcare professionals in their own right. Accordingly they deserve to be treated by their regulators with the respect due to their professional status. This latest proposal does not do that.

The contribution of community pharmacists to the provision of primary care is being actively promoted by the profession. Given that pharmacists are now taking on many of the roles once seen as the preserve of doctors, the GPhC should surely be protecting their freedom of conscience in a way commensurate with that shown to doctors by the GMC.

There are simply better ways in a democratic society to ensure that freedom of conscience is respected whilst still enabling people to access services to which they have a legal right. 

In this case there are at least three alternatives available to the GPhC.

First would be to leave the current guidance, which grants a right to refer, unchanged. Whilst this does not give full freedom, as many would regard referral as involving a degree of complicity, it does in practice give enough wiggle room for pharmacists who have a conscientious objection to dispensing certain drugs to avoid direct involvement. It has served the profession well up until now.

Second, the GPhC could follow the example of the GMC, the doctors’ regulator. GMC guidance (para 8) permits doctors to ‘opt out of providing a particular procedure because of [your] personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients’. In such situations, a doctor must ensure the patient understands her right to see another practitioner and has the necessary information to exercise that right.

Third, the GPhC could follow the example of the pharmacists’ professional body, the Royal Pharmaceutical Society (RPS), in a policy statement they drew up in 2013 to preserve freedom of conscience in the event of assisted suicide being legalised. This required pharmacists to ‘opt in’ by placing their names on a register of those willing to dispense barbiturates for assisted suicide. What is to stop a similar opt-in system operating for the practices I have mentioned above, rather than making a blanket imposition on all pharmacists?

If instead the GPhC ignores these solutions and presses ahead with imposing a ‘duty to dispense’ it will not only be running roughshod over the professional status of pharmacists, but could also be opening itself up to a legal challenge.

There is already a substantial body on law on conscience protection in British and European Law.

Article 9(1) of the European Convention of Human Rights (ECHR) provides a right to freedom of ‘thought, conscience and religion’. Whilst this is not absolute, and needs to be balanced against other democratic rights, any intervention must be shown to be both necessary and proportionate. It is hard to see how this move by the GPhC fulfils either of these requirements.

The Grand Chamber of the European Court of Human Rights has affirmed rights of conscience for sincerely held religious and moral beliefs as falling within the gambit of Article 9 (ECHR, Bayatan v. Armenia [GC], (2012) 54 E.H.R.R. 15.) They base their reasoning on the premise that a refusal to allow conscientious objection fails to strike a proper balance between the interests of society as a whole and the fundamental rights of the individual; providing rights of conscience ensures a cohesive and stable pluralism and promotes religious harmony and tolerance in society (Id.at § 124, 126).

The British Equality Act 2010, which is the sole legal precedent that the GPhC quotes in their consultation document in support of their proposal, lists nine protected characteristics, one of which is ‘religion and belief’.

It is therefore almost inconceivable that this draconian draft proposal will not be challenged in court by an aggrieved individual or organisation. 

But it should not come to that. It is just not worth the time, energy and expense and can be avoided.

There is little real evidence of widespread complaints by clients denied access to drugs under the current regulations. GPhC council meeting notes from 12 April 2012 specifically state that no data is collected and mention that only ‘a small number of complaints’ relating to 'fitness to practice' are received annually. We would expect complaints specifically about FOC to make up only a tiny subset of these.

The regulator, it seems, is using a sledgehammer to crack a walnut.

The GPhC’s proposal to remove pharmacists’ conscience rights is disproportionate, unethical, unnecessary and quite possibly illegal.

For the sake of professional freedom and reasonable accommodation, essential in a pluralist multi-faith democracy, let’s hope that they chose instead a more flexible, tolerant, respectful and eminently sensible path.

The one speech at the General Synod marriage debate which brought it all together

Yesterday the General Synod of the Church of England voted not to ‘take note’ of the House of Bishops’ report on marriage and same-sex relationships. 

