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Health and ethics


This text is from Frank Brennan's graduation address to the Australian Catholic University Faculty of Health Sciences, at Sydney Exhibition and Convention Centre on Tuesday 5 April 2011.

Pro-Chancellor Mr Excell, Professor Martin, Ladies and Gentlemen: Thank you for the honour of being the last lecturer to whom the 2011 graduands from the faculty of Health Sciences have to listen, and without the need for any marking or assessment.

This last weekend, I had the pleasure of baptising a baby in the Cathedral at Cairns in far north Queensland. The baby's maternal grandfather was a local Aboriginal leader who welcomed us to country, as did Mr Ralph this afternoon. The grandfather had been the elected leader of the Yarrabah Aboriginal community when they were negotiating their land title with the Bjelke-Petersen government 30 years ago. I was privileged to be their legal adviser at the time. So I happily join with Mr Ralph in acknowledging the traditional owners of this place and thank him for his welcome to country.

The baby's paternal grandmother had flown from her home in Ireland and presented us with baptismal water from the Jordan River, a pilgrim's shell from the Camino de Compastella and a linen cloth replete with the Celtic cross. The baptism was a truly Australian event celebrating the Aboriginal and migrant heritage of the newborn embodying the history of this land.

Yesterday, I stopped over in Townsville to visit an Aboriginal friend who is doing life in the Townsville jail. Though Aborigines are a single-digit, small percentage of our population, they are the overwhelming majority in the Townsville Women's Prison. My friend was trained in the health sciences. I asked her what I should say to you today. She said, 'Look with two eyes. Look beyond. Look for things which are unspoken. They are the things that matter. When your spirit is broken you cannot communicate your pain. That's why my people are sick.'

Those of you graduating in the health sciences know the challenges confronting us in closing the gap on Aboriginal disadvantage. The current gap in Aboriginal life expectancy is estimated at 11.5 years for males and 9.7 years for females. Non-Indigenous life expectancy is expected to rise over coming years. So Indigenous male life expectancy will probably have to increase by almost 21 years by 2031 to close the gap. This is a challenge for all Australians especially those of you who are to be health professionals. Approximately 70 per cent of the gap in health outcomes is due to chronic diseases, which tend to have common lifestyle-related risk factors such as smoking, poor nutrition, obesity and low levels of physical activity.

There are five key influences on our health: genetics, social circumstances, lifestyle, accidents, and access to health care. Often we focus only on the access to health care. There is not much we can do to alter our genetics. With better occupational health and safety at work, good design standards, and improved public infrastructure, we can reduce the risk of accident. The World Health Organisation (WHO) and Sir Michael Marmot in the UK have done a power of work finding that social determinants have a big impact on health outcomes. If you are from a poor, dysfunctional family with little education and low job prospects, your health outcomes most probably will be much worse than those of the person from a well off functional family with good education and fine job prospects.

The Rudd Government started concerted work on addressing the social determinants of health for Indigenous Australians with the annual 'Closing the Gap' report. Is it not time for a similar approach to address the health needs of marginalised groups in the community generally?

The Commonwealth has undertaken fresh initiatives to improve the lifestyle of Australians most likely to have poor health outcomes — especially smokers, heavy drinkers, the unexercised and the obese. But there is only so much government can achieve in attempting to modify people's behaviour without also improving their prospects in education, housing, work, income, and social connectedness. Policies that target behavioural change in a vacuum just do not work. There is little point in telling the unemployed, homeless person with minimal education and few social contacts: 'Don't smoke and don't go to McDonald's. It's not good for you.'

Most of the airplay on health reform is dedicated to better access to health care services. The research commissioned for the 2009 National Human Rights Consultation which I was privileged to chair found that such access is the issue of most importance to the majority of Australians — coming in ahead of pensions and superannuation issues, human rights, global warming and the quality of roads. This becomes an issue of good money after bad unless there is also action on social determinants and lifestyle questions. Though the majority of Australians think our human rights are adequately protected, over 70 per cent of those surveyed thought that persons suffering a mental illness, the aged, and persons with a disability needed better protection of their human rights.

NATSEM (the National Centre for Social and Economic Modelling at the University of Canberra) has now completed a report Health Lies in Wealth applying some of the WHO and Marmot methodology to Australia, studying health inequalities in Australians of Working Age. Up to 65 percent of those living in public rental accommodation have long term health problems compared with only 15 per cent of home-owners. More than 60 per cent of men in jobless households report having a long term health condition or disability, and more than 40 per cent of women. The most discriminating socio-economic factors for smoking are education, housing tenure and income. Fewer than 15 per cent of individuals with a tertiary education smoke. Education and housing tenure are consistently related to rates of obesity. Around 40 per cent of Australian men of working age are high risk alcohol drinkers. The likelihood of being a high risk drinker for younger adults who left high school early is up to twice as high as for those with a tertiary qualification.

