- Email: [email protected]
Moral Authority
' ' ' ' '
G U EST
EDITORIAL
The Society of Obstetricians and Gynaecologists of Canada
' ' ' ' '
Moral Authority
COUNCIL MEMBERS 1994-1995 PRESIDENT Dr. Rodolphe Maheux- Quebec PAST PRESIDENT: Dr. Robert Lea - Halifax PRESIDENT ELECT: Dr. Garry Krepart- Winnipeg EXECUTIVE VICE-PRESIDENT: Dr. Andre B. Lalonde- Ottawa TREASURER: Dr. Anton in Rochette- Loretteville VICE PRESIDENTS: Dr. Ferdinand Pauls- Winnipeg Dr. Robert Reid- Kingston REGIONAL CHAIRS & DEPUTY CHAIRS WESTERN REGION Dr. Don Davis- Medicine Hat Dr. Jan Christi law- White Rock CENTRAL REGION Dr. Chui Kin Yuen -Winnipeg Dr. Thirza Smith- Saskatoon ONTARIO REGION Dr. Donna Fedorkow- Hamilton Dr. Catherine Claire Kane- Ottawa QUEBEC REGION Dr. Cajetan Gauthier- Levis Dr. Robert Gauthier- Montreal ATLANTIC REGION Dr. Edwin Luther- Halifax Dr. David A. Knickle- Charlottetown PUBLIC REPRESENTATIVE Ms. Janet MacMillan- Halifax JUNIOR FELLOW REPRESENTATIVE Dr. Leslie Sadownik- Calgary ASSOCIATE MD REPRESENTATIVE Dr. T. Riley- Oakville NATIONAL OFFICE EXECUTIVE VICE-PRESIDENT Dr. Andre B. Lalonde COMMUNICATIONS OFFICER Martine Joly
774 Echo Drive Ottawa, Ontario K1S 5N8 tel: (613) 730-4192 fax: (613) 730-4314
Trying to see all sides of an issue requires that one be a contortionist. It is beyond most of us. Thus, there was much difficulty in responding fairly to "Proceed with Care," the final report of the Royal Commission on New Reproductive Technologies (I almost called it Brian Mulroney's Royal Commission, an anachronism which damns by association). The Report was released in late 1993, triggering knee-jerk responses from the lay media and a slightly more cautious response from a Timothy C. Rowe, MB BS, FRCSC, quickly-assembled SOGC committee. The Department of Obstetrics and Gynaecology, University of British Report clearly needed a detailed review and Columbia. reasoned responses from those members of the Society (and other professionals) most affected by the recommendations of the Commissioners. A detailed review was then undertaken by the Committees on Reproductive Endocrinology and Infertility (to which I belonged), Genetics, and Social and Sexual Issues. What was found? Much of the tone of the Report reflected the modem religion of antiprofessionalism. A long preamble included an overview of the ethical principles which guided the work of the Commissioners, and this was the beginning of the difficulties we had as physicians in producing an appropriate response. From what standpoint did we want to read the Report? Our immediate response was to review from the perspective of the practising consultant in obstetrics and gynaecology, confining this view further in many cases to the practising sub-specialist in infertility, genetics, or perinatology. This approach by no means reflected the "ethical framework and guiding principles" outlined by the Commissioners in formulating their Report-because the description of the ethic of care described by the Commissioners is somehow transformed into "a positive commitment to empowerment." There appeared to be no acknowledgement of what Eric Cassell has described as the mysterious relationship between doctor and patient. 1 And that was, to me, a terrible oversight. Couples who present to physicians with infertility (and here we note that individuals cannot be infertile in the absence of demonstrated inability to conceive) have a level of suffering which is commensurate with the degree of suffering caused by any medical condition. That the suffering may be attributed in part to social conditioning is largely irrelevant; it is the suffering itself that leads to action. Some couples do not seek a medical solution to their suffering,
JOURNAL SOGC
115
FEBRUARY 1995
