 On behalf of the McLean Center and the Department of Obstetrics and Gynecology and the Bucksbaum Institute, I welcome you to this lecture in our 2016-17 series on reproductive ethics. It's my pleasure today to introduce my old friend, dear colleague of long-standing, Dr. Farr Kerlin. Dr. Kerlin left the university about three-and-a-half years ago and is now the Josiah C. Trent Professor of Medical Humanities in the Trent Center for Bioethics, Humanities, and History of Medicine, and also the co-director of the Theology, Medicine, and Culture Initiative at Duke Divinity School. At Duke, Farr practices palliative care medicine and works with colleagues in the Trent Center and the Divinity School to develop opportunities for education and scholarship at the intersection of medicine, theology, and culture. Before moving to Duke in 2014, Farr founded and was co-director of the program on medicine and religion here at the University of Chicago. Farr has authored more than a hundred articles and book chapters dealing with the moral and spiritual dimensions of medical practice. His work is focused on the relevance of religious ideas and practices for the doctor-patient relationship. The moral and professional formation of clinicians and the virtues required of a good doctor and the care of patients at the end of life. Dr. Kerlin's talk today, as you can see behind me, is entitled, Contending Conscientiously for Good Medicine with Respect to Human Reproduction. Please join me in giving a warm welcome to Farr Kerlin. Thank you. It's a delight to be back at the University of Chicago, to be reminded of how beautiful the weather is all the time. It has an amazing day today. And it has many happy memories here and much gratitude, particularly for what I received as being part of the McLean Center for Clinical Medical Ethics, and particularly from you, Mark. I've been asked to speak on a topic that can only get me in hot water. So here I go. If you focus on the intersection of the substance of religious faith, particular traditions, and medicine and ethics, sexuality and reproduction come up, not infrequently. And if you focus, as I do, on what it is that medicine's properly understood to be for and how we become the physicians we profess to be, and conscience looms large. And I'm going to try to talk about how those come together here. Recently a friend and colleague called me to ask, did I do the right thing? This colleague is a professor of obstetrics and gynecology at a top tier academic medical center. And she focuses there on gynecologic surgery. That morning she had seen a patient in clinic. The patient came to see my colleague because the patient was having uterine bleeding. The patient requested that a hysterectomy be done to remedy that bleeding. The reason the patient was having uterine bleeding, it became clear, is because the patient was receiving exogenous testosterone from a local endocrinologist as part of a plan to transition from female to male in her gender expression. My colleague had not faced that situation before. And was uncertain how to proceed, but she told the patient in so many terms, I know this is an area of some controversy, but the reason you're bleeding is because you're receiving exogenous testosterone, not because there's something wrong with your uterus. And as a physician I can't in good conscience remove your otherwise healthy uterus. I don't think that would be good medicine. One thing I want us to wrestle with is did my colleague do the right thing, or did she do at least a thing that ought to be permitted within the discipline of obstetrics and gynecology? Is that refusal that she gave, a refusal that's consistent with her profession as a physician? Is it consistent with her choice to become an obstetrician gynecologist and then an expert in pelvic surgery? Three weeks ago the New England Journal published an essay by Ronit Stahl and Ezekiel Emanuel titled, Physicians Not Conscripts, Conscientious Objection in Healthcare. Some of you see that piece? Not many. Well in it Stahl and Emanuel argue that my colleague's refusal, however conscientious, should not be tolerated by the medical profession. How can it be they ask that healthcare professions, medicine, pharmacy, nursing, et cetera. These professions can profess to adhere to what Rohit and Emanuel called, or Stahl and Emanuel called, role morality and yet allow for their practitioners to refuse to engage in practices that the professions approve. For example, they note that under the aegis of conscience there are physicians out there who refuse to perform abortions or in vitro fertilization, even contraception, gender transitions, in all manner of other practices that the health professions accept. In most cases they write, professional associations should resist sanctioning conscientious objection as an acceptable practice. They continue, unlike conscripted soldiers, healthcare professionals voluntarily choose their roles and thus become obligated to provide, perform and refer patients for interventions according to the standards of the profession. Now there's something about that that seems right to me. No one is compelled to become a physician at this point in our polity and in becoming a physician, one surely takes on responsibilities that are intrinsic to this role, to this office. No one is compelled to become an OBGYN in particular and in becoming an OBGYN surely one takes on responsibilities that are specific to this role, so far so good. But the confident assertion that doctors must fulfill their professional obligations and not let personal qualms get in the way leaves unanswered some looming questions. What are those professional obligations? What are those responsibilities that come with one's profession to be a physician? What does it mean to fulfill one's obligations as a physician with respect to sexual and reproductive health care in particular? Now here's my argument in a nutshell. For the past five to six decades the profession of medicine has been internally roiled by an irresolvable tension between two ways of construing the content of a physician's profession. The first construal is ancient, going back at least to the Hippocratic Reform movement, taken as self-evident in Aristotle's writings, echoed by medical oaths and professions across the centuries, including those of the AMA, the ACP, the World Medical Association. And in this construal the physician's profession is to the patient's health. It's to serve the patient's good specifically with respect to the patient's health. The second construal is historically quite novel, but it has become very powerful and persuasive to many, if not most, in our day. And in it the physician's profession is to provide health care services expertly with full disclosure, provide those services according to the considered judgments of patients regarding what is important to the patient. Now often physicians can get away with maintaining both of these commitments, at least apparently, because often patients want what is in the physician's judgment consistent with the patient's health. But not infrequently these two norms come into conflict. That happens when a patient believes that some medical intervention, some intervention that physicians often engage in would be good for them. And the physician believes that the intervention is not good for them, or at least is not required by the patient's health. And there's no place in medicine where such conflicts are more common than in the domain of sexual and reproductive health care. I will say that's not the only domain. I practice palliative medicine and we have quite a few conflicts roiling ourselves. But no domain more so than in the domain of sexual and reproductive health care. And as such in no specialty is this tension more acute than in the specialty of obstetrics and gynecology. For the past 50 years the obstetrics and gynecology as a specialty has been shifting steadily toward an emphasis on the second construal. Understanding itself as a specialty committed to making available to patients health care