General practice docs, obstetrics and palliative care

This article originally appeared in the BC Catholic.
Reproduced with permission.

Their profession's regulatory bodies, the colleges of physicians and surgeons across the country, recognize their right to practise according to their beliefs: nobody can force them to prescribe medicines and treatments that they find offensive and repugnant. They have the right to refuse to do abortions, and nobody can force them to refer patients to abortionists.

However, according to Dr. Peter Seland, deputy registrar of the B.C. College of Physicians, doctors must inform their patients thoroughly: "there is an implied consent between a patient and his doctor: When a patient goes in to seek help, he is saying, 'Doctor, I expect you to give me all the info that is pertinent to my concern,' so doctors cannot simply present the side of a story with which they are most comfortable any more than a surgeon can present only the surgical options," while ignoring the medical treatments.

When a patient is seeking an abortion, her doctor does not have to engage in a long, detailed discussion, says the College's ethics spokeswoman Sandra: "Telling a patient that she must seek an abortion somewhere else is perfectly acceptable to the College." The only condition is, "doctors are not allowed to proselytize."

However, in spite of their rights being recognized, many doctors don't want to publicize their views, especially in the press, where their views are often distorted and sensationalized. They prefer to make "no comment." Or they speak "on background only." They want to remain anonymous.

They fear the wrath of a profession and a society that have accepted abortion as ordinary and artificial birth control as natural. They're inclined to believe that the practice of medicine is "going completely secular and God help you if you object."

Nevertheless there are many who aren't afraid to speak out, to identify themselves as pro-life, to proclaim that they practise respect-for-life medicine. Some of them suffer for doing so.

Ontario family doctor Stephen Dawson is facing his college's discipline committee. He refuses to prescribe the birth control pill to single women. Four women have complained. He also refuses to prescribe Viagra to single men, but no men have complained. And he refuses to do abortions.

Two B.C. doctors, Thomas McBride of Powell River and Howie Bright of Chilliwack, feel that Dr. Dawson got himself into hot water because he lectured the women on their morality.

Drs. McBride and Bright are Catholic converts who changed their practices in order to bring them into keeping with their new faith.

Dr. McBride says "the key here is that when I made the change it was for the sake of my soul, not my patients' souls. I think he stepped over that boundary when he implied that he was concerned with his patients' souls. If he had simply said, 'Look I am not going to do this for my own reasons,' they would have accepted it."

Katheryn Clarke of the Ontario College of Physicians says that the "manner with which Dr. Dawson refused to prescribe oral contraceptives to four women" is the issue. "It is fair to say that physicians have the freedom to give care in accordance with their conscience but when declining to provide a medical service they must do so in a professional, respectful manner."

"Also," McBride adds, "you have to be consistent and show no discrimination, so I don't prescribe the birth control pill at all." Whereas Dr. Dawson "was refusing to prescribe it to unmarried couples or unmarried women. So he will prescribe for married but not unmarried, which is discriminatory, implying a judgment that a sexually active single woman is doing something wrong."

Dr. McBride also serves as an anesthesiologist. He refuses to do so for sterilizations, and the local surgeon accommodates his stand. Dr. Bright says that he gets the same respect from his colleagues.

Neither doctor suffered any noticeable loss of patients when they converted. When Dr. Bright converted his practice, he spent a year informing his patients that he no longer referred for abortions or sterilizations and he no longer prescribed birth control.

"Women," he explains, "come for an annual pap smear and renewal of their birth control pills, so I had to go through a year of telling them that I'd changed my tune. And in that year I had only two patients who were upset with me. Interestingly, they are still my patients. They got mad at me but they saw that I was doing what I had to do and they stayed with me. I may have lost a few patients I'm not aware of because of converting the practice but I've always found it interesting that the two who got irate are still my
patients."

Those who insist on being on the pill, or other artificial methods of birth control, get it from their doctors' partners or colleagues. It's a bit awkward but it works. And those who want abortions don't need referrals to abortuaries.

Dr. Agnes Tanquay is a cradle Catholic who has always practised her profession according to Church teachings. She trained in the East and served as a Canadian army doctor before settling in Chilliwack as a family doctor. She delivers about three babies a month.

