Catholic Medical Quarterly Volume 67(1) February 2017


Equality and Diversity in Surgery

In 2016 the four Royal Colleges of Surgeons invited the Catholic Medical Association to input to their review of equality and diversity issues in surgical training. Enabling doctors with a con­scientious objection to train to senior levels in all health-care professions is a central part of the CMA’s work. The Colleges of Surgeons’ stated aim is that “when we (the Colleges) make changes to the surgical curricula, doctors from minority and diverse groups would feel that they are being considered and included and not inadvertently discriminated against. Another aim is that it will aid our thinking and awareness about how we can eliminate discrimination and achieve full equality, as they develop curricula. The second step, which will come later, is to put in place arrangements to consult on a regular basis when curriculum changes are being planned”.

Q1: What sort of barriers to successful careers within surgery, do your members face?

Catholic doctors and students share with many other professionals the duty to act professionally and in accordance with their conscience. In doing so, in the majority of circumstances they will work normally and well alongside colleagues of all faiths and no faith.

In a society which strongly embraces diversity, the people whom the medical profession serves must be cared for by a profession which also reflects the same range of values . There are times when, for example, a Catholic patient will request particular sorts of care that is "in line" with Catholic teaching on a medical issue. At other times they will share the fears and apprehensions about good care that many others also have.

But at times, it is absolutely necessary for a doctor to state a strong conscientious objection to certain medical procedures, or perhaps a strong objection to the withhold­ing of care. Examples might include medical assessment prior to an execution in jurisdictions where capital punishment is legal. Or perhaps, an ethical objection to sale (or at times inappropriate donation) of an organ for transplant.

We are conscious that within medicine and within society there is a deeply embedded antipathy to the Church and toward Catholics whom many see as being unthinking. Their views may be dismissed simply because they are held by a Catholic. This does make it difficult for Catholic doctors to share the fact of their faith with others. Most are afraid to do this, and keep their faith absolutely quiet in the workplace.
But there are some procedures which are ethically questioned or prohibited by the Church. When doctors have considered Church teaching and decided that they agree that that teaching is right and relevant, it may fall to them to state a conscientious objection.

An (incomplete) list of procedures might include:

  • Sterilisation (male or female)
  • Gender reassignment surgery,
  • Nephrectomy for commercial sale,
  • Some other infertility treatments though not vasectomy reversal,
  • Very heroic surgery on extremely disabled and sick people in whom that surgery is not thought likely to provide benefit
  • Some plastic surgery such as enhancement of normal labia or other sexual organs
  • Perhaps also bleaching of skin for BME people
  • Treatments with teratogenic drugs during pregnancy
  • Etc.

There are times when a patient may request a treatment not consistent with Catholic teaching. In such circumstances the doctor or student has the option of conscientious objection to performing or cooperating in that treatment. This position may be seen by their senior or trainer as obstructing the requirements of their training, and may lead to disqualification for higher training or even job prospects in certain disciplines.

In the end, some doctors find that they cannot progress in their chosen career as a result of these difficulties. That appears to us to be wrong, and also means that those who would share a conscientious objection are not served by a profession which understands or respects their views.

Q2: How are your members discriminated against, if at all,when they undertake a surgical career?

Catholic doctors and students will be (and are) frightened for their careers if they speak out and state an objection. While doing this, of course, requires considerable skills and tact (especially at the patient interface) it is absolutely essential that, doctors act morally and ethically within the law.

There will therefore be times when a request from a patient for a procedure that is legal is not provided because it is unethical in that circumstance. At times such as these, our members have been taken aside and told that their objection will mean that they will not progress in their chosen speciality and have at times been refused “sign-up” for the speciality involved.

The College will appreciate that as a result of the power relationship between trainee and supervisor, trainees rarely agree for their specific details of the case to be made public. Doing so does not help a career at all. Therefore they suffer silently.

Within teams, after the expression of a conscientious objection, relationships may be strained especially if colleagues think that they have to do extra work as a result to that objection. That is hardest for the objector who is held up as the cause of that difficulty.

Finally, it is fair to say that in this country, the Catholic Church is at a point when criticism of it and indeed its vilification is perhaps significantly more socially acceptable than it has been since Catholic emancipation in the 19th Century. With regular and on-going criticism in the media and elsewhere, Catholics may feel increasingly marginalised if they express their faith. That in itself makes Catholic doctors and students feel pressured to conform and to keep quiet.

Q3: How can we help your members to feel included and supported when making curricula changes?

The College needs to recognise that conscientious objection is a central and necessary part of a medical and health system that embraces diversity and which takes its workers from all walks of society.

The curriculum needs to be explicit about recognising the value of the conversation about what is and what is not ethical, and also supportive of doctors who do conscientiously object.

In particular, it would be wrong of the College to, for example, require that all urologists have done vasectomies in order for them to be signed off for CCST. There must be a way to enable consultant urologists who object to such a procedure to be trained in the speciality. The health care employer (e.g. NHS) in its turn needs to be able to make the reasonable adjustment to enable that person to work productively in a department where only a minority of the work relates to that procedure.

Q4: What are the sorts of things that you think we should consider and implement for the benefit of your members when we make any changes to the curricula?

Explicit recognition and support within the curriculum for those with a conscientious objection and also ensuring that those who are of faith are respected.

Submitted to the Joint Committee on Surgical Training (JCST), Royal College of Surgeons of England, 35-43 Lincoln’s Inn Fields, London WC2A 3PE