This article appears in the May 2006 edition of the Catholic Medical Quarterly

General Medical Practice: the Problem of Co-operation in Evil

Mike Delany

1. Introduction

Few would question that, for the Christian, these are trying times. Most areas of life are tainted by the spirit of a post-Christian culture. Manifestations of this range from sharp practice in business to widespread corruption of the family ideal and increasing sexual licence. `Faced with this, we may develop an envy for the cloistered life but, without a religious vocation, might instead seek an 'existence in the secular world which engages - at least - a pseudo-cloister. This may provide blanket protection from temptation and an unsullied feeling; but refusal to engage the world inevitably results in failure to evangelise it; having buried our talents, we could find ourselves empty-handed when account is finally rendered. The Christian life does involve risk.

The medical world springs readily to mind as representative of modern attitudes to the ultimate value and purpose of life. Pope John Paul II spoke of a "culture of death"; it is clear from statistics alone that the medical profession leads as a proponent of this trend: current WHO figures estimate a global abortion rate in excess of fifty million per year. There are, in addition, numerous other practices which threaten human life, directly or indirectly, from its beginnings as well as in maturity. The question must then be asked whether a practising Christian can survive in the profession and retain the nobility for which medicine was once renowned. Can he or she faithfully observe the principles of the Hippocratic and Judeo-Christian traditions in their entirety and remain free to pursue a medical specialisation of his or her choice? I would say that, for a GP, the answer is in the affirmative, but not without emphasising how morally precarious the situation may become. Further, the minefield we need to cross is not merely one of particular moral transgressions but also the rather more ensnaring danger of a disabling scrupulosity. For the greater part of the time, the evil in which we might co-operate presents itself starkly, and the means to circumvent it may be obvious; but increasingly complex procedures in the realm of reproductive medicine in particular, coupled with often irregular relationships between the sexes, threaten to catch us unawares. With this in mind, I believe our starting point should be an authentic perception of a deeply personal God, a perfectly loving father who seeks not to outwit us by multiplying and complicating the dilemmas we face but, rather, yearns for our sanctification in and through the practice of medicine. Struggle is vital, and surely needs tobegin with a concerted effort properly to inform the conscience by familiarisation with authentic Church teaching on morality. Concurrent with this, ongoing ascetical formation with constant recourse to prayer and the sacraments will serve to nurture the intrepidity required and protect us from discouragement when we fall short of perfection.

2. The current situation in general practice

The debate continues as to the wisdom of socialised medicine as we know it in the UK. There does seem to be a consensus within general practice, though, that fifty plus years of the National Health Service (NHS) has inclined many to an over-dependence on, and even abuse of, medical services which remain free at the point of contact. Recent government initiatives on waiting times and accessibility threaten to compound and exacerbate this trend. For individual GPs, the end result is spiralling stress; it is within this context that a Catholic will incur the additional tension found when confronting society with the teachings of Christ to which it is largely hostile.

For a GP, conflict of interest is inevitable in those areas relating to contraceptive services and reproductive medicine. At a time when most Catholics as well as society in general contracept, an authentically Catholic approach in medicine represents a genuine voice in the wilderness. In the light of this it is prudent to approach the medical consultation armed with a set of well planned strategies which will suffice in the majority of challenging situations likely to arise. There will continue to be uncomfortable moments and embarrassment, but these can be minimised.

3. Gaining acceptance in general practice

As an undergraduate in medicine, I took university life to be an authentic microcosm of the real world. Involved in pro-life campaigning and known to be a Catholic, I experienced frightening skirmishes with radical political groups which openly attacked the Church, and its stance on abortion in particular. The prospect of a lifetime spent working against such pressures became daunting but, within days of beginning my first paid job in medicine, it became clear that men and women engaged in the serious business of earning a living simply did not have time to pursue political ideologies in the workplace. What we in fact have to contend with is more a sense of indifference and bemusement on the part of our colleagues. I have yet to see evidence of an orchestrated campaign against Catholic doctors.

In the UK, general practitioners are subcontracted to the NHS and tend to form small business partnerships which mostly emerge as lifelong professional relationships: these, it is often said, have to be approached with the caution appropriate to choosing a spouse. The uppermost question for prospective business partners is whether they can work together in reasonable harmony. If we take, as our only agenda, Catholic teaching on abortion, contraception etc. we will inevitably raise hackles at interview to the detriment of our chances of being hired. Having failed even to be employed, we find ourselves in no position to further the mission of the Church within medicine.