She works with doctors who also refuse to refer for abortions, but they do prescribe birth control. However, like her, they don't prescribe the IUD or the abortion pill or the morning after pill."

Dr. Tanguay says that as "a lady doctor" women expect that she will fill all their needs. "I do their pap smears-I do a lot of papping- and they say, 'By the way, I want the pill,' and I say, 'By the way, I don't prescribe the pill.'"

As is the case with other doctors, her patients who insist on the pill get it from her partners and colleagues.

Dr. Tanguay says that other medical staff "just think" that she's "weird" when she informs them of my pro-life practices.

A doctor who practices according to the Church's teachings, she says, can feel very isolated. "It becomes very heavy. You feel like the Lone Ranger. If your patient doesn't feel that contraception is wrong, she will go to another doctor for it and come back to you for her general care, so it is a bit awkward sometimes.

"You know that people are talking about you. They say that you are a big nut, ha, ha, ha, or that you are a religious fanatic. That hurts. Most people are respectful to your face but they're different behind your back. Some comments get back to me:"

For instance, Dr. Tanguay had advised a friend with four children why she felt a tubal ligation is not a good option. Her friend told her doctor of Dr. Tanguay's opinion, and the doctor quipped, "Ah, Dr. Tanguay is Catholic; she wants women to have as many babies as they can, ha, ha, ha."

So, Dr. Tanguay says, you can see that your friends and colleagues simply don't understand.

Like Dr. McBride, Dr. Tanguay has never informed her college of physicians about her practices so she's not sure it knows about her stand even though some patients have threatened to complain about her. But there have been complaints concerning other pro-life doctors.

"A couple of years ago," she explains, "there was a complaint against a doctor who would not prescribe the 'morning after pill,' and so now the college is saying that doctors do not have to do anything against their religious beliefs."

Emergency care, of course, is given without question, which poses a hypothetical problem to Dr. McBride: some might consider the 'morning after pill' as emergency care since, ideally, it should be given within 72 hours of intercourse. If there's no other doctor or pharmacist around, can the doctor be compelled to prescribe it?

Being sued for wrongful birth is another hypothetical problem that Dr. McBride poses: a 14-year-old comes in for an abortion. Her doctor refuses to do the abortion and he refuses to refer for one. She's too immature to consult other doctors and carries the baby to term, and her parents sue her doctor for wrongful birth-hypothetical, but possible.

The government, Dr. McBride adds, could also argue that doctors are obligated to refer for abortions because the provincial plan pays them; however, in order to avoid this public-funding argument, pro-life doctors don't charge the system or the patient for time spent explaining respect-for-life medical practices.

Dr. McBride no longer volunteers to relieve doctors in isolated posts because being the only doctor leaves "no reasonable alternative" for patients who insist on anti-pro-life practices, which could leave him open to legal action.

He says the pressure to conform to secular medical practices is very much there for medical students and residents. However, "once you're a licensed physician, you're quite an independent contractor."

Dr. Karen Stel is a recent family practice graduate who has just completed an extra year of obstetrics. She's now a licensed physician in Ottawa. She's currently doing locums.

She has always taken an anti-abortion stand so she never had to wrestle with whether she'd do abortions. It was birth control that caused her concern.

"When I started my family medicine residency about three years ago," she explains, "I was still undecided about whether I would prescribe contraceptives but once I read about it and its potential complications I decided not to prescribe. Throughout my residency, I made it clear when working with doctors that I do not prescribe contraceptives." She does not renew birth control prescribed by those she relieves.

Her respect-for-life practices "did not affect" her "clinical evaluation," she says, but at the end of each "rotation" her "preceptors would suggest" that she "reconsider" her refusal to prescribe contraceptives. But Dr. Stel remains pro-life." And now when physicians approach me to do locums for them, I make it clear that I can if I don't have to go against my pro-life convictions."

When interviewed, she was replacing a pro-life doctor who's completely sympathetic with her respect-for-life practices, but she was about to take over for a woman who could not believe, initially, that "in this day and age" there are doctors who do not prescribe contraceptives.