' ' ' but may instead sublimate it by adoption or by other activities. The majority of couples, however, seek medical help. The physician functions to relieve or alleviate sufferingone cannot tum to social conditioning as a central cause of suffering in an infertile couple, and attempt to change society, so taking steps to ease any medical cause of infertility is logical and defensible. The mysterious relationship which then develops, based to a great extent on trust, can simultaneously work to relieve suffering (in the shortterm) and resolve the infertility. The second of these goals is the overt justification for the first, despite the lack of real concern on the part of the Commissioners regarding the anguish that infertility will cause. The position with respect to prenatal diagnosis is similar. A woman who is pregnant and at theoretically increased risk of abnormality in her baby will tum to the physician or physicians with whom she shares confidence and trust for guidance. The technology is a tool; it is not the central focus, but instead the woman and her unborn child are. The Royal Commission had a very difficult brief, and it was unfortunate that the group of Commissioners compiling the Final Report did not include a practising clinician or an individual practising in the field of reproduction and fertility. The chief disadvantage that the Commissioners had in being non-experts was that they had to rely on others to provide technical expertise, and in describing some of the technical details of drugs and procedures (in the Report), there is evidence of uncertainty-which lessens our faith in the conclusions drawn. In reviewing the Report from our standpoint as practising consultants in obstetrics and gynaecology, it seemed that the activities that we undertake and the tools that we use were consistently viewed at first from the perspective of the harm that they could cause; this is a cautious approach, to be sure, but it endowed the Report with an inhibitory tone which pervaded many of its recommendations. Policies and safeguards should not always be inhibitory. In fact, one would prefer that they were predominantly facilitatory. But it is the philosophical approach to resolving ethical concerns which leaves me with feelings of disquiet. The Commissioners describe the ethic of care and the guiding principles of individual autonomy, equality, respect for human life and dignity, protection of the vulnerable, noncommercialization of reproduction, appropriate use of resources, accountability, and balancing of individual and
JOURNAL SOGC
collective interests. But there is an unevenness with which the ethic is applied to judgements within the Report. Nuala Kenny has recently described the nature of the ethic of care and its understanding of the interdependence of the physician and patient. 2 Single-minded concern with autonomy, Kant's categorical imperative, and justiceoriented ethical perspectives are being supplanted by an appreciation of the importance of the relationship between the patient, the physician, and others. 1 Ethicists are broadening their interests to include corollary obligations as well as patient rights. It is surprising, therefore, to find that the Commissioners' interpretation of the ethic of care leads to guiding principles which, when applied to new reproductive technology, require caveats (as in the statements regarding commercialization of reproductive care) and appear to disadvantage couples with established infertility (as in the allocation of resources to the prevention, rather than assessment and treatment, of infertility, and in the outright condemnation of not-yet-proven indications for in vitro fertilization). This kind of rationalization does not help those of us who are trying to provide care and relieve suffering. So who has moral authority in determining the place of new reproductive technologies in a society? Is it the elected representatives, obeying their consciences? Is it those same individuals, reflecting the will of their constituents? Is it a constituent body like a Royal Commission? Is it the providers of care, or the wielders of the technology? Is it the populace en masse? Or is it the individuals or couples who are the consumers? Where there is real dissent there is presumably no absolute truth, and we must seek the path of greatest good-and as physicians we are obligated to relieve the suffering of our patients. I believe that there is no greater moral authority in this particular issue than the voice of the partnership between those affected and their physicians. The Report of the Royal Commission largely ignored this relationship and downplayed its significance. And that's a shame.
J SOGC
1995;17:115-6
REFERENCES 1. 2. 3.
116
Cassell EJ. The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press, 1991, pp.66-80. Kenny NP. The Ethic of Care and the Patient-Physician Relationship. Annals RCPSC 1994;27:356-8. May W. The Physician's Covenant. Philadelphia: The Westminster Press, 1983.
