Public has right to know how doctors are regulated

DAY by day, as the hepatitis C tribunal goes about its business, the Irish public is faced with uncontested evidence of the most extraordinary behaviour by doctors whose failures have scarred thousands of lives.That evidence, and the fact that the Medical Council does not seem to have taken any action against those doctors, has to make us curious about the way the medical profession regulates itself.

Since the public suffers when doctors misbehave, it surely has a right to know how the profession is policed. And it has a right to have the questions raised by the Medical Council's censuring of Dr Ivor Browne, details of which were revealed by The Irish Times recently, answered.

The public has no way of knowing whether the Ivor Browne case is typical of the Medical Council's procedures, since it is the only one whose details have been revealed. If it is typical, though, it raises some very important public issues.

The Medical Council has many of the powers of the High Court. It can compel the attendance of witnesses and the production of documents, and it can impose very grave penalties. If it finds that a doctor has misbehaved, it can take away that doctor's public and professional reputation, and even livelihood. In some respects, it is even more powerful than the High Court - it can be, as it was in the Ivor Browne case - the prosecutor as well as the judge and jury.

Since those powers are so extraordinary, it is essential that they be used to protect the public interest and not to enforce obedience to a particular notion of medical ethics that is itself, sharply contested both inside and outside the medical profession. Large areas of medical practice are of course governed by a broad moral consensus.

But only the dead can be unaware that there are huge areas of medical ethics and of the relationship between doctors and patients which are not just controversial but which give rise to some of the most bitterly contested moral debates of our times - contraception, abortion, sterilisation, in vitro fertilisation and the right to die.

And these are not just theoretical issues for, Irish doctors. They are immediate and regular practical concerns. They are about what doctors do as well as what they think. All over Ireland, in surgeries and hospitals, there are doctors carrying out procedures which are, according to the dominant ethical tradition in Irish medicine - that of the Catholic Church - unethical.

THE public has a twofold interest in this situation. There is a public interest in pluralism - ensuring that it is the law of the land rather than any specific ethical tradition that sets the limits for medical services. And there is a public interest in protecting, the civil rights of medical professionals - ensuring that no doctor suffers because of a lawful conscientious decision.

It is extremely important, for instance, that although the law permits abortion in some circumstances and recognises the right to die in some circumstances, the right of orthodox Catholic doctors to decline to take part in any such procedures should be fully protected. And it is just as important that doctors who conscientiously choose to carry out lawful procedures that the Catholic Church deems sinful, enjoy exactly the same protection.

In the Ivor Browne case, however, it is by no means obvious that that dual public interest was being upheld. It is worrying, for instance, that the only expert witness whom the Medical Council chose to call to give evidence on ethical principles was Dr Teresa Iglesias, somebody who is absolutely identified with an orthodox Catholic position. It is also worrying that in doing so the council - and not Dr Iglesias herself - somewhat overstated her academic status, describing her as "Senior Lecturer in Philosophy and Medical Ethics, UCD".

In UCD a "senior lecturer" (actually called a "statutory lecturer") is the university's recognised expert on a particular subject (rather like the specialist correspondent in a newspaper). Dr Iglesias, according to the UCD information office, is a "college lecturer" who teaches whatever courses are assigned to her by her head of department. The point is not that Dr Iglesias was unqualified to speak, but that it was wrong of the Medical Council to present her as UCD's official expert on the subject.

DR Iglesias was nevertheless a well qualified witness of the highest integrity, who holds philosophy degrees from Oxford and Madrid Universities and from UCD, where she teaches in the philosophy department. But by calling her as its only witness on medical ethics, the Medical Council implied that there is only one relevant ethical tradition and that it is - that of conservative Catholicism.

Dr Iglesias is a committed Catholic intellectual activist. She is an associate fellow and former research officer of the Linacre Centre in London, an institute established by the Roman Catholic archbishops of England and Wales to develop medical ethics "from within the Catholic moral tradition".

In her books published by the centre, she opposes absolutely and in all circumstances any procedure - the morning after pill, abortion at any stage and for any reason, in vitro fertilisation - that fails to "respect human life from conception".

She believes Catholic doctrine on these areas of medical ethics is "fundamental, enduring, unchangeable". And she does not believe that Catholic teaching in this regard is open to argument. In her book IVF and Justice, published by the Linacre Centre in 1990, she writes: "These truths are totally independent of scientific or philosophical doctrines. Therefore, the teaching office of the Church cannot be asked for convincing explanations of a scientific or philosophical nature in order to make the truths of faith acceptable or intelligible. These truths stand on their own grounds."

Dr Iglesias is, of course, perfectly entitled to hold such views, and her passionate advocacy of deeply held moral convictions is entirely admirable. But her views are in conflict with those of Irish law, which does not prohibit abortion in all circumstances, in vitro fertilisation, the morning after pill or the ending of treatment for a patient in a persistent vegetative state.

So why, when there are such divided views on Catholic medical ethics, should the Medical Council, a statutory body established under Irish law, treat those views as if they were universally accepted facts? Why should the council's only expert evidence in the case of a doctor who has behaved perfectly legally but against the interests of the Catholic Church be that of someone who takes Catholic doctrine to be unarguably true?

It is time, surely, that the Medical Council accepted that its job is not to uphold one set of bitterly contested views about medical ethics against another, but to enforce the universally agreed standards of moral responsibility and respect for patients that, as the public is discovering, cannot be taken for granted.