This article appears in the Aug 2006 edition of the Catholic Medical Quarterly
A Medical Student’s Dilemma.
Does conscientious objection
extend to role-play and simulation where these are used for teaching in
the undergraduate medical curriculum?
I am currently in my 4th year of Medicine at St Elsewhere’s Medical School, on my last rotation which is Obstetrics, gynaecology and communicable diseases.
I am mainly writing because as you are aware, there are so many ethical/moral issues particularly when desiring to practice in line with the teachings of the Catechism. I am finding it very difficult to know what to do in some situations, for example the expectation that tutors have that all students are ok with the idea of promoting condom use for ‘safe sex’ or even more commonly, the oral contraceptive. Having not found anyone in my group yet who comes from a similar viewpoint, I am feeling more and more isolated in my beliefs and less able to verbalise them. This has its own problems because I feel that without support, I will be led to take part in practices that are away from the teachings of the Church.
I wanted to seek your advice about the issue of conscience. When asked to perform things like demonstrating how to use a condom, or issuing the contraceptive pill to a patient in a ‘simulated’ setting, is it wrong to do so? My conscience, perhaps not yet fully informed, says it is. But then I battle with the idea that if as a student you do not perform the things that are required from your course, then you may put yourself at a significant disadvantage in the OSCE exams, where these things are expected of you.
I am in quite a stage of cognitive dissonance doing this rotation and it feels extremely uneasy, bringing great challenge to my Faith and knowledge of what is right and wrong.
First Response, by Dr Andrew Papanikitas, GP Trainee, and recent author of “Get Through Clinical Finals: a toolkit for OSCEs”
Playing Devil's Advocate?
In my final year OSCE (objective structured clinical examination) I was given the following seven-minute scenario: A distraught woman (played by an actress) presented in the General Practice setting, asking for an abortion and an HIV test. She did not wish her husband to know about the consultation. She added that she was Catholic and was terrified that any of the above details might find their way back to her local community.
The first point I should like to make is that very few of the marks (if any) for this OSCE station concerned abortion counselling. Covered with assurances regarding patient confidentiality, a decent sexual history concerning the details of her sexual encounter and the likelihoods of having either acquired a venereal disease or of becoming pregnant was arguably more important. Finding out her values and concerns, and establishing her ideas concerns and expectations carried more marks than advice.
She had had a drunken sexual encounter with a businessman on a weekend away. Had she since had sexual intercourse with her husband? If so had she used barrier methods of contraception? The answers I received were ‘yes’ and ‘no’. She had not used a condom during her weekend filing either. The question represents valid data-gathering. I feel that it does not represent a promotion of condoms and it would certainly be negligent not to ask. The advice I gave was that she should re-attend for the relevant screening and a pregnancy-test. There was very little time to find out what the impact of positive results would be, but we arranged to have a further discussion. She was adamant that she wanted to remove all evidence of her weekend fling, but agreed to abstain from sex until the results of her tests were back.
When we came out of the exam, I overheard a colleague commenting in his Belfast accent, “That woman was no Catholic.” While I had refrained from promoting abortion and ‘ducked’ the issue of condoms, I was under no illusions that, had I ‘preached’ to the patient, or taken a directive line against barrier contraception and abortion, I would have failed the OSCE station. Indeed attempting to evangelise or standing in judgement over patients based on one’s moral or religious views was recently regarded by the GMC as behaviour which might call into question a student’s fitness to practise. In simulations and real life students and GMC-registered doctors have to respect the views and beliefs of their patients, even when they are wrong. Similarly however, a patient should not force a doctor to perform a service that the doctor objects to on moral or religious grounds. There certainly is no legal duty to participate in an Abortion unless life is in imminent danger or health is in imminent and grave danger.
Personally I have no problem with learning about or role playing through different forms of contraception, and counselling regarding abortion. The ‘duty’ to refer to a colleague if one has conscientious objection or believe the procedure is not indicated is buried somewhere in GP employment law and not made clear in the 1967 abortion act. Also one should bear in mind that if you do not believe someone satisfies the criteria of the abortion act, then there is no reason that that a second opinion will, unless you know the second doctor to be a proponent of abortion on demand. There is a certain amount of good which can be achieved. Abortion is often promoted as the only option in unplanned pregnancy, and alternatives and impact can be explored without promotion.
Knowledge of different forms of contraception allows for clearer information about side effects, and allows one to practise safe effective medicine. Another OSCE station I took involved taking a detailed contraceptive history from a woman (again simulated by an actress) who had broken her leg and intended to continue taking the combined oral contraceptive pill. The marks were for advising her that with her immobility, obesity and smoking, she was at increased risk of a deep venous thrombosis if she continued. I had no ethical qualms about referring her to her GP for further contraceptive advice, especially when she was uninterested in abstinence. The common scenario of the ‘Fraser’ competent fourteen-year-old who demands contraceptive advice represents an opportunity to make sure that a child is not being exploited by an adult (statutory rape). You can find out why she does not want her parents to know. Even in the worst case scenario where one cannot see a benefit to taking part in a simulation, role play, of teaching session, it is good for all doctors to know why others hold different views. The emphasis is on play when one plays devil’s advocate. The OSCE is not the most effective place to make a stand for one’s beliefs. However, the Guild should support and advise any medical student who feels that they cannot for reasons of conscience prescribe a treatment or procedure, real or simulated.
