Whose conscience is it anyway?

I was browsing my September issue of Regula+e, published by the General Pharmaceutical Council, which is the regulatory body for pharmacies, pharmacists and pharmacy technicians, when I came across this article about a pharmacist who had had conditions placed on his practice, by the Fitness to Practise (FtP) committee, for 'imposing his beliefs on patients' (pp24-25).

The pharmacist, during the course of supplying the morning after pill (EHC), told a patient that it was "a chemical abortion, was ending a life, and that this would be on her conscience". The patient was shocked and felt "rotten and horrible". He did not give her the option to go to another pharmacy.

Recently I blogged, among other things, about the weirdness of the fact that while pharmacists do not have to supply EHC, they do have to tell the patient where they can obtain it. This pharmacist didn't tell his patient where they could get EHC, because he did not decline the supply. Yes, apparently he was in the habit of giving what the FtP committee deem 'an embarrassing and distressing lecture' and then giving the patient the morning after pill anyway.

 

There seems to be a whole lot of weird stuff going on here. The FtP committee, for their part, merely have to judge whether a pharmacist has breached the code of ethics and, if so, whether conditions should be imposed or the individual removed from the register, so I'm going to ignore them. It's the behaviour of the pharmacist in question which puzzles me. If it was for moral or religious reasons that the pharmacist gave these speeches to his patients, why did he then supply EHC? What was he hoping to achieve? Was he trying to absolutely prevent evil (ie the patient does not terminate her pregnancy) or just avoid co-operating (the patient gets upset and goes to another pharmacy instead). But if the latter, why did he then supply? It is a mystery to me (although I recogise that I don't have all of the information about the case). And then there is the patient, who reported the pharmacist because he made her feel "rotten and horrible". I'm not saying the pharmacist shouldn't have been investigated, as his actions come across as a bit odd, to say the least: was this his usual manner of advising patients? But as taking the morning after pill causes side effects of headache, nausea, abdominal pain, bleeding and fatigue (very commonly), and dizziness, diarrhoea and vomiting (commonly), the 'rotten and horrible' feeling was somewhat inevitable, if only on a physical level.

 

Whether you, healthcare professional, go with a straight refusal to supply or a slightly more in depth explanation as to why not, or an attempt to engage the patient in discussion as to the rights or wrongs of EHC (or whatever other substance), do so with charity and professionalism! Haranguing the inidividual is unlikely to achieve anything, and following the harangue with supply even less.

 

Interestingly, one of the conditions imposed is that the pharmacist is not to supply EHC in the future. Sounds like good news all round.

 

PS My viewing stats passed the 10,000 mark this week. The list of referring sites may suggest to me that a lot of these views are not real people, but to those actual people who are reading: thank you :-)

Is grief a mental illness (and has anyone even said so)?

The American Psychiatric Association have published their new diagnostic guide (DSM 5) and according to quite a lot of people (just google it) they have classed grief as a type of depression. As far as I can tell (without actually buying a copy) this isn't actually true. What has happened is that they have removed the so-called 'bereavement exclusion' which said that major depressive disorder (aka depression) should not be diagnosed following a significant bereavement. They have also listed something called 'Persistent Complex Bereavement Disorder' as requiring further study.

 

Why does it make sense to remove this bereavement exclusion clause? Well, suppose you had got depression already and then a loved one died and you then sought medical help for your depression. You might not be able to get the treatment you needed because DSM-IV said you shouldn't be diagnosed with it and therefore your insurance company would not pay for your treatment. Maybe you didn't have depression before this event. Maybe you just had a tendency, or a past episode, or were just starting mild depression. Given that the causes of depression are not well understood, maybe you didn't have depression at all. The result would be the same. No DSM number, no drugs. As there don't seem to have been any other exclusions (such as job loss, divorce, or other severe stress) it makes sense (to me, at least) to remove this exclusion which might be preventing people who really need help from getting that help.

 

On the other hand, as there does seem to be a trend for doctors to overprescribe anti-depressants anyway, it does mean that there is now further potential to misdiagnose depressive disorders. Furthermore, evidence shows that many doctors end up prescribing as a way of ending consultations. Also, as all of this is taking place in the USA where prescription medicines can be advertised to the public (not allowed in the UK), there is a possibility that drug companies could target the recently bereaved, who will then go to their doctors demanding anti-depressants which they will be prescribed and which will not help them because they do not have depression, they are grieving. Due to the stigma attached to mental illness it might also mean that some people don't seek the support (by which I don't mean treatment) they need in their grief because they're afraid of the potential diagnosis. All of which begs the question: when did it stop being OK to be sad?

