 Welcome to the annual W. Gaye lecture at Harvard Medical School. I'm Christine Mitchell, Executive Director of the Center for Bioethics at the Medical School. First, some of you might be wondering who George Gaye was. Almost 150 years ago, 148, to be exact, George Washington Gaye received his medical degree from Harvard Medical School in 1868. George Shattuck was dean at the time, and Charles Elliott was about to become president of Harvard College in 1869 and institutes several educational reforms that led to Harvard becoming a professional school of the college. Meanwhile, Dr. Gaye began practicing surgery in Boston with great success, leading him to establish one of the largest private practices in this region, becoming a senior surgeon at Boston City Hospital and later instructor in clinical surgery at Harvard Medical School. In 1917, he established the George W. Gaye Lectureship with a gift of $1,000, the oldest endowed lectureship at Harvard Medical School, and we think the oldest medical ethics lectureship in the United States. A century later, his gift has grown remarkably and supports, among other things, the lecture you are about to hear this afternoon. In 2016, we're still grateful to George Gaye for his gift. Now, it's my personal pleasure to introduce to you Martha Minow, a child of the 60s raised in Chicago's northern suburbs. May I first congratulate you on last night's win by the Chicago Cubs? I hope you've got to savor every heart-stopping moment of the game, despite having to give this lecture today. It's always heartening to see persistence and excellence develop and prevail even when it takes 108 years. I first met Martha in 1993 when she was the acting director of the Edmund J. Safra Center for Ethics at Harvard during the year when I was a fellow there. Once a week, we gathered to discuss topics in professional ethics across the fields of law, philosophy, medicine, nursing, religion, and political science. As I experienced firsthand, and as President Drew Gilpin Faust has said, Martha has an uncommon ability to bring people together for common goals. At the time, I might add, Martha was teaching at Harvard Law School, who had recruited her to the faculty back in 1981 when there was only one tenured woman on their faculty. As you can see in your program, Martha is now a professor of law and Harvard Law School's 12th dean, the second woman dean, after Elena Kagan, who was the first woman to hold the deanship at Harvard Law School, and we all know what became of her. Throughout her career, Martha has been deeply engaged in issues related to human rights. After college, she was interested in education, health policy, and philosophy. So she started at the Harvard Ed School in the 70s. That was the second year of legally mandated busing in Boston. And Martha became the project director for an assessment project that convinced her that she needed a law degree, which she went to Yale to get. And then, among other things, went to clerk for United States Supreme Court Justice Thurgood Marshall, who is perhaps best known for the Brown versus Board of Education decision. Martha's first book in 1990 was entitled, Making All the Difference, Inclusion, Exclusion, and American Law, Looking at Gender, Race, Disability, and Religion. As in that book, Martha often writes about the responsibilities of citizens to participate in democracy, something she herself has done, both in the United States and around the globe. For example, she was part of Boston's Facing History and Ourselves group, for which I think, are you still a trustee? Which led to a conference and a book entitled Between Vengeance and Forgiveness, Looking at Mass Violence, Trying to Avoid Treating People as Groups of People as Objects of Hatred and Teaching Prevention of Genocide. After reading that book, as a High Commissioner for Refugees, Madame Sadako Ogata called Martha for help, which led to her work with a project called Imagine Coexistence to Address Post-Conflict Situations. Around the same time, Justice Richard Goldstone of the South African Constitutional Court, who had written a preface for that book, asked her to join the International Commission on Kosovo. Martha also worked on the Divided Cities Initiative, devoted to building an alliance of global cities dealing with ethnic, religious, or political divisions. And she has served as Director of the Iranian Human Rights Documentation Center. With 20 years to reflect on Brown v. Board, Martha wrote in Brown's wake a few years ago, looking beyond just racial desegregation of schools, important as that is, to the repercussions of that decision for school reform, more generally, including gender equality and treatment of religious and other differences. In between the writing I have mentioned this afternoon have been other books and articles and lots of real world experience that informs Martha's teaching and writing. Contrary to the maxim that I'll modify a little, that no person is a prophet in their own land. Let me just close by adding that Martha has been recognized with Harvard Law School's Teaching Award and is widely admired, not only at her own school and the Staffer Center, but here and across the campus and by her former student President Obama, as well as in law and policy circles, increasingly around the world. I can't myself say from experience that a woman has to be twice as good as the best man to succeed in a leadership position, but I can say that there's often special scrutiny when Harvard faculty are being considered to give very prestigious Harvard lectureships. And I am sure that you are now as convinced as we were that there is no one more qualified than Martha Minow to speak about religion, medicine, and law, how to heal when values conflict. Martha. Okay, okay. Christine, that was so lovely. And you really did research, I guess, while watching the ball game. No, that was fantastic, fantastic. It is a tremendous honor for me to be invited to give this distinguished lecture. Walking in the building, I had some recollection of working actually with Dean Tostason many, many years ago. I was recruited to Harvard actually by David Hamburg who said, you come to Harvard, you can actually work with people in the medical school. He really said that. And I actually did a little bit, but that's the way before I was Dean, Julie Richmond, Bob Truick, Christine Mitchell, people who have actually been very significant in the intellectual and personal growth that I've had the opportunity to pursue. I wanna thank my research assistant who's here, Hannah Solomon Strauss. I wanna thank colleagues who actually read drafts and excuse all of them for my mistakes. And I wanna thank this fellow over here. First time I've ever been on a stage with a skeleton, but it's gonna keep me honest. Over the summer, the United States Supreme Court issued a short opinion that did not decide the case at hand. It instead prolonged the controversy between religious claims and the availability of healthcare. In a case called Zupic versus Burwell, the court addressed seven cases brought by colleges, nonprofit organizations, and other institutions, all of which identified as Christian. The advocates argued about the obligation to include contraceptive coverage in their employee healthcare plans as directed by the Federal Affordable Care Act. But actually, that's not quite right. The issue actually is the adequacy of the accommodation for religious groups under the Affordable Care Act. The government provided for an opt-out mechanism for religiously affiliated organizations. The plaintiffs in these cases argued that submitting the required form to seek the opt-out substantially would burden their exercise of religion and therefore violate a statute, the Religious Freedom of Restoration Act. During the oral argument at the court, some of the justices explored with the advocates the possibility of a compromise. After argument, the court asked for supplemental briefs to address whether there could be a further accommodation while also ensuring that women covered by the petitioner's healthcare plans, and I quote, would receive full and equal health coverage including contraceptive coverage. This was unusual in a lot of ways. Let me count them. First, there was the request for additional briefing. Doesn't happen very often. Second, the court departed from its usual practice by trying to elicit, if not itself, craft a compromise for the parties. Now trial judges may do that indeed, not even infrequently, may encourage settlement very commonly by saying go out in the hall and figure it out. It's not how the Supreme Court of the United States proceeds. Third, the decision vacated. It wiped out the seven opinions by the courts of appeals and sent the matter back to them. Although almost all of the judges involved in the prior decisions had considered the matter and rejected the complainants' arguments. Fourth, the Supreme Court opinion itself is unsigned. Now that happens now and then, but this is an important case and to have an unsigned opinion is unusual. And it seems to be the result of a disagreement in a court that's missing a member. So a nine-person court reduced to eight probably divided equally, four and four, and