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Paper presented at workshops on medical ethics at various campuses in England 09-31 December 2006 by Dr Omar Hasan Kasule, Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Institute of Medicine University of Brunei Darussalam
ABSTRACT
Using the oral contraceptive pill as an example, this paper argues that medical technology has an impact on social structure and social behavior. Physicians are already powerful role models in society who can influence social thoughts and practices. This influence is enhanced by the way they use the increasingly powerful medical technology. Technology can be applied by physicians to produce negative or positive social change. The way physicians are educated will have long-term impact on society by affecting their practice and use of medical technology. The paper concludes that input of positive values in medical education can lead to a more moral society. This can be achieved by instituting an Islamic Input into the Medical Curriculum that integrates moral values in the teaching and practice of medicine.
Key words: medical education, social engineering, medical technology, oral contraceptive pill, sexual behavior, sex revolution
1.0 INTRODUCTION
The oral contraceptive pill was cited as the most important technological innovation of the 20th century.[1] On its introduction in 1960 it soon replaced sexual repression and other less effective methods[2] to become a mass phenomenon in fertility control. Its impact has been compared to major discoveries such as discovery of fire, discovery of electricity, and discovery of atomic energy.[3] The present paper will explore the impact of the pill on social change and use it as an example to illustrate the argument that physicians have a potentially big impact on social change depending on the way they use medical technology which in turn is determined by the values imbued in their medical school curricula.
2.0 DEVELOPMENT AND IMPACT OF THE PILL
2.1 Development of the Pill
There is some indicative evidence that the development of the pill was not an accident but had a background agenda. There was a strong desire among family planning agencies and the feminist movement to get an effective contraceptive that would let the woman control her sexuality. Margaret Sanger of Planned Parenthood spearheaded the campaign to produce a safe and effective contraceptive. With funding provided by Katharine Dexter McCormick, Planned Parenthood invited Dr Gregory Pincus (a biologist) to develop a safe pill, a task achieved in 1950.
Dr Gregory Pincus called the father of the pill had already generated controversy by the time he developed the pill. He had achieved in vitro fertilization in rabbits a discovery that generated so much controversy that he lost his position at Harvard University and he moved to Clark University where set up the Worcester Foundation for Experimental Biology in 1944.[4] It is noteworthy that his pioneering research set the stage for 2 sexual revolutions that will be discussed below.
2.2 The First Sexual Revolution: 1960s and 1970s
The US Federal Drug Administration (FDA) approved the oral contraceptive pill on 23rd June 1960. The oral contraceptive pill (OC) was the first effective contraceptive that gave women a reliable and private control of fertility[5] that could be used without any worries about pregnancy since its failure rate was low being less than 1 percent.[6] The launch of the pill triggered a sexual revolution[7] that started in earnest in the early 1960s and laid the foundation for the second sexual revolution of the 1990s that is still evolving.[8] The first sexual revolution was a drastic change in sexual behavior of the masses involving all social classes and eventually all countries of the world. This revolution has had far-reaching effects on the fabric of society, the family, disease patterns, gender roles etc.
The major change brought by the pill was to not only to allow sexual intercourse at any time, in any condition, and without any prior preparation but also to separate sexual enjoyment from reproduction.[9] The purpose of sex could become recreation only without the possibility of procreation.[10] For the first time in human history sexual enjoyment was decoupled from the social responsibility of fatherhood and motherhood among potentially fertile couples. What started as birth control among married women soon extended to unmarried leading to promiscuity. It is now extending to teenagers and sex education programs are becoming mandatory in many schools with the message being clear that children can have sex but that it has to be safe sex using a contraceptive.[11] The mass media have been very active players in the sexual revolution by encouraging sexuality among youths while at the same time condemning teenage birth or abortion[12] which leaves effective contraception as the only option.
Studies within the first 10 years of the use of the pill explored its impact on sexual behavior.[13,14] The evidence linking the pill to the sexual revolution is circumstantial but is very convincing. It is unlikely that the sex revolution following on the heels of the introduction of the pill could have an alternative explanation. It may be true that the sex revolution was already on the way but the pill accelerated it by providing a more effective contraceptive which removed the inhibitory fear of pregnancy.