FEBRUARY 1995
G U EST
EDITORIAL
The Society of Obstetricians and Gynaecologists of Canada
' ' ' ' '
Moral Authority
COUNCIL MEMBERS 1994-1995 PRESIDENT Dr. Rodolphe Maheux- Quebec PAST PRESIDENT: Dr. Robert Lea - Halifax PRESIDENT ELECT: Dr. Garry Krepart- Winnipeg EXECUTIVE VICE-PRESIDENT: Dr. Andre B. Lalonde- Ottawa TREASURER: Dr. Anton in Rochette- Loretteville VICE PRESIDENTS: Dr. Ferdinand Pauls- Winnipeg Dr. Robert Reid- Kingston REGIONAL CHAIRS & DEPUTY CHAIRS WESTERN REGION Dr. Don Davis- Medicine Hat Dr. Jan Christi law- White Rock CENTRAL REGION Dr. Chui Kin Yuen -Winnipeg Dr. Thirza Smith- Saskatoon ONTARIO REGION Dr. Donna Fedorkow- Hamilton Dr. Catherine Claire Kane- Ottawa QUEBEC REGION Dr. Cajetan Gauthier- Levis Dr. Robert Gauthier- Montreal ATLANTIC REGION Dr. Edwin Luther- Halifax Dr. David A. Knickle- Charlottetown PUBLIC REPRESENTATIVE Ms. Janet MacMillan- Halifax JUNIOR FELLOW REPRESENTATIVE Dr. Leslie Sadownik- Calgary ASSOCIATE MD REPRESENTATIVE Dr. T. Riley- Oakville NATIONAL OFFICE EXECUTIVE VICE-PRESIDENT Dr. Andre B. Lalonde COMMUNICATIONS OFFICER Martine Joly
774 Echo Drive Ottawa, Ontario K1S 5N8 tel: (613) 730-4192 fax: (613) 730-4314
Trying to see all sides of an issue requires that one be a contortionist. It is beyond most of us. Thus, there was much difficulty in responding fairly to "Proceed with Care," the final report of the Royal Commission on New Reproductive Technologies (I almost called it Brian Mulroney's Royal Commission, an anachronism which damns by association). The Report was released in late 1993, triggering knee-jerk responses from the lay media and a slightly more cautious response from a Timothy C. Rowe, MB BS, FRCSC, quickly-assembled SOGC committee. The Department of Obstetrics and Gynaecology, University of British Report clearly needed a detailed review and Columbia. reasoned responses from those members of the Society (and other professionals) most affected by the recommendations of the Commissioners. A detailed review was then undertaken by the Committees on Reproductive Endocrinology and Infertility (to which I belonged), Genetics, and Social and Sexual Issues. What was found? Much of the tone of the Report reflected the modem religion of antiprofessionalism. A long preamble included an overview of the ethical principles which guided the work of the Commissioners, and this was the beginning of the difficulties we had as physicians in producing an appropriate response. From what standpoint did we want to read the Report? Our immediate response was to review from the perspective of the practising consultant in obstetrics and gynaecology, confining this view further in many cases to the practising sub-specialist in infertility, genetics, or perinatology. This approach by no means reflected the "ethical framework and guiding principles" outlined by the Commissioners in formulating their Report-because the description of the ethic of care described by the Commissioners is somehow transformed into "a positive commitment to empowerment." There appeared to be no acknowledgement of what Eric Cassell has described as the mysterious relationship between doctor and patient. 1 And that was, to me, a terrible oversight. Couples who present to physicians with infertility (and here we note that individuals cannot be infertile in the absence of demonstrated inability to conceive) have a level of suffering which is commensurate with the degree of suffering caused by any medical condition. That the suffering may be attributed in part to social conditioning is largely irrelevant; it is the suffering itself that leads to action. Some couples do not seek a medical solution to their suffering,
JOURNAL SOGC
115
FEBRUARY 1995