The report upheld the historic position of the church on marriage as the exclusive coming together of one man and one woman for life.  However it also gave some scope for the affirmation of those in same-sex partnerships.

Not surprisingly, therefore, the report attracted the wrath of both sides. Whilst the House of Bishops voted overwhelmingly to support it by 43 votes to 1, and the laity followed suit by the narrow margin of 106 to 83, the house of clergy rejected it by a majority of 100 to 93, and so it fell. 

This means that the House of Bishops is now back to square one without any clear way ahead after three years of ‘shared conversations’.

In a debate lasting the best part of two hours, in which a total of 34 people spoke, many excellent points were made by clergy and laity who held to the biblical position on marriage.

But there was only one speech which mentioned all of Jesus, the love of God, the Cross, the definition and purpose of marriage, sin, repentance, judgement, heaven, hell, discipline & the need for clarity and leadership from the bishops. 

I have reproduced it in full below (full audio here).

‘From what we have heard this afternoon the two positions are irreconcilable. The Bishops’ report has sought to straddle the two positions but they cannot be straddled. And this is where we as a group of people and the wider church cry out to the bishops to make a stand and to make the position clear.

Jayne Ozanne, Simon Butler, Andrew Foreshew-Cain and Robert Hammond: you have all spoken movingly this afternoon. The Lord Jesus, he loves you, he died for you, he died for each one of us. We are all broken sinners all fall short of the glory of God and it’s on the cross that he took away our sin. We are all beggars, as Andrew Foreshew-Cain described us, in need of a Saviour. But that requires repentance from what (Jesus) says is sinful.

And clearly, Genesis 2 and Matthew 19 demonstrate that all sexual expression outside the lifelong and permanent union of one man and one woman is sinful. It’s contrary to God’s purposes. We have the picture of Christ who will come for his beautiful bride clean. He died for her. We rob society of that picture when we seek to destroy the truth of what marriage is.

God’s people are called to be set apart and clergy are to be examples to their people, to model holiness, chastity, purity, to model the way of the cross.

If sexual immorality were simply a secondary issue as opposed to a first order salvation issue then the Bible would not link it specifically with salvation (1 Corinthians 6:9-10). And that is why it is so important to speak clearly with regard to sexual sin, because, actually heaven and hell depends upon it. Our very eternity depends upon it. That’s why it’s loving to hold firm to it. And it’s also beautiful and freeing for all that hear this message.

When {the apostle) Paul heard of the specific case of persistent sexual immorality in Corinth involving a person who claimed to be a Christian believer he acted decisively urging that that person be immediately excommunicated (1 Corinthians 5:9-13).

We have to make a choice about discipline. Paragraph 64 of the Bishops’ report states that there needs to be a fundamental trust in the clergy to know and be faithful to the teaching of the church in their own lives and in their ministry to others. We are looking to the bishops to lead in this.’

Andrea Williams (286, Chichester)

Sexual immorality is a first order salvation issue. The Church of England is now needing the surgeon’s knife.

On Wednesday 15 February the Church of England General Synod will decide whether or not to “take note” of the House of Bishops’ report on marriage and same-sex relationships.

Within the Church, it is now very clear that the two main positions held are irreconcilable.

On the one hand are the “conservatives”, represented by the Evangelicals and Anglo-Catholics, who hold to the biblical and traditional position of monogamous heterosexual marriage.

On the other are the “progressives”, represented by “One Body One Faith” (previously the Lesbian and Gay Christian movement), who are seeking “a significant level of LGBTI+ representation” on church boards and councils, an “approved liturgy for the blessing of same-sex couples after a Civil Partnership or Civil Marriage” and “a change to Canon C26 to make clerical civil marriage not a matter for discipline”.

They add that these demands are “very far” from “all we want to see” but they represent “a way forward, a start”.

In between, is a body of currently indeterminate size, who are seeking to live with some kind of “arrangement” in a desperate attempt to keep those holding two radically different ideologies together.

