Contraception and the
Catholic GP trainee and partner
in a Group Practice
Advice and ideas on how to follow the Church's teaching
One of a series of booklets aimed at helping young Catholic doctors by Drs Adrian and Josephine Treloar, Dr Anne-Marie Williams, and Dr Peter Au-Yeung
Produced by the Catholics in Practice committee of the Guild of Catholic Doctors
The decision to follow the Church's teaching on contraception may cause many problems in general practice. This article which was written by Catholic doctors who have already faced these situations and aims to help general practitioners and trainees who may be confronted by similar issues in the future.
Basic principles
It seems hard to discuss the issue of contraception in general practice without first mentioning the Church's teaching and personal conscience. The Church has taught for centuries against the use of artificial contraception, initially against douches and coitus interruptus, and later all other methods of artificial birth control as they have been invented. This teaching has been consistent and was clearly set out in Humanae Vitae and in subsequent documents of both Pope Paul VI and Pope John Paul II (Pope John Paul I did not have much time in which to reiterate the church's teaching). Humanae Vitae states clearly that 'each and every marriage act must remain open to the transmission of human life' and that 'depriving it...of its meaning and purpose is repugnant to the nature of man and woman, strikes at the heart of their relationship and is consequently in opposition to the plan of God. Humanae Vitae Pope John Paul II preached clearly about contraception both in England (at Wembley and elsewhere), in Ireland, in the United States and, especially in 1994, the Year of the Family, when the voice of the Church has been seen to be a 'sign of contradiction'. The teaching has been strongly restated in Evangelium Vitae and carries the full weight of the Magisterium of the Church. Unfortunately, as it seems so difficult to follow, a deaf ear is often turned.
The necessity to follow one's own conscience is frequently used to justify a less than wholehearted acceptance of Church teaching. But, as the Holy Father has frequently emphasised, and explained at length in Veritatis Splendor, our consciences on this matter should be educated. A failure to understand the Church's teaching should be met with a renewed attempt to increase our knowledge of the truth.
Once the logic of the teaching is followed through it is found, not only to be acceptable, but to be very beautiful. We can begin to perceive the purity of love intended by God for his creatures, which must yet be a poor reflection of His Divine Love. When we try to imitate this love, we find we have to struggle against many negative forces within ourselves and other obstacles surrounding us, but life becomes a great deal simpler.
It is a source of great suffering if we know we are partially rejecting the teaching of the Church we love. While Natural Law may at times be hard to understand, the close correlation of provision of contraception with divorce, abortion, illegitimacy, broken homes as well as venereal disease and cervical cancer in so many countries around the world may be easier to grasp. 'Procreation then becomes the "enemy" to be avoided in sexual activity:... interpersonal relations are seriously impoverished.'Evangelium Vitae Having studied the issues in detail we can be clear about our position, knowing that we are backed up by sound thought and we can proceed to put the teaching into practice without re-questioning the principles at every turn. This enables us to avoid continuous interior conflict and allows for greater honesty and sincerity both with patients and with colleagues.
Imposing ones faith?
As professionals we are always mindful of avoiding the imposition of our own faith and morals upon others. If we refuse to fit a coil or to prescribe the pill for a patient, we are told that we are imposing our morals. We think that it is very important to point out that the issue is really the other way around. By asking us to fit a coil, a patient is asking us to help them in what we consider to be an immoral act. If we agree, then they have imposed their morals upon us. If we refuse, they are not prevented from seeking help from another doctor who is willing to provide such a service. They may seek an explanation from us which, as shown below, need not be judgmental. We find that people respect our freedom if we respect theirs and admire our good moral standing, even if they do not agree with us, and for this reason come to trust us. It is, also, just possible that our colleagues and patients may be helped towards faith by our straightforwardness.
Hospital Training in Obstetrics and Gynaecology
The Junior Hospital doctor works under the guidance of the consultant and is not expected to make policy decisions. It is always wise to state one's position before taking up post so that the consultant can arrange the ward rotas so that someone will be available to help him run the unit in the way he wants. This can avoid a crisis and consequent ill feeling. The other junior staff may be a bit resentful that they are left with your work but this can be avoided by working well, arranging fair exchanges and showing a willingness to help them with their work especially when they are feeling tired.
