Forensic & Legal Medicine (FLME 40130)

Medical Law, Ethics and Professionalism Group Discussion

Preventing pregnancy in homeless; a very controversial issue for us to

discuss which requires the understanding and knowledge of various areas of
medical ethics. In our discussion, we focussed on the best approach to offer
contraception for our homeless women.

The Main Areas of Medical Ethics, Medical Law, or Professionalism of the

Assignment (by Audrey Zafirah Hamidi)

Throughout our discussion, we came out with few ideas but one of the
questions raised was, are these approaches ethical? The first area of medical
ethics involved was the issue of consent. It is lawfully required and is an
essential part of respect for patient’s autonomy. However, are these homeless
women have the capacity to make an informed decision regarding
contraception? One of the approaches on offering contraception to them is by
giving monetary incentives. This might be seen as a bribe and an easy way
out. So, is this then ethically accepted? By giving them monetary incentives to
accept contraceptives, it means that there won’t be any discussions between
these homeless women to ensure their understanding on contraceptives as
well as their risks on the sides effects of contraception. Based on the Guide to
Professional Conducts and Ethics for Registered Medical Practitioners 2016,
three criteria should be considered in assessing capacity: their level of
understanding and ability to retain the information they have been given; their
ability to apply the information to themselves and come to a decision; and
their ability to communicate their decision, with help or support, where
needed[1].

So from these three criterias, it is not wrong then to say that these homeless
women do not have capacity to give consent on contraception if there were no
proper discussions with them prior the procedure. From paragraph 11 of the
Guideline, it explains the necessities for practitioners to provide information so
that patients can understand and exercise their rights to make informed
decisions about their care. It also confirms that a consent is not valid if the
patient has not been given enough information to make a decision.
Furthermore, another ethical question raised was whether the decision of
giving these homeless women monetary incentive breach the practitioners
profesionalisme. Daniel mentioned in the discussion that medical
professionals are used to work hard to achieve good income. Medical
practitioners are expected to present themselves with positive attitude such as
empathy, determination and respect. Each of their actions might be judged by
the society especially if it is against the society’s expectation of their ideal
Doctors.

Finally, our discussion touched on how school ethos hamper sex education as
most schools reflects Catholic teachings on sexual morality that ban
contraception. Although taking contraception is lawfully legal in Ireland
nowadays since the amendment of The Health (Family Planning) Act 1985 in
which it liberalized the law by allowing condoms and spermicides to be sold to
people over 18 without having to present a prescription, it is still not widely
available and the society might not be well educated on the importance of it,
especially our unfortunate homeless women.

Criticisms About The Conclusions Drawn by the Authors / Presenters of the

Case (by Daniel Toh)

The topic of whether providing monetary incentives or education is a more

effective method to promote the use of contraceptives is controversial, with
many valid reasons on both sides, and no clear distinction as to which is
better. Out of the group, Gretta, Tara, Audrey, and Micheal support the notion
of the use of education, while I play the devil’s advocate.

It is not difficult to see why some would agree with education as a primary
means, and my group members have put forward good points for it. One
major point was that education leads to greater self-awareness, which has a
positive snowball effect on their overall lifestyle such as raising low self-
esteem, kick drug addictions, more frequent regular check-ups at the clinics,
improve the environment for raising children, and the adoption of an active
attitude in seeking employment. The aim here is to solve the problem at its
roots, with the hope of treating the symptoms as well. This is backed up in the
podcast from the nurse who states “We are helping them to learn to trust us,
and by offering money it would show we did not trust them”. Another main
point was that monetary incentives were considered too unethical and felt like
a form of coercion. The offer of incentives to drive contraceptive use could be
mirrored to forced consent, which was consistent with what the majority of the
actual committee felt as well. The group feels that it is comparable to paying
them to take away their rights and humanity.