nobody wanted to take the blame for the opinion. But underscoring the disagreement, Justices Sonia Sotomayor and Ruth Bader Ginsburg produced a separate opinion. Emphasizing that the majority opinion left entirely undecided whether any further accommodation was needed and not so subtly noted that the lower courts upon reconsideration could simply conclude that no accommodation was needed. This case prompts some observations. The court seems to be stalling. Perhaps awaiting approval of a ninth justice looks like a long wait. Coming as it does at the end of President Obama's term, this approach clearly puts pressure actually on the administration to devise a new solution out of court, despite the prior successes in the courts below. And as evidence that the court is stalling and pressing for a resolution outside the judiciary, the unsigned opinion says, and I quote, we anticipate that the court's appeals will allow the party sufficient time to resolve any outstanding issues between them. It's gonna take a long time to do that. The court hoped that the decision would lead to an out of court settlement or to a new dynamic after a change in the presidential administration and after changed in membership of the court or perhaps simply postponed the conflict for a later date. One observer called the court's action a bizarre decision unsupported by any of the cases cited in the opinion. It was surely an unusual moment in the United States Supreme Court. What is not unusual is the collision between religion and healthcare policy, increasingly coming to courts and other legal institutions. Consider medical and healthcare at the end of life. Consider whether parents can refuse to vaccinate their children. Consider reproductive choice. Consider issues that trigger individual disputes and policy debates inflected by religious and philosophic views. The reproductive issues can range across contraception, abortion, reproductive technology, disputes about the end of life, vaccinations, and reproductive issues involve claims of personal or religious conscience by patients but also by healthcare professionals, by hospitals, by employers. Public policies also implicate healthcare providers in regulating religious practices such as male circumcision, female genital cutting. I will focus on the United States here but the issues that I'm talking about actually reverberate all around the world. So first let's just look at the contemporary clashes between religion and medicine. What's going on and why? It's not difficult to identify the flashpoints in the United States where religion and medicine are clashing with one another. They center on end of life, notably whether physicians and other healthcare professionals can assist an individual who chooses to die. Vaccinations in particular whether parents can refuse public health vaccines for their children. Reproductive choice and access to contraception and abortion including whether employers must cover these treatments through their healthcare plans and the conditions and terms of those treatments and access to new reproductive technologies. Now the stakes of course are significant in each of these issues. Currently physician assisted end of life is lawful in six states in the United States. It's not lawful in 44 others. Some argue it's become an issue because of failures of access to healthcare, failures of pain management. It may also though be an extension of self-determination in a world with extensive healthcare systems. It may also reflect the prolongation of life due to very great successes in healthcare systems. A survey of Oregon doctors found that they granted one out of six requests for aid in dying and the numbers of individuals who actually opt for such assistance remains low in all the jurisdictions that approve it. Knowledge and understanding of options near death we know are notoriously limited. Most people don't ever wanna think about it, much less learn about it. They should be improved regardless of the resolution of any of the issues I'm talking about. But many people for religious and other reasons object to the involvement of healthcare professionals in any step that might shorten the time until an individual dies. What about vaccines? Now the issues here may seem more about philosophy than religion, but for legal purposes, the two are treated off and very similarly. Ever since the discredited 1998 paper that purported to link the measles mumps rubella vaccine to autism, there's been misunderstanding about vaccines that's contributed to surges of preventable diseases in the United States and in Europe, including mumps on my campus last spring. Anti-vaccine attitudes over time have contributed to increases in the rates of illness and it really poses important questions about public health versus individual choice and particularly individual choice by parents about their children, but also as it turns out about other people's children. What about reproductive freedom? State laws over the last 20 years have sharply restricted access to abortion. Since 2011, states have adopted more than 230 new restrictions on abortion. According to a study done in 2016, nearly one third of the women seeking prescription-based contraception reported barriers to access. Meanwhile, there are religious leaders and individuals who oppose the use of some or all contraceptives and some oppose reproductive technologies. Complicating each of these difficult subjects is the fact that they inevitably involve not just one person, but also the relationships between the most directly affected person and others, ranging from intimate family members to larger society, whose interests should govern. Each issue potentially puts healthcare providers in the middle of conflicts between family members, between groups and society. Physician involvement in hastening death, exemptions from mandated vaccinations, reproductive choice, generate conflicts between the duties to individual patients and also respect for a provider's own conscience and professional norms. These are serious issues. And because religious and spiritual dimensions can enhance patient healing and well-being, attentiveness to religion matters even from a purely healthcare vantage point. Now none of these issues is particularly new. And yet they appear to be generating heightened debate. Here are nine speculations about why this might be the case. I too was watching the ball game last night. First, political and social movements have focused on religiously inflected issues for the past several decades and they do so in part to mobilize voters to alter public policies and to express conscience. Particular issues over the past several decades have involved the status and autonomy of women, the nature of a family, the rights of LGBTQ individuals. All of this makes healthcare simply one of many, many sectors caught up in particular cultural and religious disputes that now sweep in employers, florists, photographers, hotels, and other service providers. Second, legal treatment of religion has changed in the last 30 years in the United States. The Supreme Court in 1990 in a case called Employment Division versus Smith cut back on the constitutionally required accommodation for religion. In response, legislation was widely and enthusiastically adopted by the federal Congress and by the states. As a result, we are now dealing with statutory law rather than judge-made law. And what the legislatures did was to embrace very broad recognition of religious freedom. Now what happened in 1990? Why did the court cut back? Well, maybe the court was unsympathetic to the particular claims in the case that involved two Native Americans who sought unemployment benefits after losing their jobs due to ingesting peyote in a religious ritual. Intentional possession of peyote was a crime under state law. The court said the legislature can respond and can provide accommodations, but the constitution should not be used to modify an otherwise generally applicable law that was not targeting religion at all. I don't think the court had any idea what kind of a groundswell of popular opposition would result, producing legislation so quickly and so unanimously that I don't think we would recognize the legislature involved today. Now the dominant framework used in the legislation calls for broad accommodation and no balancing tests, but just language to be interpreted and that's what courts are now doing instead of figuring out case by case what kind of accommodations there should be. As a result, judges and educators and hospital administrators and many others encountered disputes over particular situations and the scope of required accommodations. Third speculation, the practices for delivering healthcare have changed. They involve, as you all know better than I do, teams, teams of nurses and doctors, technicians and insurers. This all gives much greater visibility, greater access, more regulated record keeping around decisions that took place in the past in more private consultations. Other developments bring new technologies into play for prolonging life, for affecting reproductive practices, permitting discussion and debate on the internet and elsewhere by individuals who are