Matters of Conscience .sx Pamela F. Sims , Consultant obstetrician and gynaecologist , Hexam , Northumberland .sx Section 4 of the 1967 Abortion Act states that " no person shall be under any duty , whether by contract or by any statutory or other legal requirement , to participate in any treatment authorised by this Act to which he has a conscientious objection .sx .. " .sx Background It has long been felt by those of us working in the field of gynaecology that there was discrimination against doctors holding a pro-life position .sx As in the case of discrimination on grounds of race and sex , it is always difficult to prove .sx How has the present situation evolved since 1967 ?sx After the Abortion Act was passed the Chief Medical Officer wrote various letters to the Regional Medical Officers ( who are responsible for employing consultants ) seeking to amplify the practical outworking of the law .sx On 19 February 1975 the CMO wrote :sx " Where it can be established after consultation with the relevant specialist advisers that there is a demand which cannot be met and where patient care would suffer if a doctor appointed to a particular vacancy did not feel able , on grounds of conscience to be involved in , or advise on , the termination of pregnancy it may be stated that the post includes duty to advise on , undertake , or participate in termination of pregnancy .sx .sx .. No reference to such duties should be included in the advertisement of such a post " but prospective candidates should be able to refer to " further particulars " i.e. the job description .sx Note , the ( then ) DHSS was to be informed whenever such wording was used .sx The Select Committee on Abortion published its First Report from the House of Commons in 1976 .sx At that time they felt that certain doctors were being barred from a number of posts .sx They recommended that the CMO's 1975 letter should be withdrawn and " that any new guidance should emphasise that conscientious objection should not normally be a bar to appointment and that 'exceptions should be made only in rare circumstances' .sx " .sx Thus the Chief Medical Officer wrote again on 16 July 1979 .sx He felt that the procedures recommended in the previous letter had been working " reasonably well " but he needed to " clarify certain points " .sx The CMO emphasised that termination duties should only be included in job descriptions if adequate services within the NHS were not already available .sx If they were , then termination duties should not be specified .sx Guidance on interviewing procedure was given .sx The letter clearly states that :sx " Unless the job description specifies that the duties of the consultant appointed include termination of pregnancy or advice on termination , candidates should not be asked whether they would be prepared to undertake termination of pregnancy .sx " .sx Regarding junior medical staff , that is any doctor 'junior' to consultant , the CMO is unambiguous :sx " it is not necessary for training purposes .sx .. to undertake duties involving termination , and for this reason it would appear inappropriate for termination responsibilities to be included in the job description of junior staff .sx It follows that ( juniors ) should not be questioned prior to their appointment about their attitude to termination .sx " .sx Recent Events .sx As abortion became increasingly commonplace during the 70's and 80's so it is likely that the CMO guidelines were waived on many occasions .sx In February 1988 the President of the Royal College of Obstetricians and Gynaecologists , Mr George Pinker , understated the situation in the College newsletter :sx " there have been one or two unfortunate examples recently of Consultant Appointments in which there has been no mention of the need for termination of pregnancy duties in the job description and yet candidates have been questioned about this at interview .sx This is against the instructions issued by the Department of Health .sx .. I hope this recent rash of problems .sx .. will not continue .sx " However , his exhortations evidently went unheeded .sx By the end of 1989 there was clear evidence of three more instances of breaches of the CMO guidelines .sx The Lancet of 8 April 1989 placed advertisements on behalf of Trent Regional Health Authority for two consultant posts in obstetrics and gynaecology .sx The following appeared :sx " The successful applicants will each be expected to develop a special interest .sx .. for managing the District's abortion service within the terms of the existing Act .sx The undertaking of abortions will be shared amongst all Consultants in post .sx " Similar cases involved West Lambeth Health Authority , advertising for a consultant community gynaecologist and South Tees Health Authority advertising for a locum senior house officer .sx Both these appeared in the British Medical Journal on 7 October .sx A member of the Christian Medical Fellowship , a consultant in a related speciality , became aware of the wording of the Trent RHA advertisement before publication .sx He informed CARE Campaigns who in turn reminded the RHA and Central Nottinghamshire Health District of the CMO guidelines .sx " Despite this warning , the advertisements were printed , whereupon CARE Campaigns complained to Trent RHA .sx There was a weak apology , but recruitment continued on the basis of the discriminatory advertisements printed , and interviews of short-listed candidates were due to be held on 5th June .sx At this point CARE prevailed upon a sympathetic MP ( Sir Bernard Braine ) who contacted Mr Kenneth Clarke ( Secretary of State for Health ) directly .sx On Friday , 2nd June , on the last working day before the interviews , Mr Clarke intervened and cancelled the interviews and recruiting process , and ordered that the posts be readvertised .sx In the wake of these events the Chief Medical Officer wrote another letter consolidating the advice given in his letters of 1975 and 1979 .sx It was dated 11 October 1989 and simply reaffirms the massage of the previous ones .sx This " rash of problems " to which the College President referred began to gain a higher profile in the media .sx The Social Services Committee of the House of Commons decided to hold an Inquiry into the application of the Conscience Clause of the 1967 Abortion Act , in particular seeking evidence as to whether recruitment into obstetrics and gynaecology is affected .sx Written evidence was invited from those of us who had directly experienced