In my experience, the key to acceptance as a Catholic in general practice lies in presenting ourselves as good and competent doctors through what may initially be a non-confessional approach. By first of all establishing a rapport on common ground, the way can be opened to candid discussion of those areas likely to present moral difficulty for us. Once we feel things to be progressing favourably, it may be time to drop the Humanae Vitae "bomb". The initial response is likely to be one of disbelief: the provision of contraceptive services, in particular, is now such an integral part of general practice that it would seem impossible to work in the field without it. The first attack then has to be followed up with a salvo of enticements designed to turn the tables. My own strategy was to explain that a clearly displayed notice would be placed in the practice reception area politely advising patients that I would not be providing contraceptive services. This tends to avert the open conflict which could arise where the Pill, for example, is denied to a patient. I went on to explain that I did not wish to share in the practice profits derived from family planning; I did not expect to carry a lesser workload and would happily see extra general medical patients who would otherwise have been seen by my colleagues now engaged in additional family planning work. These measures do, I believe, have the effect of demonstrating consistency of belief, as well as providing a small financial incentive to prospective business partners.

The above strategy has worked well for me personally. There may have been good fortune involved initially, but after five years in an essentially secular practice, I have been left free to practise as I wish and have not encountered major complaints, although, undeniably, some level of background anxiety does persist.

4. Frameworks of medical ethics

In a certain sense, when seeking to practise medicine guided by Catholic principles, we will not clash with any formalised set of opposing principles because, at undergraduate level, medical ethics is taught either badly or not at all. Mostly we encounter a random cocktail of situation ethics not guided by absolute moral norms. However, where there has been a defined study of ethics in the secular realm, it is likely to be based around the four principles formulated by Beauchamp and Childress, of Beneficence, Non-Maleficence, Respect for Autonomy and Justice. Their definitions are as follows:

1. Beneficence	The obligation to provide benefits and balance benefits against risk.
2. Non-Maleficence	The obligation to avoid causation of harm.
3. Autonomy	Respect for the decision-making capacity of autonomous persons.
4. Justice	The obligation of fairness in distribution of benefits and risks.

These seem to me to be open to interpretation to some extent. What, for example, does avoidance of harm imply if harm itself is not defined according to absolute criteria? The advantage of this vagueness is that a free interpretation of Beauchamp and Childress's thinking, which identifies with Catholic teaching on morality, is feasible. From this, I would suggest that two basic guiding principles can be derived:

To act always in the best interests of the patient - in the light of Church teaching on morality. This of necessity implies avoidance of harm in Christ's terms.
To respect the autonomy of the patient - ie the freedom to accept or reject treatment and advice offered and ultimately to seek a second opinion from a doctor of his or her choice unobstructed.

5. Key areas of conflict

Because all except immediate emergency services are designed to be accessed initially via GPs in the UK, we find ourselves dealing with many more situations of moral import than do doctors in most other disciplines. Requests for contraception are made direct to GPs, who will also be asked to make referrals to specialists regarding abortion, sterilisation, IVF etc. Additionally, GPs may be expected to continue treatments initiated in the hospital setting but required to be maintained in the community. There are increasing varieties of procedures and medications which are not in accordance with Catholic morality; I have identified five broad areas of difficulty which can be expected to arise regularly, and challenge a Catholic GP. These are:

Abortion
Contraception
Sterilisation
Some infertility investigations and treatments
Erectile dysfunction treatments for the unmarried.

5.1 Abortion

Contrary to what might be expected, abortion requests do not constitute the greatest difficulty. In terms of the 1967 Abortion Act, most cases do not fulfil the stated criteria of legitimacy and remain essentially unlawful; we may therefore decline requests on purely legal grounds. The Act seeks to legitimise abortion where two doctors are of the opinion that either:

(a) "The continuance of the pregnancy would involve risk to the life of the pregnant woman or of injury to the physical or mental health of the pregnant woman or any existing children of her family, greater than if the pregnancy were terminated"

(b) "there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped."