But in reality, given the current level of entrenchment, it is only a matter of time before the inevitable separation takes place. If the bishops’ report is not “taken note” of then that separation may come earlier rather than later. If Synod does “take note” then the whole enterprise may limp on a little but the writing is on the wall.

Earlier this month, a group known as “accepting evangelicals” (who are ironically neither) wrote a letter to members of the evangelical group of General Synod (EGGS) outlining their position. The letter was signed by five well-known exponents. A few others have added their signatures on the website.

The letter, which can be read in full here, makes a number of highly contentious but familiar arguments but the signatories’ bottom line is that they remain “unpersuaded that this (ie. homosexual behaviour) is a first-order or salvation issue. We find nothing in the Bible to imply that it is so: indeed, quite the reverse.”

Interestingly, they don’t marshal any biblical arguments to back up this position but regard it as a self-evident truth.

I was surprised today to see the normally theologically sound “Archbishop Cranmer” making exactly the same point. In a blog post titled “The Church of England should not tear itself apart over homosexuality and same-sex marriage” he argues that “homosexuality is not an issue worthy of schism” as it “affects only a tiny minority of Christians” and is “of distinctly secondary, even peripheral, scriptural importance”. It is not “a battle for the soul of the church”.

This is a different argument than those normally advanced by people seeking to justify sex outside heterosexual monogamous marriage. But it is equally unbiblical.

The “one man, one woman, for life” pattern is an Old Testament creation ordinance, upheld by Jesus and Paul in the New Testament (Gn 2:24; Mt 19:3-12; Eph 5:22-33).

Sex in the context of marriage (Gn 2:24, Mt 19:3-12) is viewed as the good gift of a good creator (Pr 5:15-20, Song 4:11-16) and a sign of Christ’s coming marriage with the church (Eph 5:32, Rev 19:7)

Anything outside this context, by contrast, is seen as a disaster (2 Sa 11, 2 Sa 13, Gn 34), offensive to God (Lv 18:6-30, 20:7-21; 1 Cor 6:12-20) and accordingly worthy of judgement (Lv 18:29; Dt 22:20-22, Rev 21:8).

All wrong sexual patterns are spelt out specifically in detail (Lv 18:1-30; Lv 20:1-27; Ex 22:16-19; Dt 22:13-30) and include all homosexual acts (Lv 18:22, 20:13; Gn 19:1-29; Jdg 19:1-30; Rom 1:24-27; 1 Cor 6:9-11; 1 Tim 1:8-11).

God’s people are called to be ‘set apart’ (holy) with respect to sexual behaviour (1 Thes 4:3-8; Mt 5:27-32).

Obedience to Christ, in this and all other areas of morality, is of course only possible by God’s grace, through the indwelling work of his Holy Spirit (Jeremiah 31:31-34; Ezekiel 36:24-27), but Christians are nonetheless called to obey him. In fact the heart of the great commission, sadly so often distorted into an exhortation merely to evangelise, is to ‘make disciples of all nations… teaching them to obey everything I have commanded you’ (Matthew 28:19, 20).

“If you love me”, says Jesus, “you will obey my commandments” (John 14:15, 15:14).

As a clear corollary of this teaching that loving Christ means obeying him we are told that a life without demonstrable evidence of faith through a changed life is valueless. It is evidence of non-regeneration.

Furthermore, if sexual immorality were simply a “secondary issue” as opposed to a “first order salvation issue”, then the Bible would not link it specifically with salvation. Yet this is exactly what it does.

1 Corinthians 6:9-10 tells us, ‘neither the sexually immoral nor idolaters nor adulterers nor men who have sex with men nor thieves nor the greedy nor drunkards nor slanderers nor swindlers will inherit the kingdom of God’.

Galatians 5:19-21 warns that those who exhibit the ‘acts of the flesh’ - sexual immorality, impurity and debauchery;  idolatry and witchcraft; hatred, discord, jealousy, fits of rage, selfish ambition, dissensions, factions  and envy; drunkenness, orgies, and the like - will not inherit the kingdom of God.

