Sunday, 24 July 2011

Memento Mori - Dealing With Death

Some evolved survival mechanisms are the skeleton in the cupboard.

The death of celebrities or large numbers of regular people provokes an outpouring of shock, public grief and an intimate examination of their lives which, with the benefit of hindsight, led inevitably to their deaths.

The reaction that we are pleased to have is that the death of Amy Winehouse and the deaths in Norway provoke empathy both for the dead and for their families.

At the same time as feeling empathy, we have another reaction that it's not always quite as comfortable to admit to. Publicly-reported deaths always serve as a memento mori, a reminder of the fragility of life. The death of young people provokes particularly complex reactions; both Winehouse and most of the Norwegian dead were young.

News of any death creates cognitive dissonance, the discomfort caused by holding conflicting ideas simultaneously. So empathy for the dead and grieving creates and becomes entangled with fear of our own death. It's uncomfortable to feel sorry and afraid at the same time; we want the empathy but not the fear. Humans are (as far as we know) the only animals to be aware that we will die and we have to deal with that when we're reminded of it.

Memento mori means roughly 'remember you will die'. It's also used as a term for artefacts. These date back to antiquity but became widespread in Mediaeval times. They were a means of reminding people that death - and Judgement - were never far away to keep them close to the Church. Images of skulls, skeletons and the Grim Reaper are widespread in religious art for this purpose. The Book of Common Prayer still has the line 'In the midst of life we are in death. Earth to earth, ashes to ashes, dust to dust'. Carpe diem and all that.

As well as being aware we will die, we also have the ability to push this thought away. At the same time as empathizing, we also remind ourselves that Winehouse was an addict whose life was a mess and that we don't live in Norway.

We start to collect reasons why such deaths could never happen to us - this is the survival mechanism. This reaction can tip over into blaming the victim - Winehouse brought it on herself, for example. Some of the coverage majors on the 'fact' that she'd been on an 'ecstasy and booze binge'. Her many appearances while drunk or drugged are poked into, along with comments on her appearance - 'Amy also appeared unhealthily thin, with scabs on her face and marks on her arms, wearing scruffy clothes' in the Sun, for example. Her 'friends' are quoted as saying they were afraid for her before her death, that it was inevitable.

The shock of Norway is that it was Norway - a low-profile country where nothing much ever happens from an outside perspective. But it was Norway and we don't live there, we dodged the bullet through the good luck of geography. Calling the massacre of over 80 people (at the time of writing) a national tragedy helps bind their nation together but it also serves for the rest of us as a comfort that it wasn't our nation.

There is sometimes a certain Schadenfreude in our response too, a pleasure in the suffering of others. It's a comfort for us not being rich and famous to see how screwed up the lives of celebs are. But on this occasion the Norwegian deaths complicate the freude because the dead were not rich and famous, they were nobodies like us - and that brings it closer to home. This weekend, the Schadenfreude is less pleasure and more relief. We're not rich and famous but at least we're not Norwegian. It's not a laudable response but it's a human one just as much as the emotions and reactions we're more proud to own.

However, our success in telling ourselves that it couldn't happen here can come back to bite us when it does, especially when the perpetrators are home-grown. Freud might have called it the return of the repressed. The Norwegians had successfully insulated themselves; according to the BBC, 'Norway has had problems with neo-Nazi groups in the past but the assumption was that such groups had been largely eliminated and did not pose a significant threat'. We're all human, we're all fragile but this time it wasn't us and couldn't have been us - until it is.

The desire to read these stories or watch the news coverage may seem callous, something we shouldn't do, something tabloid and nasty for the better-educated to tut about - but it is part of the survival mechanism, the distancing process, insulating ourselves from death. Even the more rational media play into this, for example by listing other musicians who died young of overdoses or suicide - Hendrix, Cobain, Joplin etc, mentioning the 27 Club - some 38 musicians who died age 27.

