 Good afternoon, on behalf of the McLean Center for Clinical Medical Ethics, Dr. Ernst Langell and the Department of Obstetrics and Gynecology, and also the Bucksbaum Institute for Clinical Excellence, I'm delighted to welcome you to the fourth lecture in the 2016-17 lecture series on reproductive ethics. Copies of this lecture series are available outside, and as you'll see, we have an extraordinary lineup of speakers this quarter, next quarter, and the spring quarter. I'll just say a quick word that Stephen Brown from Harvard will be here next Wednesday on November 2, talking about ethical tensions between maternal fetal medicine and pediatrics, implications for prenatal counseling. But today it is my great honor to introduce our speaker, Frank A. Chirvinac. Dr. Chirvinac is the Givens Foundation Professor and Chair of the Department of Obstetrics and Gynecology at the New York Presbyterian Hospital Wild Medical College of Cornell University. Dr. Chirvinac has published more than 300 peer-reviewed papers and has co-authored or co-edited 32 textbooks. At Mount Sinai Medical Center, where he was before going to Cornell, he directed the perinatal research group and received the Dr. Solomon Silver Award for applying advances in research to the practice of medicine. Dr. Chirvinac has served as President of the International Fetal Medicine Society, the New York Perinatal Society, and the New York Academy of Medicine section on obstetrics and gynecology. Currently he serves as President of the International Society of the Fetus as patient and directs the Maternal Fetal Medicine Program at the New York Presbyterian Hospital. Dr. Chirvinac has been named an honorary member of the Italian Society of Obstetrics and has been admitted as a fellow of the Royal College of Obstetricians and Gynecologists of Great Britain. He has received many, many honorary doctorates from universities all over the world. Some of his primary research interests include ultrasound, as well as ethics in physician practice and physician leadership. Today Dr. Chirvinac will talk to us on the title, Professional Ethics in Obstetrics, Practice and Research. Please join me in giving a warm welcome, Dr. Frank Chirvinac. Mark, thank you so much. Mark, I must say this visit is a special thrill for me. Your center is unbelievable. I like you believe in clinical ethics. We'll talk about this in a minute, but you've elevated this to a height that's superlative. I see what you've done with your fellows. The scope of this, I'm sure there's no place like this in the United States or the world. What I'm so impressed with for all in the room, he still practices medicine. I was shocked to hear this. This is a thing of beauty. Can I say congratulations? Can I just say my relationship, I remember his talk. I don't have time. I remember some of the details of it from 1983 when I first heard Mark speak in a lecture. That's why I remember the details. We can discuss them. It was the first edition of his book on clinical ethics. It was 1983. What edition is it now? Eighth. Oh my God. Mark, can I give you a special token of respect, our latest book, out of admiration to you and your wonderful group and a sincere thank you. A sincere thank you to... This is a beautiful book by Dr. Chervenak and Larry McCullough called the Professional Responsibility Model of Perinatal Ethics. Quite beautiful. Thanks, Frank, so much. Thank you, Mark. Please, I could spend this whole time talking about Mark in the center, but let's move forward to the topic. Now, when Julie and Julie was so kind to invite me to this program, I thought, what could I do in the short time we have? I want to emphasize professionalism. This is a theme that Larry McCullough, and I have a partner. Larry McCullough, some of you may know the name. He lives in Texas. Don't hold this against him. He's recently stepped down from his position at Baylor, but he's very active. I'm so proud to have him on my adjunct faculty at Cornell. On one other side, I can't resist Mark. I always say I believe in long-term relationships. I'm proud that I've been at Cornell over 30 years. That's nothing compared to Mark who's been here over 50 years. Let's move forward. Very briefly, we're going to talk a little bit about professional responsibility, obstetric practice, and obstetric research. If I go on too long, give me the hook. Forgive me, I know this is a sophisticated group, but a few basic building blocks the way we see things, and you'll find there's so much in agreement with Mark and your group things. We know about morality, right and wrong behavior, good and bad character. Bioethics is the disciplined study of morality that affects all of us. If we look at clinical practice, it's derived from both science and ethics, and please you more than anyone know that you need both. I'm so happy to see so many physicians in this program more than anyone else in the country or the world focuses on getting physicians involved in this. Please, my dream for over 30 years has been to have OBGYNs involved in this, and Julie, I'm so happy you're taking up the mantle. Here's the rub. Science is based on data and statistics. Ethics is not, it's based on argument. And as you know, in obstetrics and gynecology, we have the malpractice crisis. And I make a bold statement when I talk to a group of obstetricians in this country and throughout the world, ethics is more important than the law. As you'll see in a few moments as a chairman, we take malpractice very seriously, but where something becomes unethical is where you try to do something to out guest lawyers. It's unethical to do a caesarean delivery for a breach presentation because you don't want to get sued by a lawyer. It's very ethical to do a caesarean delivery for a breach presentation if it is safer for the fetal patient. Religious belief. Have a religious belief. You may have a religious belief. We need ethical principles, virtues and concepts that are universal that relate to all of us regardless of whatever religious belief. I am a globalist. I give these same concepts, whether I'm in Jerusalem, Jeddah, Indonesia, and that's so important that we use concepts that don't deny religion. As you'll see later, I