The Future of Obstetrics and Gynecology:
The right to be trained and practice according to conscience

Hanna Klaus
Reproduced with Permission

MaterCare International and FIAMC (World Federation of Catholic Medical Associations) convened a conference under that title in Rome June 17-20, 2001. I was one of the presenters, and have been invited to summarize the conference for this audience.

The speakers who addressed this topic ranged from medical students and residents to practicing and retired physicians. They came from US, western and eastern Europe, Asia, Africa and Australia. All were Roman Catholic, shared the definition of conscience given in the Catechism of the Catholic Church, and wished to practice in conformity with principles which are spelled out, for instance, in the Ethical and Religious Directives of the U.S. Conference of Catholic Bishops, even though many came from other countries.

Until the paradigm shift in medical ethics brought about by the acceptance of contraception and later, abortion, Roman Catholics and those who shared their views on the inviolability of human life were not considered counter-cultural. However, in the last half century, those who refused to condone, let alone participate in abortion were quickly marginalized if they sought admission not only to post-graduate training programs in obstetrics and gynecology, but even entry to medical school. Soon, not so subtle discrimination extended to those who refused to participate in surgical sterilization or, even worse, prescribe contraception.

Several themes were identified as underlying reasons for the barriers to practice according to conscience

1. Laws do not protect the right to life of the unborn child. Consequences:

1. Essentially abortion on demand.
2. Manipulation and cannibalization of the human embryo and fetus
3. Coercion of women to abort by:
   • Boyfriends who do not want to assume the responsibilities of the paternity which they have in fact begun.
   • Families who for reasons of poverty, limited space or convenience refuse the assist the pregnant woman in raising her child, and actively object to the ongoing pregnancy.
   • Governments by subtle or overt pressures such as distortion of facts i.e. it's not a baby yet.
   • Clinic personnel who are often inadequately trained in counseling and act more like procurers for the abortion clinic's services than professional counselors. They frequently downplay the gravity of the procedure, fail to offer alternatives honestly, deny post-abortion grief, let alone post traumatic stress syndrome.
4. Professional marginalization of physicians and nurses who attempt to counter points A, B, C. In practice, conscience clauses do not protect physicians, let alone nursing staff, who object to abortion, and/or the manipulation of women when they are "counseled" to abort, often in the absence of honest consideration of alternatives.

2. Widespread misperception about the existence, effectiveness and utility of modern Natural Family Planning Methods. Consequences:

1. Only contraceptives are offered, limiting the patient's choice. Most often the effectiveness of contraceptives is exaggerated, while neither their side effects, or even mode of action are fully explained. If a physician is bold enough to offer NFP, (s)he is often ridiculed on the grounds that either the methods are not effective, or that the client is incapable of applying them properly.
2. If an NFP-only physician belongs to "mixed" group, where other members offer only contraceptives, either the NFP-only physician's orders have been changed by colleagues, or patients are steered away from this physician by staff.

3. Limitations of the health care delivery system.

Time constraints. Consequences:

1. There is insufficient time to counsel the woman properly about all options, be they concerned with family planning or the resolution of a crisis pregnancy.
2. Due to rotations for physicians in training, continuity of care is often lost. i.e. if a doctor starts to teach NFP to a client, (s)he won't see them a month later for followup. The next doctor may not know, or care, about NFP. See 4 B above also.
3. As far too many Cesarean sections are followed by tubal ligations, the resident who objects to participation may not get an adequate surgical experience. Alternatively, (s)he may be allowed to do the section but has to step aside and let another doctor perform the ligation. Not a comfortable situation at best, and always leaves the doctor wondering if his/her preoperative counseling was adequate.

4. Inadequate professional, philosophical, theological and legal grounding in basic principles not only by the student or resident, but often by departmental staffs, even in Roman Catholic Hospitals.

