Program for Biomedical Ethics talk: Conscience, Religion, and the Way of Medicine with Farr Curlin, MD

Name: Program for Biomedical Ethics talk: Conscience, Religion, and the Way of Medicine with Farr Curlin, MD
Uploaded: 2024-12-06T22:55:29.16Z
Duration: 1 h 25 min 55 s
Description: November 20, 2024 Conscience, Religion, and the Way of Medicine Farr Curlin, MD Josiah C. Trent Professor of Medical Humanities Professor of Medicine Co-Director, Theology, Medicine, and Culture Initiative Duke University

December 06, 2024

November 20, 2024

Conscience, Religion, and the Way of Medicine

Farr Curlin, MD

Josiah C. Trent Professor of Medical Humanities

Professor of Medicine

Co-Director, Theology, Medicine, and Culture Initiative

Duke University

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ID: 12533
To Cite: DCA Citation Guide

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00:00See all of you, for
00:02coming. Thank you so much,
00:03and, of course, welcome to
00:04the folks who are watching
00:05on Zoom as well.
00:07And we've got we've got
00:08quite a crowd tonight, and
00:09I'm delighted.
00:11My name is Mark Mercurio.
00:12I'm the co director of
00:13the program for biomedical ethics.
00:15And in a minute, I'm
00:16gonna talk about our guest
00:17speaker tonight who is doctor
00:18Farr Kurland. But first, just
00:20a little bit of, housekeeping
00:21stuff. If you wanna apply
00:23for CME, it's not a
00:24really difficult application, but there
00:26is the number to text
00:27for CME credit.
00:29For the students who are
00:29on the biomedical ethics concentration,
00:33we have sign up sheets
00:34here so you get credit
00:35for having attended this seminar.
00:37And, don't do it during
00:39the talk. So if you
00:39haven't done it yet, just
00:40please come up afterwards and
00:42sign your name on there,
00:43and don't take my pen.
00:46We're gonna have about a
00:47forty five minute lecture by
00:49doctor Kirlin.
00:50After that,
00:52I'm gonna invite questions, and
00:53I'll moderate a session where
00:55you folks,
00:56can ask him,
00:57questions and talk, you know,
00:58we'll have a a group
00:59conversation.
01:00And I think it's gonna
01:01go very well. And it's
01:02six thirty, and no matter
01:03what, who's talking or what's
01:04going on, I will stop
01:06it, no later than six
01:07thirty.
01:08So fair warning on that.
01:10Let me introduce speaker tonight.
01:11Someone who I wanted to
01:12bring here for a long
01:13time, and and I think
01:15that this is, this is
01:16a wonderful opportunity for us.
01:17So thank you so much
01:18for coming, Farrah. Doctor Farrah
01:20Kurland, MD, is the the
01:21Josiah Trent professor
01:23of medical humanities
01:25in the Trent Center for
01:26Bioethics, Humanities, and History of
01:28Medicine and co director of
01:29the Theology, Medicine, and Culture
01:31Initiative
01:32at Duke University.
01:34Doctor Kirlin has worked to
01:35bring attention to the intersection
01:36of medicine, ethics, ethics, and
01:38theology.
01:39In two thousand twelve, he
01:40helped to found both the
01:41University of Chicago's program on
01:43medicine and religion
01:44and the annual conference on
01:46medicine and religion.
01:47Since two thousand fifteen, through
01:49Duke University,
01:50divinity school,
01:51the TMC initiative, he and
01:53colleagues have brought graduate theologic
01:55training to those whose vocations
01:57to health care.
01:59Starting in twenty twenty three,
02:00doctor Koehrling also is working
02:02with colleagues across North America
02:04to develop the Hippocratic Society,
02:06so something we talked about
02:07just briefly earlier,
02:09an association whose mission is
02:11forming clinicians
02:12in the practice and pursuit
02:13of good medicine. And this
02:15is something we're talking about
02:16maybe, opening a chapter here
02:17at Yale. So that conversation
02:19began today. More to come.
02:21He is coauthor with Chris
02:22Tolleson
02:23of The Way of Medicine,
02:24Ethics in the Healing Profession.
02:26This is a book. He's
02:27well, he's also author of
02:28more than one hundred and
02:29fifty articles and book chapters,
02:31in addressing the moral and
02:33spiritual dimensions
02:34of medical practice. Doctor Kerlin