appeal to religion, but don't demand it. One secular ethical principle everyone in this room knows. Primo no no cherry. What Larry McCullough has taught me is this ancient dogma is really a latin misinterpretation from the Greek. What hit the Hippocratic writings were about were to at least do no harm. And beneficence is a more encompassing ethical principle to do good. So William Osler from Canada said it so well. The art of medicine lies in balancing probabilities. And indeed, that's what evidence is today. More than 30 years ago, we make these judgments based on evidence. It's not enough. You know more so well. The important counterbalance is respect for the patient's autonomy. And how we implement this is the informed consent process. Very succinctly. We disclose this. The patient understands it and a voluntary decision is made by the patient. Sometimes not so simple as you know from your case conferences. Justice, we're gonna talk a little bit about justice later on that deals with fairness. A Latin term, one that I believe is essential prima facie. You balance these different principles in different circumstances. Okay. John Gregory, an 18th century Great Britain, not Hippocrates, not before him, formulated the concept of medicine as a profession in response to the rampant entrepreneurial self interested medicine of his day. Prior to Gregory, all that was important for physicians was to make money. There was a fierce competition among everyone. All that counted was self interest. And I just pray we don't degenerate to this at the current time. This was what John Gregory was about. Gregory had revolutionary concepts. The physician should become scientifically clinically competent, protect and promote the health related. Another interest of the patient is the primary motivation of medicine. Thomas Percival is contemporary, pioneered organizational professionalism. And he was the one who pioneered concept how to resolve disputes among different groups of physicians and argued that physicians shouldn't run away during periods of epidemic. These two doctors pioneered professionalism in 18th century Great Britain. And their work spread like wildfire throughout the world. I like this picture. This is an obstetrics and gynecology from the time of Gregory that shows the ideal obstetrician in the blue is the obstetrician with the technological advance at the time, the Chamberlain forceps. There were no caesarean sections back then. Melded with the compassion of the midwife. So, Mark, this was an agn log of you, clinical ethics, clinical excellence, melded with ethics, compassion. And I'd argue whether we're an obstetric ethics, medicine, ENT, psychiatry, this is what we all have to strive for. One person who often doesn't get the recognition he deserve is George Engel, a psychiatrist from the University of Rochester who spoke against biologic reductionism. And I argue that in obstetrics, there is ethical reductionism sometime. The fallacy of ethical reductionism occurs when a model for ethics appeals exclusively to one ethical concept in complex circumstances that by their very nature require consideration of complementary concepts. And it's inadequate. This is rights-based reductionism because it's based exclusively on the rights of either the pregnant woman or the fetus. And it ignores other concepts. Fetal rights reductionism, you know well. It's that fetal rights systematically override women's rights at old gestational age, and women's rights are secondary to fetal rights. There's the counterpart, pregnant women's rights reductionism, that women's rights override fetal rights at old gestational age. And we'll see some of the problems with this in a minute. I argue that in obstetrics, we have to steer our ship between skill and caribbness toward professionalism and not go to the sound bites, not to these extreme positions. The professional responsibility model. Professional responsibility to patients is based primarily on professional obligations. Rights should be respected, but obligations are important. And these are owed to both the pregnant and fetal patient. These are not separate patients. It's a mistake to say this is, these are separate. Of course, they're not separate. They're intertwined. Autonomy and beneficence based obligations to the pregnant and fetal patient must both be considered. Rights-based reductionism has appealing simplicity. You know the sound bites, I won't repeat them of the two extremes, but they're incomplete and inadequate. And I make this case over and over. And it denigrates the profession to being mere technicians. I'd argue it's unprofessional. What I'm arguing for is to get away from the ethical and clinical gridlock of fetal rights versus maternal rights. Rather, let's have a clinically relevant balancing of ethical obligations. Forgive me if I go quickly, but I want to stay on time. We need to get away from arguments that have gone on for centuries about fetal rights or categorical denial of fetal rights. What we would argue is that the viable fetus is a patient. Very simply put, prior to fetal viability, we don't have professional responsibility without the woman making that connection between the fetus and the child the fetus will become. Now, viability is not a razor sharp red line. It depends on both biological and technological factors. It differs very much here in Chicago from Sub-Saharan Africa. Even for the previable fetus, if the woman has made a decision not to have an abortion, the fetus is a patient and we have obligations to the fetus as a patient because she's provided that linkage. When the fetus is a patient and the evidence is conclusive, counseling should be directive in a form of a strong recommendation. Now, with trepidation, I come here before Mark, who's pioneered the concept of shared decision-making because shared decision-making is essential, but there are times in emergency situations where the evidence is overwhelming where you don't say, Mrs. Jones, what would you like me to do? Let me give you a clinical example. If you have acute fetal distress, you don't say, we have a choice. We can either do a caesarean or do a vaginal delivery. No. You say, we need to do a