1. Functional ignorance re Ethical and Religious Directives, or, worse, a seeking of ways to circumvent them by persons in authority. There are cases of hospital mergers of R.C. and non-R.C. hospitals where for instance, women who deliver in the Catholic Hospital are then taken to a surgicenter on the premises for tubal ligation, a practice which is an obvious violation of the merger contract but sadly, has often been countenanced by authority (i.e. the Bishop)
2. The obligation to practice at the level of "reasonable skill and care of one's community" would appear to jeopardize the practicing Catholic refuses to prescribe contraception. If the paying field were level, which it is not, the obverse would be true: the physician who is ignorant of the efficacy and utility of modern natural methods of family planning would be judged below the threshold of competency.
3. Social and marketing pressure to try to be helpful to patients in accordance with the patient's value system, without averting to the fact that the physician must remain faithful to his/her own value system antecedently. The doctor-patient relationship is a fiduciary one, even though current terminology tends to mask it by referring to physicians as providers of health care, and patients as consumers. A patient is, by definition, ill, hence vulnerable, and that demands first, recognition of the patient's vulnerability, and second a commitment to serve only the patient's best interests. When there are conflicts, these must be recognized and resolved, without becoming either defensive or confrontational.
   
   It must be observed that fertility is not a disease, hence requires no medical treatment. However, the market forces which attempt to pressure women into ingesting potentially harmful drugs to alter their normal physiological state need to be unmasked and potential users much know the risks they may incur.

5. Remedies already begun:

1. More residency training programs allow for practical freedom of conscience without jeopardizing training opportunities. A great deal depends on the program director, and much more needs to be done.
2. More physicians have been exposed to NFP delivery systems, broadening the knowledge base considerably.
3. Recognition that fertility is not a disease, and that natural regulation of fertility can be learned from a trained instructor who does not need to be a physician or a nurse. The concept of NFP can be introduced even in the limited Time frame of an HMO appointment, and referral made for instruction.
4. In the U.S., the DDP/NFP has developed minimal standards for NFP instruction and programs which are professionally acceptable.
5. Certain groups are combining the natural signs of fertility with technical indicators, catering to a generation who are more apt to believe a piece of technology than their own interpretations of their signs.
6. Proactive chastity education for teens which includes fertility awareness. This serves both the present goals of maintaining chastity, thus avoiding STD's and premarital pregnancy and their emotional and spiritual consequences. They are also a remote preparation for marriage.

Remedies still needing to be applied:

7. More public enunciation of the superior value of a conscientious vs. a pragmatic ethical basis for practice. More than a century ago, it was thought to be dangerous to have a Catholic obstetrician in attendance in case he would have to choose between the life of the mother and that of the child, and by implication, that he would choose the child in order to be able to baptize it. This was nonsense, of course, yet it fell to Dr. Joseph B. DeLee, of the Chicago Lying-In Hospital, the father of modern obstetrics in the U.S. to change that dictum to "I will save the mother and the child. The opposite ethic prevails today, when too many physicians are willing to resort to abortion, selective embryo reduction, etc. under the guise of saving other babies. How can a woman entrust her life, or that of her baby, to a doctor who is willing to kill her - or another's - baby?
8. While good obstetrical care should prevent maternal injury and death, today over 600,000 women die annually of preventable obstetric death, while 15 times that number develop complications such in vesico-vaginal or recto-vaginal fistulae, women in many developing countries still do not receive timely intervention for obstructed labors. Corrective treatment exists, but does not reach all who need it.
   
   MaterCare International seeks to correct this by amplifying the training of midwives with a simple labor grid, to recognize labor arrests in a timely manner, and supporting fistula hospitals in several developing countries. Robert Walley, M.D. Founder and Executive Director plans a political approach to the G-8 meeting and an a-mail consulting service for physicians.

The recent address of Bishop William E. Lori, S.T.D., Bishop of Bridgeport, CT focused the topics cited above within the broader scope of ethics. A summary of his talk, “Six Critical Issues Facing Catholic Health Care” given in Washington, D.C. March 10, 2002, is provided.

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