My own personal journey to becoming a medical missionary began when I finished secondary school and went on a short-term mission team to Ecuador. While we ran a Bible club for slum children a five-year-old boy, Juan, came to our attention. He had a gangrenous finger due to a neglected wound and it had to be amputated. I was shocked. I had seen poverty on the television, but now I was seeing its tragic effects first hand. It was no longer nameless faces suffering; it was happening to my friends.

Jesus’ words ‘From everyone who has been given much, much will be demanded,’ (Luke 12:48) challenged me to consider what I would do with the education, skills and spiritual blessings I had been given so generously. As I looked at the injustice in the world, the sick and suffering who had no doctor to go to, I knew I could not ignore their plight. I felt compelled to go and do something to help, however small it was in the grand scheme of things.

Sorrows

Going to work abroad long term does of course bring with it certain sacrifices. It means living far from your family and distance and time take their toll on even the best of friendships. It may mean missing out on a sibling’s wedding, or not meeting a new niece until she is two years old. There is no big salary or financial security. There are always frustrations to face – obtaining the revalidation of my medical qualifications in Ecuador took a whole year. There are medicines I cannot get hold of in Ecuador that could work wonders for patients; there are patients I could help who prefer to put their trust in the local witchdoctor. Living in an alien culture can be confusing and stressful, earning to communicate in another tongue is exhausting and there are times when you wonder if you’re achieving anything at all – if it is all worth it.

Another challenge is being professionally isolated, sometimes working with local medics whose ethos, ethics and medical practice are very different to your own. Patients die who would undoubtedly have survived had they been in the UK. You need to be able to cope emotionally and spiritually in an alien environment often with little compatriot support.

Joys

But if you ask me if it is worth it I would always, one hundred percent, answer yes. It is worth it when a patient I have been visiting for a year asks me to pray with them, sing them hymns and read the Bible to them on their death bed, commending them into the hands of their Saviour. It is worth it when I can play a part in making the life of a child suffering from AIDS that bit better and see the wide grin on their beautiful face. It is worth it when a patient brings me a (live) chicken to thank me for healing their leg ulcer, and they tell me they give thanks to God.

Satisfaction

Jesus warned us ‘Do not store up for yourselves treasures on earth, where moth and rust destroy, and where thieves break in and steal. But store up for yourselves treasures in heaven, where moth and rust do not destroy, and where thieves do not break in and steal.’ (Matthew 6:19-20) Following the more obvious root of a medical career in the UK may be more financially secure than leaving everything behind and setting off to another part of the world, but I can testify that I have never been in want. I have more than I need.

We live in a world full of people who are suffering and in need. Our God has a heart for the widows and orphans, the oppressed and downtrodden. He hates injustice. Yet in Britain we have 27 physicians per 10,000 population, whereas in many African countries they have less than one. Doctors even come to work in Britain from countries that need doctors far more than we do. We should all consider how each one of us can play our part in loving our neighbour, redressing injustice and reaching out to those in need, including those who live far away. Each and every one is precious to God.

Not everyone is called to serve overseas, but for those who rise to the challenge of long-term mission abroad, you will be embarking on a lifetime of adventure. You will be tried and tested; you will face difficulties and problems. But you will also enjoy moments of great triumph in adversity; you will find great joy as you serve your Saviour. You will see God at work. You will see lives transformed.

Andrea has written a book about her life and experiences in Ecuador:

Guinea Pig for Breakfast

Posted by Dr Andrea Gardiner

While a cup of strong coffee is probably the choice of drink for most people studying for exams, perhaps coupled with a

So-called ‘brain steroids’ or ‘smart drugs’ can be purchased on campuses, or off the internet, for a few pounds. By improving concentration, attention, memory and alertness, students are increasingly using them to study longer and perform better during exams. A report by The Academy of Medical Sciences in 2008 showed that even a small 10% improvement in a memory score could lead to a higher A-level grade or degree class, which is a big improvement.

Provigil, also known as modafinil, is licensed in Britain to treat tiredness associated with the rare sleeping disorders narcolepsy and sleep apnoea.  It can easily be purchased online. It gives a sensation of natural wakefulness for hours at a time, without the jittery buzz and disrupted sleep associated with caffeine.

Another popular choice is Ritalin, originally designed as a treatment for attention deficit hyperactivity disorder (ADHD). Both these drugs increase levels of dopamine levels in the brain, and the alertness and wakefulness of those taking them.

The journal Nature found large-scale use within academia as a whole, not just among students. Of 1,600 academics from 60 countries, one in five had used ‘smart drugs’ for non-medical reasons.[1]

Frequent news articles cite students who have used ‘smart drugs’ before and during exam times. See, for example, here, here and here.

It is not only students using these drugs.

The Ministry of Defence is a user. The MoD apparently bought more than 24,000 Provigil pills according to figures released in 2004.  Military purchases of Provigil peaked with an order for more than 5,000 pills in 2001, the year Allied forces entered Afghanistan. The next largest order – for more than 4,000 pills – was delivered in 2002, the year before troops entered Iraq.

