 Good morning. Good morning. I'm just absolutely delighted to welcome you to the 29th annual Dorothy J. McLean Fellows Conference on clinical medical ethics. The McLean Center has been in operation since 1984. It's one of the oldest and largest programs in clinical ethics in the country. Clinical ethics is a field that examines the practical, everyday ethical issues that that arise when doctors and patients work together. These are issues that arise among patients and doctors and nurses, health care workers and health care institutions. The goal of clinical medical ethics has always been from the outset to improve patient outcomes while respecting patient values and wishes and while at the same time to assist physicians and nurses, health care people who are delivering care, to deal with a set of issues that they might not be entirely familiar with. Over the last 36 years the McLean Center has trained more than 425 fellows in clinical ethics and this year we're proud to be training 26 fellows who have clinical backgrounds in medicine, nursing, surgery, PEDS, obstetrics and gynecology and psychiatry. This annual McLean conference is very much the McLean Center's signature event. The conference remembers Dorothy Jean McLean who helped create the McLean Center and who was always deeply committed to its work. Over the next two days the conference will feature more than 30 talks on important topics in clinical ethics. Almost all of the conference speakers are either former McLean Center fellows or current McLean Center fellows or current McLean Center faculty. After each lecture we've made the lectures five minutes longer than they have in the past by popular demand so the talks will be 20 minutes instead of 15 minutes and I am hoping that there will be five minutes left by the speakers for questions and I believe we have microphones set up in the back on either side. When you go to the microphone I just ask that you give your name and identify where you're from. I want you to know that after the second session this morning there will be a first session and then we'll have a coffee break and then there will be a second session moderated by Marshall Chin on health disparities but after that second session there will be a group photo up here on the stage at about 11.30 a.m. and the photo will include I hope current and former McLean fellows, current and former McLean faculty and members of the McLean Center advisory board. While the photo is going on lunch will be started in what's known as the Green Lounge of the law school. It's within the building to the south and everybody I hope will join us for lunch over there in the Green Lounge. The dean of the law school has asked us to remain in the south part of the Green Lounge. There's sort of a glassed-in section because today is a school day and there are law students in class and they will use the open north side of the Green Lounge and will be within the glass enclosure. I'd also like to call your attention to the McLean Center Prize for clinical ethics. The McLean Center Prize is a $50,000 reward that recognizes outstanding work in the field of clinical medical ethics and this year as your programs will show you the award will be made to Dr. Paul Farmer, to Dr. Farmer for his contributions to ethical medicine, social medicine, infectious disease treatment and to strengthening global health systems. Dr. Farmer will present a lecture after the dean gives him the prize and the lecture will be entitled the Ebola Suspects Dilemma. That lecture and the global health panel that precedes it will not be here at the law school. This is an important point to make that after lunch, after lunch in the Green Lounge there will be about a half an hour time available to walk across the midway to Mandel Hall. Mandel Hall is on 57th Street and a lot of people will be going and those of you who don't know the neighborhood will simply follow along. It's about two or three blocks from here and at Mandel Hall there will be a global health panel headed by Horn Saucy from the university with talks on global health disparities and that panel will then be followed by Dean Polanski awarding the prize and Dr. Farmer's talk. As always I'd like to express my deepest thanks to Barry McClain who recently retired after 25 years as chair of the McClain Center's advisory board and to the whole McClain family for their continued commitment and support of the center. I also wish to thank Rachel Kohler. Excuse me. Rachel, I don't know if Rachel has gotten here yet, but Rachel is our current chair of the McClain Center advisory board and finally I want to acknowledge the McClain Center directors, extraordinary McClain Center faculty, many of whom you'll meet in the course of this two day conference and the McClain Fellows past and present for all their great work and for their involvement and participation in this conference. The opening panel today will be on general clinical ethics and the first speaker in the panel is Farr Curlin. Farr who had been at the University of Chicago for 10 years, 15 years, recently moved to Duke where he is the Josiah C. Trent professor of medical humanities at Duke. Farr is a hospice and palliative care physician, researcher, a medical ethicist. He completed the McClain Fellowship back in 2003-2004. He also completed his internal medicine residency training as well as the health services research fellowship here at the university and remained on the faculty as I say until he moved to Duke in 2014. Farr was a green wall faculty scholar from 2006-2009. While here at the university, Farr co-founded and co-directed the