caesarean delivery. You do a directive counseling. Mark, I'll never forget the case you presented in 1983 about someone in the emergency room who needed a spinal tap and he was denying it and you said, something doesn't make sense here. We need to do it. You may not remember this case, but it left a mark on me. Now, with shared decision-making, your pioneering work is so important, but it needs to be balanced with professionalism in their times we are give advice. Now, I spend most of my time with non-directive counseling and shared decision-making in its purest essence form is the form such as a decision to have an abortion, not have an abortion and reproductive decision-making. I wish I had more time, we'd spend more on this. Now, I'm going to now go into some areas that are controversial. During the 30 years, Larry and I have discussed some controversial topics. In the late 80s and 90s, it was controversial in this country whether all women should have access to routine ultrasound. Argument said it would cost too much. We made an argument that all women should have access to this because it was an autonomy enhancing strategy. Not that it was a search and destroy women mission, but 2 to 3% of all pregnancies don't get scared women in men. You choose to have a child. This is your risk of having a child with a major malformation. Ultrasound can pick at least half of them should have access to a quality ultrasound. Fortunately, this has gone by the wayside. A little later, we argued that all patients should have access to invasive diagnosis. And I'm delighted that our American college recently has endorsed this position later. And we argued for first trimester risk assessment, which is now the standard of care. Some argued that this shouldn't be done until it was proven in the United States. The classic work was done in Europe. We argued that all women should have it. So autonomy enhancement is critical in decision making. Now, a few issues about professional responsibility model. Professional judgment does not equal paternalism. Professional judgment is a justified claim of intellectual superiority of evidence based reasoning, overlay reasoning about scientific and clinical matters in there for net and not pejorative. If you go to an accountant for advice, you go to a lawyer for advice, I hope they're going to give you clear advice if the issue is black and white. I give the example 26 years ago, I broke my ankle in New Zealand. And I said, does it really need to do an open reduction now? And the surgeon said, if you ever want to walk again, you're going to let me operate. The point I'm making, this is not paternalism. This is professionalism. When the evidence is clear, you give a clear recommendation. And you make this clearly and forcefully. This is professional judgment. Now, it excludes the fetus as a separate patient to whom the physician has absolute beneficence based obligations. Absolutely not. We need to balance obligate. And we've written books about this. Many articles and books that you balance autonomy, beneficence based obligations to there. There are no autonomy based obligations to the fetal patient. But you balance both patients. Using the discourse of rights to explain professional obligations to the fetal patient. There are no fetal rights. I would argue their obligations. And that's why we argue for professional obligations. And I would argue they're not absolute autonomy based obligations to the pregnant woman. Maybe in our discussions, we can talk more about this. This excludes the concept of the fetus as patient automatically leads to forced treatment. Please. This is some of our critics have taken this to the point of ridiculousness. No, you give recommendations, strong recommendations. Let me move forward. Symmetric practice. One of the most controversial areas in our field is the topic of abortion. And I want to emphasize the decision to abort because a fetal anomaly is only in part governed by health related issues. I talk to our Cornell medical students every month, a different group of the third year students. And I ask them what goes into a woman's decision. If we diagnose a major fetal anomaly, hydrocephalus, anencephaly, anything, and I get answers, survivability, quality of life, and they often forget the most important thing. The woman's religion, her personal values and beliefs. The decision to abort is ultimately a personal decision, not a medical decision. And it's essential that this be respected. We keep our biases out of this. Please, I'm bringing Coles to Newcastle with this group. But we keep our biases out of personal decisions. And if they say, Doctor, what would you do? Or if it was your wife, you say, I can't answer that question. Now, if they ask you that question, if it's a Caesarean section for fetal distress, say, of course, I would do the Caesarean. If it's a medically related question, and the evidence is clear, you can answer that. But not if it's a personal value, you cannot answer that question. This whole issue of selective termination, fetal reduction is a subset of this. And the woman's view must be respected. So important, we've written on this, the distinction between professional ethics and individual conscience. It's fine if an obstetrician doesn't do abortions, or doesn't believe in abortion because of a personal religious view. But the clinical ethical standard is he or she has to keep the counseling neutral. And we've argued that the absolute minimum is an indirect referral. What do I mean by this? If Dr. Sigler finds a patient with who needs a surgical consult, he picks up the phone and refers the patient to a surgeon. That's a direct referral. The minimum if someone requests an abortion is an indirect referral. Say, this is available at Planned Parenthood, or at this center. So at least they're steered away from the Baird players. I'd say this is the bare minimum for anyone who's going to counsel patients. Keep your biases out of it. And believe me, I've seen biases both ways on this, where doctors try to steer people toward abortion and away from abortion. It was about four years ago, I spoke to a group that I usually don't speak to. It was a group of parents of Down