02:36got his MD from UNC
02:38and did his residency and
02:39fellowship.
02:40He's an internal medicine physician
02:42at the University of Chicago
02:44where he was on faculty
02:45for many years before moving
02:47to Duke.
02:48Doctor Curlin is very well
02:50known in bioethics circles,
02:52and,
02:53and this is a subject
02:54I don't think we have
02:55broached at least in a
02:56long time here, specifically that
02:58intersection
02:59of conscience,
03:00a religion, and medicine.
03:03And there's nobody I can
03:04think of, more
03:06qualified to speak to us
03:07about this for a little
03:08bit. So with that, please
03:09join me in welcoming doctor
03:10Farr Kurland.
03:13Okay.
03:17Thank you. I'm I'm honored
03:19and delighted to be here
03:21with you this evening.
03:25And,
03:27I hope this our our
03:28time together will will,
03:30shed light,
03:31more than heat.
03:33But I do wanna dig
03:34into
03:36a debate and a discussion
03:37that has been a point
03:38of some dispute within the
03:40field of medicine
03:41and the field of medical
03:42ethics.
03:43Consider these cases.
03:45Mister Anderson is a fifty
03:47year old man with symptoms
03:48of bronchitis who requests antibiotics.
03:51His physician refuses to prescribe
03:53them.
03:55Miss Parker, a nineteen year
03:57old woman with gender dysphoria,
03:59requests referral to the gender
04:01clinic.
04:01Her physician refuses to make
04:03the referral.
04:06What do we make of
04:07these
04:07refusals?
04:10Two decades ago, colleagues and
04:11I surveyed a representative national
04:14sample of US, of US
04:15physicians from all specialties, and
04:17we asked them the following.
04:19If a patient requests a
04:21legal medical procedure, but the
04:22patient's physician objects to the
04:24procedure for religious or moral
04:26reasons,
04:28One, would it be ethical
04:29for the physician to plainly
04:30describe to the patient why
04:32he or she objects to
04:33the requested procedure?
04:35Sixty three percent of US
04:36physicians said yes.
04:39Two, does the physician have
04:40an obligation to present all
04:42possible options to the patient,
04:44including information about obtaining the
04:46requested procedure?
04:47Eighty six percent said yes.
04:50Three, does the physician have
04:52an obligation to refer the
04:53patient to someone who does
04:55not object to the requested
04:56procedure?
04:58Seventy one percent
04:59said yes.
05:01And we found that
05:02irreligious
05:04physicians, that is to say
05:05those with no religious affiliation
05:07or or rarely or never
05:09attend religious services,
05:11were least likely to believe
05:13that doctors may describe their
05:14objections to patients.
05:16They were most likely to
05:17believe that physicians must present
05:19all options
05:21as well as to believe
05:22that physicians
05:23must refer.
05:25That study was published in
05:26the New England Journal
05:27and
05:28the subsequent years have brought
05:30an escalating drumbeat of calls
05:32for the profession of medicine
05:34and the state if necessary
05:35to reign in what has
05:37come to be called
05:38what have come to be
05:39called conscientious
05:41objections
05:42or I think more accurately
05:44conscientious
05:45refusals
05:46by medical practitioners.
05:48A twenty seventeen
05:50Nijam essay by Ronit Stahl
05:52and Ezekiel Emanuel,
05:54Doctor Emanuel, some of you
05:55may recall, had been the
05:56most prominent physician in the
05:58Obama administration.
06:01Their essay in, in the
06:02New England Journal captures the
06:03thinking of these critics of
06:05conscientious
06:06refusals.
06:08They write,
06:09health care providers
06:11note that language.
06:13We'll come back to that
06:13language of provider. But health
06:15care providers have a primary
06:17interest to promote the well-being
06:19of patients.
06:21This defines what they call
06:22the physician's role morality,
06:25which requires they continue
06:27offering and providing accepted medical
06:30interventions
06:31in accordance with patients'
06:33reasoned decisions.
06:36Are they right?
06:38Let's consider that together.
06:40Starting with the fact that
06:42physicians commonly
06:43refuse to provide clinical interventions
06:45that patients request.