If part of the consultant's policy is to offer, for example, post-natal advice on contraception, it is only fair for the junior doctor to make it clear how far he/she is prepared to co-operate with this. The consultant has a right to know if no advice is given or if full classes on Natural Family Planning are given to the patients under his/her care. If he is insistent that education is given, one must give this education to the best of one's ability which may not of course be with the same slant as the consultant. If he feels strongly about what he wants his patients told he may find an alternative way of getting the message across without involving you. It is very rarely required that prescriptions for the pill are needed for immediate hospital discharge and this can usually be written by someone else. If the consultant wishes to recommend a treatment in the letter to the General Practitioner then it may be advisable for someone else to write that letter or part of letter. The passing on of a message is a remote form of co-operation which some are not happy to be involved with.
Clinical decisions are commonly made in consultation with one's seniors except in the emergency situation. Ethical decisions will very rarely be needed in an acute situation as the best medically appropriate treatment, directed towards the preservation of life, is always good medical practice and will need to be followed. The misnomer of 'emergency contraception' need not induce an immediate response. It is clear that post-coital contraception is, in reality, abortion. A woman can nevertheless be helped to keep her conscience clear by taking a careful history of her menstrual cycle and the timing of intercourse. She can then be advised of the probability of conception.
Other unethical practices are met with in this speciality such as artificial insemination, sterilisation and, of course, abortions (for the latter, see separate leaflet).
Conflicts as a trainee and a partner
To refuse to prescribe contraception particularly as a trainee can be extremely threatening and stressful. Such an action may not be popular with your trainer, or partner and may risk loss of revenue from 'item for service fees' for the practice. In addition, partners may feel that you are being judgmental and may even be openly hostile towards you. Your entire career may seem to rest upon a decision to resist prescribing the pill. In fact, one of us offered his resignation when telling his trainer that he would not prescribe the pill just before starting in post. Another trainee found herself alone at times and felt compelled to supply prescriptions. She eventually gained courage to discuss the problem with her trainer and was surprised, not only to receive a sympathetic answer but, encouragement to stick up for her views.
Even if we are convinced, theoretically, that to prescribe the pill is like turning away from the Church and too painful to contemplate, often, at the front line it suddenly seems much harder to follow the Church's teaching than to provide the pill.
Is it, and when is it, right to prescribe?
Certainly the pill can be a useful drug for dysmenorrhoea and menorrhagia and it's prescription for these purposes is licit, even if it has a secondary contraceptive role. When asked to prescribe the pill, it is up to us to decide, in each individual case, how best to follow the church's teaching.
Just as some Catholics do not agree with the Church's teaching, some doctors do not see that prescribing the pill is an immoral act. They argue that if contraception is immoral then it is the person actually using it and not the doctor providing it who is committing an immoral act. We would like to argue that it would be wrong to provide a murderer with a gun as it would be complicity with an immoral act and thus not licit. The same argument of complicity can be applied to the provision of contraception for patients.
So how can doctors who refuse to provide the pill etc. cope in general practice?
In a large practice there is less demand for an individual doctor to prescribe contraception. It is good to be able to offer to teach Natural Family Planning and so, to study and attend courses on the subject is important. Courses are run at the NFP centre at Birmingham Maternity Hospital, the CMAC (Catholic Marriage Advisory Council) or Billings Centre.
Discussion with partners.
It seems only fair to partners to let them know early on what you will and will not do. There is even something to be said for coming out with this information at the beginning of the interview for the post. There is nothing worse for the panel than to receive this bombshell after spending an hour or so looking at all of your qualifications and credentials. They will feel deceived if it appears that you have tried to hide essential information from them. However, it is not necessary to put this in the original application or curriculum vitae, this has been found to prejudice any chances of being called to interview at all!. Especially for trainees this may be very threatening, but provided you can show that your beliefs are sincerely held then most fair-minded partners will understand. It is important to stress what you can offer a practice, and be clear that you will not impose your views on others, will not put obstacles to their freedom and will not be judgemental or intolerant of prevailing views. They may even be pleased to have a partner or trainee with some moral principles even though they may not agree with your ideas. To let them find out when the first problem arises is asking for trouble!
Discussion with patients and what to say.
When a patient comes through the door and asks for the pill you will, at some point in the consultation have to make your position clear. A lot of knowledge about contraception is very useful, and we would recommend this, as it makes you more aware of contra-indications or other problems.
It is possible to simply say that you do not prescribe the pill and patients often accept this without question. They often presume that you do not have the appropriate certificate. A minority ask further questions, so you will need to find an explanation you are comfortable with. To say you do not prescribe because you are Catholic seems to risk allowing the Church to be misunderstood as an insensitive object. The reasons for the Church's teaching lie in the natural law and, as this applies to all human beings, it is not exclusively for Catholics but for all of your patients. Some attempt to explain your position from this fundamental truth can be much clearer than the word 'Catholic'. The Church may well have guided us to this position but the reasoning stands on its own. Your clinical experience may also help you to explain that contraception, as well as premarital and extramarital relationships, makes stable marriages harder to achieve and this alone makes you unwilling to do something that you cannot feel is in the best interests of the patient.