The stimulant, Adderall, available in the US, has been used by athletes to enhance their reaction time, energy levels and performance, (but has led to some NFL players being suspended).

In the UK Provigil is apparently being investigated as an aid to maintain surgeons’ performance during lengthy, complex operations.

Some people regularly use cognitive enhancers to compete in their normal work and study environments, to help them overcome the stress, pressures and fatigue of a jetsetting and 24/7 society.

If these ‘smart drugs’ are a quick fix which helps us function better in our daily lives, then what could be the problem with them?

Are they really that different to a double espresso or pro plus pill?

Or are they more akin to illegal recreational drug use?

Is taking them cheating?

Will students who don’t want to take them start to feel coerced into doing so because everyone else is?

Will students using them miss out on learning discipline, perseverance, hard graft, personal effort and perhaps failure?

Will their use undermine personal achievements?

Are there side effects?

Are they addictive? (psychologically as well as physically)

The truth is, at this point we do not really know the answers to these questions. There are certainly warnings about the addictive properties and side effects of these compounds. No one really understands the consequences of long-term use of stimulants on the developing brain (which is particularly concerning as some of the most frequent users are young people).  At present, there is only scant data about off-label use.

The makers of Provigil warn of significant side effects such as heart problems, high blood pressure, skin reactions, serious allergic reactions, psychiatric symptoms.  And the more you take, the greater your risk of being affected and seriously harmed. We also know that the brain is a complex organ and a drug that improves performance in one aspect may hinder it in another. And we know that the effects of these drugs are short lived and may be limited.

In fact, some of the effects of their use may not be quite what was intended or hoped for.

One student says that rather than starting his essay after taking a pill, he instead organised his entire music library! He has seen others obsessively cleaning their rooms on it, not revising hard. The essays he wrote while on ‘smart drugs’ tended to be long-winded, with two pages given to creating an ‘airtight argument’ where a couple of sentences would have sufficed.

Is it possible to regulate these drugs?

Could GP’s or pharmacists become gatekeepers to accessing them?

Should universities and work places have policies on the use of these drugs, guidance on what is acceptable and what is not?

Again, difficult questions. Regulation of these drugs is certainly desirable, but not straightforward and, in practice, it is likely to be difficult to restrict access to cognition enhancers because most are too easily purchased off the internet.  But if there are no restrictions on their use, people will keep taking them to pass their exams and to stop getting tired.

I have explored in more detail in another article some of the dilemmas facing us today with these popular smart drugs, and have considered what a Christian response might be.

Christians understand that humans are of value not because of what we can do but who we are, made in the Image of God. Christians will also have a different perspective on achievement and performance. ‘But you, man of God, flee from all this, and pursue righteousness, godliness, faith, love, endurance and gentleness.’ (1 Timothy 6:11) God loves us as ourselves in our weakness, not strength. ‘God chose the foolish things of the world to shame the wise’. (1 Corinthians 1:27-29)

Technology, science and pharmaceuticals may all undoubtedly bring us benefits but will often come with real costs attached. We need God’s wisdom to weigh these up.

In the meantime, there are still the traditional, less risky yet still proven remedies for improving brain function for exams: a healthy diet, some exercise and sleep.

Posted by Philippa Taylor

CMF Head of Public Policy

Lord Falconer has finally announced that his long awaited assisted suicide bill will be tabled in the House of Lords next week on Wednesday 15 May.

It is then that we will finally see the full text of the bill which will then proceed to second reading (debate stage) sometime in June, or possibly in the autumn.

According to the BBC and Telegraph the bill will be based on the Oregon model – assisted suicide for mentally competent adults who have less than six months to live.

The timing has been carefully planned. On 13 and 14 May the Court of Appeal will be hearing the case of Paul Lamb, a 57 year old man with quadriplegia, who is seeking permission for a doctor to kill him by means of a lethal injection.

Off the back of media coverage of this case, Falconer, who is being backed by Dignity in Dying (the former Voluntary Euthanasia Society), will argue that his proposal is modest in comparison.

Lamb is not terminally ill and wants a doctor to give him a lethal injection (euthanasia).  Falconer however is only asking for people who are terminally ill to have the right to receive help to kill themselves (assisted suicide).

This model, he will argue, will be safer for vulnerable people and will have ‘upfront safeguards’ to stop abuse.

According to House of Lords calculations in 2005 a Dutch-type law (such as Lamb is seeking) would mean 13,000 euthanasia deaths a year in Britain, but an Oregon-type law (like Falconer’s) would mean only 650.

Falconer is thereby attempting to position himself as the reasonable middle ground between those who wish to keep euthanasia and assisted suicide illegal and those who want extensive decriminalisation.

We should not be fooled by this ploy and the situation in Oregon is already ringing loud alarm bells.

Members of the House of Lords should note that statistics released just earlier this year (full report here) show that the number of assisted suicide prescriptions and deaths in Oregon, once again, increased in 2012 and has now reached an all-time high.

There were 59 assisted suicide deaths in Oregon in 2009, 65 in 2010, 71 in 2011 and 77 in 2012; a 30% increase overall in just four years.

