Question of Conscience

It was quite a surprise, back in 1973, to be informed by an eminent professor of obstetrics and gynaecology, after an interview for an appointment as a senior registrar, that as a Roman Catholic specialist, that "there is no place for to practice within the National Health Service unless you are prepared to change your views or to re-specialise in another field." One had always, quite naively is seems, thought that the British "system" was based on fair play and above all, respect for an individual's right to conscientious objection, for example in the time of war. It soon became obvious that in order to stay in the specialities in the United kingdom, I would have had to compromise a conscientiously held abhorrence to the direct taking of human life. I refused and as a consequence became unemployed with a wife and three children and had to leave country, home and family in order to practise my chosen specialty in full freedom.

In 1976 I published a paper in the British Medical Journal about my experience and warned that the practice of obstetrics in the UK would suffer, as the main consequence of the denial of conscientious objection to performing abortion there would develop what I called a "sameness of practice" which would stifle further thought and progress. This prophecy concerning obstetrics in the UK has come to pass and discrimination against Catholic and other pro-life doctors continues in the UK and other parts of the world.

It was early in my medical student career that I decided to specialise in ob/gyn. The appeal was that these specialties required skills in medicine, surgery and special skills related to obstetrics. It became clear to me that obstetricians and midwives have a unique and privileged vocation in the service to life as they are assistants to the co-creators of new life. We are specialists in motherhood.

When I began obstetric residency training back in 1968 residents were told that obstetricians had one objective, which was to provide the best of care that was humanly possible, to ensure that all pregnancies should result in a live healthy mother, and a live healthy baby. It was made clear that at the beginning of every pregnancy we had two patients to look after as the following statement taken from the of Williams Obstetrics (16th edition) states;

"Happily we live and work in an era in which the foetus is established as our second patient with many rights and privileges comparable to those previously achieved on the afterbirth."

However, back in the early 70s, the general public and even Church leadership, did not anticipate the dark changes that were about to occur that would turn maternal health care upside down, and cause many obstetricians to make serious decisions about practice and living which had profound effects on their careers. As I finished training, the oral contraceptive was being introduced, and I remember attending one of the first demonstrations of the intra-uterine device. At the same time legislation permitting abortion was passed in the UK. As residents we were exposed to a one-sided, ill-informed and prejudice opinion by those determined to change how we thought and practised. Significantly in later editions of Williams that reference to the foetus as a second patient was dropped.  A subtle gradual process began to bring about a fundamental change in the way obstetricians considered themselves. The difference between obstetrics (maternal health care) and gynaecology (women's health care) became blurred. Reference to motherhood was dropped and we now find ourselves to be simply women's health specialists.

At about the same time the Encyclical, Humanae Vitae was promulgated. I remember reading it and my first reaction was to wonder if it had any relevance to my practice. I started to rationalise that there was a difference between contraception and abortion - I could accept the former but not the latter. The decision was quite simple and most of my friends and colleagues accepted that idea too. There was no one around to turn to for advice or guidance. However, for some reason, most likely the inspiration of the Holy Spirit , I re-read and thought about it and began to understand its importance to marriage, human life and family.

Abortion and contraception soon became the basis of the health care of mothers. In spite of knowing so much about the unborn child obstetricians connived in devaluing the human being in the womb, thus making it so much easier to destroy. Society accepted abortion as an easy solution for social and economic problems and ob/gyns have allowed their professional skills to be used for that purpose. Many of our colleagues now destroy more babies than they deliver babies. Little effort is made to reduce the number of abortions. It defies belief that William Jefferson Clinton, the President of the United States of America, should have twice vetoed a bill which would have outlawed the obscenity of partial birth abortion. The world has accepted the culture of death at the cost of unborn children and a once noble profession. Pope John Paul has commented;

"The medical profession today is suffering fundamentally from an identity crisis; the grave danger exists that when this profession is called upon to suppress conceived life; where it is used to eliminate the dying; where it allows itself to be led to intervene against the plan of the Creator and the life of the family or to be taken by the temptation to manipulate human life; and when it loses sight of its authentic direction of purpose toward the person who is most unfortunate and most sick, it loses its ethos, it becomes sick in its turn, it loses and obscures its own dignity and moral autonomy."