services related to sexuality and reproduction safely and expertly and not letting the practitioner's judgment get in the way of doing so. And this I contend and this is a controversial argument but this is my argument to you. This is ethically speaking hollowing out obstetrics and gynecology. It is demoralizing this specialty. And as a result is making it inhospitable to those who are only willing to provide health care services that they believe are congruent with a physician's commitment to the patient's health. My proposal to you is that as such obstetrics and gynecology is engaged in a kind of Faustian bargain and that it will either be reduced to a guild of highly skilled technicians whose judgment is beside the point to their practice of medicine or it must sustain or recover at least permit an orientation to the patient's health that it is in danger it seems to me of giving up altogether. Doing so if it does this and here's the rub it means tolerating OBGYNs who refuse to participate in practices that many of you in this room believe are essential to sexual well-being and to reproductive freedom. So let me give a very brief history that I think is relevant. In 1960 something happened that was very consequential for culture broadly and for the practice of medicine more specifically. I've already talked to the fellows upstairs but you might know what that was who didn't who wasn't upstairs with us. Approval of birth control. The FDA approved the birth control pill. It's hard to overestimate the importance of that the birth control pill and the way it changed the way patients in OBGYNs came to think of sexual and reproductive health care. To jump ahead 20 years in 1979 at a time that by that point 90 plus percent of women of reproductive age in the United States were using oral contraceptives. Dr. Mark Siegler and Ann Dudley Goldblatt wrote the following The oral contraceptive medication was the first prescription drug that was and is in effect a self-prescribed treatment. Patients i.e. medical consumers desiring elective medication demanded that physicians prescribe the contraceptive pill. Other popularly self-prescribed medications soon followed and came to be seen as appropriate solutions or treatments for problems previously considered individual or social concerns. But in any case not biological abnormalities or specific diseases. Now nowhere has this been more true than in the domain of sexual and reproductive health care. Where we have of course all kinds of different contraceptive technologies. Sterilization. Abortion of course. Assisted reproductive technologies of all types including artificial insemination, in vitro fertilization, prenatal genetic diagnosis, now gender transition services. And to accommodate this growing number of different interventions that are not obviously as required by the patient's self. Let me just say that there are a number of different interventions that are not obviously as required by the patient's self. Let me just say up front. Part of why it's hard to talk about this issue is that I'm not saying that there's not as arguments to be made even an arguments that many find compelling for why each of these things is congruent with the patient's self. I am simply at this point proposing that it's much more controversial. There's a lot more contention about these than there is say about you know doing a procedure to stop mutur and bleeding or in some other way more obviously preserving and restoring a woman's health. Anyway to accommodate these obstetrics and gynecology has had to migrate its orientation, its sense of what it means to be a good OBGYN away from a norm that stands apart from patient's wishes and particularly away from the norm of the patient's health and toward a more open-ended accommodation of what the patient believes is consistent with her good or her well-being. It had to do that for example to make sense of routine practices for example an OBGYN faces today in a clinic nearby a woman of reproductive age and decides whether the patient should have a surgical sterilization procedure or receive assisted reproductive technology and that decision may depend completely on and strictly on the patient's judgment about what she wants. Does she want to become pregnant or does she not want to become pregnant? Or to give another example whether the physician should perform an abortion for a patient at 20 weeks or move the patient into the hospital for the next two months in order to avoid preterm labor that may depend strictly on what the patient wants. And after a few decades of accommodating more and more uses of medical technology to achieve patient's goals the obstetrics and gynecology has become the specialty that is more than any other specialty according to our research committed to non-directive counsel to a non-directive posture toward their patients. In a study led by Dr. Yoon several years ago we surveyed a large representative sample of US OBGYNs and asked them whether when dealing with either typical or morally controversial medical decisions we asked both ways whether a physician should encourage patients to make the decision that the physician believes is best or whether the physician should provide all relevant facts without trying to influence the patient's decision one way or another. What we found is that 54% of OBGYNs rejected the use of directive counsel for typical medical decisions so more than half said even with typical medical decisions the physician should not be giving you know encouraging the patient to do what the physician believes is best. 78% rejected such counsel for morally controversial medical decisions and we found that there were highly significant core associations between being more non-directive in one's counsel and being female, younger, born in the United States and less religious. We noted in this piece when we published it that the findings seemed to confirm the observation that a generation of US physicians has been trained in models of medical decision making in which physicians inform patients of the scientific data and the range of clinical options but they withhold their own experiences or judgment or personal values you might say in order to avoid unduly influencing patients decisions. So whereas in earlier eras of medical education encouraged directive counsel seeing the physician's clinical judgment as a resource for patients today's medical education largely emphasizes the patient's rights and choice and autonomy there are a lot of reasons for that but it's clearly a shift and this light it's not surprising that our data suggested a kind of generational C change as younger physicians replace older physicians non-directive counsel has increasingly become the norm and in no specialty is this more true than an obstetrics and gynecology. Interestingly along the way over the past generation several prominent physicians and critics of medicine including one seated in the front row and interestingly including Dr. Manuel 25 years ago have expressed worry that the pendulum has swung too far. It swung too far away from what was trying to swing away from which was a kind of strong paternalism where doctors basically give orders and patients are just supposed to obey toward what some called independent choice or patient sovereignty where the patient just makes request and the physician just provides. What our findings suggested was that it's unlikely that we will soon see a return to models in which the physician's judgment and counsel play a more prominent role and what Stahl and Emanuel's essay makes clear is that if we follow this pattern far enough it will require us to drum out of the profession those who have the audacity to refuse interventions on the basis that in their judgment the interventions are not required by or conducive to the patient's health. That's what they propose and their paper shows how the logic works. I wish they were alone in putting forth this logic but they're not. This is the most prominent paper I've seen published on this making this case but it's not at all the