I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art. I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion. But I will preserve the purity of my life and my arts. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot. 242
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ARTICLE
The Enigma of Dr James Barry Alice Wilson
Year 4 Medicine, University College, London a.wilson@ucl.ac.uk doi: 10.4201/lsjm.hle.009 The Wellcome Collection exhibition Identity questions the concept of a personal identity. Acknowledging the amalgamation of innate and acquired traits, it questions the oversimplification demanded by official PIN numbers. Given that the deeper question of “Who, really, am I?” remains much harder to get at, this is approached through particular protagonists whose lives open up identity debates. One such figurehead in this exhibition is April Ashley who was one of the first people in Britain to undergo a full sex-change operation. Born a boy – George Jamieson – in Liverpool and growing up there in the Second World War, he went on to join the Merchant Navy travelling to Paris and taking to the stage of the Carousel night club, famous for its male impersonators. Following hormone treatment George changed to April Ashley in May 1960 and subsequently became a campaigner and friend of the stars. But although her ‘chosen gender is important to her, it is far from the sum of her parts.’1
the archaic view that ‘very little benefit will result from the best–devised means of prevention until prostitution is recognised as a necessity’,3 Dr Barry was revolutionary in her determination to provide for the civilian population so affected by the vices of Military occupation. Dr Barry was in fact brought to General Court Martial on 24 November 1836 for her precocious correspondence and for ‘behaviour unbecoming to an officer and a gentleman’,4 but eventually having been acquitted she added a triumphant postscript to the court notes: ‘Subsequent to this ... the Lords Commissioners of HM Treasury ordered the Commissariat Dept to provide for the Civilian branch of the Hospital by contract the same as for the Military- by which means the Government saved considerably and the patients were better provided for.’5 This is affirmed by Sir Henry Stork’s writing to the Commission in 1865 citing Malta, another of Barry’s postings, as an example of successful monitoring of VD.6
Dr James Barry(1789-1865) features briefly in the exhibition, because she too came to be defined by her chosen gender, despite the fact that the sum of her parts amounted to much more than a gender debate. After death, Barry was found to be female by her charwoman Sophia Blake, but she had lived her life as a male. Having graduated from Edinburgh University in 1812, James Barry went on to become a Surgeon in the RAMC. From 1816 she would not return to England for more than two years together, until ill health necessitated retirement in 1859. During her career James Barry was notorious for her obstinate nature, but this voracity was to pay off in reforms she enacted. Whilst placed in South Africa Dr Barry carried out ‘probably the most interesting Caesarian section of all time.’2 This occurred fifteen years before the first successful one in England, with vastly inferior resources, and what is more both mother and child survived; the grateful parents named their son James Barry Munnik.
In her letters and through subsequent reports Barry comes across as a fiery character. When she crossed paths with Florence Nightingale during the Crimean war, the latter noted:
In addition to pioneering surgery, Dr Barry approached medical subjects which others shunned. When Principal Medical Officer of St Helena the issue of Venereal Disease (hereafter VD) became paramount. Whilst nominally reputable men upheld
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Winner of best dissertation prize from the Wellcome Trust for History of Medicine 2009
“
(He) kept me standing in the midst of quite a crowd of soldiers, commissariat servants, camp followers etc. etc, every one of whom behaved like gentlemen during the scolding I received while (she) behaved like a brute. After (she) was dead I was told she was a woman.7
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ARTICLE
Speculation about Barry’s ‘true’ sex has produced ‘proof’ for her being male, hermaphrodite and female. The death certificate signed by Major McKinnon and verified by Sophia Blake details sex as male,9 Barry lived and corresponded as a male and she was in two of the most archetypically male professions: medicine and the military. Of the biographies and research carried out on Barry, the most adamant of male sex was Professor P R Kirby who wrote a series of articles in the 1950-60’s to counter the ‘allegation that Dr James Barry was a woman’10 and dismiss her being female as an entertaining legend. He criticises the main biography by Isobel Rae11 for willingly accepting the charwoman’s statement and accuses the Lancet series of correspondence12 as full of ‘misstatements’.13 He also takes rumours about sexuality to make the case that Barry was so male she was homosexual. In terms of timing, Kirby argues that it was only after death that rumours began, and that at no point did the military authorities deign to make a statement. To account for Barry’s notoriously effeminate appearance Kirby posits that she was a type of male hermaphrodite who possessed feminine breast development, external genitalia and testicular feminization syndrome with absence of hair. The first written suggestion of this was by Major McKinnon: ‘my own impression was that Dr Barry was a Hermaphrodite’.14 In the following years Edward Bradford backed this up but with absolutely no evidence, and Price reached the conclusion through a dubious process of elimination, concocting tales of grandiose heritage and the need to hide this specimen of a ‘third sex’. Most recently Rachel Holmes has argued more convincingly for hermaphroditism: Firstly through anecdotal evidence ‘three pillows of a particular description necessary to me under the peculiar circumstances in which severe accident have placed me’15 which she sees as trusses for an inguinal hernia or testes (though Rose contests that these were pads for menstruation). Secondly, Barry’s choice of thesis and studies are proof of an obsession with genitalia and the imperfections of the human body.16 Lastly Holmes perceives her behaviour as secretive and indicative of an empathy with other less fortunate people. However, recently Hercules Michael du Preez wrote a seminal article ‘Dr James Barry: The early years revealed’17 which is tantamount to proof of Barry’s female status prior to studying medicine at Edinburgh. Following Barry’s death Sophia Blake approached Major McKinnon and he claimed: Following wind of this in the Manchester, Ireland and London daily newspapers, it soon sparked a widespread dialogue. Numerous biographies have been written on the premise of Barry’s female sex including those by Olga Racster and Jessica Grove, June Rose and Isobel Rae. As a result of the latter’s surmising, much written about Barry’s early years has ‘not been substantiated from primary sources but through frequently repeated speculation acquired the simulacrum of truth.’19 Du Preez’s remit was thus to categorically determine the point at which James Barry came into being. He
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“
Amongst other things she said Dr Barry was a female and that I was a pretty doctor not to know this… She then said that she had examined the body and it was a perfect female and farther that there were marks of her having had a child when very young. I then enquired how have you formed that conclusion? The woman pointing to the lower part of her stomach said From marks here. “I am a married woman and the mother of nine children and I ought to know.”18
”
found, through tracing genealogy and cross-referencing letters between Mary Ann Bulkley, her brother James Barry R.A. and a solicitor in Edinburgh, Daniel Reardon, that James Barry started life as Margaret Bulkley, born 1789 in Cork, Ireland. On researching the fascinating tale of this enigmatic character, it seemed that the sex of Barry was not the most interesting point, rather, the written dialogue stemming from it, which was such a reflection of the context in which it was written. Shortly after Barry’s death in 1865 the Sunders News letter and Daily Advertiser concluded ‘The motives which led to this misrepresentation of sex and the time at which it began are both shrouded in deep mystery…I strongly doubt that even Miss Braddon could dare to make this person the heroine of one of her romances.’20 Novels were at this time in vogue, with gothic romances an outlet for those confined by domestic ideology, and the world of Sherlock Holmes imbuing the nation with an investigative spirit. Other excerpts reflected the misogyny directed against spinsters21 and the uneasy attitude to hermaphroditism concluding ‘this small and naughty doctor had always been, in body as in mind, a monstrous person’. 22 Attitudes to women and gender changed most significantly towards the end of the nineteenth century at which point
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Image: Wellcome Image
As a woman in a man’s world, it is unsurprising that Barry acquired a fierce and ostentatiously alpha male persona, seen frequently in the history of Amazons.8 These fighting women have a long history, and Barry is by no means unique in that respect. But despite Barry’s incredible lifetime achievements, since her death on 25 July 1865, it has been her sex, not her success, that has raised eyebrows.