The number of prescriptions for assisted suicide was 95 in 2009, 97 in 2010, 114 in 2011 and 115 in 2012; 115 in 2012; a 21% increase since 2009.

Overall assisted suicides have gone from 16 in 1998 to 77 in 2012, an overall increase of 381% (see chart above).

This pattern of incremental extension is similar to that seen in the Netherlands, Switzerland and Belgium other countries that have changed the law.

A major factor fuelling this increase is suicide contagion – the so-called Werther effect. This is particularly dangerous when assisted suicides are backed by celebrities as they are here and given high media profile as they are frequently by the BBC.

The Oregon numbers may not seem large but we need to remember that Oregon has a very small population relative to the UK and that they may well be an underestimate as they are based on physicians’ self-reporting.

But for argument’s sake let’s simply take them at face value. How would they then translate to Britain?

Back in 2006, and based on Oregon’s total of 38 assisted suicide deaths in 2005, the House of Lords calculated that with an Oregon-type law we would have about 650 cases of assisted suicide a year in Britain.

But as the numbers in Oregon have since doubled to 77 the UK equivalent would now be 1,300.

We should learn from the Oregon experience and be resisting these moves.

Any change in the law to allow assisted suicide (a form of euthanasia) would inevitably place pressure on vulnerable people to end their lives so as not to be a burden on others and these pressures would be particularly acutely felt at a time of economic recession when many families are struggling to make ends meet and health budgets are being slashed. Especially when fears about the NHS are actually fuelling support for assisted suicide. The so-called right to die can so easily become the duty to die.

And once legalised there will inevitably be incremental extension as we have seen in Oregon, Switzerland, Belgium and the Netherlands. Legalisation leads to normalisation. New hard cases will brought to bring pressure to widen the existing criteria to allow extension to ‘Gillick competent’ minors, people without mental capacity who ‘would have wanted it’ and those who are ‘suffering unbearably’ but are not terminally ill.

I have previously blogged about the shroud of secrecy which surrounds assisted suicide practice in Oregon, the worrying trends in neighbouring Washington state, which enacted a similar law more recently and the way the Oregon law steers people toward suicide.

Also deeply concerning are reports of depressed patients being killed without being treated, doctor shopping, deaths taking place without witnesses present (raising questions about elder abuse) and the fact that 44 of the 77 who died last year (57%) said that they were concerned about being a burden on family, friends and caregivers.

The lessons are clear. Let’s not go there.

The best system is what we have already – a blanket ban on both assisted suicide and euthanasia which provides a strong deterrent to exploitation and abuse whilst giving discretion to both prosecutors and judges to temper justice with mercy in hard cases.

Under this the number of people going to the Dignitas facility in Switzerland to end their lives remains a trickle of about 15-20 per year.

So let’s keep that system in place and concentrate on providing the best possible care to people who are dying. Let’s major instead on killing pain without killing the patient.

Posted by Dr Peter Saunders

CMF Chief Executive

The Independent has run the story of a ‘Christian-run NHS GP surgery’ which has apparently ‘attracted criticism for posting a notice warning that some of its doctors refuse to prescribe the morning-after pill to patients on grounds of conscience’.

The message on the door of The Links Medical Practice in Mottingham, south London advises patients that if ‘a consenting doctor is not available’ to prescribe contraception they should contact a local clinic or chemist.

One of the practice’s patients was apparently so outraged by this that she opted to leave the practice and Audrey Simpson, chief executive of the Family Planning Association, has said that other women should also think about leaving the surgery in response to the notice.

She is reported as saying: ‘Leaving will send out a message to them that women have the right to access emergency contraception.’

Women can of course legally access ‘emergency contraception’ in the UK and can buy the ‘morning-after pill’ levonelle over the counter without prescription from most pharmacies as well as accessing it free on prescription, from sexual health clinics and from NHS walk in centres.

But according to General Medical Council guidelines published just recently (see my full review of them here), doctors can also refuse to prescribe certain treatments as a matter of conscience.

The Guidance ‘Personal Beliefs and Medical Practice’ states:

‘You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients.’

It goes on to describe how this is to be done:

‘If, having taken account of your legal and ethical obligations, you wish to exercise a conscientious objection to particular services or procedures, you must do your best to make sure that patients who may consult you about it are aware of your objection in advance. You can do this by making sure that any printed material about your practice and the services you provide explains if there are any services you will not normally provide because of a conscientious objection.’

This seems to be exactly what these doctors have done.

The guidance adds that doctors who do not provide a certain treatment should ‘tell the patient’, tell them ‘that they have a right to discuss their condition and the options for treatment with another practitioner’ and ‘make sure that the patient has enough information to arrange to see another doctor who does not hold the same objection as you’.

Why might doctors have an objection to prescribing ‘emergency contraception’?

There are three main reasons.

Some doctors may have an objection to prescribing contraception in principle. Many Catholics take this view.