 

Or perhaps we are sadder than we used to be. With the loss of God from our culture, we have also lost the resurrection and life after death. Funerals are now termed 'celebrations of life' and even mentioning the deceased can be something of a taboo. Deciding whether to tell a friend or acquaintance that you are praying for them and their loved one presents itself as a dilemma (even if praying for them is the first thing you would do).  A friend of mine told me recently that after agonising for some time, she decided to offer her condolences (and prayers) to a colleague whose father had died, with the awkwardness of trying to broach the subject with someone she didn't know that well compounded by the fact that everyone else in the department would fall silent as soon as he came into the room. Some time afterwards, he told her that she was the only person at work who had said anything at all to him.

 

We no longer seem to know that it's OK to be sad. It is wrong, and therefore pathological, an illness. And in a way, there is something 'wrong' in that sadness wasn't part of the original plan: sadness and grief, like death, are a consequence of moral and physical evil. We have no idea how to talk about death. We worry about exacerbating grief, making someone sadder, or causing offence or embarrassment (as if brief embarrassment on either side could really be worse than the death of a loved one?!). So here it is (for what it's worth), my opinion about being sad: it's OK to be sad. And this may be the key to telling the difference between grief and depression. Grief is not an illness, it is part of life, just as death is.

Wombs to let: £28,000

I suppose a baby factory is the obvious successor to the egg bank, but it wasn't something I was expecting to come across in last week's Metro.

 

The most ridiculous aspect (and now I've said that I am torn as to which bit is actually the most ridiculous) of this article is Dr Patel's claim that she is carrying out a feminist mission. As the Anscombe Bioethics Centre wrote in their review of the Human Fertilisation and Embryology Act:

 

Surrogate motherhood involves a further fragmentation and trivialisation of parenthood, in that a woman deliberately becomes a gestational mother with no intention of committing herself to caring for the child she gestates. This practice is exploitative of both the woman and the child, and damages the way conception and gestation are regarded in society as a whole. If surrogacy cannot be prohibited altogether (the option we would prefer), commercial surrogacy, at very least, should continue to be prohibited. We do not believe that agencies should be registered with the Department of Health, as the Brazier Committee recommends, as this would constitute official endorsement of such agencies. (An analogy might be with the case of prostitution: those opposed to prostitution are rightly unwilling to accept the official registering of brothels, as this effectively legitimises their existence.)

 

Dr Patel is clearly exploiting women; of the £28,000 a couple pay for a surrogate mother, the surrogate receives less than £5,000. For 9 months manual labour (a 'physical job') the mother earns approximately 73p an hour (based on a 40 week pregnancy). And paying a woman for the use of her body is definitely analagous to prostitution. But hey, at least facilities are sterile!

 

And then we have the desperate couples who choose this option and are willing and able to pay. Are they not also being exploited to a certain extent (albeit in a design of their own making)? This is not a good way to have a family: I know of one woman who regularly tells people how much her IVF twins cost her, apparently believing that their grades should be better than those of other children because they cost more. As they get older, will she dictate to them on the basis that she paid for them? Isn't that a form of slavery? As always it is the child who loses: exploited by both genetic and surrogate parents.

 

We are now way beyond the start of the slippery slope: there are those who are 'too posh to push', those who choose the gender or disability status of their children. It would not surprise me if there were also designer pregnancies, where the pregnancy happens to another person, whether a woman is fertile or not. Is this the new feminist ideal: the exploitation of one woman to spare another some nine months of inconvenience? Even organs are not commodities to be traded, selected, bought, sold or even rented, so why do we seem to think that children are?

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.

Exciting happenings in Manchester this week

The first ordinations at the Manchester Oratory will take place on Wednesday at 5:30pm, with two men being ordained to the diaconate.

And the now annual Marian Procession through Rusholme and Fallowfield starts at 10.30am on Saturday 5th October. There have been about 1,000 people present at each of the last 2 years. Check out their video to find out more and if you live anywhere in the North West then go along and participate.



Please pray for all those involved in these two events (and for good weather on Saturday!).