syndrome children. And several people went up to the microphone and say, my doctor recommended I have an abortion. I said, if that's true, they acted unprofessionally. We need to keep our biases out of personal decisions. Now, I want to spend a minute on a topic that's gotten our attention. And this is the topic of Planned Home Birth, which has been around ever since I first heard Dr. Siegler in 1983, but it's become attention for several reasons. One, our group has recently studied this, and we've now surpassed the Netherlands. Is the country in the developed world with the most planned home birth? The Netherlands rate has gone down. Ours has gone up still about 1%. But it's been popularized. If I had more time, I'd show more evidence. It's gone up. It was three years ago. I went to a meeting of the Institute of Medicine, and I was shocked to see I was the only person who got up and spoke against Planned Home Birth. And you'll see in a few moments some of the data I presented, I felt as though I was back in Saudi Arabia where I might have been stoned. But you'll see. Now, this is a good example where good ethics is based on good facts. We need the data. I won't go through all the methodology. This has been published. The good news is we live in America, and the CDC data sets are open. And there are huge data sets with over a million of deliveries. We analyzed the home births in the United States, and our first paper showed there was over a 10-fold increase in APGAR score of zero of women who have a planned home birth, 10-fold. And when we looked at how it was coded for was neonatal seizures or serious neurologic dysfunction, there was a four-fold increase. We did other studies and looked at the different databases. They all showed essentially the same. You may say this is bad. It really gets worse than that. When there are bad outcomes, such as a patient gets transferred to Cornell, if you don't get these at the University of Chicago, you will. And the woman delivers at your medical center and there's a bad outcome. It counts as a bad outcome against the hospital. There's an infamous case from Johns Hopkins where there was a $55 million award because the doctors didn't do the section fast enough. There was a horrendous home birth. The midwife gave oxytocin, cut in a pisiatomy. Eventually she had no choice. She had to bring the woman to the hospital and it was a disaster. Now this is where the midwives wanted to throw stones, but this is what the evidence shows. Virginia Apgar did her classic work. So I realize this is not Nobby or Peed's group, but you know the Apgar School we rely on even today. It's an index of well-being of the neonate. And one of the indices we look at is the five-minute Apgar score. And it's unusual to get a five-minute Apgar score of zero. In the hospital, whether it's a doctor or midwife, a five-minute Apgar score of ten, excuse me, a five-minute Apgar score of ten, a perfect score, occurs in less than four percent of patients. But when delivered at home, it occurred in more than 50 percent of the patients. Now why is this? Because we're not assigning the Apgar scores. The pediatrician is assigning the Apgar score. Virginia Apgar in her classic work showed that whoever's going to do the delivery is going to upscore the Apgar score. And there's literature using data like this to support the safety of plant home birth. When we reviewed our data, a study came out from, this is unbelievable, from the midwife group, and it was a voluntary collection of data. We have the chairman here. He's a surgeon. It'd be as though we have a voluntary collection of the latest robotic procedure and just have a voluntary collection of data. Nonetheless, the results weren't too far off from ours. The problem with home birth in the United States is transportation system, hospital access, inadequate training of attendance, risk selection, they're big problems. Let's talk about money. Money is important whether we're in Great Britain, United States. And in Great Britain, it was purported, wait a minute, we can save a lot of money here. If women deliver at home, the minute you set foot in the hospital, it's going to cost a lot of money. So this has intuitive appeal. All of us are under pressure to lower health care costs. Let women deliver at home. They're big problems with this. They didn't include the cost of transport. More importantly, whether we're in Great Britain or the United States, the cost of a brain damage child is millions and they didn't factor this in. This is bogus economics and just one of the tricks that are sometimes played here. Now the more we looked into the database, it became very ugly. It's been purported midwives, select their patients very well and only low-risk patients deliver at home, not true. More than 1 in 200 of the home births are breached. 1 in 25 had a prior caesarean, which everyone agrees shouldn't be done. More than 1 in 200 were twins and 30% were over 41 weeks. Everyone agrees this shouldn't happen. So risk selection is very poor and it gets worse than that. Two-thirds of the births are done by midwives who are not certified. So this is the state of the art of home birth in the United States today, 2016. I tell patients what we're going to talk about how you should counsel them, but the standard in the Netherlands, in Great Britain, Canada is much higher than in the United States. Please, I don't think home birth is a mistake, but if you're dead set on having it, it's better to have it in one of the other countries. Now, no, that's true. That's true. What we'll give you a chance at the end to disagree. Now we're going to talk, let's just to show I take religion seriously. People have disagreed with me and they say, Frank, why are you making a big issue of this? 99.85% of home births do well versus 99.95% in the hospital. These are rare occurrences that the bad outcomes. And it's been said, given the absolute risk, one in a thousand, our data would show it's not one in a thousand. It may be two or even three per thousand of these bad outcomes. Why make this an issue? And as I said, I would argue that I'm a strong believer in secular ethics, but there's a value of ancient wisdom that rings through