The sexual revolution based on liberation of fear of pregnancy started with the pill and was completed by two major later developments. The morning after pill and legal abortion on demand (following the US Supreme Court ruling in Roe vs. Wade) ensured that even if contraception failed there were remedies. This removed any lingering fear of unwanted pregnancy that had remained even with the use of the pill.
2.2 The Second Sexual Revolution: 1980s and 1990s
The mass use of the pill and the major changes in sexual mores soon led to a second sexual revolution that is also referred to as the neo-sexual revolution.[15] Whereas the first sexual revolution saw the separation of sexual enjoyment from reproduction, the second sexual revolution saw the separation of sex from reproduction altogether. Using technologies of assisted reproduction such as in vivo insemination and in vitro fertilization with surrogate mothers or fathers, it became possible to produce children without coitus. Such children could identify either a surrogate father or mother so some element of parenthood existed. This remaining sense of parenthood could soon be eroded by cloning. Reproductive cloning is a further development that may usher in reproduction without involvement of any gametes and will negate the traditional concept of descent from a parent. It is conceivable that the brave new world of medical technology will soon breach the reproductive barrier between humans and animals with unimaginable consequences.
2.3 The Social Impact of the Pill
The impact of the pill was not limited to sexual freedom. Sex without reproduction soon gave way to sex outside marriage. Devaluation of the family, divorce, teenage pregnancy, fatherless families, and teenage problems such as teenage suicides[16] and drug addiction. Alongside the changes due to medical technology, the second sexual revolution has seen the elevation of homosexuality from a closet secret to social respectability with several jurisdictions legislating for same-sex marriages. The gay or lesbian couples have also had the audacity to claim parental rights by adopting children or trying to produce children using artificial means. Kindergartners in New York City were taught that gay and lesbian families are the same as heterosexual families.[17]
2.4 Conclusion: Medical Technology Leading to Social Change
This paper presents the thesis that the oral contraceptive pill is a prime example of a technology that leads to major social change and has with time led to an ideological change by affecting the way people think about marriage, reproduction, and family. I do not agree with the views of the developers of the oral contraceptive pill, Gregory Pincus and John Rock who argued that technology does not determine behavior.[18] They could have said this to avoid the guilt of having introduced a technology that in essence could be good but was applied in a wrong way with profound negative effects on society.
3.0 THE RATIONALE FOR A MORALLY- BASED MEDICAL EDUCATION
3.1 The Physician and Applications of Medical Technology
Physicians are the main agents in the development and use of medical technology. Their moral stands on the use of that technology will determine the social consequences whether positive or negative. Therefore the values imbued in the medical curriculum as well the moral values in the medical environment have a major role in determining the pace and direction of social change. The profound impact of just one medical technology (the contraceptive pill) on social behavior should be a waking up signal for medical educators who must make the effort to input values into the medical curricula to ensure that future physicians will not apply powerful medical technologies in ways that degrade the moral standards of society.
3.2 Physicians and Taking a Moral Stand
Muslim physicians dealing with technology that has profound impact on society cannot pretend to be morally neutral and can neither hide under the thesis that technology is morally neutral. They need to take a moral stand both regarding development and application of new medical technologies. Medical educators will have to provide educational curricula that will equip future physicians with the ability to take informed and positive moral stands. These moral positions should not be looked at only in a negative sense of rejecting or mitigating morally negative consequences of medical technology. They must also be looked at ways of improving, reforming, and even islamizing society if used in ways that promote morally high standards.
3.3 Physicians and Influence on Social Opinions and Practices
The physician is a social leader whose influence could move society in certain directions. This leadership role is likely to be enhanced as medical technology puts into the hands of the physician interventions that can change social behavior of individuals and societies. The physician has a bigger leadership role than ordinary persons because of intimate contact with people as individuals and as families. The medical curriculum should teach social responsibility and leadership and make sure that it produces physicians who are ethical and who have the courage to change and improve society.
3.4 Physicians as Initiators of Social Change
The physician gets the reward, thawab, for any initiative that leads to introduction of something good in the community be it medical or non-medical. The physician should be at the forefront of social change and reform to lead society to a better moral position. The physician is expected to give leadership to patients on ethical issues that arise out of modern biotechnology. He must be prepared not as a mufti who gives legal rulings but as a professional who understands the medical, legal, and ethical issue involved and can explain them to the patients and their families so that they can form an informed decision. In order to play this role well, the future physician must have sufficient grounding in Islamic law and other Islamic sciences.