Ephesians 5:3-5 echoes, ‘But among you there must not be even a hint of sexual immorality, or of any kind of impurity, or of greed, because these are improper for God’s holy people…. For of this you can be sure: no immoral, impure or greedy person – such a person is an idolater – has any inheritance in the kingdom of Christ and of God.

The book of Revelation (20:12) tells us that the dead will be ‘judged according to what they have done’.

In case we are in any doubt it adds that ‘the cowardly, the unbelieving, the vile, the murderers, the sexually immoral, those who practise magic arts, the idolaters and all liars – they will be consigned to the fiery lake of burning sulphur’ (21:8).

Outside the holy city will be ‘those who practise magic arts, the sexually immoral, the murderers, the idolaters and everyone who loves and practises falsehood’ will not partake of the tree of life (22:15).

The book of Hebrews (10:26) tells us that ‘If we deliberately keep on sinning after we have received the knowledge of the truth, no sacrifice for sins is left, but only a fearful expectation of judgment and of raging fire that will consume the enemies of God’.

Now it is clearly evident from these and other passages that sexual immorality (including all homosexual acts) are just some of many sins that are offensive to God.

But it is equally clear that sin that is justified and not repented of is a “first-order” or “salvation” issue and certainly not something “insignificant” or “peripheral”.

As I have argued elsewhere, Satan does not attack the same Christian truth in every generation. This is why the dominant heritage heresies of the past are not necessarily those of the present nor the future.

But a crucial heresy today is that which says that sexual immorality, or for that matter any other sinful behaviour, is a secondary issue not worthy of formal discipline or, if widely enough spread, splitting the church over.

The Apostle Paul’s approach was very different. When he heard of a specific case of persistent sexual immorality in Corinth involving a person who claimed to be a Christian believer he acted decisively, urging that this person be immediately excommunicated:

“I wrote to you in my letter not to associate with sexually immoral people— not at all meaning the people of this world who are immoral, or the greedy and swindlers, or idolaters. In that case you would have to leave this world. But now I am writing to you that you must not associate with anyone who claims to be a brother or sister but is sexually immoral or greedy, an idolater or slanderer, a drunkard or swindler. Do not even eat with such people.  What business is it of mine to judge those outside the church? Are you not to judge those inside? God will judge those outside. Expel the wicked person from among you.” (1 Corinthians 5:9-13)

Excommunication is simply a recognition that a person is no longer behaving as a member of Christ’s kingdom. It is, at heart, a step of obedience to Christ aimed at bringing the guilty party to their senses in the hope that they will choose to repent and become reconciled again with their brothers and sisters.

It is precisely, as I’ve argued elsewhere, the unwillingness of the Church of England to practise godly discipline leading if necessary to excommunication that is the cause of this current deadlock.

The problem now is that the church, and especially its ruling body the General Synod, is now so full of people practising, promoting and defending this particular form of sexual immorality that nothing short of radical surgery will resolve it.

When the necessary steps of discipline are not taken over a prolonged length of time, then as I’ve argued, schism is inevitable. Rather than allowing this to occur spontaneously, it is far better to make the separation cleanly and proactively. It is better to be cut apart than to be ripped apart.

There will inevitably be bleeding edges, but they will heal far more quickly if the incision is decisively and expeditiously executed.

The time for shared conversations is over. It is now time to act.

The time for shared conversations is over – the Senior Bishops now need to act

Open letter to Archbishop Justin Welby

In 2014 I sat next to a senior staff member in the Church of England at a Christian event and discussed the way the church was likely to handle the issues of same-sex relationships and same-sex marriage. 

This person thought that there were three groups: 15% who wouldn’t settle for less than full acceptance of same-sex marriage, 15% who would refuse it absolutely and 70% who might accept some kind of ‘arrangement’.  I asked ‘How is it going to end?’ ‘One of the 15% groups will split off’, came the reply. ‘Which one?’ The question was left hanging when the speaker began talking at that very moment.