Some doctors object to prescribing a drug which might in some circumstances act by preventing an early embryo from implanting in the womb as they see this as an early form of abortion. Although there is not firm proof that levonelle acts in this way there is at very least a degree of uncertainty and no absolute proof that it does not (more on this here – note levonelle in the UK is the same drug as Plan B in the US).

Finally some object because they are unconvinced that levonelle is an effective intervention. Its success rate is relatively low (95% within 24 hours of sexual intercourse, 85% from 25-48 hours and 58% from 49-72 hours).  Also in clinical trials its ready availability has been shown not to reduce pregnancy rates in a population and actually to raise rates of sexually transmitted diseases.

This is thought to be due to the phenomenon of ‘risk compensation’ – people taking more risks because they believe there is a safety net.

But regardless of the reasons for a given doctor’s objection to prescribing ‘emergency contraception’, the fact that a patient can legally access it does not mean that every doctor thereby has a legal or ethical duty to supply it.

Doctors should not be forced to provide treatments or interventions that they believe are unethical, ineffective or inappropriate. To force them to do so would be to undermine their professional integrity. They are not simply rubber stamps.

Instead reasonable accommodation should be made. And thankfully both the law and the GMC guidance currently allow for that.

As the recent CMF File on the doctor’s conscience concludes:

The right of conscientious objection is not a minor or peripheral issue. It goes to the heart of medical practice as a moral activity….  The right of conscience helps to preserve the moral integrity of the individual clinician, preserves the distinctive characteristics and reputation of medicine as a profession, acts as a safeguard against coercive state power, and provides protection from discrimination for those with minority ethical beliefs.

Posted by Dr Peter Saunders

CMF Chief Executive

In February 2012 two bioethicists provoked international outrage with an article advocating infanticide.

Writing in the Journal of Medical Ethics (JME), Alberto Giubilini and Francesca Minerva argued in ‘After-birth abortion: why should the baby live?’,   that foetuses and newborns ‘do not have the same moral status as actual persons’.

They concluded that ‘after birth abortion (killing a newborn) should be permissible in all the cases where abortion is, including cases where the newborn is not disabled’.

The same journal (JME) has this week responded to the crisis with a special issue containing 31 commentaries from a range of ethicists, some of whom have argued for years that infanticide can be a moral action; others who believe that even suggesting it is a vile stain on academic integrity.

Editor Julian Savulescu introduces the issue with these words:

‘Infanticide is an important issue and one worthy of scholarly attention because it touches on an area of concern that few societies have had the courage to tackle honestly and openly: euthanasia. We hope that the papers in this issue will stimulate ethical reflection on practices of euthanasia that are occurring and its proper justification and limits.’

Savulescu claims to be ‘strongly opposed to the legalisation of infanticide along the lines discussed by Giubilini and Minerva’ but says that they are not alone in advocating it.

Infanticide is already practised openly and legally in the Netherlands under the ‘Groningen Protocol’ which allows doctors to end the life of neonates at the request of their parents if the infant is experiencing ‘hopeless and unbearable suffering’.

In addition some of the world’s most famous living philosophers have written about its merits and justification over the last 40 years, including Michael Tooley, Jonathan Glover, Peter Singer, Jeff McMahan and John Harris.

Four of these five have contributed to this issue of JME and the full text of their articles is currently available on line.

McMahan argues that the permissibility of infanticide in some circumstances is not only implied by certain theories, but by beliefs that are widely held and difficult to reject.

Michael Tooley’s book is entitled Abortion and infanticide.

Peter Singer wrote a book in 1985 with Helga Kuhse called Should the baby live?

Jonathan Glover’s landmark Causing death and saving lives notes that ‘Dr Francis Crick (the Nobel Laureate who discovered DNA with Jim Watson in 1956) once proposed a two-day period for detecting abnormalities, after which infanticide would not be permissible’.

Many will be shocked by what these philosophers are saying but Savulescu argues that the issue throws up a broad range of ethical questions fundamental to medical ethics.

What constitutes a person with rights? Is there a moral difference between killing a baby of the same gestation inside and outside the womb? Is there a moral difference between euthanasia and withdrawal of treatment and/or sedation with the explicit intention that the baby will die? In what circumstance is ‘letting die’ morally different from killing?

These are all serious questions which many people, including many doctors, have not carefully thought through.

As I have previously argued these bioethicists have actually done us a service. If we don’t like their conclusions, then it should actually lead us to question the premises from which they logically flow.

Philosophers like Peter Singer believe that it is the qualities of rationality, self-consciousness and communication that make human beings special. What follows from this is those humans with less of these qualities are of less value and can, in some circumstances, be disposed of.

By contrast this Christian view of the sanctity of life, which Singer and others reject, is that human beings have value not because of any ‘intrinsic’ qualities, but for two main ‘extrinsic’ reasons. First, that they are made in the image of God for an eternal relationship with him, and second because God himself became a human being in the person of Jesus Christ and thereby bestowed unique dignity on the human race.

If we follow that view through to its logical conclusion it leads us to say that any human being, regardless of its age, appearance, degree of deformity or mental capacity, is worthy of the highest possible degree of protection, empathy, wonder and respect.