ARTICLE medicalisation of homosexuality and the surge of feminism caused shifts in public perception. Ellen Clayton argued that if women could fight they could vote. By this dictum Barry upheld feminist principles and this can be seen in Racster and Grove’s conclusion that Barry ‘successfully competed with men on their own ground a hundred years ago’.23 Conversely, although Magnus Hirschfield believed war sexually freed heterosexual and lesbian women alike, in fact taboos still abounded. With ongoing concerns over a ‘third sex’ Racster and Grove exemplify that ‘connotations of a person of indeterminate sex in theatre and literature could be ignored by imbuing the warrior heroine with romantic or innocent motives’24 so they fictionalise Barry’s impetus to join the army by imagining her evading ‘My husband’s spies’.25 Given that war can act as a solvent and a stimulus, in the 1950’s there were considerable tensions between women in nontraditional spheres of activity and men already there. These tensions were negotiated in two ways: either women became honorary men (like James Barry), or conversely femininity was emphasised to reduce male hostility by underlining differences between the sexes. This is reflected in the dialogue between Isobel Rae and Prof Kirby. Much of their writing has a personal slant with Prof Kirby patronisingly accusing Rae of making Barry female to qualify her use of an ‘enticing title’.26 He disregards Barry’s female status through an assumption of female incapability in a duel, echoed in Price’s similar assumption of female medical incapability.27 By the 1970’s male masculinity was giving way to homosexuality and the flowering of feminism. With this as a backdrop, June Rose wrote The Perfect Gentleman. In the preface she, like Rae, rejects Kirby’s misogyny ‘His obsession with the specifically sexual identity is typical of a…predominantly male…assumption that a woman by nature would have been incapable of sustaining the
masquerade and attaining professional prominence’.28 In recent years, the exponential increase in literature on crossdressing, women in medicine, hermaphrodites and general social history has provided a much richer tapestry within which to understand James Barry’s story. Patricia Duncker and Rachel Holmes are two authors who have woven exotic novels out of her story.29 Perhaps the most interesting response of late has been the discussion prompted by du Preez’s article within the transgender world. Whilst the 1970’s was a time for feminists to reclaim their history, it seems now transgender people are doing the same and taking James Barry as their figurehead.30 In conclusion, Dr James Barry (1789-1865) was an enigmatic character enacting profound change in many areas of military medicine and surgery. After death her achievements were subsumed under sex/gender debates, which reflected the changing social mores more than facts of Barry’s life. Du Preez’s recent research, with the benefits of modern technology and data-basing, seems to have solved the mystery of birth. However, it remains to be seen whether attitudes to sex and gender have really changed in the last 150 years, since as a whole the historiography of Dr Barry indicates an ongoing inclination for the binary division of identity, and the marginalisation of anyone challenging this.
References 1. 2. 3.
4. 5. 6. 7. 8. 9.
10.
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‘I Am’ leaflet for Identity exhibition, Wellcome Trust, 26 Nov 2009-6 April 2010 Mr A Dickson Wright, ‘Caesarian section’ from St Mary’s Hospital Gazette 1968 Jan-Feb. Wellcome Library: RAMC 748. Sir Henry Stork, Letter to the Committee. Report of the Committee appointed to enquire into the Pathology and treatment of the Venereal Disease with the view to Diminish its Injurious Effects on the Men of the Army and Navy with appendices and the Evidence taken before the Committee, London: Harrison and Sons, 1868. The Women’s Library General orders, 7 December 1836, Malta. PRO CO 247 52 8572. Wellcome Library: RAMC 455 James Barry, note appended to the General Orders 7th December 1836, PRO CO 247 52 8572. Wellcome Library: RAMC 1264 Stork, op.cit. note 3 above, p(xliii) Florence Nightingale, undated letter about James Barry, From the collection of Sir Henry Verney. Wellcome Library: RAMC 801/6/5 June Wheelwright, Amazons and Military maids, London, Pandora 1989 D.R.McKinnon, Death certificate, 26th July 1865, General Register Office, Marylebone District War Office Personal Files No.14651/1 Dr.James Barry, Inspector-General, A.M.S. Wellcome Library: RAMC 373 Professor Percival R Kirby, ‘The centenary of the death of James Barry, M.D., Inspector-General of Hospitals (1795-1865) A Re-examination of the facts relating to his Physical Condition’, Africana Notes and News, June 1965, Vol 16, No.6 Wellcome Library: RAMC 455/item2.
For references see thelsjm.co.uk.