first. So first we redefine the role morality of physicians to remove objective content. So Stahl and Emanuel assert that the professional role morality of healthcare providers and the fact that they call them providers I think is telling that that role morality is not to preserve and restore the patient's health it's to promote the well-being of patients. And here they follow a number of otherwise reasonable persons including the writers of a 2007 American College of Obstetrics and Gynecology Ethics Committee piece which criticized conscientious refusals by physicians. They fall in and stipulating without controversy that physicians must put the patient's interests above their own. Anybody disagree with that? Put the patient's interests first. I agree it's not a controversial claim. So Stahl and Emanuel write that healthcare practitioners must subordinate their self-interest and personal beliefs to patients' well-being and professional decision making. But then without conceding that this is a radically controversial claim and without making an argument to support this claim they assert that a physician who refuses a patient's request is thereby de facto putting the patient's interest ahead of the patient's interest I'm sorry ahead of the patients. Now the only way that could be true that assertion can be true is if the first construal of the medical profession a commitment to the patient's health is altogether displaced by the second construal. What our profession we should understand it to be is to to provide health care services and they don't although they don't bring themselves to say it directly Stahl and Emanuel's argument requires the physician to act as if the patient's interest that interest that the physician holds in trust as a physician as a fiduciary just is what the patient wants from the physician so long as what the patient wants is an intervention that the profession allows and that the physician has the skills to provide. And the kinds of practices that Dr. Siegler and Ann Dudley Goldblatt anticipated particularly those having to do with sexuality and reproduction loom large in their argument so they write to distinguish mental health sexual health and LGBT health as non-therapeutic realms of medicine or as medicine and service of lifestyle choices is to substitute cultural and political judgments for professional medical knowledge. They continue to classify addiction gender reassignment surgery or the use of contraception as lifestyle choices that merit conscientious refusal is to allow personal moral judgment to masquerade as medical practice. In their private lives health care professionals may condemn alcohol gender dysphoria or non procreative sex along with gluttony and sloth but in their role as health care professionals they must provide the appropriate interventions as specified by the medical profession. They go on to claim even that quote although abortion is politically and culturally contested it is not medically controversial. It is a standard obstetrical practice and they conclude that health care professionals who are unwilling to accept these limits have two choices select an area of medicine such as radiology that will not put them in situations that conflict with their personal morality or if there's no such area leave the profession. To invoke conscientious objection is to reject the fundamental obligation of health care and again here they repeat they said this six or seven times in the piece again without ever specifying the content of this the primary duty to ensure patients continued well-being. I said up front that there's something right about Stahl and Immanuel's worry I mean surely we must hold physicians to their professions. Is it reasonable for a teacher to refuse to grade their students work? Is it reasonable for a plumber to refuse to plum? For an attorney to refuse to defend his client before the court? It doesn't seem so it seems like these kinds of refusals are basically refusal to be a teacher a plumber an attorney they come with these commitments come with the role itself and it seems to follow for many that that if so then it is it reasonable for an obstetrician gynecologist to refuse to sterilize or to abort or to facilitate IVF or gender transition. Well it matters very much how we understand the content of the OBGYNs profession to what are they committing reasonably understood. So here I here I proposed to you that obstetrics and gynecology faces a choice and the choice is becoming acute it seems to me. It will either allow for and remain hospitable to those who are willing to commit themselves to practicing obstetrics and gynecology under this historic construal of the medical profession in which case it must allow for OBGYNs to forego participation in all sorts of interventions that are typically in our time provided by OBGYNs but which are not obviously the argument is made obviously required by a commitment to the patient's health. That will have consequences that are not going to be appreciated you know they're not going to be valued by many people that are going to be deeply troublesome to many people for example patients will face moments in which their OBGYNs make clear in so many terms that they do not believe that what the patient requests of them is something that a clinician should be doing. Patients in some areas particularly rural areas will struggle to find clinicians who will make available interventions that are available in other areas. The profession will sustain in its ranks an ongoing argument an ongoing contention about what good medicine requires with respect to sexuality and reproduction and the presence of these differences will push people to consider why they're making the choices they make so that when you know there are two options in front of you it forces you to wrestle with why you choose one over the other more so than if there are only there's only one option. OBGYNs will then represent the array of moral communities that are present in our plural culture rather than being continually kind of reduced to a more single secular standard and as such the range of choices among philosophies of care will be greater. That's one benefit it seems to me if you're interested in choice matching the reality of the ongoing moral disagreements in our culture. It would mean if we if obstetrics and gynecology goes this way or or hangs on to this possibility that when people like Dr. Stahl and Emanuel insist that physicians put their professional obligations first it will make sense to ask them that they make an argument for why the physician's commitment to the patient's health requires them to participate in the intervention in question. It won't be enough to just say you got to put your your professional obligations first you'd have to say well what what are those professional obligations and how does this intervention how is it required by them or the profession will gradually squeeze out this is the here's the second option the profession will gradually squeeze out or block from entry all but those who are willing to make available to patients the full range of legal technological interventions and to set aside their judgment about which interventions are congruent with the patient's health. I will say I because I speak a lot about religion and medicine and interact with a lot of students I frequently I one of the most common questions that people come to me with is can I go into OBGYN so it's already very clear that the experience of people considering obstetrics and gynecology if they are a committed Roman Catholic or a committed Muslim or a committed Evangelical Christian those are very common categories that they think can I make it in this profession it doesn't seem like this is going to be a profession which I can practice conscientiously. If obstetrics and gynecology goes this way it will be hospitable only to those who are willing to engage in elective abortion sterilization contraception and vitro fertilization prenatal genetic diagnosis surrogate pregnancy artificial insemination gender transition surgery