"To be quite honest," says Dr. Stel, "there is quite a shortage of doctors these days, so doctors are more than willing to accommodate pro-life views in order to get somebody to take over their practices."

Dr. Stel describes herself as a Protestant brought up "knowing and believing" that human life is "formed inside the womb and that God knows our every stage of creation."

She was one of two pro-life residents in the family medicine residency. The other one was a male.

"For him," she says, "it was more difficult because people felt, 'He's a man. He doesn't understand.' They respected my convictions because I am a female, but overall, I don't think being pro-life affected his evaluation."

For work she plans to do in Africa, Dr. Stel just completed an additional year of training in obstetrics.

When she applied for the extra training, she fretted about whether she should tell those running the obstetrics course that she does no abortions and no tubal ligations.

Her preceptor at Kingston told her, "Well, Karen, I wouldn't bring it up unless they bring it up in the interviews." The interviewers never asked.

She didn't raise the issue till she started doing C-sections. Since tubal ligations are often done with C-sections, she would tell each surgeon before going in that she would be standing aside for the tubal ligation. It "raised a few eye brows."

Only one doctor balked at her refusal to do sterilizations. He felt them to be part and parcel of obstetrics. However he got used to her stand once they'd hashed it out with the program director: Dr. Stel would observe only, stepping in to help only if there were complications, which is the approach she'd taken all along anyway.

Dr. Stel takes the made position on abortion: "If there is a complication from an abortion by all means I will help. I am not going to allow a patient to bleed to death, but I will not initiate an abortion."

Dr. Stel says, in general, doctors recognize that abortion is repugnant to some, so it's rarely a matter of contention. Consequently, she's more concerned about artificial birth control: "If we prescribe contraception, we 're working contrary to God's design of the sexes. It brings the man and the woman together for procreation and if I am interfering with it I am stepping out of bounds as a human, not just as a physician."

She wishes doctors would give more consideration to contraception. Far too many, she says, profess pro-life views but the prescribe birth control anyway.

The doctors interviewed have the greatest respect for natural family planning, NFP. Many if not all of them teach it. Dr. Tanguay finds that it can be "99.5%" effective for those who are "very motivated" and "do the follow up." She teaches the Billings method.

Dr. McBride explains Pope John Paul II's writings on the matter: "At all times, a spouse must be treated as a subject, never an object. As soon as contraception is used, it is almost inevitable that spouses will treat each other as objects, which is demeaning.

And, he adds, "by abstaining during fertile periods you are not excluding God," but acknowledging "the true complementarities of men and women. It's a high goal. And we all fall short of it most of the time but it is where we should be striving to go, treating each other as people. NFP virtually demands that we treat each other with respect . . . as subjects, not objects" by means of "communication, respect, and chastity."

Michael Brear, retired family doctor and father of eight, expresses the same idea somewhat differently: "The husband who does not love his wife's fertility does not love his wife totally. He rejects her fertility, her essential femaleness, thus introducing the language of rejection into the language of love."

All the doctors say that contraception or sterilization alters marriages, weakening them, making them more prone to divorce.

Dr. R. L. Walley, a professor of obstetrics and gynecology at the Memorial University, in Newfoundland, says NFP has never been taught to doctors and nurses. It has been seen "as well-meaning stuff that comes from organic gardeners," an attitude that has scuttled popular use of the natural technique.

Dr. Walley is developing an NFP course with education credits that he hopes to make available to physicians over the Internet, and he wants to provide information about breast cancer and abortions because "there seems to be strong evidence-growing evidence-that there's a link between the two, but
the information is being kept quiet."

Surviving as a pro-life obstetrics professor has not been easy. [See Pro-life OB-GYNs Left Out in the Cold - Administrator] When asked his opinion of doctors and pharmacists and nurses who refuse to comment publicly, Dr. Walley said, "To be honest, I don't fault them for it. It is exceedingly difficult. I don't think Church people, and that includes the hierarchy, appreciate what pressure obstetricians and gynecologists have been under for the past 25 to 30 years; and, you know, we all have to survive."

The selection committee at Memorial University's medical school didn't ask him his views on birth control and abortion and euthanasia and eugenics when they hired him, but when his stand became known, there was an effort to get rid of him.