For us who are obliged to do no harm, we simply cannot, in good conscience, countenance the notion that the killing of an unborn child could do other than harm to all concerned: it could never benefit either the mother or her born children. Scenarios in which there is a direct threat to the life of the pregnant woman are rare, although there may be occasional situations when removing, for example, a diseased, pregnant uterus or a fallopian tube damaged by an ectopic pregnancy constitutes a lifesaving measure. However, history reveals that hard cases make bad law, and in any case, such procedures do not qualify as abortion but have, as an unintended secondary effect, the death of the unborn child.

My approach to the patient requesting abortion or any other illicit procedure, for that matter, isto view the situation as I would any other medical consultation: I have training in medicine alone and can only offer a medical opinion. There are few, if any, circumstances where I am prepared to bow to a patient's demands without first considering the implications for all concerned: only where I conclude that my action will not constitute moral or physical harm either to myself or the patient and will be in his or her best interests do I proceed. This principle applies as much to prescribing antibiotics as it does to weightier matters. So, I begin by taking a history and performing whatever examination or further investigation is appropriate; I am then in a position to discuss my findings with the patient and propose a course of action. This may produce an opportunity for a change of heart capable of sparing mother and child the abject misery of abortion, but seizing this opportunity requires effort. As already mentioned, these dramas of conscience are often played out against a backdrop of the stress inherent in general practice which, although of little moral import, serves nonetheless to heighten tension. The consultation may very well be one of twenty or more crammed into a morning surgery. Conjuring sufficient time to deal effectively with a young woman contemplating her difficult or unsupported future as a mother is often extremely challenging. It may be that a purely operative type of charity is called for when we discover, confronted with real life, that the warm sentiment we experienced at a stirring pro-life rally gives way to the onerous burden of fulfilling professional obligations in far from ideal circumstances. Sufficient time to address the concerns of a reluctant mother-to-be is of paramount importance.

In the limited time available at a first consultation, I begin by outlining what I am able to offer: I will do all I can to provide support throughout this pregnancy and facilitate connection with other services available. Where this is not well received, I allow the patient to direct the consultation. If she persists along the lines of seeking an abortion, I share my experience of treating the aftermath of this procedure. An explanation of the possible physical and highly probable deleterious psychological sequelae is information to which every patient has a right. As with any surgical procedure, the doctor is obliged to inform fully of the nature of the procedure and the risks entailed. If no change of heart emerges, I invite the patient to discuss the matter with loved ones and return tome as often as she wishes, having first emphasised that, as a doctor, I do not feel abortion to be in her best interests and cannot support her in that choice. Sadly, few are swayed, and most simply ask how they should proceed with obtaining an abortion referral - it is here that delicacy is required if complicity is to be avoided. The first precept of doing no harm has been honoured; the rather thornier issue of respecting autonomy follows. My own response has been to lean heavily on the time-honoured principle that all are entitled to a second opinion from a doctor of their choosing. I do not have an obligation to arrange that second opinion and, in any case, I would be likely to choose a doctor who shared my view, which could be construed as an infringement of autonomy. My approach is to inform the patient of her right to seek a second opinion and leave the rest to her. Invariably there is minor friction and exasperation on her part as I repeat my advice that where and from whom she obtains a further opinion is a matter entirely for the patient. Frequently asked whether she can see one of my colleagues, I reply that she certainly can but again she chooses. Almost inevitably, this is what does happen: she consults one of my colleagues who will almost certainly comply with her wishes.

It is an uncomfortable feeling to be rubbing shoulders with the evil of abortion, but I am satisfied that I am not complicit in it and grateful that I do at least have some opportunity to attempt averting it. Up to now, I have received no major complaints; those that have arisen were more to do with a clash of personalities than the principle being upheld.

5.2 Contraception

There may have been genuine, if misguided, good intentions behind the liberalisation of contraceptive services in the 1960s. What was not foreseen by its proponents, however, was widespread sexual promiscuity and social devastation as the family began to disintegrate. Most people born after about 1970 will have been raised on the principle that contraception is a good and sensible thing for all, married or otherwise. To oppose this notion is to incur ridicule or even malice. Whilst the majority will respect a conscientious objection to abortion, few can comprehend an anti-contraceptive mentality as a logical corollary. A steady nerve is required in the realm of contraception and all that follows in its wake - ie sterilisation, IVF etc.