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REVIEW
What insights can historical analysis of case notes provide children’s healthcare today Shajheda Haque, BSc
Year 5 Medicine, Imperial College, London shajheda.hague04@imperial.ac.uk doi:10.4201/lsjm.hle.010
Abstract This paper is a historical analysis of 20th century paediatric case notes to reflect on clinical practices of children’s health. Many historians have used clinical case notes to reflect on medical activities, but none have used them as representations of patients and disease. Thus, this study is original in its centralised focus on: (1) 20th century paediatrics to explore the additional factor of the parent and the rise of social care in the doctor-patient relationship, trends which may run contrary to the standard view on the decline of patient narrative and doctors' attention to patients as whole persons; (2) the changes in record-keeping styles; challenging conclusions of previous work on use of diagrams in case notes; (3) revealing and tracing the use of consent forms before the Nuremburg code and thus challenging the “historiography” of consent as being mainly a post-WWII procedure. To date, detrimental consequences can be seen through practice of poor communication skills, clinical skills and history taking. Therefore, exploring the historical development will enable an appreciation of careful history taking and the evolvement of children’s care. Introduction Medical records document ongoing events and communication between the patient and doctor.1 As Risse identifies, they help in understanding the practice of medicine, revealing intricacies of hospital life and-reconstructing medical life.2 By further study of these under-investigated areas, we can reflect on why it is important to understand the history to appreciate and build on furthering the goals in patient care. Since the 1980’s, historians have been using medical records to reveal past medical activities, but records have not been explored nearly as rigorously as they could. I will be using these resources to analyse the changes undertaken between periods 1900 to 1975, in the context of children’s hospital practice. The 20th century was significant in the advent of medicalisation of children’s-health, demonstrated by the-vast-rise in opening of children’s hospitals.4 In
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particular, this paper will address on changes in record keeping via exploration of use of diagrams, clinical history taking and-consent. What was the focus for a children’s doctor in the 20th century? How did they interact with the parent/patient? The methodology of this study is through investigation of clinical records from 1881 Brompton Hospital notes, 1894 London Hospital, Queen Elizabeth Children’s Hospital in Hackney (QEH) from 1900, 1915, 1924, 1935, 1938, 1939, 1946, 1968 and 1975. (Table 1) Primarily, I observed the notes based on what was held at hospital archives first, then analysed my findings. In order to strengthen the-analysis of my findings I had the privilege to gain an oral history through interview with a retired Paediatric Consultant, Dr.-LeonardSinclair.3 Through his reflections of working at QEH in the 1950’s he was able to provide insight into his experiences. Although, clinical records can reveal changes in clinical practice, they may not be representative of all doctors’ practices or hospitals, I will reflect further on the limitations of the-sources andpossibilities for future research in-the-conclusion. The revelations of practices of medical record keeping One of the most important developments of the 20th century saw improvements in medical records.1 This was initiated in America by Cannon who suggested using records as a tool for educating medical staff.5 This highlighted the necessity of the value of keeping accurate and complete records. However, many physicians did not see the need to record all details as they viewed note-taking simply to jog-their-memory. Physicians soon changed their outlook on records viewing them as a vehicle to reflect and-evaluate their care. Although, such changes were orchestrated in some hospitals, others still needed reminding to complete notes. Thus, the first 25 years of the 20thcentury were hugely important in initiation of changes in the medical record, to benefit both patients and medical staff.5 At-QEH practices of the early 20th century records reflect-similar concepts. Many-lacked details, for example ‘presented unwell’, identifying incomplete history taking. However, findings of temperature charts, treatment and-pulse were always complete.3
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REVIEW Table 1. ESTIMATIONS
OF CLINICAL
RECORDS
BROMPTON NOTES
LONDON HOSPITAL
QEH MANY PHYSICIANS
QEH
QEH
DR SYDNEY OWEN
DR WILLIAMS 1881
DR.MACKENZIE
DR HELEN MACKAY 1935-39
1900- 2 volumes
1894 ~> 100 cases
~> 50 cases
~> 200 cases
1915,1924,1935,19381939,1946 Each year ~> 100/150 cases,1946~10
Use and discontinuation of diagrams in clinical-records Interestingly, one apparent change has been the use of diagrams in medical records. Why-might this-be? I will be focusing on the first diagram I came across in the notes: ‘ the thorax skeleton diagram’. (Fig 1.) Figure 1. ‘ the thorax skeleton diagram’
Early 20th Century textbooks justified the-consequential use of diagrams as a means of interrupting narrative flow to enable clear representation of clinical findings.7 Evidently, recordings identified loss of resonance on percussion where depth of shading increased with degree of dullness.6 Notably recordings on vocal fremitus, breath sounds, voice sounds and asymmetry were noted on the side rather than on the skeleton. Any adventitious sounds such as
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~Each year >100 cases
dry rales were indicated by ticking and-smaller/larger solid dots, denoted moist rales. Additionally the diagram was used to denote areas of cardiac, liver and spleen pathology. For cases without diagrams, the same information would be presented in continuous prose; ‘Abscess-in-thoracic-cavity, dullness-on-left-side-anteriorlyextends-down-to 5th rib, dullness-extends-laterally to mid-axillaryline posteriorly-about 2 inches from middle line on left side, percussion-note-tympanic...’3 This signified-the-level of detail demonstrated in case notes and-the focus on physical examination. This brings us to the forefront of questioning; why was it used in the first place? In order to analyse this I looked at case notes from Brompton Hospital 1881, London Hospital 1894 Dr Mackenzie, QEH 1900, [1915, 1924, 1935; Dr Owen] & 1935 Dr Mackay.3 Amongst these cases for each year I identified cases where the diagram was used, so mainly for respiratory cases; thus am presenting a sample from each year. The estimations of respiratory cases or cases where it was used represented approximately a 1/3 of the notes from each year. The diagram when used illustrated areas of pathology and abnormal findings on examination in combination with inclusion of narrative findings. The early 19th century Brompton notes show use of an additional diagram involving scapulas, using a gridline to mark out the distance of pathology from the scapula. This information was still evident in 1900 & 1915 notes ‘chest impairment on left side as height as 1 before left scapula’.3 The 1900 case notes used the diagram; however the majority of respiratory cases did not use this as part of the formality of history-taking, using written format instead. The 1915 case notes compiled by one physician showed use of the diagram was consistent and so was found in all respiratory spleen and-liver pathology . Amongst this compilation, there were also a few diagrams to symbolise no abnormalities in cases such as dyspepsia so stamped with no annotations, ‘chest NAD’.3 However, from 1924 onwards, use of this diagram was discontinued. These notes demonstrated much wider use of chest radiography with written findings from the chest-examination. Moreover, X-Rays were more widely used during this period as accounted by Howell; which we will explore further.8 Thus, the issue of diagram discontinuation in these notes is hugely important. Discontinuation of the diagram Figure 2.