' ' ' but may instead sublimate it by adoption or by other activities. The majority of couples, however, seek medical help. The physician functions to relieve or alleviate sufferingone cannot tum to social conditioning as a central cause of suffering in an infertile couple, and attempt to change society, so taking steps to ease any medical cause of infertility is logical and defensible. The mysterious relationship which then develops, based to a great extent on trust, can simultaneously work to relieve suffering (in the shortterm) and resolve the infertility. The second of these goals is the overt justification for the first, despite the lack of real concern on the part of the Commissioners regarding the anguish that infertility will cause. The position with respect to prenatal diagnosis is similar. A woman who is pregnant and at theoretically increased risk of abnormality in her baby will tum to the physician or physicians with whom she shares confidence and trust for guidance. The technology is a tool; it is not the central focus, but instead the woman and her unborn child are. The Royal Commission had a very difficult brief, and it was unfortunate that the group of Commissioners compiling the Final Report did not include a practising clinician or an individual practising in the field of reproduction and fertility. The chief disadvantage that the Commissioners had in being non-experts was that they had to rely on others to provide technical expertise, and in describing some of the technical details of drugs and procedures (in the Report), there is evidence of uncertainty-which lessens our faith in the conclusions drawn. In reviewing the Report from our standpoint as practising consultants in obstetrics and gynaecology, it seemed that the activities that we undertake and the tools that we use were consistently viewed at first from the perspective of the harm that they could cause; this is a cautious approach, to be sure, but it endowed the Report with an inhibitory tone which pervaded many of its recommendations. Policies and safeguards should not always be inhibitory. In fact, one would prefer that they were predominantly facilitatory. But it is the philosophical approach to resolving ethical concerns which leaves me with feelings of disquiet. The Commissioners describe the ethic of care and the guiding principles of individual autonomy, equality, respect for human life and dignity, protection of the vulnerable, noncommercialization of reproduction, appropriate use of resources, accountability, and balancing of individual and
JOURNAL SOGC
collective interests. But there is an unevenness with which the ethic is applied to judgements within the Report. Nuala Kenny has recently described the nature of the ethic of care and its understanding of the interdependence of the physician and patient. 2 Single-minded concern with autonomy, Kant's categorical imperative, and justiceoriented ethical perspectives are being supplanted by an appreciation of the importance of the relationship between the patient, the physician, and others. 1 Ethicists are broadening their interests to include corollary obligations as well as patient rights. It is surprising, therefore, to find that the Commissioners' interpretation of the ethic of care leads to guiding principles which, when applied to new reproductive technology, require caveats (as in the statements regarding commercialization of reproductive care) and appear to disadvantage couples with established infertility (as in the allocation of resources to the prevention, rather than assessment and treatment, of infertility, and in the outright condemnation of not-yet-proven indications for in vitro fertilization). This kind of rationalization does not help those of us who are trying to provide care and relieve suffering. So who has moral authority in determining the place of new reproductive technologies in a society? Is it the elected representatives, obeying their consciences? Is it those same individuals, reflecting the will of their constituents? Is it a constituent body like a Royal Commission? Is it the providers of care, or the wielders of the technology? Is it the populace en masse? Or is it the individuals or couples who are the consumers? Where there is real dissent there is presumably no absolute truth, and we must seek the path of greatest good-and as physicians we are obligated to relieve the suffering of our patients. I believe that there is no greater moral authority in this particular issue than the voice of the partnership between those affected and their physicians. The Report of the Royal Commission largely ignored this relationship and downplayed its significance. And that's a shame.
J SOGC
1995;17:115-6
REFERENCES 1. 2. 3.
116
Cassell EJ. The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press, 1991, pp.66-80. Kenny NP. The Ethic of Care and the Patient-Physician Relationship. Annals RCPSC 1994;27:356-8. May W. The Physician's Covenant. Philadelphia: The Westminster Press, 1983.
FEBRUARY 1995