program on medicine and religion. Today Dr. Curlin will give a talk entitled Gender Transition Services Progress or Medical Hubris. Please join me in giving a warm welcome to Dr. Farr Curlin. So it would not be the McClain conference if we were not off schedule already. That will grow as you all know if you've been here. I'm delighted to be here. I have mentors and friends in the room including Dr. Siegler to whom I owe a great deal and yet I will not load them with any of the responsibility for what I'm going to say this morning. As I realize I'm taking up a topic that's quite controversial, particularly controversial in the current moment. I think the University of Chicago is one of its virtues as it's the sort of university where we can talk about difficult controversial topics. I had not thought much about gender transition services. I'm not a pediatrician. I'm not a surgeon. I'm not an endocrinologist. I had not thought much about gender transition services conducted by physicians until last year when in May 2016 the Department of Health and Human Services issued a final rule under the Affordable Care Act that many people didn't even notice because it came the day after a rule that did get a lot of attention in which they instructed schools to interpret Title IX, not Title IX's forbidding of discrimination on the basis of sex as including discrimination on the basis of gender identity and gender preference. The rule that I'm speaking of was issued to in its own terms virtually every physician and every healthcare institution in the country and interpreted federal statutes in the same way. You might think that a rule that prohibits such discrimination should be celebrated by physicians and in a certain respect it should. After all, for centuries physicians have made solemn professions to care for those who are sick without respect to the patient's other characteristics. To tend to the health of our patients without respect to their other characteristics including the characteristics that HHS called the patient's internal sense of gender. Yet interestingly HHS did not claim or give evidence that physicians and healthcare institutions were turning away transgender patients with pneumonia, with heart attacks, with cancer or other illnesses. Rather what the writers of the rule found problematic was that many physicians and healthcare institutions were unwilling to use medical technologies, principally hormonal therapies and surgery, to assist patients in transitioning from one gender to expression to another. HHS acknowledged in their rule in the narrative of it that numerous members of the public had asked that this final rule distinguish between a refusal to provide gender transition services so described from a refusal to provide care that is needed to preserve or restore the health of a patient under this older commitment without respect to their gender expression, gender identity, gender preference. HHS explicitly rejected this distinction however and stated that in this rule that categorical refusals of physicians or institutions to provide gender transition services were unlawful. They violated federal law. Now that got my attention for reasons that those of you who know me can imagine. But with that background consider this case. The case of Jules, an otherwise healthy 13 year old boy who experiences gender dysphoria. Jules identifies as female and after much soul searching, much of it in conversation with his parents, he wishes to have hormone blocking supplements that will delay puberty until Jules is old enough to undergo a full sexual transition by having a surgery to remove his male sex organs and to fashion facsimiles of female sex organs. So the question is what should we make of this situation? And I want to ask what should we make of the situation as physicians, as practitioners of medicine? Stanley Howard once wrote the following. Morally speaking the first issue is never what we are to do but what we should see. Here's the way it works. You can only act in the world that you can see and you must be taught to see by learning to say. You must be taught to see by learning to say. Howard's insight inherited I learned from Iris Murdoch. I think can help us ask questions we should ask about medicine and medical ethics. How was it for example that in the early 20th century when people saw those with lower than average intelligence, what they saw were imbeciles whose existence and particularly whose reproduction threatened the future health of this body politic. Having learned to speak in this then very fashionable language of eugenics, early 20th century Americans could see that the only sensible and indeed scientific and progressive thing to do was to sterilize these people even if forcibly if necessary. Physicians were recruited to conduct these sterilizations including many of these occurred in North Carolina. If you could see that if prevalent ideas about eugenics however fashionable endorsed forcibly sterilizing women then the problem might be with the ideas rather than with the women. Instead the practice went on a pace for decades until the logical really started to break down when the logical consequences of the ideas behind eugenics were so terribly exposed in the Second World War. The practice of forced sterilization of the unfit was uncontroversially defended by the Supreme Court in the Buck v. Bell case where Justice Holmes infamously wrote for the majority three generations of imbeciles is enough. That's one example. We could choose many more. We could think of how is it that physicians involved in Tuskegee and Willowbrook