For the Catholic in training or in practice this has had profound ethical, moral and practical significance. No other branch of medicine has been so affected by these developments. It has simply not been appreciated, that obstetricians of my generation had, from the very beginning of these developments, to take a fundamental stand in defence of human life. This caused them, and their families, considerable pain as they found their careers in ruined. Many were forced out of the specialty others sadly compromised in order to survive. In some countries many are forced, to participate in abortion or contraception programmes and sadly many decide to compromise and separate what they do from what they believe.

In very personal ways Catholics specialists and their families have been subjected to a sort of professional totalitarianism. The Catholic ob/gyns who remained, faithful to the Magisterial teaching was and is professionally and socially ostracised. Sadly even in Catholic hospitals they are considered an "embarrassment" because of their public stand and are considered as ultra conservatives, professionally outdated and even possibly negligent and are subjected to the displeasure of the profession. Generally there is a recruitment crisis as few students are electing to specialise in ob/gyn basically for three reasons; the life style is quite hard; there is fear of litigation especially in North America and Europe and most doctors really do not want to get involved in abortion - it is regarded as unpleasant work. It is not surprising that very few Catholics are entering ob/gyn, thus the Catholic ob/gyn is now in danger of going the same way as the dinosaur, having been frozen out by the abortion/contraceptive asteroid. This should be a source of grave concern to the Church, to pro-life organisations and to all people of good will .

This raises important questions; what effect does all of this have on mothers and women?; where will they obtain opinions and treatment for their health problems which are in accordance with their moral convictions?; are women being unduly influenced by doctors or nurses who do not understand or care about religious convictions?. In other words who in the future will make any practical reality of the Church's teaching concerning maternal health care?

In 1995 a small international group of Catholic ob/gyns/midwives met at the Life Health Centre in Liverpool England. All had have been asking themselves the same question if we don't do something WHO WILL?. This stubborn few, believed that if they held to their ethical and moral principles, they could be effective in caring for mothers and their unborn babies and that there are mothers around the world who still want the sort of care that they can provide.

Pope John Paul II in his Encyclical Evangelium Vitae also issued an urgent appeal to all, but in a special way to Catholic health professionals, to do something extra for life;

"To the people of life for life", "to offer this world of ours new signs of hope, and work to ensure that a new culture of human life will be affirmed, for the building of an authentic civilisation of truth and love" (E.V. No 6).

"To all health care personnel who have a unique responsibility to be guardians and servants of human life". (E.V. 89).

"A specific contribution must come from "Catholic universities, Centres, Institutes and Committees of Bioethics and places of scientific and technological research." (E.V. 98).

That group established MaterCare International (MCI) which has adopted a preferential option for mothers and their unborn children. The intention was not to develop a talking shop, but an organisation that would "breathe" life back into the care of mothers through new initiatives of service, training, research, and advocacy in accordance with the teaching of the Encyclical, Evangelium Vitae. MCI intends to place itself ;

"... at the service of a new culture of life offering serious and well documented contributions, capable of commanding general respect and interest by reason of merit". (E.V. 98)

MCI is developing a revolutionary structure for the 21st century i.e. no large buildings with large heating bills, but has a small international central agency and national groups that support flexible reference centres, distributed throughout the world, all linked together through modern communication technologies. MaterCare is legally established in Canada, Ireland, the UK (and therefore the European Union) and is in the process in the USA, Australia and Ghana. Each national group has an interdisciplinary board of directors. With these national structures MCI can access funding from private and government sources to carry out projects and recruit colleagues to carry out the work.