On the other side of the coin, I feel that monetary incentives play a bigger
role. The use of incentives have always been a big influencing factor in
motivating various outcomes. While one may argue that it may be unethical
and coercive, some might argue that it would be more akin to a gentle push in
the right direction. Ironically, the use of monetary incentives versus the offer of
food and cosmetics in the podcast offers these homeless women more
choice, which was also mentioned by the judgement ethics committee.
Another point was that if these women were ‘not at the stage to help
themselves yet’ or ‘do not think of the future benefits, as they currently value
immediate returns more’ as stated in the podcast, they would be much more
likely to choose monetary incentive over education to fuel their current
priorities. Thus, since they are not ready to help themselves, the next best
alternative may be to use monetary incentives as a means to achieve
contraceptive use. Some may argue that this scheme is a form of eugenics,
recalling on Project Prevention in the US and certain experiments conducted
in India. However, in this case the focus is on protecting these women.
In conclusion, a balance between practicality and societal morality is critical to
finding a working solution. Should we consider the moral ethics of an
individual above everything else? Or should the ends justify the means?
Any bias about what the authors/presenters wanted to discuss
(by Michael Noonan)

I think it’s positive that the various dimensions of the situation were well
covered in the podcast. The perspectives of the hostel workers, Doctors and
the homeless lady herself were all given reasonable time. I think it is fair that
the piece opens with Amanda's story, upon which the conversation is based.
The presenter, Joan Bakewell, herself does not put forward a personal
opinion and acts as an independent moderator of the discussion in an
unbiased manor. The panel including doctors, professors and philosophers
provided a vast array of knowledge pertaining to the topic under debate.

Within the team working at the hostel there is a serious difference in opinion
as the the usefulness of monetary incentives. However the way in which the
podcast is structured gives a very good back and forth of opinions between
the doctor, sexual health nurse and hostel worker.

Opinions within the panel of experts differ greatly. I think that this provides a
good basis for a balanced discussion. Richard Ashcroft, a philosopher and
professor of bioethics) mentions that he has previously been involved in
schemes where monetary incentives have been used and is sympathetic with
the point of view of the sexual health doctor. In opposition to his opinion, Dr.
Tamsin Groom ( A sexual health doctor who helped to set up homeless
services in Sandyford , Glasgow) protests strongly against the use of
monetary incentives. The two remaining panelists, Anne Skinner(Director of a
non-profit social business called Resolving Chaos and chairperson of
Homeless Link) and Deborah Bowman ( A professor of ethics in St. George's
University) both have opinions falling somewhere in between conceding that
monetary incentives should be considered but only if used as part of a wider
service to homeless women. In my opinion the panelists varying outlooks
successfully mirror the debate within the hostel staff and the ethics committee.
The arguement is made from both sides and we are permitted to objectively
view the situation and formulate our own opinion.

I think that the facts of the case were presented extremely well. As mentioned
above, the podcast was structured around the homeless woman, allowing the
discussion to take on an orderly format, with each side allowed time to
present their opinion on each topic in turn before moving on. The passage
was relatively short and succinct and did not deviate from the topic at hand. I
therefore found it easy to listen to and engaging throughout.

In general I feel that the podcast was extremely informative, lacking in unfair
bias and representative of all viewpoints. A criticism I would have is that I
would have liked if we had the opinion of more than a single homeless woman
in the piece. We are given the opinion of multiple healthcare professionals
and experts in various fields and I think it may have been useful to hear the
voice of more women with similiar experiences.

Main Learning Points Gained from the Assignment

(by Tara Hamilton)
The main learning points from our assignment center around the barriers
homeless women have to contraception and possible strategies to overcome
them. There seem to be many barriers to contraception and reproductive
health care services for homeless women such as lack of knowledge about
contraception, where to access it and fear of judgment by providers [2]. In
general, women want to avoid pregnancy while homeless. Despite this,
homeless women are less likely to engage with and access reproductive
healthcare and use contraception [3].

Some of the suggested strategies to tackle this problem include provision of

free contraception, improved sexual health education, mobile health clinics to
provide better access to sexual health services and the use of incentives to
encourage uptake of contraception.