Suggestions as to what to say follow;- "It is the only medication which has the intention of making the body malfunction,... it is medicine which stops the normal functions of our body,... all other medicines aim to make your body work better (even though they may have unwanted side effects), contraceptives aim to make your body work less well... Contraceptives have serious side effects, which include headaches, weight gain, heart disease, liver problems, blood pressure, clots, strokes and even death... etc.etc. People usually understand natural arguments very well, given the popularity of 'green' issues. Indeed if you take a good history and do a good examination it is surprising how many people have a relative contraindication to the pill. To avoid a confrontational consultation, all of this can be explained at the same time as checking their blood pressure or searching the notes for the dates of last screening procedures eg. Cervical smear, and identifying other problems or contra-indications. They can be asked about side effects or difficulties they experience, which shows your care and gains their confidence.
A light-hearted but meaningful way to open the subject is "I teach natural family planning, the other doctors deal with the artificial methods"
Some doctors simply say;-"I'm afraid that I cannot prescribe the pill for moral reasons". Patients may then ask spontaneously, or guess, that you are a Catholic. Such explanations certainly seem to be very well accepted by patients who have often commented on how nice it is to have a doctor who cares about such important issues. You may also wish to say that other partners do not have the same views and would be likely to provide different advice.
Leaving messages for partners.
When a patient has booked an appointment with you, to renew the contraceptive treatment recommended by another doctor in your partnership they expect no contradictions. In any partnership one partner is expected to uphold the recommendations and actions of the others. If, as sometimes happens, the patient leaves her request to the last day, any delay in the prescription will increase the pill free days and therefore expose the patient to a pregnancy. This may open the doctor to litigation for having 'caused a pregnancy'. Coping with this is very difficult and different doctors have different solutions.
Examining the patients and performing the appropriate screening procedures gives the doctor an opportunity to talk to the patient and maybe even explain the benefits of Natural Family Planning. Having checked that there are no complications or contra-indications to the pill, the patient would then have to wait for the prescription from one of the other partners. If the patient is kept waiting for a long time or has to make another appointment a lot of ill feeling may be generated. It is therefore important that a system which runs smoothly is worked out. If another partner is on-site there may be minimal delay. The problem arises when you are the only doctor available and at weekends. The patient may resort to going to their normal pharmacy to ask for an advance of a packet.
Some would argue that passing on messages is complicity in an immoral act, but you have not agreed to supply the pill and the patient has a right to continuity of treatment and to a second opinion, so you should not deny them that access. The message you give can make it clear that this is a patient request rather than a recommendation by you as a doctor e.g. 'The patient requests a repeat prescription of the pill.' A better message may be 'I cannot prescribe for this patient'. Even this remote co-operation does cause difficulties of conscience. The alternative is for the patient to go back to the receptionists to state her request. This may risk breach of confidentiality especially if the patient knows the receptionists personally or if the reception area is not well enclosed and other patients awaiting attention can overhear the conversation. The details of how this is done must be left to the individual working situations and to the conscience of the doctor. The partner who receives the message may then prepare the prescription for the patient to collect. If the screening procedures have already been performed this can be done without too much inconvenience or the need for an appointment.
It must be remembered that as their doctor, you have a duty to make sure that the patients remain healthy, despite not agreeing with what they are doing. They therefore should not be exposed to the dangers of taking the pill without regular health checks. This is similar to the attitude we take with drug addicts. We cannot refuse to treat their phlebitis or septicaemia caused by self-injection.
Initiating Treatment.
The situation is different if the patient is asking for the pill for the first time. We could not initiate treatment. The patient would obviously have to make an appointment to see another doctor so that a 'safe' choice is made. This could not be decided by the passing of messages, without a full history and examination. This may cause inconvenience to the patient to the extent that it may delay them starting the pill for one month if they cannot get an immediate appointment. This is unavoidable and perhaps beneficial as it would give them more time to think as to whether they were doing the right thing.
Giving in.
You cannot do this. If, despite feeling that you should not provide the pill, you begin to do so because of the practicalities, you may then find it even harder to resist providing, for example, the coil or the morning after pill as you have not drawn a clear line. Logically you may start to question the difference between the progestagen only pill which prevents implantation (the combined pill does this on occasions too) and coils and morning after pills.
What does it mean?