and so on whatever comes next whatever is allowed by the law and accepted by the profession it seems to me to follow logically that then only a minority of Americans will be candidates to be obstetrics obstetrician gynecologists and paradoxically patient choices will be reduced in so far as patients will not be able to seek out trained clinicians who share their judgment that such practices contradict the purposes of medicine it's it is the case now that there are many patients who would like to have obstetrics obstetrician gynecologists who are committed to their health and committed to not engaging in an array of different practices that are legal and accepted by the profession I hear reports of people who have these kinds of clinics and have people drive long distances to see them so there's a kind of that that is a kind of alignment that will have to go away the colleague I mentioned would either have to into this construal either have to to go to leave the the the discipline or she would have to go along doing what she believes she should not do as a physician keeping to herself her judgment that the intervention requested of her contradicts as best she can tell it contradicts her commitment to that patient's health now note what this does to the idea of practicing medicine conscientiously so conscience it's amazing how often the term conscience is spoken of in ways that at least strike me as not aligning with historic uses of the term the conscience is you is the capacity of reason that any of us deploys when we're judging the moral quality of our own actions so when you decide you know should I eat that dessert you're exercising your conscience when you decide should I tell that lie you're exercising your conscience under this newer construal of medicine where medicine is its primary profession is to make available health care services then conscience the conscience of the physician is a threat it's a threat to good medicine it's an external imposition and it's often referred to in that language of individual values personal values individual conscience and so on something that doesn't belong in the mix and the practice of medicine that has to be kept from interfering under the older construal in which the purpose of medicine or the end of medicine is the patient's health the conscience is a resource it's what we call clinical judgment and under this construal my colleagues refusal would not be best characterized as an expression of personal values interfering with professional obligations but an exp but be would be described as a as conscientiously practicing her profession according to standards that the practice of medicine itself requires of her chiefly its orientation to the patient's health I'll end with this I quoted Dr. Siegler and and early Goldblatt before here I'll read a quote from them from a paper noting an alarming trend what they called the demanding patient the demanding patient presents a serious danger to clinical medicine they wrote the demanding patient denies that the physician's responsibilities and expertise have any relevance except in so far as this coincides with the patient's desires the demanding patient inverts the traditional model and makes the physician a passive agent the patient proposes the physician provides the physician becomes a technician practicing under the direction and control of his or her client now that's saying it kind of starkly but it seems to me that if obstetrics and gynecology continues the trend it's been on and doesn't at some point pull up and swing back the other way to some extent it's going to get to the point where that's the only way to make sense of this profession is that it's a profession that's at the service of of patients demands and I hope that the the this specialty is not willing to go there and I welcome your thoughts on the matter thanks your next I thank you for your talk I'm I'm Ben Brown I'm an OBGYN here I did my residency here I'm doing my fellowship and family planning and I'll be lucky enough to do the ethics fellowship this coming year so I have two major I take issue with two major parts of your argument and the first part is you use the term health in a very specific way and you it strikes me that you are arguing for a very specific and very concrete interpretation of what health is and by extension it seems that it seems easy to draw lines around what is good medicine and less good medicine and my problem with that is that the you then you then took the step to say that some of the reproductive health decision-making processes that we're discussing here i.e. abortion contraception and gender confirmation are more controversial with their in regard to their health benefit or more dubious perhaps in regard to their health benefit in comparison to other forms of care and I wholeheartedly disagree with that because the point of the reason that these treatments are so important to my patients health is because they are in meshed in a broader context in a way that strep throat isn't so I suspect that you would have a major problem with a physician saying I don't believe that giving penicillin for your strep throat is an appropriate treatment rheumatic fever isn't all that common rheumatic heart diseases and all that common that would be bad medicine and in the same sense for me to say to my patient I don't know I think you can have another baby right now or well I don't know I think you only have a 20% chance of mortality with continuous pregnancy to term therefore I reject your your request of an abortion would be bad medicine and so just because those end points are not as biochemical as the end points for strep throat doesn't mean that we should be any more quick to reject the health benefits of the treatments that we're providing and as in as as the second point building off of that I would say the challenge that I have I think you set up a very stark contrast I between the sense of physicians as technicians or the sense of physicians as autonomous actors with their own conscience and I think that that's I think that's a an impoverished view of the of the circumstance because in the middle ground is the negotiation between the physicians utilization of conscience and the patient's exercise of conscience and I didn't really hear much about the patient's conscience in this discussion and I worry that when the physician has veto power over the physicians that are the patients exercise of conscience half of the people in that room are being restricted in their conscientious activity and that can't be consistent with the values of our profession so try to be brief in my response I mean the first thing is we have to you have to get clear about what the conscience is it it just I'll just say it it can't make sense to say the physicians conscience trumps the patient's conscience because your conscience only judges your own actions right I can't have a conscientious objection to you doing something it is the it is the fact it is a case it's clearly the case that when a physician exercises conscience and a patient exercises conscience they can have conflicts and those have to be resolved according to where authority is distributed ultimately and where patients have authority then physicians have to you know I have to concede to that authority and where my part of my proposal is is is to ask what is the authority that physicians have in making judgments about which practices they will engage in now you you mentioned I you're not alone in believing that these practices are necessary for health so my claim again is not that there's not an argument there I find that argument a stretch the notion that for example let's put it really starkly patients in front of me their 28 years old had been having regular sexual intercourse with their partner for five years and have never gotten pregnant my guess is you would say I my sense is something might be wrong your health might there might be something wrong in your reproductive health and you would act in a way reasonably to try to figure out what it is and see if there's