In Ireland the general medical services scheme allows people with medical
cards to purchase contraception for €2.50. However, The UN has ordered the
Irish government to remove all "existing legal, policy and cost barriers to
adolescents and young women's use of modern forms of contraception and
ensure their access to contraceptive information and services”[4]. This is to
comply with the convention of elimination of discrimination against women
(CEDAW [5]. The Irish government responded by introducing the National
Sexual Health strategy 2015-2020, which addresses access to contraception
and sexual health education[6].

The Safetynet network for homeless health services has developed a mobile
health clinic for homeless people and female sex workers in Ireland. Sexual
health is one of the services provided by the mobile health clinic [7]. A 2016
review of the mobile health clinic showed that had it not been available over
half the users would not have further treatment and 91% of users rated the
service 10/10. Staff working in the unit also had reduced negative
stereotypes, increased empathy and more knowledge of homeless issues [8].
With regards to education, the 2011 census showed that 25% of homeless
people did not progress past primary school level education [9]. In addition to
this schools in Ireland are free to have no effective sexual education if it
conflicts with the schools ethos [10]. Addressing this issue of poor sexual
education was another one of the suggestions made to Ireland by the UN [5].
We learnt that the use of incentives, especially monetary incentives is very
controversial. For example project prevention in the US offer money to women
to get long term contraception and sterilization. However, this practice has
been reported as being unethical in Ireland and the UK [11][12]. This
effectiveness of this practice is also controversial with a study in India
claiming this strategy increases levels of contraceptive acceptance [13]. While,
Heil et al. showed that only 1 in 8 studies reported a positive outcome in using
monetary incentives, with incentives increasing attendance rates but not
unplanned pregnancy rates [14].

In conclusion, during this project we learnt that mobile health clinics, free
contraception and improved sexual education would be good areas to target
to overcome some of the barriers between homeless women and access to
contraception while the use of incentives remains a controversial topic with
unclear effectiveness.

Five Suggestions for the Medical Profession

(by Gretta Sheridan)

From the research conducted on the topic at hand; ‘Prevention of Pregnancy

in Homeless Women’, it is evident that the sexual health needs of the
population are not being met. Not only the homeless population, but our entire
Female population as a whole. Not only are they not being met, but the
government is in breach of the reproductive and sexual health rights of
women, according to the CEDAW, by not providing free access to
contraception [15]. It is clear that the government and HSE must implement
adequate measures to educate and encourage contraceptive use among all
Irish Women.

5 suggestions I would make to medical professionals based on our topic are:

1. increased ease of access to education and contraception
2. free contraception
3. contraceptive counselling
4. setting up of a mobile sexual health unit
5. non-monetary incentives to encourage engagement

Increasing accessibility of education and contraception is an easy and

effective way to encourage engagement with sexual health professionals.
Using services that are already setup, such as ‘SafetyNet’, an excellent and
efficient service, specific for the health needs of the homeless population and
increasing the number of clinics in different locations [16]. However also
increasing awareness by clear and concise leaflets and word of mouth, of the
available services, as many of the homeless population are unaware of the
services available to them [17].

As mentioned previously, the CEDAW issued a statement to the Irish

Government that it was in breach of the rights of young women’s access to
information on contraception and services, and encouraged them to remove
all barriers to access, namely, cost, legality and policy [18]. Recently the
Oireachtas, following recommendations made by the Citizens assembly,
debated implementation of free contraception and subsequently deemed
‘possible’ by the Department of Health’s Chief Medical officer Dr Tony
Holohan [19].

A commonly identified barrier to contraceptive uptake was lack of counselling

[20]. Lack of counselling leads to misconceptions and lack of understanding

about contraceptive types and potential side-effects. Looking at the homeless

woman interviewed on the Podcast; upon adequate counselling, she was
taught the different forms of contraception which she had no previously known
about and subsequently started using the contraception. A prime example of
the effectiveness of education and counselling [21].
Following on from the Mobile Health unit, already setup by ‘SafetyNet’ and
Simon community, branched the idea of a mobile sexual health unit. Targeting
both populations, homeless in hostels and on streets. Proven to be an
excellent service and removes another common deterrent; cost of transport
[8][22]. While also providing a source of sexual health education, tests and

contraception for free in a safe non-prejudicial environment.