For patients there may be some frustration at not getting what they came for. Patients also feel this if they do not get antibiotics for a sore throat when they feel they should. This has, in our experience led to almost no expression of anger from patients. As we said before patients have often complimented the doctor on having morals which he or she feels are important.
With time this becomes less of a problem as the patients learn to avoid you when they need another supply of pills, but often continue to attend for other reasons as they know they can trust you.
For our mission.
Strangely, perhaps, the group who have the biggest problems are Catholic patients themselves. For example a girl who wanted the pill so that she could start sleeping with her boyfriend said "I'm a Catholic too but feel that we should sleep together", to which it was felt necessary to reply by encouraging the need to be careful not to enter a physical relationship rashly while pointing out that "my faith makes me take a different view to you". This story does however show one of the enormous potential benefits of admitting to our faith, as the girl in question did, to our knowledge, go away and think carefully and further about whether or not she had made the right decision. Indeed, if we say nothing, then patients, whether they are Catholic or not, may never hear that there are positive alternatives to the to the current world view of sexuality which is so incomplete and often seems so "compulsory" especially to the young.
If we are put into the position of regularly admitting to and standing up for our faith then we are clearly doing what Our Lord asks of us. We do not of course want to damage the Church by insensitivity etc., but we do feel that provided that we are sensitive, it is possible to be valuable witnesses for our faith.
'Our work can and should be the means of bringing many people to know Christ. Some professions have immediate repercussions on social life,....There are no jobs that have nothing to do with the doctrine of Christ....the Christian's way of behaving will sometimes clash with the current fashion, or will not be in accord with the accepted practices of colleagues within the same profession. These circumstances are particularly favourable for making Christ known, if we give a natural and firm example of Christian living.'In conversation with God. Francis Fernandez, Sceptre
'To doctors and nurses. Likewise we hold in the highest esteem those... who endeavour to fulfil the demands of their Christian before any human interest. Moreover they should regard it as an essential part of their skill to make themselves fully proficient in this difficult field of medical knowledge.'Humanae Vitae
For our partners.
Loss of income will be minimal, as most patients will go to another doctor in the same partnership. We are not aware of patients who have left a practice because one partner refused to prescribe the pill. More importantly, if we are well versed in family planning and can provide a Natural Family Planning service then we have something good to offer a practice. NFP is "green" and you may be seen as an asset for a practice by partners.
It may be an advantage to get onto the 'contraceptive list' on the understanding that you do not actually prescribe the pill or fit coils. This will enable you to obtain revenue for Teaching NFP, which is time consuming and uses resources in the way of charts and explanatory leaflets. Some FHSA's and Health Boards have been supportive of this. Although not providing contraception may cause extra work and even annoyance to the other partners, if you point out that you want no share in the profits from this 'item of service' work they may be pleased to facilitate things. We cannot make enemies of those around us by continually showing our dislike for what they do nor by obstructing their freedom of choice this would frustrate any chances of helping them. In exchange, we have a right to demand the same toleration and understanding from them.
For ourselves.
Living by our faith and love of God will foster our faith. If our faith tells us that we should not prescribe the pill, then doing so may put the depth and reality of our faith at risk. We may also put our jobs and careers at risk but very many doctors who have refused to prescribe the pill have been able to get into and survive in general practice. We are aware of some who have had career problems over the abortion issue so there may well be difficult times ahead. Perhaps one could take courage from knowing that even if we do not gain the whole world, we have at least tried to do what is right and so should keep our souls.
Conclusion
We have witnessed that it is possible to become partners and to work successfully in general practice without prescribing the pill and other artificial forms of contraception. We believe that this can be done tactfully and without harm to our patients, the church, or to our practices and can provide an opportunity to witness our faith in our work.
Helpful contacts
N.F.P. centres
NFP centre, Dept of Obs and Gynae, Birmingham Maternity Hospital, Birmingham B15 2TG
Billing's family life centre, 58b Vauxhall Grove, London SW8 1TB
CMAC, 1 Blythe Mews, Blythe Rd, London W14 0NW
N.A.O.M.I. 47 Heathhurst Rd, Sanderstead, South Croydon, Surrey CR2 0BB
NFP Education foundation, Rochkhead House, Cowdale, Buxton, Derbyshire, SK17 9SE
Scottish Assoc of NFP, 196 Clyde St, Glasgow G1 4JY
SAFE, Seraphim Ltd, PO Box 4471, London SE9 4XA
SPUC can be contacted for advice if there is any potential legal difficulty as they will give advice to health workers and may be prepared to back you up in any proceedings. They can be contacted at 5/6 St Matthew Street, Westminster, London SW1P 2JT.
May 1995