Unplanned and therefore unwanted?

This week in our staff meeting, we had a brief talk from a local charity which provides counselling for women in crisis pregnancies. Our patient population has a very high number of women who have had abortions, and many of these have had more than one abortion (this, despite the fact that of the 7 doctors I work with, only 2 will refer for terminations). This charity is, I would say, pro-choice but their approach to choice is that it should be a considered choice, and they do play an important role locally in identifying women who are being coerced into abortion (at the point where the woman has already checked into hospital for the termination) and supporting them in keeping the baby should they decide to do so. They also provide counselling to those suffering the consequences of abortion: women, men and family members. One of the reasons I do not mention their name here is that I do not wish to endorse them - yes, some of the work they do leads women to choose not to have an abortion, and too often the long-term consequences of abortion are ignored or denied - but the fact is that they support a 'woman's right to choose' rather than recognising the evil of abortion for what it really is.

However, something very interesting (or possibly horrifying) which was mentioned during the presentation, were some statistics around abortion, namely:

- 34% of women under 30 have had an abortion

- 10% have had more than one

- one third of pregnancies end in abortion

and then the one which struck me as most interesting

- 50% of pregnancies are unplanned.

It wasn't so much that the proportion is fairly high (given our contraceptive mentality in this country) but that the person giving the presentation felt that this was a surprise, as she said, 'given everything we know'. Well, the fact is, that we surely must know by now that babies never come when they are planned. I don't know anyone who can say, yes, our baby arrived exactly when we wanted it to. I know couples who have waited years (regardless of whether they had previously used hormonal contraceptives or NFP and really wanted children), I know couples who decided not to and then went through IVF and still didn't end up with children, I know a couple who got pregnant having slept together only once, the fact is that what we actually should know is that the contraceptive mentality is not working. If it was, then there wouldn't be so many abortions and so many unplanned pregnancies. And the fact that whilst 50% of pregnancies are unplanned, only (God help us, it's still horrific) 34% are terminated means that an unplanned baby is not necessarily and unwanted baby, therefore why this conviction that planning is everything, that we must be in control of absolutely everything? 

I generally think that abortion debate comes down to the fact that people don't recognise that the unborn child is a person. But from these figures, and the accompanying attitude, it is presumably about our desperate desire to be in charge of the universe.

Professor Dawkins and the increase of the sum total of happiness

Poor Professor Dawkins has apparently caused a furore on twitter after tweeting, to a woman who said that she would face a serious ethical dilemma if she found she was pregnant with a baby who had Down's Syndrome, that she should abort it. He seems suprised by this. His apology, as reported by the Guardian, seems to be an apology for causing a riot rather than for what he actually said, claiming that those who objected did so from an emotional point of view, that twitter did not give him enough space to put his whole argument across and that because of this he left himself vulnerable to wilful misinterpretation.

However, the thing that really bugs me about this is that Dawkins claims that his response is totally down to logic. According to the Guardian, he wrote: "If your morality is based, as mine is, on a desire to increase the sum of happiness and reduce suffering, the decision to deliberately give birth to a Down's baby, when you have the choice to abort it early in the pregnancy, might actually be immoral from the point of view of the child's own welfare." I take issue with this, and in fact, I am frequently irritated by people who claim that anyone who disagrees with them is arguing emotionally, and that they themselves are basing their argument purely on logic. 

• If your morality is based, as Professor Dawkins' is, on a desire to increase happiness and reduce suffering you should presumably never say anything that might offend anyone because offense generates suffering, even if this is a subjective response. 
• If you believe that this life is all there is, that there is no life after or other than this one, then the abortion of an unborn child would presumably decrease the sum total of happiness, seeing that without life there cannot be happiness.
• If your aim is to increase the sum total of happiness rather than the happiness of the individual, and given the amount of great joy which those families express regarding their children with Down's Syndrome (and indeed their children without Down's) then presumably the termination of a child would not increase happiness and the reduction in suffering (given the absence of the child and the effects on the family) could well outweigh the non-increase in happiness.
• Given that people who are objectively suffering can experience happiness, and that people who are happy can suffer, suffering and happiness are not necessarily opposed and therefore the aims to decrease the former and increase the latter may, in fact, be conflicting.
• By extension of his argument that it is immoral to maintain life where there is suffering, all those who suffer from any illness, or indeed with the potential to suffer from any illness, however short or long term, should be exterminated because their existence may lead to their own suffering or the suffering of others.