06:48This is often overlooked, but,
06:50they do. And they do
06:51so even when those interventions
06:53are legal
06:54and permitted by the medical
06:55profession.
06:57Now for centuries, of course,
07:00in, the the medical ethics,
07:03realm, physicians who took the
07:04Hippocratic oath
07:06promised to act for the
07:07benefit of the sick according
07:08to my ability and judgment,
07:10to refuse requests for deadly
07:12drugs and abortive patients,
07:14to practice in purity and
07:16holiness, to guard my life
07:17and art, and to enter
07:19houses for the benefit of
07:20the sick remaining free of
07:22all intentional injustice and all
07:24mischief.
07:27So for for the history
07:29of medicine, there has been,
07:31some profession to refuse certain
07:33kinds of requests.
07:34But in all eras, including
07:36the present,
07:38physicians refuse things they believe
07:39will harm patients
07:41and refuse things they believe
07:43are not medically indicated.
07:46Surgeons refuse to operate when
07:48they believe a surgery is
07:49unlikely to be successful,
07:52and
07:53they refuse in those cases
07:54whether or not all of
07:55their colleagues agree.
07:58Primary care physicians
08:00frequently refuse requests for antibiotics
08:02when they think the patient
08:03has a common cold
08:05as we see in the
08:06case of mister Anderson.
08:08We might say, I think,
08:09without controversy
08:11that doctors have always refused
08:14request to do things that
08:15they believe are inconsistent with
08:17their professional obligations.
08:19Inconsistent that is with good
08:22medicine.
08:23So
08:25insofar as that's true, it
08:26seems to me that critics
08:27of conscientious
08:29refusals
08:30cannot be bothered by refusals
08:32per se,
08:34but only by
08:35conscientious
08:36refusals. That must be the
08:38key.
08:39Well, then what makes a
08:41refusal
08:42conscientious?
08:44The term conscientious means according
08:46to Merriam Webster,
08:47governed by or conforming to
08:49the dictates of conscience.
08:52What's the conscience? Well, the
08:54conscience is simply
08:55the human faculty.
08:58Most people would call this
08:59the human faculty of reason,
09:01but the human faculty that
09:02judges the moral quality,
09:04the goodness or badness
09:06of one's own actions,
09:09either
09:10past actions
09:11or future actions,
09:13foreseen actions.
09:15To say it's that faculty
09:16that judged whether it was
09:18all things considered a good
09:19thing for you to come
09:21to this talk versus do
09:22something else that you might
09:23have done.
09:24To say a physician's refusal
09:26is conscientious then
09:28is simply to say that
09:29the refusal is based on
09:30the physician's judgment
09:32about what he or she
09:34ought to do in a
09:35given case,
09:36all things considered.
09:39Critics of conscientious refusals invariably
09:41treat conscience as something other
09:44than what I just described.
09:46They tend to treat conscience
09:48not as a faculty of
09:49reason,
09:50but as a set of
09:51arbitrary and idiosyncratic
09:54personal values.
09:56So Ronit Stahl and Ezekiel
09:57Emanuel equate conscience with appeal
10:00to, quote,
10:01personal religious or moral beliefs,
10:03end quote.
10:04The American Congress of Obstetricians
10:06and Gynecologists,
10:07ACOG,
10:09associates conscientiousness with a need
10:11to be able to sleep
10:12at night and a defense
10:13against
10:14moral disintegration.
10:17With conscience so construed,
10:19the physician who acts
10:21conscientiously
10:22is focused on himself.
10:25He's focused on his personal
10:26values,
10:27his own needs to maintain
10:29integrity
10:30rather than being focused on
10:32the good
10:33and what is required of
10:34him in in the situation
10:36that he faces.
10:39And in this construal, he
10:40looks like this,
10:42an entitled white guy
10:44acting self protective and self
10:46righteous at the same time.
10:50So Stalin and Emmanuel contend
10:52that to follow conscience in
10:53refusing a patient's request,
10:55as they put it, violates
10:57the central tenet of professional
10:59role morality in the field
11:00of medicine.
11:01The patient comes first.
11:04Physicians' personal commitments they add
11:07cannot outweigh outweigh the interests