The use of non-monetary incentives, such as food and clothing, to encourage

engagement with services has been proven to be effective [23]. However, a
line must be drawn using incentives to encourage the use of contraception.
Women must be able to make an informed consensual decision about their
own sexual health needs, not influenced by coercion from financial
incentives[24].

References:

1. Guide to Professional Conduct and Ethics for Registered Medical

Practitioners [Internet]. 8th ed. 2016 [cited 27 November 2017]. Available
from: https://www.medicalcouncil.ie/News-and-Publications/Reports/Guide-to-
Professional-Conduct-and-Ethics-8th-Edition-2016-.pdf
2. Begun S, Massey Combs K. An unmet need: homeless youths’
experiences, attitudes and decision making regarding contraception.
Contraception. 2017;96(4):274-5.
3. Kennedy S, Grewal M, Roberts EM, Steinauer J, Dehlendorf C. A
qualitative study of pregnancy intention and the use of contraception among
homeless women with children. J Health Care Poor Underserved.
2014;25(2):757-70.
4. Holland K. Contraception should be free to teenage girls in Ireland, UN
told. The Irish Times. 2017 12/4/17.
5. Concluding observations on the combined sixth and seventh periodic
reports on Ireland. Committee on the elimination of discrimination against
women; 2017.
6. National Sexual Health Strategy 2015-2020. Department of Health;
2015.
7. Greene D. Focus -- mobile health clinic -- A safety net. WIN. June
2011.
8. O'Carroll A, Irving N, O'Neill J, Flanagan E. A review of a GP registrar-
run mobile health clinic for homeless people. Ir J Med Sci. 2017;186(3):541-6.
9. Homeless persons in Ireland, a special census 2011 report [press
release]. Central Statistics Office2012.
10. O'Regan M. School Ethos hampering sex education, SF senator
claims. The Irish Times. 2017 13/7/17.
11. Young NM. Project prevention coming to the UK, but not as a charity.
Civil society. 2010.
12. Seamark M. The American woman who wants to 'bribe' UK heroin
users with £200 to have vasectomies. Mail Online. 2010.
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14. Heil SH, Gaalema DE, Herrmann ES. Incentives to promote family
planning. Prev Med. 2012;55 Suppl:S106-12.
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Record [Internet]. The Irish Human Rights and Equality Commission. 2017
[cited 5 December 2017]. Available from: https://www.ihrec.ie/un-publishes-
assessment-irelands-womens-rights-equality-record
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from: https://www.primarycaresafetynet.ie/
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https://www.ihrec.ie/app/uploads/2017/02/Overview_Ireland-and-the-
Convention-of-the-Elimination-of-Discrimination-against-Women.pdf
19. Free contraception in Ireland to be looked at, Dáil Committee is told
[Internet]. The Irish Times. 2017 [cited 5 December 2017]. Available from:
https://www.irishtimes.com/news/social-affairs/free-contraception-in-ireland-
to-be-looked-at-d%C3%A1il-committee-is-told-1.3311529
20. Corey E, Frazin S, Heywood S, Haider S. Homeless women’s desire for
and barriers to obtaining effective contraception. Contraception.
2017;96(4):287.
21. Podcast: Preventing Pregnancy in Homeless Women, BBC Radio 4,
Inside the Ethics Committee, Series 8, Episode 3, 2012.
22. Institute of Medicine (US) Committee on Health Care for Homeless
People. Homelessness, Health, and Human Needs. Washington (DC):
National Academies Press (US); 1988. 4, Access to Health Care Services for
Homeless People. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK218231/
23. Lucke, J. and Hall, W. Under what conditions is it ethical to offer
incentives to encourage drug-using women to use long-acting forms of
contraception?. Addiction, 2012; 107(6), pp.1036-1041.
24. Sarah H. Heil, Diann E. Gaalema, Evan S. Herrmann, Incentives to
promote family planning, In Preventive Medicine, Volume 55, Supplement,
2012, Pages S106-S112