Given the logical outcome of his moral framework, perhaps it is time to reconsider the starting point. If the outcome is outrageous and not what he intends at all, perhaps that is because some of his reasoning is based on an emotional understanding of happiness and suffering. 

Eugenics, ante-natal testing and choice

Some time ago I blogged about testing for Down's Syndrome. Now, there is news about some other genetic disorders: namely Patau and Edward's sydromes. Like Down's Syndrome they are due to trisomy - where a person has three copies of one of their chromosomes instead of the usual two - caused by random genetic mutations. Like Down's Syndrome their risk increases with maternal age. And like Down's Syndrome they can both be detected by amniocentesis. Now, according to to this article, earlier testing will become available.

 

Now, women will be able to make important decisions earlier on, says the article. There is only one important choice that we are allowed to make, as women. Everyone tells us so. When we talk about women and choice we are talking about the choice not to. The choice not to have a child who is less than perfect, the choice not to have a child with less than perfect timing, the choice not to have a child who doesn't fit into our plans, our budget, our lifestyle. We are not allowed be radical, or make sacrifices (except of our fertility). Whilst screening for such conditions could allow a family to prepare for a disabled child, perhaps learn more about what their condition entails and engage with support services available before the baby is born, this is not what is implied. The fact that many unborn children with these conditions will not survive to full-term is a tragedy and I do not wish to negate the suffering caused by such events. But abortion is not the solution. It will not mean the baby does not suffer and it will not mean the parents do not suffer. Earlier testing will not lead to better choosing or better preparation or more research about why such things happen, it will only lead to more deaths as we gradually seek to eliminate every single inconvenience (and especially inconvenient people) from our world.

In co-operating with evil, where is the line between reality and paranoia?

Yesterday, my brother Andy* and his girlfriend sat down and filled out a mortgage application. Every so often I was asked my opinion about what I thought certain questions were getting at. I did my best to answer them but mostly, given my total ignorance of mortgages, credit cards and money in general, I pointed them in the direction of more reliable answers. I found myself wondering whether I should refuse outright, be rather more non-comittal or launch into a lecture on how co-habitation is not in God's Plan for them, despite the fact that my big-sisterly-omniscience apparently doesn't extend to morals. Andy and Gertrude** plan never to marry (G wouldn't mind if A insisted, I am told, but A is against it) or have children (A would secretly like to but G is vehemently against) and wish to buy a house together so that they can live happily ever after. My other brother, Chris, married Adele*** earlier this year, and prior to this they had been cohabiting for two years in the house they bought together. Now, when Chris told me the two of them were moving in together I expressed my concern and talked about it with him. He was unreceptive, but there was no animosity. Chris and Andy are extremely different in their openness to different ideas, and Chris at least has some basic appreciation for Christian morals. It was worth a try. With Andy there would be no point.

This issue of what counts as co-operation has been on my mind for some time, and I have a tentative plan to follow up my post on healthcare professionals and the law with one on conscience. Here's the deal: Pharmacists have a conscience clause in our Code of Ethics. We can refuse to do something if it is against our moral or religious beliefs. However we must "make sure that if your religious or moral beliefs prevent you from providing a service, you tell the relevant people or authorities and refer patients and the public to other providers". In general, among pharmacists, it is agreed that a conscience clause is a good idea because healthcare professionals constantly have to make difficult decisions about what the best course of action may be. However, the fact that we have to refer the patient to another provider rather makes a nonsense of it: I won't give you the morning after pill but my colleague here/over the road will.

 