something to be done about it the fact that that's true I think points to that it has to be at least somewhat controversial to say that making someone in unable to get pregnant is required by it is health promoting in the same way it's I hear the arguments you could say well they it reduces their risk long-term of other things but the state of being incapable of pregnancy is treated in your own practice as a state of reduced health well if I can further that question so if a patient comes to me and has had peripartum cardiomyopathy after her last delivery and her ejection fraction is 20% I know she has a very high chance of mortality in a future pregnancy yes so would you argue that doing a sterilization for that patient is not in the promotion of health no I that's a good example of where that's a good example of where the intervention is much it's it's much harder to argue that that's not a health promoting intervention and that's a that's a that's a outlier situation well so then let me ask me because we're in an ethics conference and everything can go one step further one step further one step further until we get to something we should probably let some others sorry so if that patient then subsequently if that patient has five children at home and just lost her job and another pregnancy would mean that she can't afford to put food on the table for her kids or buy her other kids insulin it strikes me that that's health promoting as well yeah I wouldn't follow you there and I realized there's arguments you may but you have here's the question can you think of a definition in your construal of health is there anything not included in health that a patient values and finds really important to her I'm not sure I can give you a succinct answer off the top of my head but I would say there's very little because I because I subscribe to the debt to a similar definition what you're describing the paper in terms of well-being and and and to a just as minded approach to the health care that we that we provide for our patients no you're not alone in that but it what it means then is that physicians are responsible and have an obligation to use the the resources available to them to pursue any almost anything our aim is is is not to me it's it's much too broad and historically it's it'd be unprecedented to construe it that way it seems to me so but it's again this is that's that's where the argument is yes so as an OBGYN I take offense to the contention that or that the proposal that essentially I'm pursuing a lifestyle profession right that that all the things that I do are essentially addressing lifestyle issues and I think it's really interesting that this move towards you know that that things like contraception and gender transition etc are becoming part of our profession probably it's not a coincidence that our profession is also becoming more and more female right so we as OBGYNs are more and more female and I think that we are therefore reflecting what women view as our health and it's very easy to be a male and obviously not you know all men are in this position but I think it's an incredibly patriarchal take on what health is and I don't think it's a coincidence that my profession now is you know 85 to 90 percent women and as a profession you know granted not everyone in this profession but the vast majority of OBGYNs view these components as being essential to health and again I think you know one person's definition of what is or is not a part of health should that dictate what services or what care we're able to offer to individuals I don't think so should that should a individual OBGYNs judgment about what's conducive to their patient's health should that bear on what what they're willing to do again I think that I don't think that an individual should be bound to actually provide I don't agree I don't agree that an individual should have to participate in a procedure that they feel is morally wrong I think that they are obligated to help a woman access that care and I think that as a profession we have to have a commitment that we will enable patients to access this care I think that there has to be a base level of acceptance that these are the things that we have to ensure women have access to I mean do you think it's a coincidence that that these these aspects of care have become a bigger part of our profession as more and more women enter this field no I don't think it's a coincidence that the you know the the the women make up most physicians now coming into medicine so and it's not surprising to me given that obstetrics and gynecology attends to women's reproductive lives and their sexual organs and so on that that most OBJYNs in the future are going to be women I mean what else what what else is there to say I mean I is if the argument is that I guess I would I'll say this if the argument is that if you're a woman you can see that that the second construal is the right construal then that's clearly not true I mean you're finding you find we do find statistically significant associations but but the the these disagreements only modestly correlate with gender across the culture so I'm not so I'm not sure what I'm not sure what the what am I missing if I'm not responding to something Dan says to stop talking it's interesting this question of what counts as health good to see you hey good to see you too you know it's a chiatry it's it's controversial prescribing stimulants for people who don't satisfy the criteria for attention deficit disorder and it's kind of seen as a lifestyle choice it's not treating a disease it's not present preventing a disease I've heard the term cosmetic psychiatry I guess it comes from cosmetic surgery which is maybe the original precedent in medicine for using technology for what a patient wants and not for necessarily treating or preventing disease sure I've never thought of contraception along the same lines but it's also not usually well it's not preventing a disease it's not treating a disease it's providing access to a pill a medical technology and and it seems like a different way of a different sort of relationship it's one thing to be to have what we call a therapeutic alliance where you're both working together along for a common goal which is I think maybe your ancient relationship it's different to be the gatekeeper for medical technology true and it inherently puts us in an adversarial role and we have control over something they want it's it's true and it's very different it's true just I'll note it's an important point and it does put pressure on you know if there's if there's something that as a society we have decided using the authority of the state is going to be permitted and many people value and the only way to get it is to go through a gatekeeper that puts that puts pressure on the gatekeepers just note that that it's it's a historical accident that physicians are the ones that to do this it doesn't have to be and there have been other kinds of accommodations have been made for example emergency contraceptives you know we've been made available without a prescription party because they're they're relatively safe in terms of major health outcomes but party also because so people could get access to them without a gatekeeper you know when time is of the essence and there are political arrangements like that that could be made if it turns out that people are not people want access to a treatment that's not obviously required by health so far I am not I'm going back to our pre lecture discussion and where we left off because I too find that as a psychiatrist I have difficulty with your construle of health because it seems to me that it implies either a carve out for mental health or a kind of tone deafness to the importance of psychiatric health and well-being so in the previous discussion where we left off you were you were allowing that someone with with preeclampsia needing to terminate a 20-week pregnancy that using double effect that might be permissible but the same would not be true for a 14 year old in her first trimester of pregnancy