The media aren't really doing anything that we don't all do, even if on an unconscious level. We may not like all of our instincts, and some we should probably not give in to, but covering them up or identifying them as something other people do, people we look down on, is not realistic. Doing that is also another human response though. Human beings are complicated buggers.

Friday, 22 July 2011

Always Let Your Conscience Be Your Guide? Part 3

Should students be accepted for medical school if they have no intention of treating certain people or conditions?

A survey shows that a significant number of medical students think doctors should be able to refuse any procedure that contradicts their beliefs. The procedure that causes the most contention is, as always, abortion.

Not all of the respondents were religious; non-religious students thought opt-outs should be a right too - 35% thought there was a place for conscientious objection. The survey also found a prevelance among the religious to object to certain procedures and patients.

In general, support for a doctor's right to refuse any procedure that troubles their beliefs was highest among Muslim medical students at 76.2% while 54.5% of Jewish students thought the same, as did 51.2% of Protestants and 46.3% of Catholics.

More than double the number of Muslim students than non-believers would refuse an abortion when contraception failed. A higher percentage of Muslim students than others would object to prescribing contraception. Nearly eight percent of them also stated they would object to ‘intimately examining a person of the opposite sex’. The survey didn't ask how students would feel about examining LGBT people which, along with not exploring the reasons for objections in the non-religious, is a limitation.

Doctors opting out of treating certain patients is only part of the problem. Some students are refusing even to learn certain areas of medicine in the first place.

It was reported in the Sunday Times four years ago that some Muslim medical students were refusing to attend lectures or answer exam questions on alcohol-related or sexually transmitted diseases because they claimed it offended their religious beliefs. This was corroborated by both the BMA and the GMC. Professor Peter Rubin, chairman of the GMC’s education committee, said: “prejudicing treatment on the grounds of patients’ gender or their responsibility for their condition would run counter to the most basic principles of ethical medical practice”.

GMC guidelines recognise the right of freedom of expression for medical students but state that this 'cannot compromise the fundamental purpose of the medical course: to train doctors who have the core knowledge, skills, attitudes and behaviour that are necessary at graduation'.

The GMC also specifically states that a foundation level doctor cannot practise while refusing to examine patients on grounds of gender or those patients whose illness can be attributed to their lifestyle. Guidance drawn up by the GMC advises doctors to refer a patient to a colleague if they object to a certain procedure or treatment. They must also give patients enough information so they can seek treatment elsewhere within the NHS. In some situations, doctors' consciences can (and should) be accommodated but the foundation level doctor is often the first one to see acute patients and any delay in treatment could have serious implications.

The research paper on the survey concluded that ‘Once qualified as doctors, if all these respondents acted on their conscience and refused to perform certain procedures, it may become impossible for conscientious objectors to be accommodated in medicine’. It also states that ‘The views of large numbers of Muslim students are contrary to GMC guidelines, and thus the medical profession needs to think about how it will deal with the conflict’.

Although Muslim students are clearly a growing problem, Muslims are not the only ones to object to certain procedures. The Christian Medical Fellowship, which has 4000 members, is also strongly anti-abortion, for example. Almost a third of the students surveyed wouldn’t perform an abortion for a congenitally malformed foetus after 24 weeks, a quarter wouldn’t for failed contraception before 24 weeks and a fifth wouldn’t even perform an abortion on a minor who had been raped.

Some of the reporting of this survey has gone straight to worse-case scenario and ignored the finding that a lower percentage of students would refuse to carry out a procedure than actually objected to it. However, the percentages are still significant and the situation needs to be addressed while respondents are still students. If the number of medical students prepared to carry out a termination when they qualify is shrinking, then women will find it hard to access abortion safely and quickly in the future.The UK may be drifting towards the situation in Italy where nearly 70% of gynaecologists refuse to perform abortions and 50% of anaesthetists refuse to assist on moral grounds even though abortion is legal.