here. The value of the individual human life. He or she who saves the individual human life, it's as though we save the entire world. And this is not even my personal religion, but I argue this is the core truth of medicine. For those of you who say we shouldn't use any religious tradition, I argue what goes on in the University of Chicago today. If there's a preventable death, there's a sentinel event. There's a sentinel event. There's a spotlight put on why did this death occur that's preventable? We don't just push it aside and say it's excusable. We say what's going on here and say how can we prevent this from happening? We shouldn't make excuses for this. Very briefly, we should discourage this. And this is my criticism of our American College. I'm proud to be a member of our American College. I'm proud to be in the Royal College in Great Britain. When they backed away from a recommendation against home birth, they acknowledge that it's more dangerous. You give a clear recommendation, don't do it. I'm not saying to put these women in jail, but you give a clear recommendation not to do it. It's as though a woman wants to smoke or use alcohol during pregnancy. It's the professional responsibility of the doctor to give a clear recommendation not to do this. Not to incarcerate the women. I'd say it's unprofessional not to give a clear recommendation. What if someone wants you to participate in a home birth? Just say no. And this is where I would argue with the rights-based reductionists. Women don't have absolute rights to demand everything. If something is unprofessional, you just say no. You cannot participate in a planned home birth. Insistent on absolute or unchristened rights to control birth location, this is an ethical error. Let me make this a synch. It may generate discussion for your groups. If we accept a woman has a right to abortion up to fetal viability, a woman who chooses not to have an abortion has an obligation to the soon-to-be-born child. I argue this is not an anti-feminist position. This is reasonableness. The Lancet said it well. Women have the right to choose how and where to give birth, but they don't have the right to put their baby at risk. How should we respond when a patient is received on emergency transport? And we get our fair share of these. You do everything you can for the patient. This is not the time to moralize or denigrate the patient. And please, I'm proud to say with our excellent neonatology Cornell, we can help some of these women. Others, it's too far gone. You can't. Let me put on my other hat as chairman in risk reduction. We do drills so that we're prepared we don't end up like poor Johns Hopkins Hospital. So we're sued for 55 million for not doing a section quick enough. And that's an unfortunate part of obstetrics day today. We can talk more about this. What about randomized clinical trials? Let me just get to the bottom line. Forget it. The fundamental ethical imperative research ethics is to protect subjects which would be violated, I would say absolutely not. Now, this is so important. What are the obligations concerning the improvement of hospital birth, improve patient safety and improve patient satisfaction? And please, your excellent chairman took away my punchline work toward creation of the home birth setting in the hospital for patients who desire this setting work, prevent unnecessary intervention, integrate scientific excellence with empathy. I put this forward not to put forward Cornell because I'm sure these efforts are going on here at the University of Chicago. We have tamed the beast of our professional liability by improving patient safety by a whole host of intervention, drills and team training. At the same time, our caesarean section rate has gone down. I want to emphasize improving patient safety doesn't mean increasing caesarean delivery. This is a mistake. For example, when we introduced our Potosin protocol, our institution is where Duveniel won the Nobel Prize. You have many more Nobel Prize winners here. But I'm not sure if you deserve the Nobel Prize for all the damage oxytocin is done, but nonetheless, when we introduced a Potosin protocol, many of my doctors said, Frank, this is crazy. We're going to increase the caesarean section rate. It decreased the caesarean section rate because we had fewer emergent deliveries. I emphasize in all my writings, all my talks, I support midwives. Please, part of my training was through a midwife. We work at Cornell to make it a beautiful experience. We've voted the best place in New York City to have a baby. I'm proud of our lights and the hallways. So not for traffic, but for noise. We keep our hallways quiet. We make it a beautiful experience. I know time is short, but I want to read this quote from Gregory and because it's beautiful. If the physician possesses gentleness of manners and a compassionate heart, which Shakespeare calls the milk of human kindness, the patient feels his approach like that of a guardian angel to his relief. While every visit of a physician who is unfeeling and rough in his manners makes his heart sink within him, as at the presence of one who comes to pronounce his doom. And one of the beautiful transformations that's gone on in obstetrics in the past generation is the whole influx of women obstetrician. It's become a more human specialty. I show this again and Mark, this goes to you, clinical ethics, the melding of clinical excellence with compassion and virtue and ethics. The best form of home birth is a hospital-based home birth, move home birth units into the hospitals, create the home birth setting. I pay for a midwife to teach our residents and this is valuable. We need to have our knowledge base broaden. I'm proud at great expense at our lower Manhattan campus. We developed a birthing center and this was the kick-off. A huge amount of money, time and effort has gone into this. The first delivery in the birthing center, there was fetal distress and the woman was wheeled over right across to labor and delivery and had a caesarean and everything was fine. The second delivery occurred in the birthing center was beautiful. This is what I would argue is the answer. None of this home birth