that occurred through rape or incest and I would argue as a psychiatrist that that young woman's psychological health and well-being but but health would be include in health would be included in my definition would be as as greatly at risk as the preeclamic woman so I guess I'm just expressing once again as a psychiatrist I feel that your definition of health leaves out the the psychiatric piece I don't think it does but obviously it requires further further discussion of how it does not but it seems to me that the the idea that psych I my guess is because from the psychiatrist I know that the psychiatrist themselves are making judgments frequently about whether the use of a drug is restorative of of mental health capacity that makes it possible for someone to kind of flourish that to have what you might call that you know the Leon Cass called health the well-being of the organism as a whole and activity of the body in accordance with its specific excellences that there's a kind of whether it's it's restoring that capacity or whether it's trying to obtain some capacity that's actually something else performance on tests you know staying up all night etc having having relief from a feeling that one finds difficult you make those judgments do not yes and and I think that's what Bob was alluding to and I'm familiar with that concept of cosmetic neuropsychopharmacology but I think that in the instance of a 14 year old who was raped by her father for for her to be deprived of the opportunity to exercise her conscience and undergo a first trimester abortion would be would be harmful would be life threatening in the same way that denying the pre-Atlantic 20 week gestation woman would be harmful and life-threatening I don't think I think the cosmetic this isn't one of those nuanced cosmetic judgments just notice that the it seems to me that the the harm there that you're worried about is is it's real it is a it is an effect it is a consequence of of the pregnancy and continuing the pregnancy it's not the the abortion itself does not it has effects on those on on health but it's not itself health restoring would you agree the the pregnancy is not a health restoring do you mean continuing the pregnancy what it what is it that is unhealthy in that young woman this is a tragic awful case but I but I maybe we should move on because it is so tragic and awful would you require of physicians that they do the abortion yeah yeah I I don't think in any of us well I I'm speaking for myself I wouldn't require any individual person to carry out that abortion but you were saying earlier in our earlier discussion that you felt that it was unjustifiable in in your view and so I'm I'm pressing you on that because because I think it speaks to the larger issue of of health and that's what I mean by a psychiatric car yeah so this is this is the point at which it gets the most controversial it seems but the argument Dan if you're interested is that in a such a tragic case by killing the fetus if if it just builds on the most basic human or sort of ethical construct which is you don't kill the innocent you just don't well that that that's what it builds on if you believe that you if your your your idea so I make a lot of sense I think doctors should not do things that are against their conscious you know and but at the same time you know I wouldn't do CPR in a person who is obviously dying so I'm not an ICU doctor you know I don't put myself in that situation and I I follow my conscious at the same way if you know you go into an area that one of your things that you do is to to do abortions then either you get that person the abortion or you find someone else to do it you know it's it's pretty straightforward and the fact that people will go distances to find somebody who has their same religiosity is fine people can do that and they should be allowed to do that but to to predicate that whole the whole practice of medicine on that I think is a mistake I think what happens is that you have some really good philosophical and religious arguments not religious ethical arguments but that it gets such a huge by your own religiosity which I was plus it was pleasant that you didn't get into it during this talk I appreciated that but I think the subtext is there and so that that's the problem I have with it so just notice that the statement I made was the norm that you that you're never it's never permissible to kill the innocent now you may argue that okay so I'm not aware of the pope we're sending the opposition abortion but the idea is you can't kill the basic argument is and it's tragic it's a tragic case is that it's you don't resolve the tragedy by by killing the innocent fetus but that's not an acceptable means even though you have a terrible situation that's the argument and I don't you can say well that's a religious argument okay I mean then then I would want to hear what is the argument about what when it is permissible to kill the innocent or that the fetus is not innocent or the fetus is not a human being or that you're not killing or that you're not killing you could make that argument well I guess just sorry sorry that's really loud just what I appreciated about this and I think like we got in the weeds and you kind of talked about it in your the what is medicine for chapter I guess what I appreciated about it as a person who is interested in primary care and who personally couldn't perform in a abortion I appreciated the argument that I hope would keep going of finding room room at the table for people who have different views and I do agree with Dr. Holmquist that if that oh I'm sorry Dr. Kaur I'm sorry I agree with Dr. Kaur that that you we do have to we can't we can't obstruct patients access to services that they they're in their conscience feel that they need but I do I would be saddened if someone who felt like I did didn't have a place at at the table because I do think that there are patients who would value some of the other things that that I would have to offer but I agree that we can't if it goes so far as obstruction that that crosses a line that I think does harm to the patient so that's what I found really compelling about your argument because sometimes it's hard to you know it's hard to wonder whether is there a place for someone like me at the table and I think I have a lot to offer as a primary care provider but I definitely have concerns about those services I hope the profession remains open to anyone who's willing to discipline himself or herself to attending to the health of women throughout the reproduction seeing them through pregnancy safely it seems to me that the profession is enriched by being open to anyone who's willing to make those commitments and that it's reduced insofar as it starts to require more yes yeah I agree with what you're saying and I think there is I think there is a place for everyone's beliefs at the table but I didn't really under and I think your arguments are good for the most part I just have one question but I'm not sure how far you meant to go with this idea of you sort of created a dichotomy where OBGYNs either have to be all in or all out and I think it's kind of false I think there's a place in the middle for people who want to do who want now I'm not an obstetrician gynecologist so this is not fair right for me to say this but I think but I think I think there's probably a place for people to practice obstetrics and gynecology as long as they say you know what I don't perform abortions but if that's something that you're interested in you should go here but I know in conversations that we've had before there are many people who believe even that is not acceptable because if it's unacceptable to have an abortion if you feel strongly religiously that it's unacceptable for an abortion then you shouldn't ever recommend anyone else have one and I think that like like you were saying that argument goes too far I don't I don't really have too much to add beyond that except I was wondering if I could pin you down a bit on on what you think of that gray zone in