The Gillard Government maintains a commitment to social inclusion. Sir Michael Marmot found in the UK that health inequalities result from social inequalities. He has put forward the idea of proportionate universalism. He says, 'Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage.'

It is not a matter of just providing more resources which improve the lot of all persons much like the rising tide raises all boats. At the same time as we lift the bar, we want to decrease the steep gradient between those with the best and those with the worst outcomes, whether the indicators are income, education, housing, employment or social connectedness.

We need to break down the silo mentality. As health professionals, you need to be aware of the inequalities confronting your patients, being committed to greater equity in their local regions so that the scarce health dollar might deliver better real health outcomes for all, especially those whose health is most at risk.

In last month's edition of the Australian Nursing Journal, the national president of the Australian Nursing Federation wrote a very one sided article on voluntary euthanasia espousing the case of the Dying with Dignity lobby group. She said:

Most Australians want the availability of both palliative care and VE (voluntary euthanasia). Experience in countries with legalised VE confirms that VE does not undermine palliative care but often enhances it in terms of services and funding ... I urge all nurses and midwives to actively participate in the VE debate as it intensifies and consider the issues at hand.

I agree with her that nurses and midwives and health professionals generally should be engaged in the debate, and I would hope that graduates from ACU would consider all sides of the debate espousing the time honoured medical principle 'Do no harm' and adopting the approach of Catholic social teaching seeing the issue from the perspective of the common good and the public interest, with a particular eye to the needs, dignity and entitlement of society's most vulnerable members. There is a lot of trendy political correctness around this issue at the moment. I would hope that today's graduates will be at the forefront of public discussion about how best to ensure a dignified death for all without placing at risk the poor and vulnerable who can least afford good long term palliative care. If euthanasia laws are instituted (and I hope they are not), we need to ensure that our most vulnerable citizens have a real choice freely to choose continued life despite their demands on the rest of us, and we need to choose life for the incompetent who have not previously freely chosen death.

Today's health science graduates will need to be well informed about issues affecting the health of future generations — issues such as climate change.

In his recent encyclical Caritas in Veritate Pope Benedict XVI said, 'The international community has an urgent duty to find institutional means of regulating the exploitation of non-renewable resources'. He insisted: 'The technologically advanced societies can and must lower their domestic energy consumption'. He put this challenge to us all: 'We must recognize our grave duty to hand the earth on to future generations in such a condition that they too can worthily inhabit it and continue to cultivate it. It is incumbent upon the competent authorities to make every effort to ensure that the economic and social costs of using up shared environmental resources are recognised with transparency and fully borne by those who incur them, not by other peoples or future generations: the protection of the environment, of resources and of the climate obliges all international leaders to act jointly'.

As graduates of a Catholic university, you are not expected to be experts in the science, economics and politics of climate change. But you are expected to be citizens who will bring your critical minds and open hearts to the issue at hand, once again from the perspective of the common good and the public interest and not just your own self interest, and with an eye to the needs, dignity and entitlements of the vulnerable including future generations who are not here to vote or speak for themselves. There is no doubting that climate change is real. There is no doubting that we human beings contribute to that climate change. There is no doubting that per capita we Australians contribute more adversely to that change than any other people on the planet. By unilaterally cutting our emissions, we will not arrest the threat of climate change. By unilaterally putting a price on carbon, we will not pave the way for the development of new less threatening energy sources. But we must do our bit to reduce emissions and to encourage the development of new technology. We might not agree on the politics or the economics for ensuring action by all big polluting nations, but we should agree on the need for them and us to change — and soon — for the well being of future generations and for the well being of the planet.

Today we join with your loved ones and those who have supported you most during your years of difficult study. We thank them for their support, patience and practical help, including those late night suppers which appeared mysteriously beside the computer and those early morning additional commitments they undertook getting the kids to school or at least getting you out the door. With the rapid changes in the health sciences and the increasing demands on our health services, we need you always to be educated, informed and conscientious health professionals. Considering just one further statistic — that the number of Australians aged over 85 will increase from 400,000 to 1.8 million during the working life of today's graduates (i.e. by 2050) — we need very clever strategic and moral thinkers in your midst. Having an eye just to the treatment of the patient in front of you will not be enough, even for that patient in front of you in the years ahead.

Thanks for your commitment to health care. May your professional lives be blessed and enriched by the satisfaction of contributing to the healing of the sick and of the planet. Remember to look with two eyes. Look beyond and look for things which are unspoken. 