concerned, for example, about vaccinations. These are changes that affect the conflicts that are now coming to court. Fourth, expansion of the government's role in healthcare provision and notably in insurance with the Affordable Care Act as a prime example, producing many more regulations, institutional oversight, more visibility, more occasions for potential dispute and conflicts over religion and other issues. Fifth, some religious groups that used to not participate in American politics have become more engaged and actually use litigation and legislation to express their views and their views about what they need for their own groups but also what they think their religions tell them is right for everybody. Sixth, junk science and even antipathy to science has certainly fueled opposition to vaccinations even as new technologies, imaging fetal life, for example, have affected the politics of reproduction and abortion. I fear we're facing the end of the Enlightenment but that's a topic for another day. Seventh, disputes over religion and medical issues like many other societal conflicts have landed in the hands of lawyers and judges, some of my best friends but there's a problem with this. When disputes are framed by litigation, adversarial politics and allergy to compromise follow because lawsuits require casting an issue in terms of competing either or arguments and seeking a definitive yes or no answer to a complaint by a plaintiff makes middle or compromise positions not possible if the matter is in court. That differs from traditional justice methods that are used, for example, by American Indians used in Jewish law, used in African customary law and other systems. The United States, the adversarial framing of issues in court affects discussions not just in court but outside and in the United States hard issues end up in court. Eighth, medical ethics principles have shifted over time from reliance on medical expertise to individual choice. Dr. Lynn Peterson explained, by the late 70s, ethics began to take root in medical education and number of events led to this, the controversial Karen Quinlan case, increasing worry over clinical trials, litigation over the standards of informed consent and public battles over abortion and organ donation were some of the key issues. His emphasis on choice and individual decision making as a response to these issues actually also reflects concerns of overpower imbalances in encounters between medical professionals and patients in the activities in hospitals and medical centers. Also, of course, risks of potential litigation and increasing philosophic and legal treatment of individual patient choice and decision making, consent, self-determination as a value now reaches even the rules for experimental treatment for people with terminal conditions. Fascinating innovations such as open notes developed right here at Harvard Medical School enable patient participation, education and engage decision making. But individual choice means facing the variety of choices that individuals want to make and there can be therefore new kinds of conflicts with the healthcare providers as well as with public policies. Ninth, individual choice generally is not just a deep American value, it's the solvent for intergroup conflict. That's how we solve our intergroup conflicts over time. Classic decision in the United States Supreme Court about whether compulsory education schools could forbid kids from going to religious schools. Supreme Court in the United States says no, it can't, there has to be individual choice. That was a fight between religious groups and immigrant groups and others. Another classic case, whether or not an individual teacher could be denied the right to teach German to students. Supreme Court says no because there have to be choices. That was a fight between immigrant groups and nativist sentiments. Individual choice is a solvent for group conflict in the United States and on questions about how best to raise children, whether children should learn a language other than English, whether women should change their names upon marriage and even what religion to adopt are treated as questions of individual decision making in the United States. In other countries, comparable decisions are subject to more collective or even governmental policies. We fall on the far end of the spectrum of individualism. We value that and ascribe events even to individual effort. But individuals make choices that can pose conflicts and conflicts with one another and conflicts with institutions and conflict with law. So for all of these reasons, conflicts between religion and healthcare decisions are present, increasing and not going away. All of this imposes costs. It fosters the kinds of disputes that take time, go to court, produce tension, mobilize political disagreements, generate anguish and occupy more and more time of professionals in the healthcare business and in law and elsewhere. Now, discerning right answers is really hard when there are religiously motivated conflicts over medical care. It may not be possible. The conflicts reach to the very notion of what is right and who can and should make a decision. Ours is a nation that requires separation of religion and government. So any decision made by the law will have to be secular. And ironically, this very commitment to separating religion and government has accompanied in this country a flourishing of religion. We are, by self-report, the most religious society in the world. And the flourishing of religion here includes the flourishing of multiple religions. We are the most diverse in our religious traditions. And by that, I mean to include atheism. The United States has a growing number of Muslims, Buddhists, Sikhs, Hindus. And although the number of people identifying as Christian is declining, United States is home to more Christians than any other nation in the world. And evangelical Christians hold an increasing proportion of those who identify as Christian. Religious diversity includes many who are secular, atheist, agnostic, many who affiliate, many who switch religions. And a vast variety of adherences to religious traditions and teachings occur inside the United States. Remember, we're people of choice. Observers who used to predict secularization following the modernization this country and others I think are now really back on their heels because that's not what has happened. Instead, we focus on pluralism and respect and multiculturalism with multiple groups contrasting beliefs and conflict. To many, in this context, there is no neutral point of view. When religious views come into play on public policy questions, is it neutral to say the religious view does not prevail? Not from the vantage point of those who adhere to the religion. And even the option of a secular approach leaving choice, for example, to individuals does not seem neutral to those who view a particular choice as immoral or who view the resort to individual choice itself as disrespect for a religious viewpoint. How many people here have gone to Wikipedia, everybody? Right? How many have actually written, contributed to a Wikipedia site? Have you done that? Okay, so the Wikipedia aims for neutrality, right? It came to an impasse in the entry dealing with the definition of abortion. The entry was adjusted 6,000 times based on peer-to-peer contributions and the editorial war prompted the site administrator to close off the discussion. When disputes reflect religious views, come to visible focus. When they come to legislatures, majorities can win, but courts in our system are entrusted with hearing objections and objections from minorities. Wikipedia just shut it off. The courts have to hear what comes. Permitting individual choice can be an attractive solution but the legally protected choice to secure assistance from the medical professions in ending one's life to avoid otherwise mandated vaccination, to pursue contraception and abortion, these are not neutral options. Permitting such choices means allowing people to engage in conduct to which many people object. And conduct which could harm them or others. A nation that seeks to promote individual liberty inevitably allows and even supports many choices which people may object to. And many choices which bring about harm. So to say this is not to say therefore there should be no choice, let's be clear. We after all encourage people to join the military. We allow people to skydive. We allow people without warnings to eat raw fish to smoke cigarettes, to drink alcohol, to drive in Boston. The choices that involve medical care though implicate symbolic and practical dimensions about life itself. And to permit individuals to accelerate death with medical help is to make death a choice. And this to some devalues life itself. Disallowing medical assistance to patients who wish to hasten death consigns individuals, many of them to suffering. Any framework allowing healthcare professionals to have the conversation and pursue action, accelerating an individual's death runs risk, risk of abuse, great care has to accompany any such efforts to protect those who are vulnerable due to their physical, mental, emotional, financial, or