Sir, – The question is not whether the Irish Medical Council “approves of deliberate killing of patients” but why protecting patients from being killed is no longer thought worthy of specific mention in its ethical guidelines for doctors (“Does Irish Medical Council approve of deliberate killing of patients, asks Catholic bishop”, News, January 22nd).
In contrast, the Irish Medical Council spends eight paragraphs emphasising the importance of protecting the privacy of patients. It may be noted that while Dr Harold Shipman in the United Kingdom killed more than 200 of his patients, there is no suggestion that he failed to respect their privacy. What he did, he did in private, and afterwards had the bodies cremated. His actions were of course illegal but, apart from the law, the Irish Medical Council no longer states that such actions contradict the ethical obligations of a doctor. They strain out the gnat and swallow the camel. – Yours, etc,
DAVID ALBERT JONES,
Director,
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Anscombe Bioethics Centre, Oxford
Professor of Bioethics,
St Mary’s University,
Twickenham,
London.
Sir, – The recently updated Irish Medical Council’s ethical guidelines for doctors contain significant departures from the previous edition, notably around conscientious objection, and the omission of reference to the deliberate killing of patients. These changes are presented to the profession as being of the day, as it were. In doing so, I fear the council has made the mistake of conflating issues relating to legal compliance with the well-established and accepted principles of bioethics which help guide the practice of medicine. Put simply, expecting a doctor to behave in a certain manner due to legal requirements does not necessarily mean the behaviour is ethically sound. There is a clear distinction between the two. – Yours, etc,
JOE MORAN,
(Retired GP),
Fermoy,
Co Cork.
A chara, – The Medical Council’s new edition of the Guide to Professional Conduct and Ethics for Registered Medical Practitioners came into effect on January 1st, 2024, replacing the eight edition of 2016, updated then in 2019 following the legalisation of abortion in Ireland. The introduction to the 2024 edition says: “This guide outlines the values and principles that underpin professionalism and good medical practice in the interests of patients and the broader population.” It matters to both doctors and “the broader population”.
Two aspects of this 2024 edition concern me: the basis on which the Medical Council decides on professional conduct and ethics, and the way in which these affect medical practitioners.
The 2009 edition of the guide stated, in relation to abortion: “Abortion is illegal in Ireland except where there is a real and substantial risk to the life (as distinct from the health) of the mother.” The 2019 edition stated: “Termination of Pregnancy is legally permissible within the provisions of the Health (Regulation of Termination of Pregnancy) Act 2018.”
I can find no mention of “abortion” or “termination” in the 2024 edition. Can it be that the Medical Council has no ethical position on the matter, and is content to take their ethics from the Government? If so, this is a dangerous position, knowing from history how governments around the world have at times enacted legislation which contravenes the principles and values of medical ethics. Is there any possible legislation which the council would not implement? Is there a future for medical ethics?
This impression is strengthened by another change. The 2019 edition of the guide, in relation to end of life care, said: “You must not take part in the deliberate killing of a patient.” This is omitted from the 2024 edition. It is as if the Medical Council is preparing the way for legalising euthanasia, even before any such legislation, as if there is no ethical problem with killing a patient.
This is especially relevant when we come to conscientious objection on the part of a medical practitioner. In The Irish Times last year, you pointed out that the 2024 guide uses the word “must” 150 times, up from 120 in 2019 (“Conscientious objection rules changed in new ethics guide for doctors”, News, November 1st, 2023). The 2024 edition is unambiguous: “The term ‘you must’ is used where there is an absolute duty on you to comply with the guidance that follows”. In relation to conscientious objection, the 2019 edition uses the word “must” twice; the 2024 edition uses the word “must” five times, and the first of these covers five provisions. An additional obligation is imposed over the 2019 edition. As well as providing the patient with the information to enable them to transfer to another doctor, it also states: “If you have a conscientious objection to providing or participating in a lawful procedure, treatment or form of care you must make such arrangements as may be necessary to enable the patient to obtain the required treatment.”
Providing the patient with the necessary information is one thing; but making the arrangements for a procedure to which the medical practitioner has a deeply held conscientious objection is surely a demand too far. If the practitioner complies, it could result in “moral injury”. Prof Gaye Cunnane (Health & Family, January 23rd) wrote of “moral distress” in relation to the wellbeing of health professionals. An article in The Lancet (June 2021) said: “Moral injury is understood to be the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code.” This can have serious consequences for the person whose core principles (for example, not to assist in killing a person) are violated.
It could be a very serious matter for a medical practitioner who refuses to comply with what the Medical Council says is “an absolute duty” if it could lead to being struck off the medical register. It is a matter which concerns both medical practitioners and the broader population. Medical practitioners are already under pressure in an understaffed and under-resourced health service with an increased population. A dictat to contravene one’s core principle of respect for all human life disrespects medical practitioners.
Germany has learned from its history. Its basic law (constitution) opens with: “Human dignity shall be inviolable. To respect and protect it shall be the duty of all state authority.” Its military manual (1992) says that “an order is not binding if it violates the human dignity of the third party concerned or the recipient of the order . . . Orders which are not binding need not be executed by the soldier” and “Punishment for disobedience or refusal to obey shall be impossible if the order is not binding”. – Is mise,
PÁDRAIG McCARTHY,
Sandyford,
Dublin 16.