This is an important issue, and I would like to see some debate in the correspondence pages of this journal.
- General Medical Council Education Committee: Final Report: Strategic options for undergraduate medical education (consultation), section 90; A40-41, June 2006, Manchester
- Communication Skills (p13) and Ethics for OSCEs (p.12) in Papanikitas, Bahal and Chan, Get Through Clinical Finals, RSM Press London 2006
- Philip Howard and James Bogle, Lecture notes in Medical Law and Ethics, Blackwell Science 2006, arguably the fairest account of Students’/Doctors’ rights re: conscience
- Kennedy I and Grubb A, Medical Law: Text and materials, Butterworths, London 2000, refer to the NHS (General Medical Services) regulations 1992, SI 1992 No 635, Sch. 2, para. 12, also cited by Montgomery (see below)
- Abortion: Rights of Conscience, p.369-370 Montgomery J, Health Care Law, OUP, Oxford 2001
Papanikitas, Bahal and Chan, Get Through Clinical Finals, RSM Press London
Philip Howard and James Bogle, Lecture notes in Medical Law and Ethics, Blackwell Science 2006
Montgomery J, Health Care Law, OUP, Oxford 2001
Kennedy I and Grubb A, Medical Law: Text and materials, Butterworths, London 2000
Second Response by Dr Robert Hardie, Secular Franciscan, Retired GP but still GPwSI Minor Plastics
Christianity is radical and extreme as well as gentle and loving. We only have to look at the Beatitudes (1) and the lives of so many saints (notably the radical St Francis of Assisi) to see how we are meant to live. They followed the radical life of Jesus Christ Himself, who both redeemed us and left us an example of how we should follow Him. We are to be fearless in proclaiming His name and willing to take up the cross of discipleship and penance in whatever form or shape that turns out to be. The readiness to take up the cross of following Him and to be willing to receive insults for so doing is the noblest cross of all.
From my own sad experience I have great practical sympathy with the watered down views that in Medicine we all need to rub along together and should not rock the many boats that may put our reputations and careers at risk, but even from a secular view "This above all - to thine ownself be true". (2). How much more is this of absolute importance when the eyes of the world are watching and waiting for our example so that they too may have the opportunity to follow. Perhaps the lack of support for the Guild and all the greatness it stands for is due to the lack of radical, brave and exciting behaviour in public places.
Dear and precious student of the great and noble art of Medicine, with consecrated and hallowed ideals that protect the sick and weak and fight to preserve that precious gift of life, do not be intimidated by an increasingly sad European medical society that limps along in opposition to itself, one moment calling upon its gods to embalm its ancients in lipid lowering agents while offering to Moloch the lives of countless millions that are deemed unworthy by an equally sad political public. In the repeated words of John Paul the Great (and of God Himself) "Be not afraid".
Lord God of Abraham and Isaac and Jacob and of all our glorious martyrs, help us to show to an unbelieving nation your truth and love and the beauty of the teachings of your Holy Bride the Church.
Many years ago in a practice of Protestant Christians I refused to prescribe the OC Pill or refer for termination of pregnancy and eventually became impossibly marginalised for taking an interest in a Franciscan mission hospital in a part of the world immersed in the AIDS epidemic. Having left that practice, and against all advice I set up and advertised my new practice as a Christian practice abiding by Pro-life principles and the teachings of the Catholic Church and received about 99.9% respect (3) from my patients who largely did not share my views, but neither left my list. I retired amidst much criticism while refusing to sign the new GP Contract of 2004. I am not heroic but a wobbly worm wobbling along a path that leads to the Light. Years ago when I "came in from the dark and cold" of making repeated attempts to foul up my own life, and the lives of others, I was hit right between the eyes by the beauty and truth of Catholic moral teaching. The end result (finals etc) never justifies the means by which we get there. I had to learn this a hard and painful way. Catholic teaching insists that the means themselves are justifiable.
Dear Student, do not allow your conscience to be dulled or your principles to be compromised. Fight the good fight and win the crown reserved for you from the beginning of the world. Be as gentle as a dove but as cunning and as wise as a serpent (4) and by all means avoid situations that might put you unnecessarily on the spot, but do not lose your integrity. "The one who disowns me in the presence of men I will disown in the presence of my Father in Heaven." (5)Our future depends on you. You are our hope. Realize that "our strength is not in ourselves, indeed there is nothing in us that allows us to claim that we are capable of doing such work. The capacity comes from God." (6). March into the work place with the full armour of Christ (7), and also be fully equipped with alternative ways of dealing with patients, ways which are glaringly better than the pragmatism presented so often to us. Know that Natural Family Planning offers 99.2% method reliability (8) and as well fostering long term relationships between a man and a woman (9) known to the Christian world as marriage. On such long term faithful relationships the future of society depends as the family is the building block of Society. It was to help and protect the family unit that many of us became "Family Doctors" (rather than Primary Care Physicians).
- St Matthew Ch 5 v 1
- William Shakespeare. Polonius in Hamlet Act 1 Scene 3
- Not just a wild guess but an approximate calculation based on about 5 patients leaving the list solely due to my Catholic views over a 12 year period.
- St Matthew Ch 10 v 16
- St Matthew Ch 10 v 33
- St Paul. 2 Corinthians 3 v 4,5
- St Paul. Ephesians Ch 6 v10 onwards
- John and Evelyn Billings. The Billings' Ovulaton Method.
- As 4.