the middle of the dichotomy is yeah oh no you know I think these are intention and you can't make sense of what most OBGYNs are doing most of the time without them being committed to the patient's health but what I'm saying is that what's happening when when that it's been shifting it's clearly been shifting our evidence shows and there's an increasingly the sense that we within the profession we are not in a position we don't have authority to be making judgments about what's really good for a patient we are we should make available these resources if a patient chooses them we should provide that in a safe expert way personal and on the basis of safety and and sort of the art of medicine like here's the road that would be the easiest for you or the best or here's probably without you worry about this particular type I think there's a lot of art of medicine in that and giving off the art of medicine in terms of deciding what's best for a person from a religious or cultural point of view so it's it's just that distinction that I'm challenging can be made that can be made without a norm whereby you could judge when you're doing one versus the other so how do you know when the physician says I'm not going to give you contraceptives because that sterilizes you temporarily and that's you know that's not what I do I'm a physician I'm oriented your health there are people who will give you that but I don't think it's a good practice is that is that is that physician thereby can you can you show that that's a religious or cultural thing and not not medical not professional I'm not going to give you contraceptives because in your particular situation here you're a woman who smokes over in supporting I don't think it's safe for you but you can see my colleague and here you could also say that surgeon might say here the alternatives that might be the same aim but if you as a physician are saying but I'm not going to offer you any alternatives either because I don't think it's going to be because I'm hysterically you should get in the way of having children that that's where you see the difference I think in where you are your offer you're saying I can't do this review because I don't think it's safe for you but here's how you can achieve the same goal where you can go to try again is different than saying I routinely do not prescribe contraceptives it is different I was just going to say sort of talking about being at the table one thing that I think is interesting is all your words sound very nice and talking about sort of the definition of health and providing and protecting health and I think a lot of what we have is a different definition of health clearly and what we think is important because we all do want to do the right thing for our patients but what you're asked it seems like what you're asking for is some respect for people that want to refuse or defend health according to their conscience but you don't seem to be providing that same type of respect for people for whom it is in their conscience that the abortion is the right thing to do and that in their relationship with the patient that and by their conscience and their understanding that is the right thing to do and so it seems a little it's what led you to say I'm not providing that respect it's just a feeling in how you're talking about things and I think I think that it's everywhere I mean I just finished my OBGYN residency a year ago and you can hear how people talk about the resident that won't prescribe contraception and you can hear about the person that says well I really care about my patients and that's why I won't provide abortions and clearly there's a lot missing in between the two and so I think that maybe I'm just hearing the overtones that is everywhere else and I'm projecting it on what you're saying but I think that that's a huge thing that's missing in this entire conversation is having the conversation and not jumping down each other's throat. Well you notice that you're not seeing in the New England Journal a lead article arguing that the time has come we need to get out of OBGYN all those people who are doing things like contraception sterilization who are make you know how people get babies in ways that sort of circumscribe their their head or go around health etc etc we need to be focused on the health of the of the woman and so I'm not I'm speaking to you from a minority position recognizing that what's not in play right now is obstetric obstetrics and gynecology detaching itself from all these practices I just don't see it's gonna be politically feasible in the short term or the near term or the long term well my point is I'm trying to I'm trying I'm trying to argue I'm holding out to you the plausibility that I think OBGYN is clearly losing I mean this this conversation makes clear that it is it is reasonable as a OBGYN you are fulfilling your it's reasonable to think of yourself as fulfilling your profession and being a good OBGYN by attending to the health of of your patients and and you don't need to be committed to doing all these other things that are uses of medical technology that's that is that idea is offensive to lots of people I recognize that it is it is it's the definition of health and I'm not I'm talking about health is something less than it looks like saying I as your physician I I can't do an abortion that's one of things physicians as I understand it should should never do elective elective abortions that's what it means I just I just want to add a little bit to the discussion and just to bring some statistics about the patients the statistics indicates that patients over 80% of our patients are they believe in something they're religiously oriented in something and if the physician how then physician can exercise conscience if he completely pulls aside the patients believes that's a question that I guess I would like to address to the crowd that's trying to justify non-spiritual views versus spiritual views I think I agree with Dr. Curlin that the discussion here is to broaden the view not to narrow it down I think the matter of conscience it's a very profound matter and the conscience of the physician should definitely include the conscience of the patient somehow in their beliefs thank you you had asked about what it was about the way you phrased your response that would indicate in response to the lady over there what about what you said was didn't take into consideration the other point of view and it struck me that when you talked about the 14-year-old who came in and was raped and you talked about killing the fetus it's the very language that you use and the way you phrase this the description of the situation that marginalizes the health and well-being of that 14-year-old who got raped so that to me was an example you know I'd be honest with you I don't know I realize this is an area of disagreement but it seems to me the very point of an abortion in that case is to kill the fetus very point of the abortion in my estimation I'm not a medical professional I am a woman the very point of the abortion is to restore to that young woman who has been so tragically abused some modicum of health and mental what absolutely that's the reason the abortion is done I get that that's that's the end that someone has in mind the act itself is an act of killing the fetus and that's that's all that's why people that's why abortion is controversial I don't I don't see why this should this shouldn't be a controversial idea this is this is this is why people still argue so much about abortion from a religious perspective no it's not it's it's you know the idea that you're killing the fetus I don't think is a religious idea it's just a it's just an observation that the fetus is dead afterward well if you were talking about it from a non-religious perspective you would refer to it as terminating a pregnancy not killing a fetus okay so you're very language otherwise I appreciate the vision of a more pluralistic profession I'm wondering how you would ensure that if I were going to a physician or to a hospital