nonsense. It's ridiculous. This was our latest paper and people asked me what about what goes on in other countries. I argue that yes it is better in Canada, Great Britain, New Zealand, Australia where we have professional midwives but this whole concept of home birth is flawed. What this slide shows is when you look at bad outcomes in the hospital, sure it's improved when you have a certified midwife as compared to an uncertified midwife at home but you see the outcomes are much more improved when delivery occurs in the hospital. I still have a few more minutes. I'm doing okay? Okay. Let me touch on what I'd argue the most important area. This topic of the some global issues, women and children first. When you look at lifetime risk of maternal death in United States, Europe, it's maybe one in 3,000. Latin America maybe one in 200. Asia one in 100s, Africa one in 20 in parts of Africa it's much higher than that. This number has come down. It's still over 300,000. This is not our status at Wall Cornell at University of Chicago. This is state of the art transportation in parts of Africa today. I'm going to be going back to Ethiopia later this year. This is a not uncommon anti-partom ward, a far cry from your anti-partom ward, a labor and delivery suite. This is a bed that women can birth on. It's been estimated for every woman who dies approximately 30 more suffer injuries. And this affects the children horribly. When we look at perinatal mortality, whether it's before after birth, the disparities are horrible. 35% of these women have no perinatal care, 50% of deliveries are unattended while I'm very critical of planned home birth in developed countries. I wish they could all have a midwife with the planned home birth. It's much better than having nothing at all. Why hasn't there been an adequate public response or response from government or private agencies? Margaret Heffernan said it well, willful blindness. When something is too ugly, there's cognitive dissonance. We just don't want to look at it. We just don't want to consider this issue. And I say that's our first task as physicians, people who are into ethics, don't deny that this exists in the world. Dr. Fatala, who's a past president of Figo, our largest international group, said it well. Women are not dying because of diseases we cannot treat. They're dying because societies have yet to make the decision that their lives are worth saving. Should women and children come first or at least not last? This is an ethical question. What ought to be the priority in health care policy for medical care of women and children? Ethics makes a difference in how women and lenders, leaders, should conduct themselves in how they should affect the lives of women and children by identifying obligations of physician and leaders to women and children. Aristotle looked into justice millennia ago. In general, the ethical principle of justice requires every run receive his or her due. Health care policy should allocate resources for fetal, neonatal, and pregnant patients on the requirements of justice to eliminate economic and political bias, age bias, bias in favor of persons, bias against those who cannot speak for themselves. We've elaborated on all this. This is essential. Our responsibilities to increase awareness of these bias in the first step to eliminate them. And it's time for us to take this important step. Now, I'm involved in different international efforts. We're not politicians. I'm delighted that there's an international brotherhood and sisterhood of obstetrical leaders. The greatest good we can do is education. After I leave this meeting, I'm going to Bosnia and we teach. That's the greatest good we can do. But we need to be aware of the disasters that go on the world today. Our International Academy presented this at the United Nations. Not sure how much good we do with this. I believe international education is the best we can do. Now, I would argue if a ship were going down today, if you can't read the caption, there'd be a rescue helicopter that would say if you're the ship's captain, it's investors or manufacturers, we're here to rescue you. But let me close on something beautiful, which I consider one of the most transformative moments in civilization. And when I presented at the United Nations, I used this. It was the middle of the 19th century. It was a time of rampant British colonialism, imperialism. And the British were involved in one of their many colonial wars. And there was the HMS Birkenhead, the Her Majesty's ship, who was evacuating women, children from South Africa from one of the colonial wars. As you know from the story of the Titanic, these ships didn't have enough lifeboats. And the ship hit rocks and started to sink. So what should be done? Commander Seaton gave a historic order. Women and children first. And sure enough, all of the women and children were saved. And some of the soldiers and sailors, there was room, but he prioritized women and children. And I say, in so many parts of the world, we've devolved. We've gone backward from this. You don't need me to educate you. You just look at the news and see what's happening. How are we on time? Should we? We would. Five minutes. OK, then I'll do very quickly. I'll touch on some research issues. With research, please, we could go on forever. We need both scientific and ethical excellence. Larry and I serve as the ethics consultants for NAFnet. It's not North America Free Trade Organization. It's the North America Fetal Therapy Group. And now more than ever, we need some ethical excellence here. I won't give you some of the historic background, their criteria for innovation, research, clinical practice. But this whole issue of equipoise we've looked at. And I'm sure this group, everyone knows, equipoise is the only time a randomized trial is warranted. And we've argued that this should be done on the basis of expert judgment. So we review protocols. And I put forward the excellent study that was done of randomization of surgery versus not for spina bifidone utero. As an example of an ethical trial that was done and came up with a clear answer. Now a good thing that's happened in research ethics is that after