familial situations. But there is no neutral option here. Raising the subject is not neutral. Worse than the lack of a neutral option is the fact that often there is simply no good option. For people with lingering illnesses, massively compromised healthcare, grave suffering, for people with unwanted pregnancies, for parents with objections to vaccines whose neighbors have children, especially vulnerable to the illness that the vaccine can prevent, there are no great options. There are chairs, so come on in. There are often no good options for the healthcare providers. States that forbid physician assistant under such circumstances that providers must consider whether or not they face sanctions. Explicit criminal sanctions, for example, for hastening death or peer professional sanctions. Religious traditions may undergird laws that actually punish medical professionals for being involved in any of these activities. Dr. Timothy Quill, a physician who prescribed barbiturates for a patient who was diagnosed with terminal leukemia, then faced himself some difficult choices. The patient took a lethal dose. Dr. Quill then had to decide how to report the cause of her death to the medical examiner. And here's how he described it. He said, although I truly believe that the family and I gave her the best care possible, allowing her to define her limits and directions as much as possible, I am not sure that law, society, or the medical profession would agree. So I said acute leukemia to protect all of us, to protect Diane from an invasion into her past and her body, to continue to shield society from the knowledge of the degree of suffering that people undergo in the process of dying. Suffering can be lessened to some extent, but in no way eliminated or made benign by the careful intervention of a competent caring physician given current social constraints. A healthcare provider in Dr. Quill's situation knows that law, society, and the medical profession do not all agree about how to handle such situations. Dr. Quill himself lost his argument in the United States Supreme Court that a state ban on physician-assisted suicide violates the Constitution. The court concluded that such a ban is within the discretion of a state and that the Constitution itself does not create a right to die. It was that decision that then cast this issue back to the state legislatures, and that's where it is now. With vaccinations, a current problem is the reliance on healthcare providers by lawmakers who want to provide parental choice, and they also want to guard against public health disasters, they want to be re-elected, and they don't want any accountability. California, therefore, under the direction of its legislatures, has required conversations. Isn't that the great solution? Conversations between the healthcare providers and parents who seek exemptions from the vaccinations. That's what they did until the measles were an epidemic in California. And the state then amended the law to eliminate personal belief exemptions while grandfathering in. How's that for compromise and incoherence? Grandfathering in those families who had already received an exemption, so they can simply infect everyone else. As more parents seek exemptions or delays in vaccinations, the healthcare professionals may be pressed to suspend their own best medical judgment or risk pushing a patient to another physician who's willing to forego or delay the vaccinations. Some physicians are urged to take on the role of refuting the beliefs of the families opposed to vaccinations. Now, how well is that gonna work? Abortion providers have faced death or threats or burning of their homes or worse. Contraceptive use may have passed into the area of assumed ordinary medical care, but physicians who know the value of contraceptives now have to watch as courts navigate disputes brought by religiously affiliated employers who oppose even having to ask to be exempted from the obligation to provide contraception. Any such accommodation requires an expansive view of a potential interference with religious beliefs. It requires viewing complicity as itself, something that religious belief guards against, being complicit with someone else doing something you disagree with. The current situation permits repeated legal disputes over physician-facilitated, dying, vaccinations, abortion, contraception, that it imposes serious costs on healthcare, on people. And of course, for those who oppose medically-facilitated dying, employer-financed insurance for contraception, lawful abortion, vaccines, they may view the current regime as immoral. And for others who face obstacles in attaining healthcare, as they seek assistance in any of these matters, the costs of the current regime are very severe. But there's another cost that I don't think has gotten enough attention. And that's damage of respect for the legal system. I know it's not your concern, but it's mine. Legislatures and courts often face hard questions and come up with unpopular decisions. The questions that come to philosophers and theologians, physicians, family members, often end up in the laps of judges because no one else can decide. And judges decide, lawyers decide, and it's not, despite what some of my students think, because we are smarter than other people, it's because it's our job. Our job is to resolve the disputes when nobody else can agree. The legal system gives answers to eternal questions that philosophers have debated for centuries, questions about guilt and innocence, blameworthiness and excuse, free will, responsibility. The legal system may not get the right answers, but it will produce answers because that's its job. And the contests over religion and healthcare don't produce answers. They produce more debate. There's a debate even over what's the ground on which you're standing when you're making the decision. That's a problem. Enormous financial resources in public confidence and law can be strained as the courts are repeatedly confronted with competing in irreconcilable worldviews. And as political parties appeal to people's personal and religious beliefs in order to mobilize support for candidates, change elections, and yes, cast out on the legitimacy of the legal system. The current situation puts many institutions and many individuals in untenable positions. Medical professionals risk criminal prosecution when aiding patients facing terminal illness or terrible suffering. Doctors and nurses are asked to stand between the political furor over vaccines and public health disasters. Lawyers are expected both to define what is a compelling state interest when religious objections arise over healthcare matters and at the same time to respect religious conscience of patients, employers, healthcare providers. Courts face questions that they are not well equipped to answer with the expectation that they can resolve issues precisely because no one else can. Now this current situation at a societal level resembles what Sigmund Freud called repetition compulsion. Individuals persisting in recreating interactions despite ample evidence of their dysfunction and failure. Judge Jerome Frank once cautioned that confidence in the predictability of judicial decisions reflects an illusion born and I use his words of a childish desire to have a fixed father controlled universe free of chance and error due to human fallibility and that's from a judge. We don't need to subscribe to his thesis to consider that illusions surround the reliance on judicial resolution of conflict. The illusion of neutrality, the illusion of wisdom and that illusion is ripped apart in some of the disputes at hand. Now because of reliance on litigation to resolve the conflicts between healthcare and religion there are tough questions that are alive right now and they are unresolved and I'm not sure they can't be resolved. The first is what is the test for when an assertion of a religious free exercise deserves legal concern. Is it whenever a religious objecter says so? Subjective statement, I have a religious need. Or does there have to be some sincerity and if so how do you establish sincerity? Or does there have to be a reasonable religious belief? Or does there have to be an official established religion that recognizes that belief? Any of those decisions is problematic. What kind of countervailing concerns justify denying claims for religious exemptions? Preserving life, what's a life? According to what standard medical practice? What about the protection of rights for third parties? What kinds of counterarguments can ever be compelling enough in the face of someone's assertion I have a religious need? Third, when should courts have the final word? When should instead in a democracy should the final word be given to the democratic branches? Legislatures, if they are democratic. And what room is there and what room should there be for compromise or for settlement of religious claims concerning healthcare? And fourth, does repeated reliance on courts to resolve conflicts over religion and healthcare offer a path towards resolution or instead a kind of repetition compulsion exacerbating the conflict, eroding respect for the rule of law? Now these questions, particularly