As already outlined, in my own practice I have sought to construct a protective mechanism efficient at deflecting contraceptive requests on most occasions; when the system fails, a patient requesting (usually) the Pill will present.

In many cases, simply informing the patient that I am not a family planning doctor brings the consultation to a swift and mostly amicable conclusion where the patient leaves to seek an appointment with a different doctor. However, some persist or even insist and thereby avail themselves of my medical opinion which, after all, is the only thing I have to offer. Proceeding then through the usual protocol of history, examination and special investigation, I arrive at my conclusion that I do not believe contraception to be in the person's best interest. This may provoke an immediate and angry response or, possibly, prepare the way for a discussion of the philosophical principles underpinning Catholic teaching in this area; there may even be an opportunity to introduce the possibility of natural family planning (NFP) as an alternative. Other than this, the consultation evolves as with abortion matters: the patient is advised of my opinion and informed of the right to seek another elsewhere.

Where contraception is concerned, tempers fray more readily than with abortion matters, tending one to feel a greater sense of humiliation and ridicule on the receiving end of the common response. However, complaints are unlikely to be sustainable where autonomy has been observed and the all important second opinion left unobstructed.

5.3 Sterilisation

Most women of child-bearing age who read my advisory notice regarding contraception will conclude that the umbrella extends to surgical sterilisation but, since the notice is addressed to female patients, men will tend to slip through the net. Interestingly, the man's response, when denied this particular request, is more one of disbelief than anger; he finds himself unable to apprehend the notion that the snipping and tying of a couple of tubes should have such moral significance. But, as ever, I have been approached in my role as a doctor and therefore respond accordingly - history, examination etc. My conclusion, of course, it that vasectomy is not good for men. Once again, there may be an opportunity to explain why, but failing this, I proceed to an outline of what the operation entails, its potential side effects and the (mostly) extreme difficulty of reversal at a later time. Finally, I advise of the right to a second opinion.

5.4 Infertility

Without personal experience of an infertile marriage, I cannot entirely identify with the type of suffering incurred by couples in this situation. Certainly, from my observations as a GP, it appears to be profound. To anticipate children as the fruit of a marital union is natural and logical: when they fail to materialise, a sense of failure or of having been cheated may ensue. These sentiments may arise in individuals or couples of any social or religious background but, increasingly, overcoming infertility by any means likely to succeed is viewed as an absolute right. The child has been commodified, and it is this, along with the numerous morally abhorrent methods of achieving pregnancy, which render the field of infertility treatment so perilous for a Catholic doctor.

The key problems are raised by procedures which remove conception from the setting of marital intercourse and those designed to produce multiple embryos, with the inevitable loss of most. A GP will rarely be directly involved in the procedures themselves but will certainly be approached with a view to initial investigation and subsequent referral to a specialist who may engage the couple in morally illicit tests or treatments. A particular difficulty for the GP is the question of obtaining a semen sample. The post-coital test, which did not present moral difficulty, seems to be out of vogue today; most specialists will now recommend masturbation. To the majority, this is a trifling matter, but obviously it constitutes a serious moral transgression for a Christian.

When a childless couple or single person present to me, I will not, in most cases, be in a position to co-operate with infertility treatments. However, my practice is to view the problem in a wider medical context as perhaps a case of primary infertility but also, quite possibly, an indicator of other underlying pathology such as diabetes or even more sinister conditions; and, of course, psychological malaise should not be ignored as a potential precipitant. A thorough history and examination along with urine and blood tests and perhaps scans or X-rays are then perfectly legitimate or even obligatory, but an uncomfortable line has to be drawn where the question of a semen sample is concerned. We might be fortunate enough to live close to a centre willing to undertake the post-coital test but, most likely, we will find it necessary to explain our conscientious objection to the couple or individual - the question is what to do next. Having taken patients part-way through the investigative process, it would seem uncharitable suddenly to wash our hands of the situation. I have not entirely resolved this matter for myself but have the feeling that the most charitable way to proceed is with a referral for further investigation, having first advised both patient and specialist and I am unable to co-operate in certain of the tests or therapies which might be suggested.