Since 2014, seeing events unfold… the legalisation of same sex marriage,  the quadruple lock, the rise of GAFCON, the facilitated conversations, and now the publication of the House of Bishops’ report on Marriage and Same Sex relationships… I have often pondered over that brief yet candid conversation.

Now, next week, on 16 February the Church of England General Synod (full agenda and papers here) will finally debate the Bishops’ report. There is expected to be very little meeting of minds and a real possibility that the proposed ‘take note’ motion will not pass.

The LGBT lobby within the church, backed by powerful ideological and political vested interests in wider society, abhor the fact that the report upholds the teaching, recognised by canon law, that marriage is the lifelong union of one man and one woman.

But many Evangelicals and Anglo-Catholics are wary about plans to ‘revisit’ and ‘clarify’ advice to clergy on informal prayers for same sex couples marrying or forming a civil partnership. They feel red lines have already been crossed.

Paragraph 64 of the Bishops’ report states that, ‘there needs to be a fundamental trust in the clergy to know and be faithful to the teaching of the Church, in their own lives and in their ministry to others’.

But the current breakdown in trust is due precisely to the fact that some members of the clergy are not being ‘faithful’.

The Bible is clear that the only admissible context for sexual relations is within the context of a lifelong marriage relationship between one man and one woman. It is equally clear that all homosexual erotic acts are morally wrong (see here and here).

But some Church of England clergy are already involved in active homosexual partnerships, others have clearly signalled their openness to involvement and others are openly teaching that sex within such partnerships is morally acceptable.

This situation deeply compromises the witness of the church.

The foundation document of the Church of England, the 39 Articles, makes it crystal clear where ultimate authority lies:  

‘The Church hath power to decree Rites or Ceremonies, and authority- in Controversies of Faith: And yet it is not lawful for the Church to ordain anything that is contrary to God's Word written, neither may it so expound one place of Scripture, that it be repugnant to another.’

The Church of England’s official doctrine on marriage in Canon B30 (and in other statements including the 1987 Motion of General Synod and the 1998 Lambeth Conference Resolution 1.10) upholds the key principles in this biblical testimony.

The 1987 Motion reads as follows:

This Synod affirms that the biblical and traditional teaching on chastity and fidelity in personal relationships as a response to, and an expression of God’s love for each one of us, and in particular affirms:

1. that sexual intercourse is an act of total commitment which belongs properly within a permanent married relationship;

2. that fornication and adultery are sins against this ideal, and are to be met by a call to repentance and the exercise of compassion;

3. that homosexual genital acts also falls short of this ideal, and are likewise to be met by call to repentance and compassion

4. that all Christians are called to be exemplary in all spheres of morality, including sexual morality, and that holiness of life is particularly required for Christian leaders

So, given this clear doctrine, why are those clergy who dissent in word or deed not being called to repentance? Why further, if they refuse to repent, are they not being disciplined by being removed from office?

The biblical pattern of church discipline is unambiguous: ‘If your brother sins, rebuke him, and if he repents, forgive him.’ (Matthew 18:15; Luke 17:3). Its purpose in restoring erring members of the church is clear: ‘Whoever turns a sinner from the error of his way will save him from death and cover over a multitude of sins.’ (James 5:20) Discipline is necessary not only to protect and preserve the church but also to save sinners from judgement.

The Lord Jesus Christ himself lays down the pattern of restoration in Matthew 18:15-20:

‘If your brother or sister sins, go and point out their fault, just between the two of you. If they listen to you, you have won them over. But if they will not listen, take one or two others along, so that “every matter may be established by the testimony of two or three witnesses” If they still refuse to listen, tell it to the church; and if they refuse to listen even to the church, treat them as you would a pagan or a tax collector.’

The Apostle Paul addresses a specific instance of serious sexual sin in 1 Corinthians 5. The principle taught is that, although we should not judge those outside the church, it is our duty to judge those inside and to call people to repentance. If someone calling themselves a Christian refuses to repent, then they are to be excommunicated.