I often have conversations with people about how we should handle these ethical dilemmas. For practical purposes I think it is virtually impossible for a Catholic pharmacist to work in community pharmacy (ie a shop) because although 'Emergency Hormonal Contraception' is not an essential service under the NHS community pharmacy contract, it is locally commissioned by PCTs and unless you have the luxury of owning your own pharmacy its unlikely that you would be in a position to say that the pharmacy won't have anything to do with it, and in any case you would still have to tell the person where to access said service. In hospital pharmacy it is a bit easier to pick and choose what field you work in. Most hospitals do not supply contraceptives to in-patients (for obvious reasons), but if a patient is usually takes hormonal contraceptives, you still need to clinically check that prescription. So then what? Is clinically checking when you aren't going to supply a problem? Even if you work in geriatric medicine there is still the dispensary slot, the on-call time when you can't hand over to a colleague. Leaving scripts to one side for other pharmacists to handle is practically a hanging offence. One friend and I were shocked to hear that a consultant simply passes over the ethically problematic patients. For us, that is not how it works. Some people would say they wouldn't dispense Viagra, in case the person was not married, or having an affair, or other immoral behaviour...but surely there comes a point when you have to give someone the benefit of the doubt. What if the person is married and erectile dysfunction is placing a huge strain on their relationship? How far can we go down this line of thought: should we even be working in the NHS?

 

What should we be doing as Catholic pharmacists or other healthcare professionals? Where should we go and work? I don't think the answer is for us to seek out fields of healthcare without ethical dilemmas, because that would also limit our opportunity to transform all of the temporal order which is in contrast to the Gospel (always supposing such fields exist). And I think we definitely need Catholic healthcare professionals. Must we just accept that our career options will be limited, our colleagues will mistrust or despise us and that we end up doing an unfulfilling job because we need to provide for a family?

 

Answers on postcard, please.

 

*Not his real name; if I use a psuedonym myself I'm hardly going to reveal his identity.

**Obviously not her real name, but follows a pleasing pattern known only to myself.

***Likewise.

In the public interest: Law and the healthcare professional

As I understand it from a quick look at the coverage of the CPS's seemingly (wait for it) bizarre decision not to prosecute doctors involved in sex-selective abortions, apparently this relates to two doctors (abortionists) who were asked to carry out terminations on the grounds of the child's sex, but did not do so and were not planning to do so. Prosecution is deemed to be not in the public interest, and better dealt with by the GMC. My Hunt has apparently referred the case to the attorney general. Leaving aside the matter of whether doctors who have not and do not intend to carry out illegal activities need to be disciplined by their regulating body I have been thinking about law, what it is for, and how healthcare professionals should and do see it.

 

I may be naive, but I have come to the conclusion that any laws we have should, at root, be in the public interest. Whether they protect or promote the rights of a minority, the majority; or regulate the workings of organisations; or stipulate the responsibilities of groups and individuals, all laws serve the public interest. This is not to say that I think all of our laws are right merely because they are laws, but our elected officials have made these laws on our behalf, and therefore they (the laws) presumably exist because of a belief that they are needed and are in the public interest. Therefore it is no great leap to conclude that those who break laws are not acting in the public interest. And, because of the way that the law operates, those who break laws receive some form of punishment, and perhaps the opportunity for public atonement (damages) or rehabilitation depending on the circumstances. (These consequences are, in theory, also in the public interest.) A quick flick through 1897-1927 of the Catechism reassures me that I'm working along the right lines here.

 

It would seem, then, that prosecuting those who break laws is in the public interest, by virtue of what law itself is. I removed the word 'always' from that sentence because I can see that spending a large amount of public money prosecuting a child who stole a bag of sweets from a supermarket would not be, and there is such a thing as legitimate protest which often necesitates a certain amount of disruption. Of course, in this case the Abortion Act, which permits abortion, is an unjust law and therefore not binding in conscience as authority has broken down (cf. CCC 1903), but I don't think that this immorality clause applies to the parts of the Act which are morally right (that is, abortion is basically illegal, according to the rule of law). I am not a lawyer or a theologian and if anyone would like to expand upon, clarify, or correct any part of this they should do so and welcome.

 

As an undergraduate I sat through a lot of lectures on Law relating to Pharmacy. Pharmacists are the 'guardians of medicines' and therefore at undergraduate and registration level we are required to pass exams which require intimate knowledge and understanding of the law (it should be noted that while the university standard is 40% for a pass, for the pharmacy law exams it is higher - I think 70% but I can't actually remember). The Medicines Act 1968 arose following the scandal and tragedy of thalidomide; along with the four other Acts we studied, the majority of this law is about making sure that only the people who need and/or are entitled to possess lethal, or potentially lethal, substances are able to do so. For pharmacists, and by extension for other health professionals, the law is important. And not just the law directly relating to our work: last month a pharmacist was struck off for stealing controlled drugs (codeine, morphine) to feed his own addiction, but a pharmacy technician was also suspended from the register for benefit fraud.