REVIEW Historian Howell researched the effect of technology on patient-care in hospitals; one focus being the effect of X-Rays in record-keeping at Pennsylvania Hospital and New-York-Hospitals. His findings acclaim that the reasons for use of diagrams were due to the increasing use of x-rays during this period.8 However, my sources show a very different history and yield opposite conclusions. In-fact, Howell’s findings are misleading as evidence clearly underpins that diagrams were in use from before the period of use of the x-ray machine. The discovery of X-Rays in 1895 was received with mixed reception. Clinicians felt that it was an unnecessary investigation and-physical examination would remain superior.6 Additionally, limitations existed as use of machinery was expensive, dangerous and-required technological expertise. However, despite radiation hazards from 1905, most physicians and patients ignored advice to use X-Rays cautiously.8 Many physicians were enlightened by the fact that they could evaluate pathology in a group and-that ‘sight offered much more satisfactory agent of-information-than-hearing-or-touch’ especially in specific to lung disorders.6 Thus, it became more commonly used by the 1920’s, coinciding with the period of discontinuation of diagrams on medical-records. Reasons for discontinuation may be that radiography was sufficient graphic-representation of the clinical findings. As clinician Gordon identifies paediatricians were trained in radiology so would be more likely to-use-X-Rays-for diagnosis.9 In support of my findings, Reiser highlights concepts of physicians having to conjure up mental pictures of anatomical defects thus, explaining the tool of using the diagram.6 Another factor to consider for the apparent differences in findings could be due to disparities between US & UK hospital practice. Significantly, the case notes from as early as 1881 & 1894-5 London Hospital Records show use of the diagram to record findings from the chest-examination, illustrating standardisation of records appeared earlier than Howell’s findings. Following his analysis of use of X-Rays on forms, it is correct that this period of the-1920’s/30’s led to huge changes in record keeping. However, his findings identify drawings evolved in 1912 and a standardised stamp in 1917. Clearly his conclusions that diagram use was concurrent with the increasing use of x-rays during this period are unrepresentative of the records within London Hospitals.8 Indeed, my findings suggest an-alternative-history, reopen the question-and-make clear the need for further research. An Example of Patient Consent Forms in Use before the Second World-War and the Nuremburg Code One of the earliest references to duties of physicians stems from Hippocrates where emphasis is placed on building trust.10 Amongst the revelations of post WWII was recognition of informed consent.11 Following the 1947 Nuremberg trial, American judges laid down principles stressing the professional duty to inform of hazards to avoid unnecessary ‘physical and mental suffering.’ The Nazi experiments were symbolic of war crimes, against humanity, emphasising principles to act morally towards patients.11 Hence, I will be investigating the-practice of-consent through analysis of consent forms. Consent forms Consent forms have been seen to serve a variety of purposes not limited to-ethical -requirements. One of the purposes is for documentation of events which took place. Primarily the goal
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should be to protect the interests of the patient; a formulatory device in the dialogue between doctor and patient.12 Additionally, legal documentation may protect physicians from liability in some jurisdictions. Although it may serve as defence from battery it cannot protect against disclosure unless the form includes information about the risks. Therefore, through reflection of the proposed intervention the signature is seen as reinforcement of understanding the presented information.12 Origins of Consent Many historians agree on the-issue-that there is paucity of information on consent practices prior to the 1960’s, thus records at-QEH allow insight into this practice.13 As Berg identifies that early ‘simple consent’ was valid by interchange between physician and-patient12. Although, American Law in 1932 made it a general law to obtain consent before operations and, if needed, in exceptional circumstances it could be implied.12 Many early 20th century case laws influenced the emergence of informed consent. The courts had an influential role dealing with consent before 1957, so already had an enforced structure before that of medicine.13 Particularly, the 1950’s Salgo case was fundamental where aortography resulted in paralysis; the-physician was sued for negligence and physician’s failure to disclose crucial information.13 Later in 1953, ethical guidance was issued by the Medical-Research-Council, expressing the importance that new-procedures should be made ‘amply clear’, distinguishing the difference in granting consent and-explaining the procedure.12 Also, the guidance addressed the need to be empathic towards patients subjected to novel treatments. On the other hand, doctors felt that the need to ask for ‘permission’ was acceptable but ironically viewed that having to sign a form would only cause mistrust.11 These fundamental events refined the definition of consent to include the need to understand all the necessary information about procedures, yet the courts were still hesitant to mandate full disclosure by physicians.13 Around this time Nazi-atrocities and-cases of abuse in medical research drew light on the trustworthiness of the profession.11 Initial propositions of informed consent were outlined by US physiologist Andrew Conway Ivy in-1946 who recommended voluntary consent and need to inform of all potential hazards.11 This identifies Ivy’s draft code as fundamental in shaping the events of the Nuremberg Trial.11 Further, developments were made by a neurologist who expressed that if patients could not make an informed decision, consent should be obtained from next of kin/guardian.11 Many physicians became aware of the-need-to-obtain-consent but, no universal application of the practice was present till the law was formulated in 1970’s through combination of battery and malpractice cases and the Nuremburg Trial.12 How physicians reacted to the formalities is unknown, but possibly many feared that, through disclosure, patients would be deterred against operations. Certainly, Pappworth provides extensive proof of thedomineering influence of Doctor’s taking advantage of patients.14 Significantly, subjecting children to experiments was seen as less justifiable, leading to debates over parental rights in deciding what may/may-not-be morally correct.14 An important question drawn was, ‘did patients give ‘informed consent’/‘blanket’ consent’? Consent practices at QEH Evidence from QEH, shows practice of obtaining patient consent was formalised from as early as 1932.3 Consent forms were used
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REVIEW in all cases, as prior to the consultation with the doctor, parents/ guardians would consent to any necessary procedures. This is in disagreement with Evans’ conclusions that informed consent was a phenomenon of the post second world war period11. However, in reflection on the underlying principles of informed consent in 1970, we may argue the extent to which these cardinal principles were applied. This is indicated by a heartbreaking case in 1938 where a child had a large cavity compressing the brain’. The mother gave consent for surgery. However, 2 hours into the operation, the ‘child dies on the table’. The surgeon removed the ‘large cavity with yellow, soft caseous material. But, ‘at this point, respiratory difficulties were encountered, given Cocamine subc, and artificial respiration for ½ hour-given, blood-transfusion given, patient died’.3 Correspondence from the child’s mother indicated the consent form was signed (Fig 3). But, through reading this letter we can question whether the mother was really ‘informed.’ Although, it is undeniable that she was grateful for the care and attention her child received. It seems that she was under the impression the operation would lead to complete recovery, therefore not prepared for the risks of the procedure. This explains her emotions and disbelief at the loss of her son. ‘I am desperately upset and cannot believe I shall never see him again’, ‘…terrible blow to me’. The impact of this correspondence identifies that the reasoning behind consent forms may be a way of protecting the doctor from any allegations of malpractice, rather than a focus on acting in the best interests of patients. This was identified in 1929 minute books where acknowledgment that, if the procedure were known, it ‘would deter patients’. In 1933, King Edwards Hospital suggested that QEH should change the design of their consent form; however there were no details with regard to how they should change. Minutes show that QEH were content with their Form and decided to ‘continue with existing form for the time-being’.3 Consent forms from 1932-1949 illustrate this concept, that is of ‘blanket’ consent. Here, agreement is obtained before admission which presents a sense that there is no drive to educate parents about procedures and no real choice for the parent. At QEH, parents consented to five scenarios before-hand: operation/fever or other hospital/post-mortem parents responsibility for burial/immunisation, cutaneous or intradermal tests.3 Figure 3.