the first two are occupying lawyers, scholars and judges but they're very little attention given to the last two questions and that's where I'm gonna spend my time. Who should have the final word and is there a problem going back to court over and over again with these kinds of questions? I think this means we need to stand back and even rethink the framework that's taken for granted about all of these matters. The central role of courts in controversies over religion and medicine stems from the long standing pattern of reliance on courts to resolve hard problems that elude political or other resolutions. Are there some alternatives? The first alternative may be to turn to substance. Let's get a solution on the level of what the norm is and let's have someone other than courts define what the norm is. Disputes over physician facilitated dying, exemptions from vaccines, access to abortion and contraception have generated constitutional arguments, issues of individual choice but the United States cannot embrace a one size fits all solution. Other countries take India that have a pluralist democracy, assign rules to individuals based on their birth, what religion they were born into, tells them what legal regime they'll be in. I'm not recommending it but I'm just saying there are other ways to handle this. It's not a plausible direction for us. In the United States, the law guarantees individual choices up to the threshold of harm to the individual or others. Disputes in the healthcare and religion conflict center on when that threshold is met. What is harm to self or others? And although disagreements reflect fundamental beliefs about theological commitments that call for respecting the free exercise of religion, that free exercise must give way in the face of compelling governmental interests like substantial harm to self or others. Courts can identify compelling governmental interests. These could include self determination of patients, the public health of communities, the equality and liberty of women seeking control over their own bodies. Not everybody's gonna agree about what is a legitimate, much less a compelling interest. And therefore the turn to substantive norms using law as attractive as it may seem abstractly is not likely the route to go. It's not gonna end the cycle of politicized debates that affect arguments not only over individual cases but also over judicial appointments and presidential elections. I think there's seats down here if you want one. Raise your hand if there's a seat next to you. There's seats, okay. Another approach though is to ask whether the presumption of individual choice should be overcome because of significant harms to others or lack of sufficient information or lack of capacity to decide or lack of rationality. By this I mean to shine a spotlight on whether or not a person who is seeking assistance to speed death is doing so in a way that imposes harms on others. Whether that person has sufficient information and ability to decide. Whether healthcare providers can actually ensure adequate pain management before exploring the hastening of death. Asking about harm to others highlights how exempting one person from vaccination puts another at risk. And with abortion asking about harm to others unavoidably joins the woman's choice with effects on the fetus which is why current law treats early stage pregnancies differently than late stage ones. For religiously affiliated employers who seek to avoid contributing in any way to the use of contraceptives because that violates their beliefs. The harm to employees seeking access to contraceptives is clear. But so is the possibility of meeting their needs through other forms of insurance which is why the Supreme Court hopes for a settlement in the Zubik case. There's another alternative, several more. We could go back to relying on medical expertise. Would that mean leaving involvement in treatments that could end a patient's life to the patient in consultation with a healthcare professional? Would it leave exemption from vaccines to that kind of consultation? Just keep the law out of it? Leave access to abortion and contraception to the healthcare professionals? This is what is not possible anymore given the nature of modern healthcare. It's just not possible. It's not a conversation with one person. There's what reimbursement code do I use? So this is not a likely option. But there is a different kind of expertise that has emerged within the medical world. There's an expertise in dispute resolution and I think this is worthy of serious consideration. People involved in ethics committees and hospitals, many people in this room. People involved in bioethics mediation and collaborative problem solving have expertise and abilities that offer strong alternatives to the purely legal approach. Values related arguments on each side of the debates indicate kinds of conflicts that may not be well suited to this kind of decision making. But hey, they're not well suited to the decision making of courts. Courts and litigation depend on an adversarial approach. That exacerbates disagreements because of the either or terms. It discourages compromise and accommodations. It forces people into abstract and hardened positions. And the general field of negotiation has lessons to offer. My colleague, my late colleague, Roger Fisher, William Urie argued in their now classic 1981 book Getting to Yes, that even in the most difficult disputes it helps to separate people from the problem. And it helps to imagine the situation from the viewpoint of others. And it helps to notice that there are underlying interests that may be different than the position that people seem fixated upon. And it helps to look at motivations rather than the abstract positions that people declare. Effective negotiation involves identifying and even inventing options where there could be mutual gain, where there can be independent standards, where there can be face-saving and symbolic solutions, where there can be management of emotions and allowing participants to tell their stories. Turns out to be incredibly powerful. Turns out even if people tell their story after a decision has been made against them, they feel better. And creating a context where people can have their perspective heard may head off vicious cycles of adversarial argument. And here the very specific emerging practices of bioethics mediation might be a promising resource. Mediation itself involves a neutral decision maker who acts not as a decision maker, a neutral individual who acts as an aide to the disputing parties in resolving dispute out of court by focusing on a negotiated solution. And the solution in turn is one that reflects their needs, their rights, and their interests. Bioethics mediation developed as practitioners sought to ensure decision making by patients and families and wanted to respect laws and wanted to acknowledge the power dynamics and the institutional momentum that affect the provision of care. Developed with practical details by people like Nancy Neville of Dubler and Carol Liebman, bioethics mediation offers avenues for hearing about patients' values and wishes and religious commitments and ethical principles. Now, any mediation of these issues will be a feature of our own society. And that means our own healthcare institutions. And clinical ethics consultants and institutional ethics committees have emerged to help people. The physicians and nurses and philosophers and social workers and lawyers who collaborate together are actually a demonstration that patients aren't allowed to make decisions all by themselves. Mediation becomes a context for exploring the options and shaping what is available. But they also provide possibly avenues for personal values and history as well as medical assessments to be part of the answer. One of the most interesting features of mediation, in my view, is that according to reports and studies, it gives people a sense of control and control may be precisely what people feel is most missing when they're dealing with the kinds of circumstances that lead to the conflicts that I'm describing. So I'm simply asking whether some of these kinds of approaches might be expanded to address the disputes where the legal framework itself is so uncertain or highly contested. Of course, negotiation only happens within the parameters of what's permitted by the law. But it turns out the law is ambiguous and uncertain dealing with many of the issues that I have raised. Where the societal rules and medical protocols do not point to clear results or even clear parameters where the affected individual has something to contribute as well. Is it possible? Is it promising to consider mediation rather than going to court? And as difficult as mediation over religiously inflicted social conflicts can be, it holds the possibility of individualized accommodation and attention to the meaning in the lives of those most effective. Advanced planning, of course, would also be helpful. And options like mediation and planning that are individualized are most promising in the individual cases where you can meet with people face to face. It's much more difficult when you're talking about groups, when