These bioethicists are arguing that infanticide is morally no different to abortion.

But we can draw one of two conclusions from that – either we should embrace infanticide or stop doing abortions.

But whatever view we opt for, we should have the courage of our convictions to draw out its full practical implications as these bioethicists have done.

Most people are just not that consistent.

Posted by Dr Peter Saunders

CMF Chief Executive

Marie Fleming (pictured) is a 59 year old former Irish lecturer who has multiple sclerosis and wanted her partner to be able to help her kill herself without risk of prosecution (See Irish Times and BBC Europe reports).

She had argued the ban on assisted suicide breached her Constitutional rights and discriminated against her as a disabled person.

This morning, however, the Supreme Court’s seven judges concluded that “there is no constitutional right to commit suicide or to arrange for the determination of one’s life at a time of one’s choosing”.

Fleming’s landmark case in Ireland is very similar to that of Debbie Purdy in Britain, who won a case in 2009 forcing the Director of Public Prosecutions (DPP) to make public the criteria he used in deciding to bring a prosecution for assisting suicide. These criteria were published in February 2010 and have been the subject of some controversy.

What makes the Fleming case particularly interesting is that her partner who wishes to avoid prosecution is none other than Tom Curran, the Coordinator for Exit International Europe (EIE), a pro-euthanasia lobby group (EIE is part of Exit International, which is headed by controversial Australian euthanasia campaigner Philip Nitschke).

Suicide was decriminalised in Ireland in 1993, but Section 2.2 of the Criminal Law Suicide Act 1993 makes it an offence to ‘aid, abet, counsel or procure’ a suicide. Those convicted under this law still face a custodial sentence of up to 14 years.

The Irish Act is almost identical to the Suicide Act 1961 of England and Wales, with the exception that in the latter the words ‘aid, abet, counsel or procure’ were amended to ‘encourage or assist’ by the Coroners and Justice Act in 2009 in an attempt to make it easier to secure convictions in cases of internet suicide promotion where the guilty party did not personally know the victim.

In her case against Ireland, the Attorney General and Director of Public Prosecutions (DPP), Fleming claimed section 2.2 of the Criminal Law (Suicide) Act, which renders it an offence to aid, abet, counsel or procure the suicide of another, was unconstitutional on grounds that it breached her personal autonomy rights under the Constitution and European Convention on Human Rights (See more here)

Fleming argued that the absolute ban should and must be relaxed to meet her particular circumstances as a terminally ill person in severe pain who is mentally competent to decide when and how she wants to end her life but cannot do so without assistance. She claimed that the law discriminated against her as a disabled person who needed assistance to kill herself.

A three judge High Court ruled earlier that the absolute ban did not disproportionately infringe Ms Fleming’s personal rights under the Constitution and was wholly justified in the public interest to protect vulnerable people.

The High Court also ruled that the Director of Public Prosecutions had no power to issue guidelines setting out what factors she would consider in deciding whether to prosecute cases of assisted suicide. However, the court was however ‘sure’ the Director would adopt a humane and sensitive approach to Ms Fleming’s plight, Mr Justice Nicholas Kearns said.

Ms Fleming was not appealing against that aspect of the court’s decision. Her appeal instead focussed on arguments that the absolute ban on assisted suicide breached her personal autonomy rights under the Constitution and European Convention on Human Rights and that, in her particular circumstances, this ban was not justified on public interest grounds but was disproportionate and discriminatory

This claim has now failed, with the Supreme Court rejecting ’the submission that there exists a constitutional right for a limited class of persons, which would include the appellant. While it is clear that the appellant is in a most tragic situation, the Court has to find constitutional rights anchored in the Constitution… [and it] has not been the jurisprudence of the Constitution that rights be identified for a limited group of persons.’

Fleming’s case rested on the flawed assumption that, since suicide itself is not illegal, there is thereby a right to suicide. It is on this basis that she claimed that as a seriously disabled person she was being discriminated against for not being able to exercise that right, when able-bodied people can.

Dignity in Dying (the former British Voluntary Euthanasia Society) has used a similar line of argument.

However this is to misunderstand the basis and intention of the law.

When the British Parliament passed the Suicide Act in 1961 it was assured that the decriminalisation of suicide did not indicate any reduction of the seriousness with which either (a) suicide or (b) assisting suicide were viewed.

The Joint Under-Secretary of State for the Home Department, moving the Suicide Bill’s Third Reading, said:

‘Because we have taken the view, as Parliament and the Government have taken, that the treatment of people who attempt to commit suicide should no longer be through the criminal courts, it in no way lessens, nor should it lessen, the respect for the sanctity of life which we all share. It must not be thought that because we are changing the method of treatment for those unfortunate people, we seek to depreciate the gravity of the action of anyone who tries to commit suicide…..’ (Hansard: HC Deb 28 July 1961 vol 645: 1961(a): Cols 822-823)

He went on:

‘I should like to state as solemnly as I can….that we wish to give no encouragement whatever to suicide…..I hope that nothing that I have said will give the impression that the act of self-murder, of self-destruction, is regarded at all lightly by the Home Office or the Government.‘ (Hansard:HC Deb 19 July 1961 vol 644: Cols 1425-1426)

Fleming and others wish to argue that in some cases suicide is not serious and is in fact a morally good course of action. That is a position that needs to be strongly resisted at all costs.