4.0 THE ISLAMIC INPUT INTO THE MEDICAL CURRICULUM (IIMC)
4.1 Vision
The vision of IIMC has two separate but closely related components: Islamization and legal medicine. Islamization deals with putting medicine in an Islamic context in terms of epistemology, values, and attitudes. Legal medicine deals with issues of application of the Law from a medical perspective including
4.2 Five Main Objectives, ahdaaf asaasiyyat
The first objective is the introduction of Islamic paradigms and concepts in general, mafahiim islamiyyat ‘aamat, and as they relate to medicine, mafahiim Islamiyat fi al Tibb. The Muslim physicians must have some general concepts deriving from Islamic teachings that can guide their work and research. The second objective is strengthening faith, iman, through study of Allah’s sign in the human body. Medicine and medical knowledge have been described as the altar of faith, al tibb mihrab al iman. Study of medicine leads to the conclusion that there must be a powerful and deliberate creator because such a sophisticated organism could not arise by chance. The third objective is appreciating and understanding the juridical, fiqh, aspects of health and disease, al fiqh al tibbi. There is a close interaction between injunctions of Islamic law, shariat, and medical practice. The fourth objective is understanding the social issues in medical practice and research, al qadhaya al ijtima’iyat fi al tibb. Medicine is not taught or practised in a social or ethical vacuum. The fifth objective is teaching professional etiquette, adab al tabiib, from an Islamic moral perspective. The physician carries a heavy trust, the amanat of being professionally competent. He must be highly motivated. He must have personal, professional, intellectual, and spiritual development programs. He must know the proper etiquette of dealing with patients and colleagues. He also must know and avoid professional malpractice. He needs to be equipped with leadership and managerial skills to be able to function properly as a head of a medical team.
4.3 Application of IIMC
The curriculum has been applied at the Kulliyah of Medicine of the International Islamic University in Kuantan Malaysia and at the moment several other universities are seeking to emulate it. Further information can be obtained from Assoc Prof Ariff Osman Coordinator of the Islamic Input Unit IIUM at ariff@iiu,edu.my.
NOTES
[1] www.usyd.edu.au/research/news/2004/aug/20_bedrooms.shtml - accessed June 30, 2006
[2] www.usyd.edu.au/research/news/2004/aug/20_bedrooms.shtml - accessed June 30, 2006
[3] www.fda.gov/fdac/departs/2000/400_word.html accessed June 24th 2006
[4] Segal SJ. Segal SJ. Gregory Pincus, father of the pill. Popul Today. 2000 Jul;285:3.
[5] Fraser IS. Forty years of combined oral contraception: the evolution of a revolution. Med J Aust. 2000 Nov 20;17310:541-4.
[6] www.science-spirit.org/new_detail.php?news_id=545 – accessed June 30, 2006
[7] www.science-spirit.org/new_detail.php?news_id=545 – accessed June 30, 2006
[8] www.science-spirit.org/new_detail.php?news_id=545 – accessed June 30, 2006
[9] www.en.wikipedia.org/wiki/Oral_contraceptive#Social_and_cultural_impact – accessed June 30, 2006
[10] www.archives.tcm.ie/thekingdom/2003/01/29/story8124.asp – accessed June 30, 2006
[11] Besharov DJ, Gardiner KN. Trends in teen sexual behavior. Child Youth Serv Rev. 1997;195-6:341-67.
[12] Money J. Sexual revolution and counter-revolution. Horm Res. 1994;41 Suppl 2:44-8.
[13] Black S, Sykes M. Promiscuity and oral contraception: the relationship examined. Soc Sci Med. 1971 Dec;56:637-43.
[14] Cohen L. The "pill", promiscuity, and venereal disease. Br J Vener Dis. 1970 Apr;462:108-10.
[15] Sigusch V. The neosexual revolution. Arch Sex Behav. 1998 Aug;274:331-59.
[16] www.archives.tcm.ie/thekingdom/2003/01/29/story8124.asp - accessed June 30, 2006
[17] Brown J. Contraception and abortion: the deadly connection. Family Found. 1993 Sep-Oct;202:9.
[18] www.pbs.org/wgbh/amex/pill/peopleevents/e_revolution.html - accessed June 30, 2006