could not see that the people in front of them deserved a kind of respect that we now can see so clearly. Many of the studies described in Beecher's famous article about morally problematic research. How could people not see what they were doing? Less controversially how was it that during the 1960s and early 1970s physicians encouraged women to forego breastfeeding in favor of the superior benefits offered by scientifically designed formula? Many of you guys bottle fed in that era because of this? Yeah a few hands going up. So as intelligent as you are you would have been more intelligent on average. Had physicians not discouraged mothers including my own mother from breastfeeding. So what kept physicians from seeing that if the fashionable modes of thinking about the superiority of advanced scientific therapies led them to conclude without evidence that a formula made in a factory is to be preferred to a mother's breast milk then that is evidence against the fashionable modes of thinking not against breastfeeding. So my question which I know is a controversial question but I think it's an essential one to pose and we ought to pose it is that is it possible that we are seeing or failing to see a similar moment with respect to gender transition? So what is it that we have been taught to say that leads us to see Jules this 13 year old as a person needing exogenous hormones to block the pubertal development that he would normally undergo? And to do so in full recognition that this therapy will almost certainly render Jules sterile for the rest of his life incapable of one of the characteristic activities of healthy human beings. How have we come to see his sexual organs as deficient relative to the simulacra of female sexual organs with which we might be willing to replace them surgically? Current cultural fashions lead otherwise reasonable people to say that for a physician to be affirming of Jules the physician must change Jules body to at least have the appearance of being the body of a girl. And to do so by destroying the organs and capacities that distinguish Jules as a male human being. So what is it underlies are seeing this as progress rather than seeing it as evidence that the current cultural fashions must have something must be mistaken in them? How will I suggest that what we see is shaped by what we have learned to say? And it seems clear to me that whether gender transition services for Jules are medical progress or medical hubris depends on two different ways of saying what medicine is for. Two ways that John Lantos anticipated a few minutes ago. In 1979, 20 years after the United States FDA approved the first oral contraceptive Dr. Siegler and Ann Dudley Golbat wrote, The oral contraceptive medication was the first prescription drug that was and is in effect a self-prescribed treatment. Patients, i.e. medical consumers, desiring elective medication demanded that physicians prescribe the contraceptive pill. Other popularly self-prescribed medications soon followed and came to be seen as appropriate solutions or treatments for problems previously considered individual or social concerns. But in any case, not biological abnormalities or specific diseases. Now, to my knowledge, neither Dr. Siegler nor Mrs. Golbat had moral concerns with contraceptives as such. Rather, they worried that the widespread prescription of contraceptives by physicians was setting in place a problematic pattern in which patients and physicians alike come to speak of the physician and to treat the physician as a mere provider of healthcare resources. 38 years later, we can say that what Dr. Siegler and Ann Dudley Golbat anticipated has come about. So in what I will call the new medicine, we have learned to say, we have practiced saying for more than a generation, that medicine is an evidence-based healthcare industry in which the physician acts as a highly skilled provider of services. Making those services available to be used by patients, not so much in pursuit of the patient's health, which would seem rather closed-minded and paternalistic, but rather in pursuit of well-being, overall well-being, holistic well-being, as the patient perceives their well-being requires. Medicine, that is, becomes a way of helping patients to live out the lives that they authentically choose, and so become the persons they authentically are becoming through their choices. This way of thinking led, as Siegler and Golbat observed a generation ago, led to physicians thinking it obvious that a good doctor makes her patient sterile if the patient requests it. It's led physicians, too, on one hand, do intra-fetal surgeries on 20-week-old fetuses in hopes of preserving the fetus's health, or on the other hand, kill the same fetus by dismembering it alive, and deciding whether one or the other is obligated by the physician strictly on the basis of the patient's perception of what their well-being requires. In the area of end-of-life care, which is my area of practice, this thinking has led doctors to decide that for one patient you might intubate them and put them on pressers and move them to the ICU, to the other you might give them a lethal injection if you're in Canada anyway, all based on what the patient says he or she wants. Changing the secondary sex characteristics of people like Jules seems to me takes the new medicine's rationale one step further. Treating the patient's sexual organs and underlying sexual physiology as either a good to be preserved, which is the case in 99% of our patients, or as a harm to be remedied, strictly on the basis of the patient's perception of himself or