It is one thing to argue that people who attempt suicide should be treated with mercy and compassion by the courts. But it is quite another to argue that committing suicide, taking one’s own life, is a moral good and thereby a right.

That would be a very dangerous precedent indeed, which once established would be used as a legal lever for more and more incremental extension.

Judgment Of the Supreme Court: Fleming v Ireland 

Posted by Dr Peter Saunders

CMF Chief Executive

Last week there was a meeting between David Cameron and leaders of major UK NGOs on the process to find the new set of development goals post 2015.  Many issues were on the agenda, and it is a meeting which will have influence on the process, because Cameron is one of the triumvirate of national leaders that have been charged with taking forward this process.

Health was not on the agenda of that meeting, it would seem.  Faith certainly was not.  I have said more about these omissions and some of the fundamental problems with the whole notion of global development targets elsewhere.  Not least is the dangerously patronising notion that we in the West have anything meaningful to say to the developing world about how best to lift itself out of poverty.  Now, to be fair, there has been a considerable amount of input from the nations of Africa, Asia and Latin America into the consultation, but it still feels a very Western driven agenda to which they are being invited to participate, rather than something coming from their own concerns and needs. But that may just be my prejudices showing through.

Nevertheless, the British Government’s position worries me, not least because their focus is not on universal goals (including developed nations as well as developing), but on goals for the developing world only.  It seems to be tied to a focus on economic issues (which is very much a symptom of late twentieth century Western capitalist groupthink), and health barely features at all.

The cross cutting priority for the UK’s agenda is equity – equity of access to health, education, and the means of lifting oneself out of poverty.  That we are still a long way from such equity here in the UK makes this smell of hypocrisy.  That our own health institutions have been found wanting and the need for trust to be rebuilt between the NHS and the citizen has not featured in their thinking (consider, for example the feeble and largely irrelevant government response to the Francis Report into Mid Staffs).

Yet I frequently meet with Christian organisations engaged in supporting churches and health entities in the developing world.  They work to help these institutions to reconnect with their communities, address issues of trust, and get under the skin of the real needs, aspirations and hopes of local people.  Real equity, real empowerment, and driven by a love of Jesus, a concern for God’s justice in the social and economic spheres, and a passion to see people flourish in spirit, body, mind and social relations.  The vital contribution of both faith-based organisations and local faith communities to health was the subject of CMF’s recent submission, Faith Matters, to the World We Want 2015 consultation.

Our health institutions, our churches and our government need to learn lessons from Christians in Africa and Asia and Latin America.  Why are we setting them goals for development that we cannot even consider for ourselves?   Why do we presume to know best when they are ahead of us in so many areas?  It’s time that we all got off our high horses and learnt to listen – to the global South, to our own communities here in the UK certainly, but above all to the Spirit and Word of God, reminding us that we all need a big dose of humility and a willingness to learn and be challenged by those we seek to lead.

My hope is that the British Government’s agenda for the post-MDGs does not derail the wider global concern that health remains high the agenda for new targets, and that the challenge offered by Christians, motivated by the good news of Jesus, working for health in the global South, would begin to permeate our thinking here in the UK, restoring trust, compassion and integrity to our health service.

Posted by Steve Fouch

CMF Head of Allied Professions Ministries

Mary Doogan, 58, and Concepta Wood, 52, (pictured) lost a previous case against NHS Greater Glasgow and Clyde (GGC) when the court ruled that their human rights had not been violated as they were not directly involved in terminations.

However appeal judges have now ruled their right to conscientious objection means they can refuse to delegate, supervise or support staff involved in abortions.

The Guardian, BBC and Scottish TV have all reported on today’s ruling and I have previously blogged more extensively on the case here and here. The midwives have understandably welcomed today’s verdict.

The judgment is hugely significant and means that official guidance from both the Royal College of Midwives (RCM) and the General Medical Council (GMC) will almost certainly now need revision.
The Abortion Act 1967 gives healthcare professionals the right to conscientiously object to ‘participate’ in abortion but the scope of the word ‘participate’ has been the matter of some legal dispute.

But Lady Dorrian, who heard the challenge with Lord Mackay of Drumadoon and Lord McEwan, said: ‘In our view the right of conscientious objection extends not only to the actual medical or surgical termination but to the whole process of treatment given for that purpose.’

She said the conscientious objection in the legislation is given ‘not because the acts in question were previously, or may have been, illegal’ but ‘because it is recognised that the process of abortion is felt by many people to be morally repugnant’.

Lady Dorrian added: ‘It is in keeping with the reason for the exemption that the wide interpretation which we favour should be given to it. It is consistent with the reasoning which allowed such an objection in the first place that it should extend to any involvement in the process of treatment, the object of which is to terminate a pregnancy.’