such discrimination , or witnessed it first-hand .sx But we were given very little time to respond .sx Individuals wrote , bodies such as the Christian Medical Fellowship and CARE - to whom we owe grateful thanks for bringing the whole matter to a head the previous summer - also submitted evidence .sx It was all in by the end of November 1989 .sx For once we were able to see an organisation such as CMF making its position clear .sx A range of positions on abortion is represented within its 4,000 members , nevertheless it was able to clearly state " we believe there IS evidence for discrimination against those holding conservative views on abortion " .sx This evidence was based upon results of two surveys conducted by the CMF amongst its own members during 1986 and 1987 .sx CARE , in its submission to the Social Services Committee was able to refer to its 70,000 supporters .sx The CARE Report clearly outlines the recent development of " an abortion culture " , reminding the committee that as consultant gynaecologists retire they tend to be replaced by those holding more liberal views .sx In the present climate not only is recruitment to the specialty sic !sx affected , but also the training and professional advancement of young nurses and doctors .sx Both CARE and CMF expressed concern over a wider range of issues than would appear to be immediately relevant - from the recruitment of medical students to the secretary who is unwilling to type letters referring patients for abortion .sx I submitted my personal testimony , recounting my experience as a registrar in a large London hospital .sx I was applying for senior registrar posts at the time and was actually told by my consultant that " I would never get a job while I held those views " .sx Oral Evidence .sx The Social Services Committee sought oral evidence from various sources .sx Firstly they sat with representative members of the Department of Health .sx That meeting took place on 10th January 1990 .sx In the Chair was Frank Field , the rest of the Committee comprised Andrew Bennett , Jerry Hayes , Ian McCartney , Geoffrey Pattie , David Price , Roger Sims , Ann Widdecombe , and Nicholas Winterton .sx This Committee was altered slightly when oral evidence was taken on 21st March 1990 ; Jerry Hayes and Ian McCartney were replaced by Martin Smyth and Audrey Wise .sx From the published Report of the Minutes of Evidence of the first session , it would seem that the Department of Health has most certainly not been fulfilling the requirements laid down in the 1975 CMO guidelines .sx They had not been effectively monitoring medical job descriptions and advertisements .sx Mr Roy Cunningham , Assistant Secretary , Department of Health , stated the following in response to the challenge from Ann Widdecombe as to whether the DoH is " doing their job which statutorily they are obliged to do ?sx " - " .sx ..It is possible with the passage of time the advice issued in the late 1970's had fallen into some kind of disuse in the Health Service .sx " .sx The problem of nurses holding to a position of conscientious objection was also explored .sx Daphne Patey , Principle Nursing Officer , was of the opinion that the Conscience Clause of the Abortion Act was working out satisfactorily for nurses .sx Naturally Ann Widdecombe had evidence to the contrary !sx It is worth remembering that numerically very many more nurses than doctors could be affected by the Abortion Act simply because there are very many more nurses than doctors .sx However , nurses are much more likely to move jobs or take a break from their career than doctors ; certainly once they have become established in a definitive post .sx The second session of oral evidence before the Social Services Committee took place on 21st March 1990 and heard evidence from doctors .sx Some of us who had earlier submitted written evidence were given the opportunity to amplify our position .sx Four gynaecologists , John McGarry , David Paintin , Timothy Rutter and Wendy Savage were the first to be examined by the members of the Social Services Committee .sx They were of the opinion that doctors were not being discriminated against on the grounds of conscientious objection to abortion .sx The three consultant gynaecologists ( all except Timothy Rutter ) were at pains to explain that they regularly appointed junior doctors who did not perform abortions , on the grounds that they were otherwise well qualified and had other qualities to offer .sx They presented glowing statistics showing that they did much of the abortion work themselves .sx In discussion there was a tendency to veer off the point ( the implementation of the Conscience Clause ) towards the pros and cons of abortion itself and current practice in the UK .sx Eventually it was the turn of 'our side' to give voice to the other point of view .sx Representing the view that discrimination is in fact rife was family planning doctor , Naomi Bankole ; recently ( at long last ) appointed consultant gynaecologist , Jonathan Brooks ; teaching hospital consultant ( Birmingham ) John Kelly ; general practitioner , Adrian Rogers and myself .sx One by one we were placed under the spotlight and quizzed - fairly mercilessly at times - about our respective positions .sx Not all of us held quite the same views , and indeed the waters were even muddied by the issue of freemasonry by Jonathan Brooks !sx .sx We had met as a group shortly before going to the House of Commons but were somewhat unprepared for the questions .sx A view was emerging by the end of the questioning of both sides which was to prove quite worrying to onlookers ( particularly friends from SPUC , Society for the Protection of the Unborn Child) .sx The Committee was wondering whether the answer to the problem of doctors not wishing to do abortions , and for women wishing to obtain them easily , would be to separate abortion services from the rest of gynaecology .sx Both sides felt this might possibly be an answer , though speaking for 'our side' we had not been able to give this due consideration beforehand .sx SPUC worried that this could pave the way for even more 'abortion on demand' than we have at present .sx The presence of anti-abortion doctors within the system has a breaking effect , which once removed could possibly result in an increase in abortion numbers .sx This is conjecture , however , as one could argue that there might be a new stigma for those undergoing abortion , perhaps even having an inhibitory effect .sx