 

Healthcare professionals make life and death decisions on an hourly basis. Sometimes we pharmacists may not even realise the import of our actions, as we re-write the scrawled prescription, annotate the dose, check the patient's allergy status, cross off the duplicated items and manage the drug interactions (collectively known as 'supporting safe and effective prescribing'), but they really are that serious. We need laws which help us in and underpin those decisions because of the magnitude of those decision and the power we derive from our ability to make them. If laws are, in themselves, in the public interest then flagrant disregard of those laws by the very people who should be serving the public, in their capacity as healthcare professionals, is a grave matter indeed. Given that it is held that such people must respect the rule of law outside their professional field in order to function with integrity within their field, then surely a breach of law which impacts directly on their practice must be prosecuted in the public interest and for the public good.

Sterilizing our children

This week there have been two articles worth mentioning in the news about contraception and teenagers.

The first is from the Telegraph and gives the details of girls as young as 13 being given contraceptive implants (effective for 3 years) and injections (3 months) at school, or in clinics, without parental knowledge or consent. First of all, I believe that patient confidentiality is essential, regardless of the age of the patient. However, confidentiality is intrinsically tied to consent: the person consenting is entitled to confidentiality. All medical treatment (legally this includes contraception - Medicines Act 1968) requires informed consent, and those under 16 can only give informed consent if they are deemed to be Gillick competent. Competence varies with every individual and intervention and I do not believe that any teenager, however smart can be deemed to be competent where a long-acting contraceptive is concerned. We see enough adults who struggle to conceive after years on the Pill; I cannot see that a teenager, who is unlikely to be considering the probability that they will one day want to have a family, would be able to give informed consent. Actually, come to think of it, there probably aren't many adults capable of giving fully informed consent to such an intervention, but unfortunately we aren't subject to the same criteria. If you are consenting to contraception, that assumes that you are consenting to sex, and that requires a level of psychological and spiritual maturity, not just intelligence. As such, not being competent, they cannot consent and therefore they are not entitled to confidentiality.

Secondly, we have an age of consent in this country which is 16. Why do we bother if promiscuity is going to be encouraged in this manner? Who are these 13 year olds sleeping with? Granted, there may be a small proportion who seek contraception as a badge of honour (a GP I knew who also worked in a Family Planning Clinic told me that she was somewhat plagued by teenagers who wanted contraceptives for the purpose of having them rather than using them), a rite of passage if you will. But given all the concerns over internet grooming and child abuse should we not be asking more questions? Teenage girls are not usually interested in boys their own age; even if a girl is 15 and her boyfriend is 16 that is still illegal.

This strategy is derived from the desire to decrease the incidence of teenage pregancy (I get it) at all costs (I don't). Given the current rates of STDs, especially the chlamydia epidemic, why aren't we thinking outside the box? What we need is a culture of openess: parents should not be their childrens' best friends or their worst enemies, but children should be able to talk to their parents. And the only guarenteed way to prevent pregnancy and STDs is through abstinece and I do not think we can promote abstinence without teaching young people about their own intrinsic dignity. Of course we have a problem in that we are now in the 2nd generation of permissive behaviour, the belief that freedom is all about doing what you want when you want, and the total absence of God which leads to seeking value in pleasure.

The other article states that girls are choosing the pill over condoms. Around 2006, the student newspaper in Manchester published the results of a survey which found that female students didn't want to go on the pill because they didn't want to be considered "easy". (It also discovered that a significant proportion of students believed that it was not possible to conceive whilst standing up, which says something about the level of education they had received, but I digress.) This suggests that they were not considering the pill because they were already in a sexual relationship but because they were expecting to have what I think could be termed 'random' sexual encounters. Someone who knows you is not likely to be judging you on being easy.

What am I bothered about? Well, firstly, these articles are about girls. No-one is talking about boys. Granted there are not so many contraceptive options available to them, but it appears that the current strategy is completely targeted at young women, and comes from an anti-life basis rather than the promotion of health and well-being. There was recent outcry when it was proposed that girls be taught abstinence. I agree that it is rather ridiculous, because boys also need to know about their dignity and worth (and sadly, teaching only one half of the population about abstinence would likely lead to an increase in the use of prostitutes). It could be argued that girls choosing these longer-acting forms of contraception are sleeping with their long-term boyfriends. But I think it could equally be argued that actually what is happening, extrapolating from the prevailing attitude of Manchester undergraduates, is that at least some girls are effectively sterilizing themselves in the expectation of casual sex. It is time that sex education was based on something real (anything! but preferably good anthropology) rather being completely out of context and taking sex out of context. Bring on existential sex education.