In the earlier judgement Lady Smith had said that since the midwives were not covered by the conscience clause as ‘they (were) not being asked to play any direct role in bringing about terminations of pregnancy’.

But this has now been overturned.

If this latest ruling is not overturned by a higher court (and it is not yet clear if an appeal will be made by the Greater Glasgow and Clyde Health Board) then the current RCM guidance will almost certainly need to be revised. It currently reads as follows:

‘The RCM believes that the interpretation of the conscientious objection clause should only include direct involvement in the procedure of terminating pregnancy. Thus all midwives should be prepared to care for women before, during and after a termination in a maternity unit under obstetric care.’

In addition, the latest GMC guidance, which ironically came into force only two days ago, will similarly need to be rewritten. It currently reads:

‘In England, Wales and Scotland the right to refuse to participate in terminations of pregnancy (other than where the termination is necessary to save the life of, or prevent grave injury to, the pregnant woman), is protected by law under section 4(1) of the Act. This right is limited to refusal to participate in the procedure(s) itself and not to pre- or post-treatment care, advice or management, see the Janaway case: Janaway v Salford Area Health Authority [1989] 1AC 537′

As Neil Addison points out in para 33 of the Judgment the court makes clear that professional guidelines can be legally wrong and cannot overrule statute, it says:

‘Great respect should be given to the advice provided hitherto by the professional bodies, but prior practice does not necessarily dictate interpretation. Moreover, when the subject of the advice concerns a matter of law, there is always the possibility that the advice from the professional body is incorrect’.

Because this Judgment is from a Scottish Court (and Scotland is a different jurisdiction to England and Wales) it is not strictly binding on an English Court. However it will have nonetheless have significant persuasive force in England. The Abortion Act 1967 applies in England, Wales and Scotland (but not in Northern Ireland) and when Scottish Courts have adjudicated on such ‘cross border’ legislation in the past their decisions have been taken very seriously in England and Wales and vice versa.

I have previously argued that the GMC was over-interpreting the law in a grey area in issuing its guidance. But this latest judgement clarifies the law in a way that now makes that virtually certain.

I trust that the RCM and GMC will move swiftly to review and revise their guidance so that midwives and doctors with a conscientious objection to abortion are clear where they now stand.

Posted by Dr Peter Saunders

CMF Chief Executive

Loss of trust

An unproven theory about a possible link between measles-mumps-rubella (MMR) vaccine and autism led to the publication of a seriously flawed study in 1998. The paper was retracted by the prestigious journal that published it but unfortunately the damage had already been done and its publication set off a panic among many parents that still results in low immunisation rates in the UK (1). The recent death of a young man with measles in Wales has been a belated wake-up call to the danger of this infection and special weekend immunisation clinics have been urgently established in South Wales.

Encouraged by an atmosphere of fear, mothers’ groups have campaigned against MMR because of putative, but erroneous, concerns about the vaccine. Individuals and pressure groups have also tried to take some international organisations providing immunisations to the courts because of these organisations’ justifiable claims that ‘vaccines prevent child deaths’. Others have spread rumours that vaccines are contaminated by mercury and contraceptives. A shocking list of some of the many myths about vaccination has just been published by WHO.

In Pakistan, immunisation teams have come under great suspicion and attack since the widespread, albeit unfounded belief that the capture of Osama Bin Laden near Rawalpindi, was assisted by intelligence gathered during a fake door to door hepatitis B vaccine campaign run by a CIA asset. In Nigeria, a fundamentalist group called Boko Haram, which is opposed to all Western ideas, has fostered many myths about immunisation. In both countries, health workers on immunisation teams have been murdered.

The necessity of immunisation

But are immunisation teams really necessary? Yes-but they are a sign of failed health care systems. Even in the poorest and most remote communities in the world there are great examples of regular maternal, newborn, child health (MNCH) programmes in which the same staff members support a pregnant woman, deliver and treat her and her infant and young child whenever they are sick. Those same health workers provide immunisations. They are trusted. However the trust, based on consistent care and built up by between parents and health workers over years, can be destroyed by health care systems which fail to deliver regular staff, equipment, supplies, vaccines or salaries. While ‘top up’ immunisation programmes do often contribute to increasing immunisation coverage towards ’safe levels’, their staff are often not well known to the community and therefore not as trusted as MNCH staff. That, tragically, makes them more vulnerable.

Biblical principles

So what Scriptural principles guide the development of a better system for immunisations for all?  Firstly, ensuring that integrity is foremost in everything we do, whether it is research, communications or relationships. In John 14: 6 Jesus says ’I am the way the truth and the life‘. We need to model our lives and work on Him.  David speaks of integrity and uprightness in Psalm 25:21. Jesus noted that there was ’no deceit‘ in Nathaniel in John 1: 47.