The situation in 1968 identifies a better sense of the fulfilment of definition of ‘informed consent’ where the incorporation of the words ‘nature and effect explained by’ implies intentions to
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of both doctor and parent further-are-a-confirmation-of-a-unified discussion. This again highlights QEH may have been ahead of legislation of informed consent as Evans states that the 1970’s was the period of accepting this regulation.3 Thereby, through history of consent documentation one can see that inclusion of information in simple form is beneficial, to address patient concerns or confusion. One of the presenting practices of child-health is that younger children have less autonomy and individual rights, so parents act on behalf of them.15 If children are under-16 years of age, the Gillick principle now applies where if they have sufficient understanding they can give legally effective consent independent of parents’ wishes.16 This now highlights that doctors have to consider parents and patients in decision making. Doctor-Patient Relations in Paediatrics: Patient Narrative, Parents & Social-Issues There is existing historiography on patient narrative but I have taken a un-investigated-spin on this, looking instead at how paediatrics presents parents narrative. Fissell argues that the middle of the 18th century saw transgression of patients’ narrative. Thus, by this omission, common ground of the doctor-patient relationship was eroded.17 ‘increasing medical autonomy patients’ narrative of illness was made utterly redundant’.17 Fissell’s findings that hospitals an 18th century invention directed doctors’ focus on ‘signs, symptoms and-disease orientated diagnosis’, ‘the body, disease became the focus of the medical gaze, not the patients version of the illness’.17 Jewson is in agreement where he expresses greater social distance in context, to a change from the era of bedside medicine to hospital medicine; where the doctor has more control.18 Paediatrics is perhaps different in the sense there may be a greater need to engage with the child to ensure they co-operate, therefore, incorporating a doctor-parent and doctor-patient relationship. In light of this, communication skills are tested more in paediatrics than other specialities.15 Paediatricians have to assess the situation whether the patient is able to give a history. In particular, obtaining the co-operation of 2/3 year olds may-be challenging.19 Views of History taking One influential clinician who draws on concepts of clinical history taking in 1920 is Robert Hutchison.20 It is clear as paediatrics established as a speciality in 1915 there was still room for establishing practices.20 He likens ‘paediatrics’ to be similar to veterinary work, where because the-patient is unable express their symptoms he believed the-focus-should be entirely based on observation; signifying-great-reliance-on-examination.20 He addresses the need to be precautious of ‘anxious mothers’ perceptions and concerns which may stem from ‘neighbours worrying her’.20 This is illustrated in 1915 notes ‘mother says child never healthy, as believes from birth something wrong with heart’.3 Additionally, his view of mothers as ‘loquacious persons’ further support a sense that he is not willing to rely on this part of the history.20 Through, examination of notes from 1900-1975 what is clear is the impact of parental involvement and disuse of Hutchison’s theories. The earlier notes of 1900-1939 present a greater
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REVIEW involvement of the parents’ history. The presenting illness would be incorporated with parents’ comments and ideas such as ‘had always been delicate’, ‘developed rash’, ‘poisoned by plums’. This identifies a sense that the doctor would ask the parent what was wrong, to which the parent would continue and everything wouldbe-documented. Furthermore, focus was on what happened prior to the symptoms and observations rather than finding out about current symptoms for example, many accounts of cough were described briefly as dry/wheezy etc with no further details. Although from 1894 there is a stark difference, where complete lack of focus on patients-symptoms is evident ‘patient does not know what is wrong with him.3 ’Shorter’s conclusions identify reasons why the long winded story of what happened prior to being unwell was a part-of-the-history-taking.22 He reflects that doctors were hugely reliant on the psychological dimension, as therapeutic perspective was poor the focus of the doctor was to concentrate on understanding the disease and-diagnosis; hence adopting-a cathartic consultation.22 Contrastingly to other fields of medicine as Hutchison mentions, observations are important, but don’t take precedence as he believed20. Thus consistently, physicians passed comments; ‘child miserable’, on appearance; ‘well nourished’, ‘child looks awful’, on mental thinking; ‘backward’ ‘very bright’, on personality; ‘lively’ ‘quiet’, and emotions; ‘child playfully happy’. Occasionally, this would be an initial presenting statement; ‘very thin poorly nourished child, pale not puffy’, ‘fretful or tired’, but frequently was categorised into the ‘condition on admission’. This is significant in envisaging the state of mind of the patient and doctors interpretation on children’s non-verbal communication; ‘child semiconscious, knees drawn up’.3 It identifies combination of observation and examination cemented a close physical rapport with the patient.20 Yet there were no recording of the child’s views. The mothers influence was certainly evident; ‘mother says he is very disobedient at home’ for a boy presenting with chronic constipation. In cases of rickets, histories were orientated towards diet and home conditions; ‘neglected child’.3 Although, analysing the same diseases in 1935 by two different physicians identified differences in the extent of comments they made on patients. Transitions of history taking Alterations in emphasis on parents’ narrative in 1968 records are apparent with more detailed focus approach on symptoms. ‘bad cough…..non productive’, ‘keeps him awake at night’. Notably, diagnosis was written at the end rather than at thefront of the-notes, asserting that through careful history-taking and-investigations, an-accurate-diagnosis could be obtained. Although, observations of patients remained; ‘looked unwell’ … ‘fussy with food’…..looks peaky; ‘lively little girl’ ‘very irritable girl, resenting examination’.3 In reflection, historiography analysis identifies parents narrative was predominant in periods 1900-1939 and altered in emphasis on medical detail in 1968. This view is in conflict with historians such as Fissell who found doctors to be greatly focused on the disease rather than the patient in the-mid-18th century.17 Similarly to my findings, Shorter found 1930’s was a period of strong reliance on listening to the patient as therapeutics was poor. But changes arose in the 1950’s where there were views of doctors being uninterested in patients.22 This marked the-period where therapeutic-perspective was much greater; which may be a cause for less influence of the parents’ history within the 1968-notes;
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expressing historian Warner’s’ view that therapeutics was core to the-doctors’ profession.23 Increasingly, patients felt doctors were too preoccupied in treating diseases rather than listening to them. This was supported by the noticeable abbreviated style of history taking.22 Additionally, Dr Sinclair a retired paediatrician who also felt many professionals very much focused on investigations and-treatment; acting as ‘authoritative figures’.3 This not only created a greater barrier, it flawed the patients trust in the doctor. Furthermore, paralleled by the apparent effect of media and knowledge from experiences of families and communities, the-parent became more questioning against doctors wishes; ‘patient well but still referred’.3 Shorter addresses ironically how this period saw high rate of court suits for malpractice.22 Social-Issues In 1938, Dr Mackay shows elements of concern for social care when she was faced with issues of neglect under the care of a-neighbour. She even goes as far as to say that the ‘history is unreliable’, and observed, ‘the child was undernourished, pale, tired, seems unhappy’.3 Through hospital admission she noted the child was much happier. They traced the mother at a-mental hospital to arrange alternative care with family, thus indicating the extent of care that happened at this hospital where the doctor had to engage in all elements of care. This was further confirmed by Dr. Sinclair’s observations where doctors had to do their best for the patient and had to ‘take matters into their own hands’.3 It draws on the beginnings of needs