World War II and the disasters that happened in Germany, Japan, please, our own disasters in America, there was a move to protect vulnerable populations. And what more vulnerable population is there than the pregnant woman with the fetus? So for decades, research was prohibited in women. Fortunately, we moved away from that. That randomization, I said, whether to do open surgery or not, wouldn't have been permitted a few years ago. So I'm delighted we've moved beyond this so we have a more balanced approach to ethics. And lastly, it's critical we keep the counseling clean. If ever there was a paradigm for non-directive counseling as research ethics, don't give women full hope. Keep the counseling clean. Keep our biases out of it. This is so, so essential. Mark, there's so much more I could say, but let me end on time. It is a true privilege and pleasure to be with this you and this important group. Thank you so much. Thank you. The talk is opening for comments and questions. Dr. Hekmat. Thank you for the talk. Very compassionate. It seems to me, and I like to clarify for me, is that all this confusion that we have in a society, it seems to me, based on whether or not one consider a fetus a person. Because if one considered the fetus a person, one then has all the right, equal to the mother and equal to the adult. Therefore, every consideration or expenses or all has to be the same. On the other hand, if you consider no fetus is not a person and it's primarily the right of the mother and the fetus is just an appendix until it is, then the mother could do anything once, drink alcohol, take cocaine and all these sort of things. On the other hand, if it is a person and then drink alcohol, then that's a child abuse. Then if it's just the child is disabled, well, we don't kill disabled children. So it seems to me, a lot of this confusion is that individual haven't really decided what right a fetus has and I hope you could help me on that. You are so right that this is a core question for obstetric ethics, obstetrics, ethics in general. I would argue it's irresolvable disputes. In other words, you're not going to get even two religious traditions to agree on this, let alone people who don't have religious traditions. We live in a pluralistic society. You have stated so well that people are going to argue vociferously to the point of fighting, sometimes even killing for these different positions. I would argue, leave it alone, push it aside. We are physicians. Let's take a professional approach. Once you reach viability, we have a professional obligation to take care of the patients in front of us. Not absolute obligations to the fetal patient needs to be balanced to the woman in front of us as well. And I would argue that once you reach viability, we have professional obligations to the fetuses of patient and to be balanced with the woman as well. Prior to fetal viability, if the woman chooses not to have an abortion, she's still providing that linkage and we have obligations to the fetuses patient. That's why I believe this concept of the fetuses patient is how we should proceed as professionals. Leave the philosophic disputes in the right space. The legal disputes aside because we're never going to resolve them. There have been reams, reams, reams, books upon books written about this and they get us nowhere. Larry has taught me these debates have gone on since the ancient Greeks. We'll get nowhere. We're never going to resolve them. We are doctors and I think this is a theme that Mark has talked about in 1983. We have issues in front of us here today with the patients we serve. Let's take care of the patients in front of us. And I'd argue this is a practical, ethically sound. It respects all traditions. It respects all religions. Approach to proceed. Dan and then Peter. Thanks for that talk. Given that there appears that there will remain a certain percentage of people who really are invested and want to have home births that this is sort of a, this is something that's a fact. So what do you think is a professional obligation to ensure that they can have those births in the safest environment? For example, having, you showed data that showed that professional midwives did better than lay midwives. Should we support professional midwives to help in those births knowing that a certain percentage of women are going to have home births? Absolutely. Anything we can do to make it safer, I would support. Low tar cigarettes are better than high tar cigarettes. So I support it, but I'm against all cigarettes in pregnancy. So the answer to your question, yes. Anything we can reasonably do to have a higher standard of midwifery in these home births, I support. What's amazing to me that the midwives, you understand the great majority of midwives in this country have nothing to do with home births. You realize that. The great, please. I work with midwives. I don't know if, here at the University of Chicago, you have nothing to do with it, but they're reluctant to speak out against this. But I agree with you. There should be standards and there are attempts to do this. Thank you very much for your talk. I've really enjoyed reading your writings for many years. My question has to do with when someone comes to see you or any physician, and in particular I'm thinking about surgeons and surgical procedures, when someone comes to see you for a procedure that perhaps some minimally invasive approach that you don't do, if you think that it's an appropriate operation, you may say, well, you got to go see someone else because I don't do this, but this person does. How do you decide when something goes from being sort of fringe? Maybe some people do it, but I don't think it's a good idea and therefore I don't do it to, if I don't talk about it with my patient, then I'm not giving adequate informed consent. Excellent question. ACOG has a normative force. We're crossing the line from ethics to law and what you could be sued for. Ultimately, I'd argue professional judgment is the key here, but once they're technical bulletins and ACOG statements endorsing something, then you should utilize it. Before that, it's a judgment call and different doctors can respond