Secondly, we need to develop compassion in our relationships. Paul describes how we need to be transformed into his likeness in 2 Corinthians 3: 18.  Ephesians 5: 1 and 2 describes how we need to live a life of ’love and service‘.  Thirdly, we are told to be courageous. The Lord told Joshua to be strong and of good courage in Joshua 1: 3-9. At the end of his life, David commended his son Solomon to be strong in 1 Kings 2: 2. The Lord encouraged Isaiah in Is 41: 10 not to be fearful or dismayed because ’I am your God‘. We need to have evidence based convictions and be courageous wherever we work but especially in difficult circumstances. And if we do not personally work in such circumstances, we need to support and pray for those brave health workers who do such vital frontline work.

There are still many biological challenges for development of vaccines and these need supporting as described in the Lancet.  However, unless health workers can restore the trust that they once had, even the most brilliant technological breakthroughs will not prevent disease, disability and death.

Restoration of trust is urgently needed.

Posted by Andrew Tomkins
CMF International Study Group 

Savita Halappanavar (pictured), 31, was an Indian woman who tragically died in Ireland from overwhelming infection after allegedly being denied an abortion.

Her case has been seized upon by the pro-choice lobby as grounds for liberalising Ireland’s abortion law.

Savita was 17 weeks pregnant when admitted to the University Hospital Galway on 21 October 2012 with an inevitable miscarriage.

At that time a fetal heart beat was detected and doctors opted not to end the pregnancy by inducing labour but instead waited for her to deliver naturally.

Her baby was born dead three days later on 24 October.

Savita died from multi-organ failure from septic shock due to an E coli infection on 28 October, four days after her baby’s birth.

The coroner, Dr Ciaran MacLoughlin, said the verdict of medical misadventure did not mean that deficiencies or systems failures in University Hospital Galway necessarily contributed to Mrs Halappanavar’s death; these were just findings in relation to the management of her care.

The chief operating officer at the Galway Roscommon Hospital Group, Tony Canavan, acknowledged that there were lapses in the standards of care provided to Mrs Halappanavar and said that deficiencies identified during the inquest would be rectified by the hospital.

Leading obstetrician Peter Boylan outlined a number of deficiencies in her care, but stressed that none on its own was likely to have resulted in Mrs Halappanavar’s death.

The coroner’s nine recommendations  (summarised below) were strongly endorsed by the jury.

The key recommendation read as follows:

‘The Medical Council should lay out exactly when a doctor can intervene to save the life of the mother in similar circumstances, which would remove doubt and fear from the doctor and also reassure the public. An Bord Altranais should have similar directives for midwives so that the two professions always complement one another.’

The other eight recommendations involved improving hospital systems and procedures.

There are four key questions in this tragic case:

If the doctors had intervened earlier to induce labour when the baby’s heartbeat was still present would Savita have died? Quite possibly not, but at that stage there was no suggestion that her life was in danger.

If they had acted more quickly to diagnose and treat her E coli infection might she have been saved? Possibly. There were several acknowledged errors and omissions made in her care but it is impossible to prove that these led to her death.

Did Savita die because of the Irish abortion law? No, because Irish law already allows abortion when there is a risk to the life, as distinct from the health, of the mother.  Making this judgement, however, sometimes requires considerable skill and experience, which is why clearer guidance from the Irish Medical Council, within the existing law, is to be welcomed.

Does the Irish abortion law need changing? No. As I have previously argued in much more depth on this blog, Savita’s tragic death is not a reason to change the law.

Ireland remains one of the safest places in the world to have a baby. Its maternal mortality rate is just six deaths per 100,000 live births. This compares with 12 in the UK, 15 in the US and 200 in India.

As there are about 75,000 live births a year in Ireland this means that there is an average of just four maternal deaths per year from all causes.

Savita’s death was indeed a tragedy and there was medical misadventure involved in her care, but we should be very wary of knee-jerk legislation. It is far better to handle exceptional circumstances like this by way of guidance from the Medical Council.

Ending a pregnancy to save the life of a mother by inducing labour when the baby is too young to survive outside the womb is sometimes necessary in extremely rare circumstances.  But this is already legal in Ireland.

Changing the law in Ireland to that of the UK would not save any mothers’ lives but instead would lead to around 11,000 more abortions annually.

The baby in the womb is the most vulnerable of human beings, worthy of wonder, respect, care and protection. The law should reflect that fact whilst allowing intervention to save one life (the mother) in cases where not intervening would mean that two lives (both mother and baby) are lost.

Summary of Coroner’s recommendations (from the Independent):

* The Medical Council should say exactly when a doctor can intervene to save the life of a mother, which will remove doubt or fear from the doctor and also reassure the public;

* Blood samples are properly followed up;

* Protocol in the management of sepsis and guidelines introduced for all medical personal;

* Proper communication between staff with dedicated handover set aside on change of shift;

* Protocol for dealing with sepsis to be written by microbiology departments;

* Modified early warning score charts to be adopted by all staff;

* Early and effective communication with patients and their relatives when they are being cared for in hospital to ensure treatment plan is understood;

* Medical notes and nursing notes to be kept separately;

* No additions or amendments to be made to the medical notes of the dead person who is the subject of an inquiry.

Posted by Dr Peter Saunders

CMF Chief Executive