stakeholders are institutions, or religious employers, or religious hospitals, or organizations that oppose certain practices. And mediation is not advisable where there are sharp imbalances of power between disputing parties. I do wonder also about third parties that are affected by these decisions. Could they be represented in mediation? Any kind of agreement in any of the kinds of cases that I've raised will be remote if the very locus of the proper decision making is disputed. If people disagree, not just over what the right result is, but who should have a say about it? And whether the government itself can make the rules. Some people want to go to court because it gives high visibility to a dispute. Journalists cover it. They won't want to go to mediation. And in tough contests over important social issues, somebody's gonna lose. And at the end of the day, assistance in hastening death or in reproductive choice or in exemptions from vaccines will or will not be mandatory, or will or will not be available to an individual. But the broader public could learn from the attitudes and methods that undergird bioethics mediation. Because those are attitudes that call for listening, for humility, for respect, for acknowledging the depth of meanings and feelings. And let me tell you that is not what litigation does. So I began with the Supreme Court's decision or non-decision in the Zubic case. The division of the justices in that case captures well the disagreements in the nation over politicized and religiously inflected healthcare conflicts. Court seems divided, four to four. If the judges had, justices had done what you usually do in that circumstance, they would have left in place the decisions below. They would have rejected the acclaimed accommodation for religion by the employers. The court is at an impasse. It didn't want to do that. They thought that that would create more controversy or there were four members of the court who felt so strongly that was a bad idea. By remanding the case to lower courts with direction to please negotiate a settlement, the court did what courts are not supposed to do. They didn't decide. And it remains unsatisfying. But the justices had an intuition that the courts aren't good at this. And that maybe some matters should be resolved somewhere else. Individual accommodations through bioethics and mediation or other methods will have to be explored to amplify what have turned out to be very limited solutions in the judiciary. When should the presumption of individual choice be overcome because of significant harm to others or because of the limitations of choosers? Those are the questions we ought to be thinking about. With humility in the face of conflicts that we cannot resolve for all times and all places. But let me just say, let's break free of our compulsion to repeat unresolvable conflicts. Thank you. Change. And Marcus, I agree to answer some questions. If you have a question, would you stand up and say who you are and then project because I don't think we have a handout like to bring to each of you. Maybe I'll start by saying that you did such a great job at laying out some of the flash points of conflict in medical care today. And I couldn't help but like the alternative you seem to favor of dispute resolution using mediation techniques. The thing that always worries me about that is that the ability to get to compromise becomes the principle that prevails. And I know you said within the scope of what's legally permissible, although sometimes ethics would choose outside the law. But it's hard to say what the ethical principles, what role those should have when parties agree to something that might be hard to ethically justify. Right. So the rougative of the law professor said I get to ask questions back. That's just so, so important. And the dynamic of favoring a compromise no matter what its content is the real risk of these kinds of alternatives. I guess another risk is the fact that these tend to be very private and not develop norms that then get tested or broadcast or developed over time. So those are two drawbacks. And I just wonder if there are ways to deal with those drawbacks. If there's ways to create presence in the mediation of someone whose job it is to say actually, this is starting to run afoul of some ethical concerns and whose job it is to also to attend to the possibility of learning over time. And maybe not talking about the particular cases but developing principles over time which case rounds can do. So I think those are very real concerns but I don't have the answers so I'm throwing it back to you. Is the process that's underway flexible enough to include those kinds of changes? Yeah, I think I do think that's possible. It reminds me of Robert Klitzman's book about the ethics police and the idea that we really have to have a central registry for IRB decisions so that research ethics committees can look at the way reasoning has occurred in various places around ethical questions and protocols and perhaps there's something similar that could be done around mediating conflicts in medical care. Right. I mean the tradition of precedent that informs how judges behave in some ways is a time saving device. Why do I have to think of a solution when somebody did it before? But we also hope that it reflects what we now call crowdsourcing. The wisdom of the crowd over time developing ideas and so if there was a way, people are spending a lot of time on these matters. It would be good if there could share it. Robert Sachs' team and I'm the farthest thing from a lawyer you'll ever meet, okay? So it gives the innocence of this question. But when I was in public high school in Miami, Florida, in Pleasant Miami, we were instructed on the role of the court in what was called parent's patriae. That there was the perception at least as it was taught to me, that the court had a responsibility to step up as a benevolent parent in a situation where something was gonna be unsettled. And I need to ask you then with this question of vaccination why did the court advocate that responsibility? Number one, and number two, can you give us an idea when exactly was the last time the Supreme Court acted in that fashion of parent patriae? So it's, did everybody hear the question about a kind of traditional view that courts have an obligation to act as parents patriae in the shoes of a parent? That is indeed a tradition, but not of the federal courts. That's a tradition of state courts, state courts, state law. There's a residual unbounded power, police power, to actually govern for the good of the community, not the federal government. The decision that was made in the founding of this country is we don't trust the government. And therefore, the Constitution says that the federal courts have only the powers that are explicitly given to them. That's just the same way that the legislature only has the powers given to it, which is why we had to fight over the Affordable Care Act. Can the Congress Clause support it? So there is no parent's patriae power in the United States Supreme Court. Would you nice have that parental authority? Even as a parent? I used to give baby gifts before I was a parent. I always used to give a T-shirt to the new baby that said question authority, and then I became a parent. Charlotte Harrison from Children's Hospital. Thank you for that really comprehensive view of the terrain. And I don't know whether or not to thank you for focusing yet on a function that many of us struggle with already, but I think it's a great question and great suggestion. So I wanted to ask you a little more about sort of the parameters of bioethics mediation as you're envisioning it. And in particular, I think, I mean, there's already a question relating to the fact that most of the ethics consultation that happens now is based in hospitals and with the natural concern that there's some captive interest of the hospital itself or perhaps the clinical staff that is, our committees always struggle to be sure to try not to be captive, to try to really have a level playing field and have all the parties feel that, and in fact be, have equal representation and status in the proceeding. I think there's already some litigation now on Texas around their Advanced Directives Act around the adequacy of the due process in that act because it's based in an in-hospital review committee. And so I wonder when you think about these bioethics mediation outputs, what should be their relation to the institution should they be independent or does that then move you into a realm that's further away from the context and closer to the court? Wow, that's powerful and you of course have been laboring in this field for a long, long time. It's a great question and the question of capture and unconscious bias is one I think that's occupying many of us in many contexts right now. So to ask the question is already to be in a better position. It does strike me that although here in this building, in this city, we focus on tertiary care hospitals. Most people's health care contact is not in that setting and that it's possible to think about the community-based clinic and other settings where health care is delivered as