"They didn't realize what they'd got until I was in. And the funny thing is, one of the strongest pro-abortionists supported me all the way down the line. I'll never forget him. He'll be in my memoirs. His name was David Charles. Dr. David Charles, a Welshman. He got me tenure. With people out to expel him and with "no support from the Catholic community, Dr. Charles came up from Boston; he was under indictment down there over the abortion issue, and he came up to support me."

"He had the guts to support me when there were other people so-called Christians and so on who would have been quite happy to get me out because I was just this irritating sore. They didn't want somebody who kept on and on about the abortion issue."

"There were many people who wanted to be the [only] Catholic physician and the Catholic obstetrician in town."

Dr. Walley says he survives because the school "has accepted" his pro-life "stand to come extent" and because he has been "successful," introducing programs, doing joint research, getting published, winning awards, and forming MaterCare International, which provides care for poor countries: the obstetric fistula project, midwife training, emergency transport with blood transfusion, developing simple treatment for post-partum hemorrhage, and raising money to build a birth trauma center in West Africa.

As for those who question his practices because they fear the so-called population explosion, Dr. Walley says, "There isn't one, and the U.N. admits it."

Life begins with conception and birth and ends with dying and death. Dr. Michael Brear says patients need their doctors to be strong when their facing death: " You have to let the patient know that he is dying and you have to be cheerful about it; after all, we all die. There's no point in being glum about it. Being very positive with the patient gives him that little bit of confidence."

"I always found," he continues, "that by and large the average person facing death faces up to it. Usually, the nursing is good. And families are good, usually, and so there's lots of support. I've always found it is no big problem."

Pain control is usually good, Dr. Brear explains, so quite often when a patient complains that he's in pain, he is, in fact, complaining about fear, fear of a painful death or fear of not being in control of his death.

Dr. Brear illustrates this point with an anecdote about an elderly patient admitted through emergency. He spent two days in intensive care before Dr. Brear returned from days off.

"He was an elderly patient, an Irishman, a smoker, a lovely man. And when I went in to him, he said, 'Doctor, get me out of here. I've died seven times.' That's what he said."

He called in the Irishman's family. They discussed his condition. They gave "it another 24 hours" and finally Dr. Brear suggested a change in treatment.

He told them, "I think we should put him in a bed and hold his hand and look after him. And that is what we did, and he died about 48 hours after I'd taken the tube out.

"I'll never forget that man. Wonderful man. You see, if I'd been in emergency to admit him, he'd have taken whatever treatment I advised. He knew that I knew him and that I'd be acting in his interest. But I was not there. I was on a weekend off."

Changing a dying patient's treatment is not euthanasia, defined as treatment given with the intent to kill--murder. But it's legal in some jurisdiction, like Holland and Oregon.

However, Dr. Romayne Gallagher, head of UBC's palliative (hospice) care unit, points out that euthanasia accounts for only one per cent of deaths where it is legal. Patients want to live as long as possible if they can die in peace and comfort; so, if they have the choice, they choose palliative-hospice care, which strives to relieve physical, emotional and spiritual pain.

In Holland, she adds, they've noted that those who do choose euthanasia are rarely in physical pain; they're usually in "intractable" emotional or spiritual pain, "which is often hard to treat."

Dr. Gallagher realizes that many people are "confused and wound up about the issue." Polls say that 80 per cent of the public wants euthanasia but what they actually want "is the right to stop treatment if it is not doing them any good, which is a right that they already have under the Health Act."

She tells of many elderly patients who, when she was in general practice, came to her suffering from "enormous breast cancers and they didn't want to go through the surgery and the chemo," so she offered "them medication that controlled the cancer" explaining to them that they did not in fact have to have surgery and chemo. "Absolutely, it's everybody's right."

However, if a younger patient declines treatment, a doctor finds out what might be affecting his decision: Pain? Depression? Incompetence? Early Alzheimer's?

The opposite can also happen. A patient might say that he will take all the treatment available and then feel he cannot change his mind if his case proves hopeless. It's up to the doctor to review treatment with patients.