of social care of children which appeared in the 1940’s.24 Importantly, this again conflicts to an extent with historians such as Jewson and Fissell’s findings of doctors’ attention to patients as test results and examples of a disease. Indeed, the integration of the-social elements is evidence to show doctors concern for the patient’s well-being. Discussion: What insights can we gain into practices of 20th century children’s health using clinical case notes? It is essential to reflect how practices of medical record-keeping changed in order to appreciate the medical record as it is today. Primarily, Warner and-others used medical-records to reconstruct medical practice.23 Ultimately, my approach is unique in focusing on changes in the records themselves-as representations of patients and disease. Furthermore, the discussion focused on three-main-aspects drawn from the case notes use and discontinuation of diagrams, consent forms and practices of record keeping in relation to the patient and parent as persons (rather than only disease cases) with individual and social characteristics. This is significant in relation to history of medicine where these issues have not been addressed in a collective sense and towards paediatric care. Paediatrics differentiates from other specialities by the need to build a relationship with parent and patient, so we have been able to gain an insight into the doctor-parent element. Thus, Shorter’s concepts in the doctor-patient relationship illustrate reasons for my findings. The modern 1930’s period highlights the psychological role of the physician; evident by a greater influence of the parents’ history and the post modern 1950’s period; with medical advance in treatments evident by emphasis on medical symptoms with social issues referred to the relevant Children’s Officer. 22 Concerning the availabilities of hospitals’ notes, there was a
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REVIEW good range and quantity from 1900-1930’s, fewer notes for the 1940’s, no notes for the 1950’s, and-few in 1960’s and 1975. I have provided estimations of notes as guidance of the amount of records I analysed.3 Moreover, such limited availability of notes was a presenting feature in-this research. Access to records from other institutions was not practicable within the time-scale and some were destroyed by environment or-too fragile. Thus, comparison between QEH and other children’s hospitals could provide a better insight into these elements. My research was largely focused on using clinical case notes, I understand that they may not be representative of all hospitals and I appreciate that physicians’ practice may vary. Yet it is an avenue for historical investigation to investigate discrepancies between clinicians.5 Indeed Paediatric Medicine is a branch where clinical skills are tested to the utmost in terms of maintaining a relationship between parents and children and to be flexible in dealing with the range of ages. Through using the trend of clinical case notes, we have been able to draw on a range of practices that depicted twentieth century paediatric care, fundamental to shaping the branch as it is today.
Sinclair for his time in providing an insight into his own experiences of paediatrics
Acknowledgements: Many thanks to Dr Andrew Mendelsohn, Jonathan Evans and Dr Chris Derrett for all the guidance, advice and support. I thank Dr
9.
For references see thelsjm.co.uk.
References 2. 3.
4.
5. 6.
7.
8.
d
Et ci al
hics conc
ern s al
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Weed,L(1971) Medical Records, Medical Education and Patient Care, Ohio Press case western reserve Risse,G. Warner,J(1992) Reconstructing clinical activities patient records in medical history, Society for the Social History of Medicine 5(2):183-205 Case Notes from Volume 1and 2 1900/ Dr Helen Mackay 1935,1938,1939/ Dr Sydney Owen1915,1924,1935,1938,1939,1946 /Microfilms Clinical files 1968,1975 Queen Elizabeth Children’s Hospital, Royal London Hospital Archives Centre and Museum, QE/M/11,QE/M/11/27, QE/M/11/41,QE/ M/11, QE/M/13 Dr Mackenzie 1894-95,Royal London Hospital Archives Centre and Museum, London Hospital, Royal London Hospital Archives Centre and Museum LH/M/13/1-3 Dr Williams Royal Brompton 1881, Royal London Hospital Archives Centre and Museum BH/M/1/20 Parents admission consent register,1932-34,1935-37,1937-38,193840,1940-42,1947-49, Royal London Hospital Archives Centre and Museum QE/M/8 Minutes of the QEH Medical Committee (subsequently Medical Advisory Committee 1881 – 1981, Royal London Hospital Archives Centre and Museum QE/A/5/71 - 91. Minutes 1928 - 1935 Royal London Hospital Archives Centre and Museum QE/A/5/74. Minutes of the hospital’s House Committee. 1929 - 1936 Royal London Hospital Archives Centre and Museum QE/A/4/26-27 Dr.Leonard Sinclair,Personal Communication,30th April 2009 Retired Paediatrician Chelsea and Westminister Hospital 4Viner,R Golden,J (2000) ‘Children’s Experiences of Illness’ In: Cooter,R (ed) Medicine in the 20th century, Amsterdam,Harwood Academic pp.575
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Should the private conscience of a health professional interfere with their professional duty? Uaama Sheik
Year 4 Medicine, University of Leeds um06uqs@leeds.ac.uk doi:10.4201/lsjm.hle.011 Abstract: Many doctors believe that in modern medicine, central to which is patient care, there is no room for the doctor’s conscience. At the same time, more and more doctors choose to assert their right to a conscience when faced with contentious issues such as abortion. Under current professional body guidelines, a conscientiously objecting doctor must refer their patient onto a doctor who will provide the service. This complicates matters for doctors who feel that the referral could be construed as a step in the facilitation of an unethical act. There are several possible ethical justifications for both views and I aim to look at the arguments surrounding this issue. What is conscience? The idea of conscience has different connotations for different people. For some it is an inner sense of right or wrong, evoked only when they are faced with a difficult decision, whilst for others this same sense continually guides their judgement and therefore defines the way they live their life. A person’s experiences, beliefs, upbringing and religion can shape their conscience, and also the extent to which they use it in decision making. This demonstrates the fact that a person’s conscience is part of their individuality and identity. It is because of this that we all hold different views and opinions, allowing us to be independent, autonomous individuals. The current stance on conscientious objection Conscientious objection is currently permitted by professional bodies, and in some instances, the law. The General Medical Council regularly updates guidelines on this issue, through its core guidance, Good Medical Practice. These guidelines specify that doctors always have to make the care of their patient their first concern. Therefore, physicians are not allowed to discriminate against their patients based on their own views, even if these conflict with patient’s personal views. However, in spite of this, doctors are permitted to refrain from carrying out procedures which conflict with their moral or religious beliefs, as long as some criteria are met. Conscientious objection is disallowed in the case of an emergency. In practice if a doctor is faced with a situation to which he conscientiously objects, the patient must be asked to see another physician. It should be confirmed that the patient has the relevant means to do so. Otherwise, arrangements should be