The Bible is equally clear (1 Corinthians 6:9-11) that ‘homosexual offenders’ will not ‘inherit the kingdom of God’. This is not a secondary issue (one on which true believers might have flexibility to disagree) because it impacts on salvation itself. Therefore, those Christians ‘who are spiritual’ (Galatians 6:1) have responsibility to restore their erring brothers and sisters ‘in a spirit of gentleness’ in order to stop them facing God’s judgement.

Just as culpable in the eyes of Jesus as those who persist in sexual sin are those who give false teaching, who ‘mislead my servants into sexual immorality’. The Lord tells the church in Thyatira not to ‘tolerate that woman Jezebel’ who promulgates such teaching (Revelation 2:18-29).

The Church of England appears to suffer from two key problems. First of all, there are some in leadership who seem not to hold to biblical authority or the traditional teaching of the church. Second, there are others who are clearly violating Christian biblical standards of sexual behaviour and are not being properly disciplined or called to account.

There are a number of practising homosexual clergy who are ‘tolerated’ and have not been disciplined by the relevant bishop(s). A clergyman currently on the Church of England Synod has also  had a same sex ‘marriage’ in defiance of Bishops’ guidelines, openly advertises his church hall as a venue for celebrating same sex partnerships, and is vocal in the media about his heterodox views.

A leading member of the Archbishops’ Council makes no secret of the fact that his same-sex relationship is not celibate. At least one bishop advocates the full acceptance of homosexual relationships, undermining the Church of England’s historic teaching on sexuality without being censured.

These individuals are personally known to, or under the oversight of, either yourself, the Archbishop of York or to the Bishop of London, the three men occupying the highest offices in the Church of England.

Bishops in the Church of England are not primarily managers, politicians or administrators – they are rather ‘ordained to be shepherds of Christ’s flock and guardians of the faith of the apostles’. This is based on the Apostle Paul’s commissioning of Timothy and Titus. They are to teach the truth, protect the people from false teaching and correct error. The Lord’s servant must be ‘able to teach’, and opponents ‘must be gently instructed, in the hope that God will grant them repentance leading them to a knowledge of the truth’ (2 Timothy 2:24-26). He must ‘hold firmly to the trustworthy message as it has been taught, so that he can encourage others by sound doctrine and refute those who oppose it’ and appoint people to positions of leadership ‘who love what is good’ and who are ‘self-controlled, upright, holy and disciplined’ (Titus 1:5-9).

The Bible is clear that from those to whom much has been given much will be demanded (Luke 12:48). This surely means that those with highest office in the church should be leading by example.

The Church of England is currently drifting slowly towards an inevitable disintegration with no possibility of reconciliation. The situation cries out, not for mediation and more conversation, but for discipline and for leadership.

The upcoming Synod may well be the last chance to grasp this nettle. But before that the three most senior bishops surely need to lead by example and fulfil the first two steps of Christ’s commands in Matthew 18 – going to the offending clergy they know individually and then as a group. They can then, if these men refuse to repent, present the matter to the entire Synod when it meets on 13-16 February.

If the three leading bishops are not willing to take the lead then others must do so. Once the process has begun it must continue throughout the church.

Those who support, or are involved in, homosexual partnerships (ie. not celibate) who are not willing to repent, according to the 1987 resolution, should be removed from leadership. This of course applies equally to all involved in any other form of sexual sin.

The principle is clear. There has so far been much conversation but no real action. It is now time to act.

You have been felt burdened to apologise, on behalf of the church, for sins and failures for which you are not directly responsible. But with respect to the discipline of clergy promoting or involved in homosexual partnerships you, along with John Sentamu and Richard Chartres, are in fact directly responsible.

To obey Christ in this matter will undoubtedly lay you open to criticism from the media, the LGBT lobby, other sections of society and dissenters within the church itself. It may cost you dearly in terms of popularity and in other ways. But the key question is whether, like the apostles, you are willing to ‘obey God rather than men’ (Acts 5:29).

Jesus was uncompromising, ‘If you love me you will obey my commandments’ (John 14:15, 15:14).

May I urge you and your two fellow bishops to perform your duty before God as ‘shepherds of Christ’s flock and guardians of the faith of the apostles’.