Making such referrals is a difficult balance of potential harm and good. On the one hand, I am fairly certain that masturbation will be advised for semen collection, and the overall treatment of the couple is highly unlikely to meet the moral criteria of legitimacy established by the Church. On the other, whilst the couple do not have an absolute right to a child, they have rights regarding investigation and treatment of disease in general; I therefore feel that I have an obligation to obtain some form of specialist help for them. There is also the advantage that, by engaging with the couple, an opportunity to explore NFP methods aimed at optimising contraception rates might arise, as well as the chance to discuss adoption.

5.5 Erectile dysfunction

Requests for treatment of erectile dysfunction seem to be more frequent these days, probably because of the greater ease with which people feel they can discuss such intimate matters. The

condition has often been the subject of humour but, in reality, is a tragic loss of the integrity ofmarriage, particularly for young couples. As with infertility, erectile dysfunction may be attributed to a primary failure or some underlying pathology of organic, psychological or mixed origin. Once again, it is a medical problem requiring a medical approach.

Where is the moral significance in this? The answer lies in the variety of unions formed by couples at the present time. Many still marry for life but, with a divorce rate now exceeding one in three and with some subsequent remarriage, it follows that there must be a considerable number of marriages where validity is, at least, questionable. Consider further that co-habitation and civil marriage are commonplace, along with rising numbers of same-sex unions. And what of the single person who has relations with serial partners? The question is to which of these unions is it licit to restore erectile function. The answer is not straightforward but can, I believe, be simplified by considering erectile dysfunction in the separate contexts of a primary problem and one resulting from underlying disease.

Patients are likely simply to present with a request for Viagra or other treatments but, as already emphasised, their condition requires full assessment before treatment can be contemplated. A full medical and psychological history and examination are vital; these, together with blood and urine tests, may very well reveal a cause amenable to a treatment which effectively restores potency - no moral dilemma here: erectile function returns concurrent with health. Whether the individual now chooses to engage in illicit sexual intercourse is not the doctor's concern in terms of co-operation. The doctor has simply fulfilled his or her professional obligation to investigate and treat disease. But what of those cases where a thorough search for conditions, the treatment of which could restore normal erectile capacity, proves fruitless? In these circumstances, the use of, say, Viagra facilitates an erection on demand but does not restore overall health, only a facet of it for a brief period. Since the erect penis has only one function, the doctor may find himself or herself co-operating, if not directly, at least proximately in an act of illicit intercourse. So, the doctor is faced with the task of assessing the validity of marriage among patients.

During the earlier part of my career in general practice, I wrestled with this problem and felt that it might preclude working as a GP for me. However, after several years experience and having sounded various experts, I have, I hope, arrived at a solution which will suffice in moral terms. Firstly, since I have nothing other than medical training, I am not in a position to make a competent judgment on the validity of a given marriage. In a ten minute consultation, I cannot hope to ascertain what a marriage tribunal might take years to rule on. Further, it may be extremely offensive and damaging to pry too deeply into a couple's marital history. I believe, therefore, that the most good and least harm is achieved by a simple enquiry as to marital status; I accept the answer at face value, proceeding to treat the married and withhold treatment where a couple are unmarried, co-habitating or of the same sex. This again is an area where one feels the burden of personal humiliation, especially when a heightened emotional response ensues. However, recourse to the principle of respect for autonomy and the right to a second medical opinion is usually an effective defusing tactic.

6. Conclusion

The experience of continuing to practise medicine in an environment where the Hippocratic tradition, having been effectively turned on its head, has a surreal quality: we are deeply immersed in what is happening but somehow entirely separated from it. It is sobering to consider objectively the true nature of what is going on. For me, this came into sharp focus during my hospital career prior to general practice when I spent time as a junior anaesthetist. I remain indebted to the consultants I worked for who treated me very well and entirely respected my position as a Catholic. When assigned to gynaecology operating sessions I would obviously not anaesthetise for abortions or sterilisations; another doctor would take over, leaving me to wander the corridors or drink coffee whilst, the truth is, a baby was crushed and dismembered. When I returned to anaesthetise the next case, the blood from the abortion might still be drying on the floor. My co-operation in this was zero; in general practice, I believe my level of co-operation also to be either zero or very remote and indirect at worst and then very rarely. However, having to work at such physical proximity to the evil being perpetrated remains disturbing. The only alternative I see, though, is not to work as a doctor at all; this as implied in my opening remarks, would be to abandon ship and forego all hope of restoring nobility to our profession.

Catholic Medical Quarterly