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made for this to occur on their behalf – the patient must never be left with nowhere to turn. The GMC does not stipulate to which procedures these guidelines apply, although the most common are abortion, abortifacient contraception and end of life decisions such as withdrawal of care. This guidance applies only to performing the actual procedures and the doctors are not exempt from undertaking medical care of the patient before or after the procedure (1). Furthermore, in 1993 the British Medical Association adopted its current policy of supporting doctors who wish to conscientiously object to certain procedures (2). The BMA stress that doctors who do object should not be professionally marginalised in any way. Although the above are professional body guidelines only, a doctor’s right to not participate in abortion is currently protected under UK law in section 4(1) of the Abortion Act, 1967. Protecting the doctor’s right to conscience There are many reasons a doctor might object to performing an abortion. The most common is the belief that life begins at fertilisation and that an embryo is a ‘potential person’ – that it is able to develop into a human being. Killing the embryo removes its potential to develop into a human being and this equates to killing which is morally wrong, as no one has the right to take life. Historically, the doctor’s right to a conscience and therefore conscientious objection has been maintained. Part of the reasoning behind this is that the proposition of conscientious objection is that an allowance is made in exceptional circumstances only. It does not mean that doctors who exercise their right to conscientiously object do so to anything they find distasteful or unpleasant. Rather, it is a mechanism to uphold their convictions, guided by their conscience, in cases where they are asked to perform procedures they find to go against their moral judgement. The simplest argument to support this view is that if it is possible to accommodate the views of doctors, then why shouldn’t we? As the current system stands, the continuity of care is ensured, and no options are withheld from the patient. This means that their health does not suffer in way, other than perhaps the patient being inconvenienced in having to go to another doctor. It is important to consider that whilst abortion is legally allowable, it is not always true that what is legal is ethical, in the same way that what may be ethical is not always legal. Asserting one view onto everybody can be considered unfair. Many of those opposed
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to conscientious objection argue that doctors should not let their conscience affect the care of individual patients, and should instead raise this objection at a national or legislative level (3). However, most conscientious objectors realise that not everyone holds the same views and that it is perfectly acceptable to have opinions which differ from others’. Therefore, these doctors are happy to respect their colleague’s views, in return for their own views being tolerated. This diversity of opinion is also important because it allows the medical profession to reflect some of the views inherent in society. Abortion is an issue towards which different people have different attitudes, and for the medical profession to reflect this can only be a good thing. It is not entirely inconceivable to imagine a pregnant woman, who conscientiously objects to abortion, wishing to seek out a like minded obstetrician. Finally, although it can be argued that doctors with moral views against abortion, religious or otherwise, are likely to impose them onto their patients, there is nothing to suggest that the same isn’t true of doctors without such beliefs. It is not possible to be fully impartial when advising patients on any matter, and learning to suppress ones own convictions to respect the views of others is a skill, one which is unrelated to conscientious objection. As previously mentioned, religion can be a major influence in the formation of conscience. As such, many strict Christian, Jewish and Muslim doctors may be against abortion where there are no necessary medical grounds. If the right to conscientious objection was revoked, competent doctors may be driven out of their roles. In addition, revocation of this right may lead to conscientiously objecting doctors to avoid entering specialties like obstetrics and gynaecology or general practice, even though abortion may only make up a small part of the job. At a more extreme level, capable students may refuse to enter the medical profession if there is no allowance for contentious objection, negating the GMC’s desire of a “diverse medical student population” (4). This would be a great loss to the medical community, because these students and doctors may otherwise have good qualities which lend themselves well to the profession. As mentioned previously, a person’s conscience is shaped by their beliefs and values. Therefore by applying their conscience to their work, these doctors are seeking to treat their patients in what they believe to be a moral way. It is impossible to apply this ideology in an inconsistent manner depending on the treatment being provided. To dissociate conscience from the practice of medicine for the purpose of patient care is either impossible or problematic. For example, withdrawing the right to conscientious objection, which equates to removal of the doctor’s personal conscience, may be the first step in the path to doctors becoming subservient
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to the state. If a doctor loses the right to make decisions based on their own best judgement, they are reduced to mere automatons, in place solely to follows orders. The patient places their trust in their doctor and hopes that their best interest will be kept at the heart of the doctor-patient relationship. If there is no allowance for the doctor to deviate from set guidelines, patient care may suffer. In relation to this argument, if a doctor has no conscience, it becomes much easier to lose other virtues such as integrity and honesty, which are essential to the practice of medicine. It is not difficult to imagine that few patients would want to be treated by a doctor without a conscience. Withdrawal of the right to conscientious objection would create a discrepancy between the United Kingdom and other democracies. In the developed world, wherever there are contentious issues, there are opt-out clauses or the right to conscientious objection, such as with physician assisted suicide in the US state of Oregon (5) or with euthanasia in the Netherlands (6). No room for conscience in medicine Although there is no harm in having a conscience or using it to make decisions, in medicine, the patient’s requirements, beliefs and best interests should be central to the doctor’s actions. Medicine revolves around the principle of beneficence, doing what is best for the patient, disregarding the interests of the doctor or anyone else. Conscientious objection complicates this. Arguably it is not in the best interest of a pregnant woman wanting an abortion to wait to be referred to a different doctor because of the beliefs of her current one. Furthermore, by allowing conscientious objection, we are forced to accept the views of others, for fear of offending them. If this continues, will anyone speak up if conscientious objection borders on discrimination? After all, one person’s conscience may be another’s prejudice. A doctor’s conscientious objection may cause distress, anxiety or even offence to the patient. In the case of abortion, a doctor’s refusal to perform the procedure may cause the patient to have doubts over their decision, and may leave the patient unwilling to see another doctor. Objection towards abortion could also harm the doctor-patient relationship and the patient may no longer feel comfortable coming to the same doctor, even for an unrelated problem. This may be especially true as some patients might feel that they were judged by the doctor because of their personal, religious or moral beliefs. Furthermore, by opting out of abortion training and not participating in the procedure, doctors could be left in the dark about some important aspects of abortion, post-intervention care
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pregnancy is an increasingly common procedure and doctors will come into contact with countless patients who will have had an abortion in the past. Those who have conscientiously objected may not be able to provide the best care possible to such a patient, having never been exposed to the issue before. The decision to conscientiously object also affects colleagues. It leaves them to carry out more of the tasks which may be considered unpleasant or objectionable; this inequity may lead to indignant coworkers. At this point, it is also important to consider the reasons for conscientious objection. A doctor who refuses to perform abortions on religious grounds alone is more likely to have his views respected, whereas a secular doctor with just as scrupulously thought out reasons against abortion might not have his objections regarded as highly. A rising numbers of conscientious objectors could soon mean that there will not be enough doctors to carry out the increasing numbers of abortions demanded. In 2007, the Royal College of Obstetricians and Gynaecologists issued a statement highlighting the concern regarding potential future shortages of doctors to carry out abortion (7). Increased waiting times to have an abortion are hardly in the patient’s best interest. In some parts of the world, such as southern Italy, abortion is often unavailable to patients seeking it, because even though it is legally allowable, the number of conscientiously objecting doctors is too high (8). Should the current pattern of more doctors choosing to not perform abortions continue in the UK, the same situation is not entirely