Frank BrennanFr Frank Brennan SJ is professor of law at the Public Policy Institute, Australian Catholic University and adjunct professor at the College of Law and the National Centre for Indigenous Studies, Australian National University.

Topic tags: health, Australian Catholic University, Faculty of Health Sciences, closing the gap, euthanasia



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Existing comments

These comments apply to the portion of the address that deals with voluntary euthanasia.

First, there is Frank Brennan's fear that poorer patients may be unfairly treated. If so, it should be recognised that they are already discriminated against under Australia's two-tiered health system, with its long waiting lists for those without private insurance.

Next, if Frank Brennan's use of the expression 'trendy political correctness' refers to the opinion of the majority of Australians that VE should be legalised, it adds little to serious discussion of the subject.

In practice, the treatment of some of the terminally ill already verges on euthanasia when appropriate treatment to minimise pain shortens life.

Bob Corcoran | 11 April 2011  

My comment too, apply to the portion of the address that deals with voluntary euthanasia.

Father Brennan: Do you abhor the death penalty? (I do.) Leaving me to ask you: Is being sentenced to die against your will as abhorrent to you as being sentenced to live against your will?

As for the slippery slope argument, would anyone ever
again attempt to climb the next mountain?

Joyce | 11 April 2011  

Thank you Fr Brennan; an amazing amount of good sense in such a short time! but I would agree with Bob`s comment, that we in australia need to look at the very strucdture of our health services and they way the governmant pays for them: they are actually designed to discriminate not so much against the poor, but towards the better off.But the effect is the same.

What surgeons and proceduralists in particular make out of the system and take from the tax-payer is scandalous. And through its private health institutions the Catholic church is up to its neck in this societal evil. You did not mention any of that, Frank!

Eugene | 12 April 2011  

In the regional centre where I live and work there are three hospitals. One large Roman Catholic hospital, one large hospital run by Protestants and one large public hospital. It is shameful that the Roman Catholic hospital has opted to provide only the most expensive, selective and profitable of medical services. It is the public hospital that provides all the services that would make a difference to those to whom that Father Brennan refers. Where are the Roman Catholic services for oncology, palliative care, renal dialysis, paediatric services, acute and chronic mental health not to mention all the chronic lifestyle health issues suffered by the socially disadvantaged. All provided at the public hospital and to a lesser extent at the Protestant hospital. I have withdrawn my services from the Roman Catholic hospital as I have watched with sadness their retreat from all non-profitable services. With the greatest respect Father Brennan, beware of hypocrisy .

graham patison | 15 April 2011  

There is a lot in here which I'd like to comment on. Maybe the main point is "we need very clever strategic and moral thinkers". But we don't appreciate the ones we've got, we don't listen to Aboriginal women like Frank's friend in jail for life (why? we can't ask) we don't fund science and R & D adequately, we don't value our environment (except to sell it!) we don't seem to feel a moral obligation towards suffering beings such as those children who are being destroyed by the cruel and unreasonable processes of Family Law. Frank doesn't talk much about mental health but the health of these children is being seriously undermined and their futures - and present - put at risk. For more info www.justiceforchildrenaustralia.org

Ariel Marguin | 16 April 2011  

How do Australians balance the need to feel free against the need to feel safe? Freedom to choose voluntary euthanasia may lead us up a very queer and unsafe street, namely the one called involuntary euthanasia.
Frank has recently (and rightly) chastised me on my reference to "chicken marraiage" but has not addressed my question about the Big A (apology) to the descendants of the Daly River people abandoned by the Jesuits in 1899.

Claude Rigney | 19 April 2011  

I believe it would be wrong for me to ask another to kill me.

Thus assisted suicide would be wrong.
I believe that it is not wrong to refuse treatment (such as extended life-support) or accept dangerous treatment that may be fatal (such as pain relief), so I am not bound unreasonably to life.

Power and control and their manifestations mean that consent can easily become unfree in states of illness or institutionalisation for even the most independent and powerful and wealthy amongst us.

This means that determining the voluntary nature of any euthanasia may be impossible.
I do not think euthanasia is an appropriate addition to the health care system nor to the bureaucracy and law of the health care system.

However we should discuss the issue of whether it should be allowed that people close to a person be able to witness the dying aspect of a suicide without the legal obligation of preventative intervention under the defence of the suicide's request for non-intervention.

This does not remove the imperative of legal inquiry into the circumstances of such a death in order to expose, and hopefully prevent, murder or death by negligence or failure of duty of care.

anon | 04 May 2011  

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