Help required

EllaOne, the morning after pill which works for up to 5 days after (er...the 5 day after pill?), is now available from Co-op pharmacies without a prescription, the Telegraph reports. I'm feeling a bit out of the loop because I didn't know anything about this and apparently it's been around for a while now. I did a little googling and found that the Mail reported on it a couple of years ago.

The article in the Mail says that the manufacturers state that EllaOne can 'help stop an accident from becoming something more life-changing'. This is the first thing I would like explaining: how is having sex is an accident? I know that's not what they mean. It seems our brains are completely broken in this pleasure-seeking society. For one thing, accidents should make you stop and think, and then see how you can stop them from happening again, whether that means looking before you cross the road, fitting a stair gate or padding the corner of the cupboard where you always bang your head (maybe that's just me).
The Telegraph says that 250,000 women use emergency contraception every year. In 2011 there were around 190,000 abortions which is very slightly down on 2010. The morning after pill became available over the counter in 2001 since which time there has been a general upward trend in the number of abortions, which peaked in 2007 and seems to have remained stable for the last few years (although the number of abortions for non-residents is falling off, so actually the number of abortions for residents is increasing). However, considering that the goverment strategy of throwing contraceptives around is supposedly for the purpose of reducing abortion one has to ask what is going on: yes, the number of abortions has decreased slightly in women under 20, but this is more than compensated for by the increase among those in their 20s and 30s. AND 250,000 women take the morning after pill every year. It is clear then that increasing the availability of the morning after pill is not really affecting the number of abortions carried out.

Here are some reasons why this might be:
(1) It doesn't work. However, we should probably discount this one as it is demonstrated to be effective.
(2) The women who took the morning after pill weren't pregnant anyway. We have no way of knowing this.
(3) People have stopped using other forms of contraception. Difficult to say for sure without other prescribing data but would explain why chlamydia rates are rapidly increasing.
(4) Increased promiscuity - as postulated beforehand, and likewise explains STD rates.

 As STD rates are increasing so fast, I have to say that, sadly, (4) seems the most likely, which is reinforced by the general sexualisation of society which surely influences sexual behaviour. It would be interesting to see a breakdown by age of women taking the morning after pill.

As a final note 255,000 women died in 2010 in the UK. That means that EVERY YEAR APPROXIMATELY THE SAME NUMBER OF WOMEN TAKE THE MORNING AFTER PILL AS DIE! I grant you that there may be women who take the morning after pill more than once, and those who died are definitely exclusive, but still...doesn't anyone else find this a bit worrying?

Sometimes there are no shades of grey

A couple of weeks ago pro-abortion campaigners delivered 600 coathangers to the Department of Health in protest at Jeremy Hunt's supposedly pro-life views. Their concern is that if the abortion limit is reduced (not that anyone seems to have plans to do so) that abortion will become "illegal and unsafe".

As a young adult, I had rather contradictory views on abortion. I was convinced that the unborn child was a person, and arguments at what point exactly it became a person seemed deeply flawed to me. However, I also believed that it was inevitable that women would have abortions and therefore it was better for them to have legal access to abortion so that they didn't die in back-street abortions. In short, I subscribed to the 600 coathanger view.

I have long since changed my mind about this. I realised that if the unborn child was a person (and furthermore, if we cannot say definitively that it is not) then there can be no justification for abortion. The "people will do it anyway so lets make it legal" argument has long been applied from everything from prostitution to speeding and doesn't hold water: if something is objectively wrong then making it legal doesn't make it objectively right.

After reading about the coathanger delivery I started thinking about it again, and I realised that what really worries me is what it is that drives women to seek an abortion at all costs. Things have changed since the Abortion Act was first introduced. Single mothers, although obviously they have extremely difficult lives, are not ostracised from society. And if she really doesn't want to or can't look after a baby, then there are hundreds of couples out there going through IVF and surrogacy who do want to have a child.