But Dr. Gallagher says that you can't assume that those in old age face death and dying more easily than their juniors: "Some people, if you can believe it, get into their 80s without ever having thought about the
possibility that they would die. They go through this enormous 'Oh, my God, I am going to die.' It is really quite amazing. I don't think people face death any-well perhaps a little easier if they're older and they've kind of thought about it. But people still love living; even at 80, it is often hard to let go."

Near the end, when death is imminent and further treatment is hopeless, the patient and doctors have recourse to Do Not Resuscitate Orders: no heroics. Pain control and comfort are the only concerns.

"If people are dying," explains Dr. Gallagher, "and we know they're dying, I'll just say, 'We'll keep you comfortable, but, when you die, we will not come in and put you on a respirator.' People reply, 'Of course not, why would you do that?'"

Often, too, Dr. Gallagher finds that patients believe that modern medicine is much more miraculous that it actually is. TV leaves the impression that we can resuscitate 70 per cent when in fact we can do only three per cent. "Healthy people who suddenly drop on the street from heart attacks have a 20 per cent chance; patients with cancer who are dying have no chance. But what people perceive from TV is that they can be resuscitated no matter what."

The press, she adds, likes the sensational: "It sounds good to be championing the person who is suffering, as Svend Robinson does, saying, 'Those bully doctors. How can they keep dah, de, dah, de, dah.' They really feed on people's fears. We need to keep explaining what we can do for people and how we can make them comfortable."

Dr. Gallagher points out that when Svend Robinson was speaking for Sue Rodriguez's desire to die, pain wasn't the issue, control was: "It was just a control issue. Our society is so used to controlling everything, including when and how we die. The people who've I've seen grow the most are those who 've been able to say, 'OK, today is today. I am alive. I am going to live it the best I can.'"

Gallagher acknowledges that patients' wanting more control over your health care is "completely understandable. That's why we're trying to get patients to make advance directives, laying out whether they want life-sustaining treatment, or whether they want big interventions; that's the way for patients to have the control they want, not by advocating euthanasia."

Unfortunately, though, people do still die in pain, probably because the patient and doctor aren't 'communicating' with each other, says Dr. Gallagher.

"Sometimes it is due to the physician's lack of knowledge, and we are trying hard to correct that. I am a firm believer that, if we educate the public, they will know better and say, 'Hey, wait a minute, I am not supposed to be in pain. I am going to let my doctor know and make sure it gets treated.' A lot of time, though," Dr. Gallagher says, "family members project their own suffering on patients. So I think: Well the patient is unconscious, so the person who is suffering here is actually the family member.' Sometimes that's because dying is not understood so if we give them some pamphlets to read so that they know what's going on. They have a much better understanding if they know what role they can play."

Perhaps the secret to palliative-hospice care is realizing that pain "is a very subjective emotion"-physical, psychological, spiritual-"and that fear of pain can make pain worse."

"I find that people feel much better once I explain what I can do to treat their pain and so on. They feel better because they feel somewhat in control" knowing "that somebody's paying attention and that somebody has a plan."

Dr. Gallagher says she has family members tell her that they're quite surprised that their mother's or father's death was so peaceful. But she doesn't feel complimented by their praise; rather she feels that "people have seen too many TV deaths, which are far too dramatic, and not enough real ones."

However, Dr. McBride of Powell River says that there are always the exceptional cases. For instance, people can build up a resistance to a narcotic, so that you get a paradoxical effect: giving more narcotic causes more pain instead of relieving it. Switching to a different drug can get around the problem, or, if all else fails, nerves can be numbed or deadened.

Dr. Gallagher also instructs students. "It can be confusing for students because they're taught a lot about the autonomy of the patient." If she's seeing a patient who's pleading with her to speed up his death, students will often wonder why she doesn't comply without question. "If that is what he wants, why not give it to him?"

She has to explain that treating dying patients is not "like taking an order at McDonald's." The patient is in fact trying to say something else, something other than a wish to die. Rather than begging for euthanasia or assisted suicide, he's more than likely telling the physician that he's in pain, or that he's afraid of being a burden, or afraid of being plugged into a machine, indefinitely. The patients' autonomy she says has to be balanced with whatever unmet needs or misperceptions or fears he might have.