Trivial problems with having 3 parents

One group of scientists have raised concerns that the three-parent IVF technique may lead to problems with fertility, learning and behaviour, the BBC reports. Other scientists say that the effects of a mismatch between mitochondrial and nuclear DNA must be trvial because otherwise we'd have noticed already. Aside from the fact that biologically we have two parents, and therefore I can't see why we would already have noticed, and the ethical minefiel (OK, so it's not a minefield because there isn't a way through, it's just a bomb shaped like a field) the political problems of having 3 parents should not be ignored.

 

My parents are divorced, my father is remarried. A lot of people are in this position. I get on fairly well with my dad's wife these days, but I rarely refer to her even as my stepmother, although she has referred to herself as a parent in relation to me. My poor sister-in-law has two women who consider themselves to be her mother-in-law (fortunately she is a keen cook and my brother is keen on eating so there is no danger of accusations of underfeeding). Between 6 step-siblings, we only have 4 names, which is a bit confusing at times. Birthdays, Christmas, funerals and now weddings require hours of discussion and planning dedicated to the 3 parent issue. These problems are time consuming, upsetting, complicated but esentially trivial: they do not touch on our identity. At least we are clear on who exactly our parents are, who we are and where we come from. To those who still struggle with these questions, and to those who are and will in the future be born as a result of 3 parent IVF and other bizarre human interventions, I offer the answer a friend of mine discovered as a teenager (very complicated remarriage situation): first and foremost, we are God's children.

A trip to the egg bank

On Tuesday the Mirror reported that an egg donor bank had opened in London; it has been operating on a trial basis since the beginning of the year. In my health news email digest, it stated that women would be able to choose characteristics of the baby, such as eye colour. (It has got a little more difficult to review these stories since the newspapers realised that people were accessing their articles free online and that they were clearly missing out and should start charging.)

 

Choosing eye colour might seem harmless enough, and I understand that a woman might well want a baby to bear some slight resemblence to her, but we have already seen the tragic consequences of sex-selection of babies, and allowing and encouraging any sort of picking and choosing definitely sets us on the path to designer babies. Having children is not a right, it is a privilege. Babies are not convenient: they do not sleep or smile or eat when we want them to, they are hungry and tired when we don't want them to be. They are people, and like all people they are creatures. We are created. We are fragile. We are dependent. There are some things that we don't get to choose because we are not in charge.

 

This was as far as I got when I actually went and read the Mirror's article. I was struck by the fact that the director talked about the 'needs' of people 'needing' donor eggs. Need is not the right word - children are a privilege, not a necessity. It would be more accurate to talk about desire and want. I also took note of the 53 year-old woman who said that she'd always wanted to have children but had never met the right person. There is in that statement a clear understanding that the 'right person' is a necessary part of the process of having children. There is no mention that she has now met that person, but she's decided to have a child anyway. In the same way that we have separated sexuality and procreation (see Humanae vitae and if you haven't read it, then read it) we have also separated the concepts of children and family. Sometimes there are ways of doing things which are just different. Other times there are right ways and wrong ways, and being created and finite we also don't get to choose what is right and what is wrong. We can choose whether to do right or wrong, between good and bad and frankly that is a complete misuse of the precious gift of our freedom. Right use of our freedom is using it to choose between good and better, not between good and bad.

 

It was at this point that I discovered the Telegraph's article on the same subject and realised how incredibly naive I am. It may be couched in terms of altruism, but this is not some benvolent institution, set up because of tragic needs which we cannot ignore (like, say, a food bank). The donors (something of a misnomer) will receive £750 for providing eggs. How long before we see young women funding their way thorough university by selling their eggs? And the profit margin is presumably quite high, as treatment (purchase of eggs) costs £10,000.

 

Whilst I have thrown words like right and wrong around, and asserted that children are a privilege and not a right, I do empathise with older women. And I do not wish to generalise or assume that it is only single women who seek IVF in later life, I know women who did not meet and marry their husbands until they were in their 50s and 60s and therefore never had children. My great uncle's second wife told me cheerfully that she had no regrets over not having met her husband sooner as he, a widower, had been married to someone else. There are also couples who are sadly, persistently infertile. Women are called to be mothers, whether biologically or spiritually, and the inability to answer that call for whatever reason must bring heartache. But we also need to remember that our actions always have consequences. The consequences of delaying children by prolonged, repeated use of contraceptives in order to advance a career, go on holiday more often and generally 'enjoy life' might be infertility. We are not in charge and we cannot have it all.