I was reading a friend's column in El Colombiano yesterday, in which she explains that being pro-life isn't just about mindlessly shouting about something you disagree with, but that it is important to inform your conscience about why abortion is wrong. I then read the comments section. I try not to do this, it generally annoys me. What I found was that whilst the comments where anti-abortion, quite a lot of them said things like "there's no need for abortions in this day and age because we have contraceptives". (That is something that I still struggle with. I am 100% with the Magisterium on this, but it has been so well drummed into me throughout school and university here in the "geopolitical epicentre of the culture of death" that contraceptivees are the solution to all the world's evils that often it is the first answer to pop into my head. I choose to reject this answer, but it is still there.)

What we have lost here is love. Love of a mother for a child is surely the most fundamental kind, and if a mother can argue that her child is not a child, or puts her right to what she considers life over his or hers then we have lost something fundamental. And for those women who have abortions because they are desperate and struggling and genuinely see it as the only solution, well, they are also called to make a great act of love, and so are the rest of us, to support them (practically, spiritually, psychologically) in that love. And if, horrifyingly, a child has been conceived in rape then that woman is also a mother and she too is called to make a sacrificial act of love. Acts of love are not easy. We must die to ourselves, say no to our own comfort, our own plans, in order to love. And "dying to ourselves" is not just a nice turn of phrase: Jesus really died on the cross out of love. And that is the measure for which we must strive.

Not your body, therefore not your choice.

I frequently hear advocates of choice and abortion basing their opinions on the foundation that "a woman has the right to chooose what happens to her body".

To a certain extent that is fair enough. Subjecting patients to unwanted medical procedures is classed as assualt and battery, although interestingly refusal of treatment is said to require a higher level of competence than consent.

However, when it comes to abortion we immediately hit a massive stumbling block, nay, a wall: the unborn child is not part of your body. Yes, it needs your body, it relies on your body, but it is not part of your body.

Here are some medical facts in support of this statement.
1. The baby has its own DNA, from both its parents. Genetically distinct, he or she is a human being in his or her own right. The baby is not a limb or an organ.

2. The body has an immune system which attacks anything which is not its own. That is why organ recipients have to take immunosupressants. Aha! That proves the baby is part of my body! No, it doesn't. There are two privileged sites in the body. One is found in the eye and the other is the uterus. That is why if you have the lens of your eye replaced with a plastic one ("getting your cataracts done") or you are pregnant you don't have to take immunosuppressants.

3. Haemolytic disease of the newborn. This occurs when there is incompatibility between the blood group of the mother and that of the baby, which leads to the mother's body producing antibodies against the child's blood cells. This condition can cause haemorrhage of the mother and child and (I think) shows that the mother's body recognises that the baby is "foreign".

4. The baby is not a parasite feeding off your body. Parasitism is a non-mutual relationship between organisms of different species where one organism benefits at the expense of the other. The mother and child are clearly the same species.

If you don't want to fall down the slippery slope, don't go near it

Apparently we could soon have three-person IVF. At first I thought this had something to do with the three-person civil union which has been recognised in Brazil. But no, this is an entirely differnt kettle of ethical fish (dophin-friendly tuna, perhaps?). Genetic manipulation could result in babies with DNA from 3 different adults. Leaving aside the issue of IVF itself, the suppoosed medical benefits would theoretically be the elimination of genetic mitochondrial disorders.

The Nuffield Council on Bioethics highlight a number of ethical concerns but have given this proceduce the ethical OK - so long as it is medically safe - but Human Genetics Alert (a secular, independent public interest watchdog group) is concerned about the procedure leading to demand for genetic designer babies. They argue in favour of abortion on the basis that "the foetus is part of the mother's body" (a topic for another time methinks) but are against sex-selection because it smacks of discrimination and eugenics.

Frankly, I think they are right to be concerned. Despite being illegal, it has been demonstrated the sex-selective abortions are taking place for purposes of "family balancing" throughout the UK, (ie 'I can only afford to have two children and I've already got a girl so I need a boy this time'). Talking about the slippery slope may be a cliche but it should be obvious by now that if it is possible to abuse a technique in some way, then people will find a way of doing it whether within or without the law. With sex-selective abortion we have seen a step towards designer babies; with the ability to add the DNA of a third person into the mix, how long will it be before parents decide that they need their child to be taller, thinner, smarter, faster or better looking than all the others in their classroom.