differently. Obstetrics, unlike medicine, they're often not clinical studies or ran level one evidence to resolve issues in their legitimate disagreements about some of our most fundamental issues. So the answer is do the best you can, but if there's documented evidence in an ACOG statement, then it crosses the threshold. Frank, thank you so much for your talk. It was very illuminating. Did you see the statistic about a month ago that I found entirely shocking that of the 24 most developed nations in the world, maternal mortality was on the decline with a single exception. And the single exception was the United States where we had been on the decline, but in the last year or so, we've reversed that curve and out of the 24 countries were the only one that increased our maternal mortality. Could you say just a word? Absolutely. A few issues that make me wonder how valid those statistics are. I wish Helen were here, our reproductive endocrinologist. Sometimes our reproductive endocrinologist, of course not at the University of Chicago at Cornell, set us up. Please, I can tell you, my wife works at Bellevue and she had a patient who had metastatic cancer and reproductive endocrinologist had this, impregnated her with IVF for profit. This was a for-profit center that this is still going on in the United States. And she has her, my wife is a maternal fetal medicine specialist and she's between a rock and a hard place at 23 weeks of gestation. The point is, is this gonna be a disastrous outcome? Now, should this woman have been had in vitro fertilization? No, but this is part of the problem. When you have a profit, I wish Helen were here so she could comment on this in reproductive medicine, people take advantage. I hate to say it, but this is the say-it-true remark, you know this, that people take advantage of our American system. Another issue is obesity. As if it's a battle I fight, Americans are less healthy than they were a generation ago. That's for sure. And one of the good things is, is that one of the good things, thanks to you and your colleagues in medicine, women who, you know years ago would have never lived to have gotten pregnant. But thanks to great breakthroughs in medicine and surgery, you're now getting pregnant. That would never happen in other countries. So I mean, they're mitigating factors here. I wonder how clean this data really is. I don't believe that our healthcare system here at the University of Chicago at Cornell, we care for patients any worse than we did before. I'm sure that's not the case. I'm sure that's not the case. Do I? Yes, Julie. Thank you so much for your talk. Yeah. Can you expand a bit on circumstances in which, cause you've proposed that after viability, the fetus should be considered a patient. Can you expand a bit on circumstances in which the woman post viability does not necessarily consider the fetus a patient? And some conflicts that may arise post viability in which your beneficence based obligations to the fetus may be challenged. Well, I think the planned home birth, what why focused in on this is one, it's getting worse in the United States. And they're very vocal advocates of this in our professional societies are sanctioning this in Great Britain, they outright endorse it. And to me, this is a clear example that a woman who's clearly chosen not to have an abortion is this is a wanted child, needs to be told, don't do it. There needs to be directive counseling. And I think this is a failure of the profession not to give clear advice, not to do it. The same way with alcohol or cigarettes, not saying put the woman in prison, not to, but this is a clear error in the physician. I put it on the physician, not the woman. She's getting bad advice. There's misinformation out there. Our New York Times always popularizes this with beautiful women and wonderful experience, but the disasters don't get published because the women are ashamed. But this is a classic conflict with the woman. So ultimately the woman's decision. I'm not saying the woman doesn't have the right to deliver at home. Please, that there are public issues that I wouldn't interfere with that. But I would argue it's morally irrational for her to do this and it's our responsibility to educate her and make a clear recommendation in these matters. And that's it, the stronger the evidence, the more clear and more directive we would be. Does that help with that? I guess one of my questions is in that statement or the declaration that the fetus by definition has, or we as physicians have beneficence based obligations that these, is there any space in there for termination of pregnancy beyond viability? And I know that that's a dicey topic, even amongst us, as family planners. But are there any circumstances in which? We've written about this, we've written about this. We have argued that ethically, we'll talk about legally and whether I'll permit it at Cornell in a minute, but ethically, I believe for certain serious anomalies, ethically it's not contraindicated, let's say, alobar holoprosencephaly, renalagenesis to perform a termination in the third trimester. I think that, and we've given criterion made arguments about this. I would argue that for a chondroplasia, where normal intelligence is the outcome, the answer is no. I would say for, and why bring this up in Europe, some of you may be aware that fetus side may be available in some countries for very loose indications. So the answer to your question, it depends what the anomaly is. For a chondroplasia, I take a stand, no. For normal intelligence, even with the problem of a chondroplasia, post, after 24 weeks, no, but for other serious anomalies, the answer is yes. Now whether I would permit it at Cornell, it's a macroethics decision, and with, it's on a case by case basis. I'm old enough, not quite as old as Mark, but I remember when I was at Yale, when the federal government came in, you know what I'm talking about, when the federal government comes in, and I wouldn't do this unless I had full administrative report to support what I would consider an ethical option. Well, I think I want to thank you so much for your wonderful thoughts. Mark, thank you. Mark, this is a pleasure.