The international centre in located in St John's Newfoundland, Canada provides the specialist support for national centres. The centre presently consists of an obstetrician, a professor of nursing , a secretary, a public education co-ordinator and a volunteer board. In the future we hope to have a staff that will reflect the unique, international, interdisciplinary, diverse vocational character and experience of our Church, and will include an administrator, medical and nursing directors, theologian/ethicist, health educator, communications expert, and support staff. It is the board of MaterCare International which is made up of two members from each national MaterCare groups that determines policy and chooses projects. The international board meets quarterly by international telephone conference call which is quite cheap. In the future it aims to set up a method for international teleconferencing using the internet, which is free. National reference centres will be established, where there is interest and according to local needs. The first one will be in Ghana, West Africa. These reference centres will be the initiators of local activities and will gather information, implement services and educational programmes, conduct research and also provide the group of specialists.

MCI has shown, despite scepticism and not without considerable labour pains, that it can be relevant. In 1998 MCI developed a West African Maternal Health and Obstetric Fistula Project, the first phase of which is now underway in Ghana and consists of prevention, research and advocacy programmes. The prevention programmes are designed to reduce maternal mortality and morbidity in rural areas by improving the care given to mothers by traditional birth attendants (TBAs) in villages by using a pictorial antenatal card, by training nurse/midwives in maternity centres to use the labour partograph, a visual means of monitoring the progress of labour; by an emergency obstetric transport system with blood transfusion capability to transport mothers with complications to the district hospital safely.

A research programme has been completed which has evaluated a new oral, effective and inexpensive method of managing life threatening postpartum haemorrhage, which could be used safely by TBAs when medical aid is not available.

An advocacy programme is also being developed to bring to international attention the tragedy of maternal mortality and the suffering of mothers with obstetric fistulae

MCI is also developing a 60- bed birth trauma centre to provide treatment and rehabilitation centre for mothers with obstetric fistula, which will also have a special interest in training nurses and doctors in the management of these patients. All of these projects are being carried out in partnership with the Catholic Conference of Bishops of Ghana. MCI is also developing an obstetric fistula teaching CD which will be made available free of charge and which also will be available on MCI's website.

In 1999 Dr Gigli and I visited Albania and to cut a long story short we organised a rotation of obstetricians to a Austrian military field hospital to provide care for about 20,000 refugees. The reason that it did not get off the ground was that the bombing of Kosovo stopped and the refugees went home. Last year I made three visits with Adrian Thomas and then Gian Luigi Gigli to East Timor to look at the problems facing mothers. MCII with the help of FIAMC is in the process of developing a programme to provide essential obstetrical care where as of now there is no obstetricians for a population of 700,000. What we did discover however form these experiences is that there is no international organisation that exists to provide mothers with specialists care. The ICRC nor MSF itself. Emergency services are also being developed in East Timor.

MCI has had requests to find an obstetrician/administrator for a Catholic hospital in Bethlehem and the Archbishop of Freetown Sierra Leone has asked for help in developing maternal health services.

MCI is particularly concerned about the future of ob/gyn and the training . Three years ago we tried to set up an international meeting to discuss the training of future specialists but without success. In our opinion there still remains throughout the world academic and hospital departments of obstetrics and gynaecology which could offer quality residency courses and electives using the new information technologies and distance learning. All we have to do is to organise ourselves.

Conclusion

As we approach the 21st century, millions of mothers throughout the developing world are dying from childbirth complications frequent during the middle ages. In the developed world millions of unborn children are being destroyed by the medical profession with surgical procedures which were common in the dark ages of human ignorance.

Obstetricians and midwives share a unique and privileged vocation in the service to life. A group of Catholic health professionals has taken a preferential option to care for mothers and has created an international organisation, which will be different to any other professional organisation as it will provide mothers with the best of obstetrical care which is firmly based on medical excellence, life and hope. We know WHAT must be done and for WHOM, this proposal is one way of answering the question HOW are we as Catholic health professional are going to do it.