a place where this kind of mediation could occur. A harder question is whether there could be partnerships with religious institutions which are also community-based. I think it's worth exploring but there's the same question will reiterate itself there. If it's hosted by the church, how is there neutrality? But I am intrigued by the development at Loyola Law School in Chicago of a ecumenical mediation program to deal with child custody disputes. The partners are representatives of different religious traditions. I guess the law school is the neutral party but in resolving disputes, particularly with couples who are intermarried, what they found is to have mediators not necessarily of the same religion but who have a religious identity has been productive. It's interesting because we think of that problem from the perspective of protecting the status of patients in ethical differences of opinion. And in fact, in one of the Catholic hospitals, a nun who was the ethicist on a community was fired by the hospital for support. Choice of patients. I saw a couple of other hands. Yes. My name is David Oran from here at the School of Public Health, Mopedia Truthin. At another medical school in the city, there was an ethics course that I was involved in teaching and the person who was leading the discussion was a Catholic priest. And in the discussion of how to raise case studies like you have in the law school and the business school, there was a discussion by one of the other facilitators like myself who raised the question of that from a Buddhist perspective, this was not an ethical principle. In fact, they took a different task and I think somebody else brought up Native American. So when you say about the limits of the ethics and what's out of the ethics, it depends on what your frame of resolution. I wish you would comment on that. And thank you very much for a wonderful lecture. Oh, thank you very much. You know, one reason that I guess I feel that courts may be so ill-suited to these issues is that the assumption that there is any commonality is what's at issue here. I do think that pluralism, pluralism, religious pluralism in particular, but pluralism of any sort requires a kind of humility about what's the truth and what's the right answer and if it's right for me, it doesn't mean it's right for you. And that's not how courts proceed. That's not how law proceeds. And it is very striking that I have had the privilege of representing religious groups in litigation. And I will say the experience is humbling because they disagree with each other, people inside the same religious group. And so what does it mean to represent a group of nones in a piece of litigation where they disagree and they disagree with the church. So who speaks for whom? These are really, really tough questions. And I think that where there are really good grounds to respect the integrity with which each individual is struggling, I think any decision-making process that forces people to polar opposites is the problem. I am very struck by your opening though, describing being in this class led by a priest. I took an economics class led by a priest and he always began the class saying there are three points which I thought was always very good. It's... It's not being valuable in the February circumstance but so found in the relationship to the issues of pluralism that you just articulated. So I just, in fact, have a political question really which is about the relationship between legislatures and courts and mediation practices in this regard. So if one could imagine getting this out of courts but isn't the problem at the moment that the legislatures are trying to continually produce big, broad forms of accommodation legislation. Yeah, no, it's a great, great question. Thanks, Danielle. I think we do have the Religious Freedom Restoration Act. I don't think it's going anywhere and it is framework for the federal one and also the state ones that call for all kinds of accommodation. I think that there's gonna be case law that develops over time about the parameters and what's meant by it. I do think that because there are no clear answers who the judges are, it's gonna matter a lot. If ever a judge gets confirmed again, it will matter a lot. I also think that the dysfunction of this framework is becoming very palpable and very clear to a lot of people and it's against that kind of a backdrop that people come up with alternatives and the Religious Freedom Restoration Act tells you what has to be done if you come up with a conflict. If people can come up with an alternative, it doesn't have to be governed that way. So my name is Aldo Menon. I'm a master's student in the Center of Bioethics. And most people are asking questions that are a little bit more established in their career. My question is what unique accommodations in this post-enlightenment world, do you think those of us who now have to build almost our entire career in that post-enlightenment world will need to make in terms of how we interact with patients or clients or things like that? Wow. Do I get to ask you the question in return? That is really, really deep. You know, I guess, first of all, I have to say I have such regard for this center and so glad that we collaborate with the Petrie-Flom Center and other kinds of activities around the university. One of the things that results from that is a lot of mutual learning. And I think that one thing that is part of your own professional training, I know you're already doing this, is to have experiences of encounters with difference and then time to reflect on it. And professional difference and differences about worldview and differences about assumptions. And it's not just cultural competence, it's kind of competence in dealing with the floor beneath your feet shifting when you realize that they were not sharing the same ground rules. And I think being able to do that while you're still at earlier stages of your career is certainly much better than coming to it late. I also think that there are lessons to be learned from places around the world, places inside this country where differences have been accommodated successfully. Why these days am I looking to Canada a lot? I can't imagine, but I am. And it's to me extremely interesting that Canada has as its founding for its Charter of Rights and Freedoms, which is like a Bill of Rights, the assumption that there's a pluralist society, that's where they start. And any Canadians here, will you accept me when I wanna come? Thank you. Um, so the assumption starting with the fact of two different cultural and linguistic traditions actually creates a different foundation for multiculturalism and pluralism than what we have in the United States. And that's not perfect, but at least there's a starting point of there's gonna be multiples, there's gonna be plural. And it's interesting to see how the First Nations people in Canada have actually found a way in to the Constitution because of the tradition of accommodating the two languages and two cultures. So there are things that we can learn, I think from others. There was a period in medieval Spain that seemed better than some other, I mean there are things that we can learn, we can learn. My name is Richard Schwarzding, I'm a physician and professor here at the Med School. To have mediation strikes me that the parties at least have to be willing to consider compromise. And the cases at least at when their way up to the circling court seem not to truly be about the issues on the surface. They're about the politics of the Affordable Care Act or the politics of big government. And they're interested in making that case and they need to be funded, I assume mostly, by outside sources who want to have that big win. So how do you think about mediation in the context of those cases that get there because they're not really interested in what's seen in compromise? Well, you're quite right and I did identify and I do believe one of the causes of the kinds of conflicts we're talking about is a kind of instrumentalization of people and their beliefs and turning them into a tool for larger political conflicts. I do agree. One of the things that's interesting is that courts make their own rules, including the rules about what to hear. And one of the things that courts are incredibly good at doing is coming up with rules about we shouldn't hear this. And if that kind of a rule is exercised early on before it gets all the way up to the Supreme Court, you'd have a very different trajectory and providing opportunities for people to actually have the chance to say, is this what's good for us now here? Might actually be helpful not just for the courts but for them and for society. I'm just gonna say that I run the ethics program at Harvardville Health Plan and the psychiatrist. The Roger Fisher-Yuri work is really quite elegant and as Dr. Schwarzstein just said, it can work very well for people who get into that dance. But did your colleagues have much to say about how you get them to dance together? I mean, that's also a big challenge in psychiatry. How do you get people involved with treatment? The other piece at the far end that I wanted to ask if you could comment more about