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unimaginable. It has also been documented that women undergoing abortion have been refused services by many individuals such as nurses, pharmacists and even hospital transport and catering staff (9). It seems logical that if there is allowance for conscientious objection in one group of professionals, namely doctors, then it is reasonable for these other groups to demand similar rights. This would cause an increase in the number of staff refusing their services, further exacerbating the shortage of abortion services described. In addition, there is little official monitoring of the reasons that doctors use to object to abortion. It may simply be that many doctors who find the procedure distasteful use conscientious objection as a way of not having to perform it. Having parity across the board by disallowing conscientious objection altogether would remove this potential problem. A doctor who conscientiously objects to abortion will never be able to provide impartial advice to patients on this matter. The powers of persuasion are always likely to be at play, even if subconsciously. This again negates the principle of beneficence, as the best interests of the patient will not be the main concern of the doctor. It can be argued that if a doctor feels particularly strongly against certain procedures, he should make every effort to choose a career path which does not come into contact with these procedures. Medicine encompasses a wide range of specialties, some of which are unlikely to present with morally debatable issues like abortion. Doctors can minimise problems for themselves, their colleagues and their patients by choosing their speciality wisely. Some ethicists, like Julian Savulescu, suggest that conscientious objectors should raise their objections at a national or legislative level (3). If someone strongly believes that abortion is morally unacceptable, they should believe this regardless of who performs it. Therefore, instead of continually letting their views impinge on their relationship with patients and colleagues, they should aim to seek a long-term resolution by engaging in debate with the public and the government with a view to alter policy. Clash of rights Ultimately the argument over conscientious objection simplifies to a conflict of rights - the rights of the patient to receive the healthcare they require and the rights of the doctor to not do anything against their moral judgement. On the one hand, the patient is simply exercising their right to receive healthcare which is in their best interest, without feeling discriminated against or judged, a right enshrined in law. After all, one of the founding principles of the NHS was providing care that meets the need of patients, shaped around the patient’s preferences (10). The doctor, paid by public funds, has a duty to
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fulfil the requirements of the patient. Conversely, the doctor too has a right to make decisions regarding his actions and it seems unjust to compel him to do something to which he is opposed. The patient is provided full freedom of choice regarding treatment they do or do not receive, and the same should be applied to doctors with regards to which treatment they do or do not provide. The European Convention on Human Rights serves to protect freedom of thought, conscience and religion (11); rights which extend to doctors too. It can be argued that a balance can be reached as the patient is presented with the option to receive the same healthcare elsewhere. For this reason, in this situation, the law and professional body guidelines side with the doctor’s right. Doing Wrong vs. Facilitating Wrong As previously discussed, the current guidelines for conscientious objection to abortion state that provisions must be made for patient care to be handed over to a doctor who is willing to perform an abortion. This leaves open the matter of facilitating wrong. By objecting to perform an abortion, the doctor has acknowledged that he wants to be exempt from an act which will cause the death of the foetus, which is he considers to be an immoral act. As many ethical decisions are made using the principles of intention, it is fair to suggest that this principle can be applied to the situation of abortion too. By referring the patient on to someone else, the doctor is facilitating, in his own view, an unethical act. Although facilitating the unethical act is not the same as doing it, arguably, the difference is minute. In this scenario, the doctor may not have had the direct intention of killing the foetus, but the doctor’s action is one of the contributing factors which will eventually lead to the abortion. I therefore think that in this situation, the difference between doing and facilitating wrong is not a large one. Some might argue that the gap between doing and facilitating wrong widens if the facilitation is not certain to lead on to the immoral act. This does not seem to apply here, simply because if a patient has come to a doctor for an abortion, it is likely that she has already made her mind up, and in the time that she waits to see another doctor, she is unlikely to change her mind. Consequently, I am led to believe that where abortion is concerned, facilitating wrong can be just as morally questionable as doing wrong. It seems that it would only be morally acceptable if the doctor refused outright to be involved in the abortion procedure; this however contravenes the professional guidelines set out by the GMC and the BMA, and also the law. Conclusion Conscience is an important aspect of our individuality, and at first sight it may seem that it should not be constrained in any way.
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However, not all conscience is the same. As with anything else, in private matters no one has a right to interfere with an individual’s conscience or the decisions that individual makes with respect to their conscience. However, when the impact of a doctor’s decisions starts to impinge on the care provided to patients, we need to reconsider the right of the doctor to unrestrainedly conscientiously object. There may be a case for allowing conscientious objection in some situations, such as outlined below. For example, some argue that conscientious objection is only acceptable when the “ethical values on which it is based correspond to values in medicine” (12). In the case of abortion, this may be relevant to doctors who feel that abortion for social reasons is equivalent to killing. Undeniably, this is indeed in conflict with one of the intrinsic values in medicine. However, it is feasible that some objections may not correspond to values in medicine in any way, but are still just as strongly felt by the objector, and so personally, I feel that this view of conscientious objection is incomplete. Another situation where conscientious objection should be permissible is where the doctor has a well founded claim for objecting to something in conflict with their moral or religious beliefs. Here, the objection should be respected, so long as the individual is able to substantiate their claims to prevent misuse of this allowance. It must also be ensured that the correct protocol is followed with regards to ensuring continuity of care. Various sets of criteria have been set out by different ethicists to judge conscientious objection; one such criterion suggests that the objection should be serious, sincere and consistent. Also, the objector should reciprocate similar respect by accepting others’ views (13). Such a system may be a good starting point towards a standard which must be fulfilled before a doctor can object to performing a procedure. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Personal Beliefs and Medical Practice. General Medical Council; 2008. Conscientious objection and doctors’ personal beliefs. British Medical Association; 2008. Savulescu J. Conscientious objection in medicine. British Medical Journal. 2006;332:294-7. Rubin P. Core Education Outcomes: GMC Education Committee. 2006. The Oregon Death With Dignity Act: A Guidebook for Health Care Professionals. 2007. Termination of Life on Request and Assisted Suicide Act (The Netherlands). 2002. Abortion crisis as doctors refuse to perform surgery. The Royal College of Obstetricians and Gynaecologists (RCOG); 2007. Dickens BM, Cook RJ. The scope and limits of conscientious objection. International Journal of Gynecology & Obstetrics. 2000;71:71-7. Beal MW, Cappiello J. Professional Right of Conscience. Journal of Midwifery & Women’s Health. 2008;53(5):406-12. National Health Service: Core Principles. Available from: http://www.nhs. uk/aboutnhs/CorePrinciples/Pages/NHSCorePrinciples.aspx
For full references see thelsjm.co.uk.
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