that I would know what that understanding of health and well be health is or the moral framework because I think that a lot of what we've heard throughout the year is that in institutions it's not clear who you're going to get many folks who have very strong perspectives about what is entailed in health especially around reproductive health are not likely to be transparent in advertising that so how would we ensure that I would be going to somebody who aligns with my perspective and I wouldn't be somehow then I'm I'm thinking of as almost coercion if I'm in there by somebody saying this is not good for your health and I come in with a different understanding of what health is and I have no clue so I'm thinking well I'm gonna suffer as a result of this that what do you think would be a reasonable I have no idea but I think that's what it would entail is somehow being more transparent about this pluralistic community that we have I I'll just say I don't think that I mean there's there's the kind of there's a vision of that religious person who's highly moralistic and it's kind of condescending and and self-righteous and is also hiding what he or she believes but I think that's that exists a lot bigger in our kind of a specter of something we're afraid of than in reality the people I know who don't do things that they know people are gonna expect them to do find ways to make that clear as as upfront as they can and of course it varies by their situations particularly tough for trainees who are not responsible for their patients you know in the act in the academic system but clinicians in the community that I know for example who don't prescribe contraceptives which is a very small number in the OGO and it's probably about 2 to 3 percent at most they make that clear on their first phone call or in literature and so on because they you know they're not interested in people being hoodwinked and people a lot of people seek them out because that's the way they all they share that that sense a quick question about conscientious objection you mentioned you're in the minority that you sort of offhandedly mentioned I think it's really important observation about the structure of this debate I want to just entertain a hypothetical if you were in the majority if there was a medical procedure that around which there was some debate but that was outlawed let's say abortion was illegal and in OBGYN conscientiously elected to perform that procedure would you defend that person's right to to exercise their own conscience that's a great question and it comes down to the question again we talked about briefly before of authority it seems to me that the one of the most basic authorities that a state has is to defend the life and limb of its people and I realized this is controversial but the reason abortion was illegal until in many states until the Supreme Court decision in 1973 was because of the judgment that the unborn are still part of the human community and the state has a authority a proper authority to protect them from being killed that seems to me reasonable the profession of medicine has has had until the last two generations pretty uniformly at least in the West a uniform opposition to abortion by physicians and I think that's a reasonable opposition because it is so directly related to the life of the the the fetus involved and because healing it seems to me reasonable is contradicted by the active of destroying I know but I intentionally didn't ask you if you would agree with that policy if it were the case I instead I want to know if if there were a controversial procedure that were banned if you would take the same position with regard to conscientious objection as you do now it depends on the procedure but I would not support so you would not not so conscientious objection no this I mean this is so I my argument maybe clear my argument is not that if people should be able to say my conscience says to do something and then they're therefore we say oh well if it's your conscience then then I'll defend you there is a priority in free societies this is what makes our society like ours different from a society like Maoist China or something like that there's a priority in giving people space to live according to their best judgment about how they ought to live that seems to be reasonable but there have to be limits on it and it seems like one of the limits is the limit of life and limb you can't you can't destroy so that would be one I wouldn't you couldn't have a conscious it seems to me the state can say even if you in good conscience think you must do this we are going to tell you you cannot I think this is this is contentious because people people are kind of seeing it as a zero sum game the woman wants an abortion the physician doesn't want to perform about abortion who wins if the physician doesn't perform the abortion then the physician won and imposed their will their morals their preferences whatever on the woman and but I'm not but in a in a free society like this the woman can always can lots of times go somewhere else to get an abortion so I don't see how it necessarily needs to be a zero-sum game yeah and even the idea that well in addition maybe maybe the physician doesn't have to perform the abortion but the physician needs to refer the woman to somebody who can who will perform the abortion but maybe the physician isn't comfortable with that either but I don't know that that information necessarily needs to come from that position I mean there could be public service announcements there could be billboards there could be signs on buses informing people that if they want certain services this is where they can go it doesn't I don't know that it's necessary to coerce the physician into doing something they don't feel comfortable with so I just want to clarify your view on something the idea has been raised multiple times so far that a patient comes in requests an elective abortive service and the physician says that they have conscientious objection against that my question trying to be very clear is do you think that it is the physician's obligation in that moment or for that patient to another provider who will do it for them it's a good question and it's it's interestingly picking up on Bob's comment as well it's being put to the test in a way that it hasn't before right now in Ontario the College of Physicians and Surgeons a year and a half ago issued a new policy called something like patient health care rights something and the policy says in so many terms that if a physician cannot in in good conscience participate in some legal medical intervention their career that includes the whole array which includes now assisted suicide which is part of why it's an abortion the physician must take and this is the language positive action to bring about an effective referral and then it stipulates that that's basically you got to make sure the patient has an appointment with somebody that you know will provide what they're they're seeking that seems to me unjust in so far as it in two on two ways one is it again just steps past the question of what it is that the physician's profession requires it essentially takes for granted that the profession requires making available services and and to it it coerces physicians to engage in practices that took to become and they use language in a positive action and effective referral is essentially language you could almost draw out of Catholic moral theology to say you will make yourself complicit in this action you will have cooperated in this action so I know I don't think the physicians obligated to make a referral physicians are obligate your referral is a moral action I don't refer people to people that I don't think are offering something they they should have you know if patient yeah I mean so I I would I would not encourage a physician to refer that patient I think we'll what let me just say this this has been told you I was gonna get in hot water away the most controversial session of our 25 sessions thus far I want to thank far far and away