While the GMC is holding out against students' right to pick and choose what they learn, the question remains - why do people want to become doctors if they are only going to treat certain patients or conditions, and where do they think they will practice this limited form of medicine? It's not just women's needs that are taking second place to beliefs; the provision of universal healthcare is being challenged too. Perhaps medical students need to be triaged when they apply to colleges and clearer limits set on the conscience to make sure that patients' needs always come first.

I wrote a response to the GMC consultation on conscience opt-outs for the National Secular Society some time ago.

In Part 1 I looked at the affect on women of pharmacists being able to opt out of selling emergency contraception if it's against their beliefs. I also wrote a consultation response for the NSS on this subject. It's not just in the UK where conscience is becoming a problem. In Part 2 I looked at the debate in the Parliamentary Assembly of the Council of Europe on doctors' opt-outs.

Update 3 August 2011
In related news, a Christian midwife is refusing to wear trousers because Deuteronomy 22:5 says that it's wrong to wear the clothes of the opposite sex. Trousers are part of the uniform for hygiene purposes and the hospital is so far sticking to its guns saying that wearing them is 'proportionate'. Let's hope she never wears clothes of mixed fibres and doesn't have pierced ears.

Friday, 1 July 2011

Barking Up The Wrong Tree

I was taught at school always to read the question before answering an exam. Basic, really.

In 2009, the Broadcast Committee of Advertising Practice (BCAP) ran a consultation on changing the rules for advertising Post Conception Advice Services (PCAS). I wrote a response for the National Secular Society, sent it off and waited to see what happened.

The new rules would allow more PCAS to advertise and would also ensure that adverts were not misleading about the services they offered - principally whether they would refer a woman for abortion or not (some can't if they're run by nurses and some won't if they're Pro-Life). There were certain restrictions about when adverts could be run - not close to children's programmes, for example.

BCAP were well aware that adverts might cause offence to some people who have a moral or religious objection to abortion but considered there were strong public health grounds to justify showing them and that the 'specific consumer interest in question is that of pregnant women'. It took into account the fact that 'these are legally available services offering a range of advice and that providers should be permitted an appropriate level of freedom of expression to advertise'. it also stated that 'offence taken by some members of the audience is not in itself sufficient reason to prohibit a particular category of advertising'.

I wondered why there had been no results of the consultation published.

This week, we got an email from BCAP saying they were running the consultation again.

The new consultation notes explain that the 2009 consultation resulted in 27,000 responses from people stating they were offended by the proposals, mostly on religious or moral grounds. However, 'most respondents appeared to have misunderstood what was being proposed' and 'few respondents commented on the specific question of whether it is appropriate to allow a broader range of PCAS (including commercial services) to advertise and whether it is sensible to require services that do not refer for termination to say so'.

27,000 is an awful lot of 'offended' people. So offended that they didn't bother to read the questions properly. Or maybe they did and just wanted to have a rant anyway.

Some of these responses were:

* BCAP's proposal will encourage promiscuity among young people and divorce sex from mature relationships.

* BCAP's proposal will promote abortion as a means of birth control.

* BCAP's proposals are in conflict with the Audio Visual Media Services principle that audiovisual commercial communications shall not cause moral detriment to minors.

* Abortion providers mislead women into thinking that abortion is a quick-fix solution to a problem pregnancy with no harmful consequences.

The consultation notes also say - 'you need only write a second time should you feel that your understanding of the proposal has changed'.

This is a polite way of saying - rant as much as you like, we'll still ignore you. Maybe it will make a difference, maybe they will get another 27,000 misguided rants. The NSS response does not need to be submitted again.

If you believe abortion is wrong for moral or religious reasons, that's your prerogative, as is saying so publicly. Replying to a consultation that exists only in your head is neither persuasive nor productive. All you achieve by barking up the wrong tree is frightening the squirrels. Don't be surprised if they throw nuts at you.

If you want to respond to this public consultation, it's here.

I'll be attending the Pro-Choice rally next Saturday.