I appeal to you to be faithful in this matter to the Lord you profess to love and serve. The future of the Church of England depends on it.

Christmas - The miracle of the incarnation

Many people today are sceptical of the miraculous elements of the life of Jesus Christ: the virgin birth, the healing miracles and the resurrection. They ‘know’ that such things are scientifically impossible.

But the real miracle, on which all rests, and which we celebrate at Christmas, is actually the incarnation, the Word becoming flesh. C S Lewis, in his classic book ‘Miracles’, calls it ‘the grand miracle’.

If we can accept the incarnation - the idea that God could become a human being - then all other aspects of Jesus’ life follow on naturally. They are exactly what we would expect if God were walking on the planet.

Apologist Josh McDowell has suggested that if God became a man we would expect to see the following things.

He would have an unusual entry into life - which is exactly what we find in the virgin birth.

He would be morally perfect. When Jesus challenged others to find him guilty of sin no-one could answer.  

If God became a man, we’d expect him to perform astounding miracles. The gospel accounts are full of them: he heals those who are deaf, blind and paralysed; he calms storms, walks on water and turns water into wine. According to eyewitnesses Jesus healed diseases for which even today there is no treatment; instantaneously, irreversibly and unambiguously. 

We'd expect him to speak the greatest words ever spoken. People responded to Jesus in amazement. ‘How did this man get such learning without having been taught? ‘No one ever spoke the way this man does’.

Psychiatrist James Fisher has written: ‘If you were to take the sum total of all the authoritative articles ever written by the most qualified of psychologists and psychiatrists on the subject of mental hygiene - if you were to combine them and refine them and cleave out all the excess verbiage - if you were to have these unadulterated bits of pure scientific knowledge concisely expressed by the most capable of living poets, you would have an awkward and incomplete summation of the Sermon on the Mount.’

If God became a man, we would expect him to have a lasting and universal influence. Why is it that all religions try to accommodate Jesus somehow, to find a place for him? In the words of historian Kenneth Latourette, it is simply because ‘measured by his effect on history, Jesus is the most influential life ever lived’, profoundly shaping our worldview, our laws, our history, our culture.

We would expect him to satisfy the spiritual hunger in man. Millions testify that Jesus Christ has filled the spiritual vacuum in their lives; that his promise that those who come to him will not thirst or hunger is amazingly true.

Finally if God became a man, we would expect him to exercise power over death. The resurrection of Jesus Christ is the best attested historical fact in all of antiquity; over 500 witnesses to his rising from the dead. It is the only logical explanation for the empty tomb, the dramatic change in the disciples and the spread of the early church.

But what does the incarnation mean for us personally? 

First, it reminds us that Jesus understands us. He knows what it is like to be a human being. He knows hunger and thirst, pain and sorrow, bereavement and loss, rejection and betrayal. As the writer of Hebrews tells us he can sympathise with our weaknesses because he has been tempted in every way as we are, and much more.

Second, it reminds us that Jesus can help us: ‘because he himself suffered when he was tempted, he is able to help those who are being tempted’. What are our areas of weakness? What do we despair over? What is it that is stopping us growing as Christians? What is it we are fighting that perhaps no-one else sees or knows about? He is able to help us. 

Third, the incarnation is a model for us in our own Christian lives. We are called to walk in Jesus’ footsteps. The cross is a pattern for us to follow. We are to carry the cross, to take our share of suffering, to bear the burdens of others. 

Fourth, the incarnation helps us in our evangelism. It challenges us to cross social barriers as Jesus did, to make ourselves accessible and vulnerable, in the way that Jesus was, to be, in the words of Paul, 'all things to all people'. 

But finally, and most importantly the incarnation reminds us of why Jesus came, because Christmas is the prelude to Easter. The same Jesus who grew in the womb and lay in the manger was sent to die on a cross and rise from the dead in order to reconcile us to God. 

Christmas starts and ends with Jesus Christ. Let’s keep him at the centre.