herself. In the framework of the new medicine for Jules, who does not want male secondary sex characteristics, those characteristics are to be understood as harms to him, as at odds with his well-being, and therefore which the physician has an obligation to remedy insofar as possible. So my proposal is, or my question is, might this not be an opportunity to see not the problems with Jules secondary sex characteristics, but the problems with the new medicine, with this framework, this way of understanding our work. If we think that, if our language and framework lead us to think that we should make a 13-year-old boy sterile in order to block his sexual maturation, then perhaps we need a new language and a new framework. Now there's another way of speaking about medicine that's a rival to the new medicine, it's lost ground against the new medicine, but that does lead to this second conclusion. You might call it the traditional approach to medicine, according to which medicine is a moral practice that aims at the patient's health, and where health, human health is an objective, that is to say a genuine, a real human good, and it's the good that gives us a singular purpose as physicians. The new medicine obviously does concern itself with health, but in the new medicine, health is taken to be only a subjective and strictly socially constructed concept. As such, in the new medicine, an appeal to health cannot tell us whether health as well-being cannot tell us whether to sterilize a young woman or give her in vitro fertilization, cannot tell us whether we should treat Jules secondary sex characteristics as goods to be preserved, or as anomalies to be corrected. In contrast, in the traditional approach, health is an objective norm of the living body, a norm characteristic of the kinds of animals we are. On the traditional approach, physicians have a reason to avoid and even refuse interventions that would undermine or directly harm the health of their patients. And here's the thing. Our existence, it seems to me, our existence and our health as human animals is sexed. We are male and female organisms, and this makes possible human reproduction, a feature of healthy working of human organisms that physicians attend to. We know this from our observation. Unlike the digestive function, no individual human being suffices for the performance of reproduction, and our sexual characteristics and features constitute this reproductive capacity. They are, again, these are, again, characteristics and features of healthy human organisms, male and female. So the one who speaks out of the traditional approach to medicine will say, will see that Jules, will say and see, that Jules male secondary sex characteristics are expressions of and essential to that dimension of health that makes possible reproduction. Insofar as these features are suppressed or destroyed, Jules health is thereby diminished, seems to me. So the physician has a good reason as a physician to decline to participate in gender transition services, so described. When physicians set aside their constitutive profession to the patient's health, their practices come to be characterized by contradictions and come to be health damaging rather than health preserving. And I'll close with this. That's what we saw with forced sterilization. That's what happens, I think, with assisted suicide in euthanasia. It's even what happened when we set aside healthy breastfeeding. And it seems to me to be happening with respect to physicians changing secondary sex characteristics to adhere to a gender preference or a gender identity. Here's a couple of the contradictions. Sex in this way of thinking is fluid and gender is socially constructed. It's not dependent on biology and anatomy. So if we're to be reasonable, we will set aside the binary of male and female sex. And yet, strangely, this intervention proposed for Jules focuses precisely on biology and anatomy, changing with substantial side effects for the rest of the organism, the very characteristics that are not supposed to matter for gender. Another contradiction. In order to affirm Jules in this way of thinking, physicians should conduct gender affirming interventions that in their objective character, the objective character of these interventions, instead reject what Jules is in favor of bringing about some kind of envisioned new Jules, one that does not exist at present but which the pretense of which at least can be fashioned through hormonal and surgical interventions. So why not, if we want to affirm, affirm to Jules that you are good as you are. Your body is good. And in that you have gender dispositions that are not typical, is not something that you should see as making you not good or your body not good. Third contradiction, in changing sex, we actually don't change sex. Our male and female sexual organs can only be identified by reference to the role these organs typically play in the overall biological economy of a sexed human being. No transplant, much less any reconstructive plastic surgery can integrate a female sex organ into the biological life of an organism whose root capacities are male, nor vice versa. So it's impossible medically because impossible biologically to change Jules sex. I'll stop. Except just to say that it seems to me we are in this case putting so much weight into the positions of a child leading us to do something that in any other context we would judge would be an egregious harm. And that carries the logic of the new medicine to its conclusions but I think it shows also the logic of the new medicine has got to be problematic. Sure.