is how might one bring some analog to case law out of the mediation process? Because the Fisher, you'd be getting to yes, is quite good when people enter in in coming to a conclusion. But to the best of my knowledge it's not as good, at least historically, in yielding findings from that conclusion that others can use. Well, two really important questions. One, and I don't mean at all for this to be a dodge, but I do wanna say that what people think they should do changes based on whether it's an established practice or not, and we will have a transition time. But if it becomes the norm that actually, well, what you do is you go to mediation, that will change people who right now would say I wouldn't do that. So how do we get there? That's the transition problem that seems very different than the problem, just as you put it generally. That said, I guess I do think that there are there are ways in which you can identify steps that are prior to or aside adjacent to mediation rather than say enter into mediation. Could be let's have a conversation about what your interests are and what your needs are and let's see if there are avenues to explore. And that's what many mediators that are connected to courts do. You don't call it mediation to begin with and you see whether or not it can develop. The opportunity to have lessons learned is really what Christine and I were talking about earlier. And I do think that there's much to be gained by having members of mediation groups actually write about what they find. And anthropologists and others to be able to study it and to learn really from the very human, painful, productive encounters. Just one more thing about the Fisher-Urie framework. One reason I think it's been so incredibly successful, translated into 64 languages, I mean unbelievably influential is that contrary to the way people usually talk about mediation, it doesn't actually focus just on compromise. It focuses on identifying the range of possibilities and opening up options that are beyond the ones that the parties came with and so that there can be win-win. There can be something that each get. And that seems to me to demonstrate a kind of direction that legal professionals, healthcare professionals, others could go into that we have not in the past, which is to take imagination as the goal. How do we expand imagination rather than taking problems the way they have already been framed? And to see that there are possibilities and there are possibilities for everyone to win. One of the books that has most influenced me in my life is a book called Loss and Change by Peter Maris, a sociologist. And the premise is very simple. That every change involves a loss. And if you don't acknowledge that, you're gonna be dealing with it. And it could be a change that you choose. It still involves a loss. I think this is completely right. And when we think that the only way to solve a dispute is either to have win or take a loss or I compromise, that's about loss. I think we need to generate ways to think about generativity, about creativity, about gains, about, and I think it's possible. Just one more thought, you know, I've written in the past about conflict that emerged in San Francisco when San Francisco city government said it would not do business with any company that didn't provide healthcare for same-sex couple partners. This is obviously before Obergefell. And at which point the Catholic Church said, well, we're out of here. We can't do business with the city of San Francisco. So did the Orthodox Jewish community. And then something very interesting happened. Bishop Levada of the Catholic Church called up the mayor and said, you know, before we depart, let me just say, we share with you the goal of expanding access to healthcare. So maybe we can have a conversation. And out of that conversation came not a compromise, but convergence is the word that I would use. So what emerged after many, many conversations was a new regulation that says the city will not do business with anyone who does not give an employee the opportunity to name one other person in their household to get healthcare. And the Catholic Church was fine with that. And the city was fine with that. And it wasn't a compromise. It's interesting that the form of mitigation you have in mind is, and it seems to be informed by your work and lots of other domains is inherently transformative. But something happened to those discussion of values and interests of positions that in the activity of doing it changes. Am I, that's, you're so perceptive. I mean, I'm not, you know, I hadn't even put my finger on that, but you know, the very first thing I ever published, I was in law school and I wrote a paper on the judgment of Solomon, because I was doing a lot of child custody disputes and it just seemed like everybody kept looking for the judgment of Solomon. Can't we find something here? And as I wrote about it, you know, the story, everybody know the story where Solomon is the king and you know, there's two women and they're fighting over the baby and Solomon says, okay, I'm gonna, you know, I'm gonna divide the baby in half. That's the solution. And then suddenly one of the women leaps forth and says, oh, don't do that. At least don't do that. Give the baby the other one. And he says, ah, you're the true mother. And I wrote about how that's a transformation, that there's a possibility, I don't recommend that particular version, but there's a possibility of setting up dispute resolution systems that can become pedagogical, become an experience for learning and growth. So yes, this has been a long time coming, yeah. Suzanne. Suzanne Arrows, I'm a clinical bioethicist, but also an empirical bioethicist in the Cleveland Clinic. And one of the, I see this sort of double in the details, but also in the empirical evaluation, which I think you mentioned, but one place that may be a model that has had empirical support is, they call it by different names, is sort of patient hospital reconciliation programs, right? So, and it's one area where it's interesting where there has been quantitative and qualitative research that has shown benefit. And much of the many of the ways that you've mentioned, like people telling stories, the narratives, the benefits that patients have gotten expressing their grievance over an error that's been committed in their medical care. But also, as you mentioned, something beyond that, financial provision in the case of an error has been committed by a hospital or a doctor. You know, there are other elements to this, other than just the, as we call it, the new term, I guess, is reconciliation. So, you know, are you thinking along those signs that are familiar with those problems? It seems like that model might bring and add a little bit more to this idea of just serve, just mediation, right? Very helpful. I need to learn more about the research in particular. And it's interesting to think about, I hadn't made this connection. You know, I wrote this book that focuses in part on the Truth and Reconciliation Commission in South Africa, and to think about the ways in which new institutions have grown up in recent years to deal with terrible, terrible things. With a focus on giving people a chance to tell their stories, a focus on actually providing a kind of acknowledgement, and yes, reparations, that there may well be lessons, therefore, to be drawn from even very large-scale societal conflicts that are coming out of apartheid. I need to learn more about that. It is very interesting to me to think about the ways in which money enters into these issues. That can complicate matters. It can solve matters. It can make them worse. So I'll think about that some more. One last question, and then we'll stop, David. You kind of range from micro to macro, and so mediation is clearly valuable on the micro level in keeping some of the conflict between religion and medicine away from law. Is there something comparable, is it mediation, is it something else on the macro level when you're talking about country-wide or even statewide, particularly in such a pluralistic society? So this is a question that I have been thinking a lot about, in part, because some colleagues who read the draft said something very similar to what you've said, and I am not sure. It certainly has been the aspiration of the Fisher-Yuri tradition to be able to take the tools they developed to deal with the Middle East and other kinds of conflicts. Obviously, once you move beyond interpersonal, things change. And there's a tremendous, I think, mistake that we make when we generalize from the interpersonal experience to something that's societal, because there are dimensions that are different, or even something that's intergroup, there are dynamics that are different. And having said that, I do think it's possible. Labor negotiations. We have experience with groups coming up with resolutions and the relationship between the dispute resolution form and the different groups that can participate in it, we could explore that. There are issues about who speaks for whom, who's left out, you'd have to deal with, but I don't foreclose that as a possibility. Thank you very much. Well, thank you. Thank you.