11:09of patients.
11:13These construals of what the
11:14conscience is and does,
11:17I think, are misconstruals,
11:19and they
11:20lead critics to make unsupportable
11:22claims.
11:24Some claim
11:25that a clinician who refuses
11:27a patient's request thereby allows
11:29the clinician's
11:31conscience to trump the patient's
11:33conscience.
11:35But this is a contradiction
11:37in terms if the conscience
11:39is the faculty that judges
11:40one's own actions.
11:43Then consciences
11:44cannot trump one another
11:46for no two consciences judge
11:48the same thing. Your conscience
11:50judges your actions. My conscience
11:53judges my actions.
11:57Same thing. So the patient's
11:58conscience judges the patient's actions,
12:00the clinician's conscience judges their
12:02action.
12:03Each can object
12:05to how the other acts,
12:07but these objections,
12:08which are important, these you
12:09can have an ethical objection
12:11to how another one acts.
12:12You may believe that what
12:13they're doing is wrong.
12:14But these objections are not
12:16conscientious objections.
12:20They are moral objections of
12:22another type.
12:23The conscience judges one's own
12:25actions.
12:27Now
12:28some claim that physicians should
12:29distinguish personal personal conscience from
12:32professional conscience
12:34or that physician should balance
12:35one or both against other
12:37considerations in deciding what to
12:39do in a given case.
12:40So for example, in this
12:41way of thinking,
12:42one might have a professional
12:44conscience that counsels one to
12:46refuse antibiotics to mister Anderson
12:49and a personal conscience that
12:51counsels one to prescribe them.
12:54Or one might have a
12:55conscientious
12:56objection to referring
12:58miss Parker to the gender
12:59clinic,
13:00but balance that against a
13:02punitive professional obligation to make
13:04the referral.
13:06This whole way of thinking,
13:08however, can make sense only
13:10if the conscience is a
13:12set of values.
13:14Then one could have a
13:14professional conscience,
13:16a personal conscience, perhaps others
13:18as well.
13:19One could use some other
13:20rational faculty
13:22to weigh up these different
13:23consciences, one against the other,
13:26or to weigh the judgments
13:27of conscience against other considerations.
13:30One might even, in this
13:31way of thinking,
13:33have a reason to act
13:34against conscience.
13:36But
13:37none of these considerations
13:40or none of these construals
13:41make sense
13:43in light of what the
13:44conscience is.
13:46The faculty of reason that
13:48renders the final judgment
13:50as regards what one ought
13:52to do or ought not
13:53to do, all things considered.
13:56That is
13:57the conscience is the faculty
13:59that renders the final judgment
14:00about whether one should, all
14:02things considered, prescribe the antibiotics
14:03to mister Anderson
14:05or whether one should, all
14:06things considered, refer miss Parker
14:08to the gender clinic.
14:10And so understood, an individual
14:12has but one conscience
14:14and integrity requires that her
14:16conscience cannot be split into
14:17components.
14:19She cannot take up her
14:20judgment of conscience as one
14:21consideration among others.
14:24While a physician might well
14:25have reason to reconsider
14:27an initial judgment
14:29much as a jury might
14:31reconsider its initial judgment after
14:33hearing you know, the judgment
14:34made after hearing the prosecution,
14:36it might reasonably reconsider after
14:37hearing the defense.
14:41It can never be right
14:43to act against conscience just
14:44as it can never never
14:45be right for a jury
14:47to declare innocent one that
14:49it, is persuaded as guilty
14:51or declared guilty one is
14:52persuaded as innocent.
14:53For in doing so, one
14:55is acting contrary to one's
14:57final judgment about how one
14:59ought to act. That's a
15:00paradigm case, it seems,
15:02of acting unreasonably.
15:05In the meantime,
15:06as these cases make clear,
15:09we all know that in
15:10our morally plural world, conscientious
15:12persons,
15:13so people acting according to
15:15what how they believe they
15:16should act,
15:18can and do disagree.
15:21And such disagreements
15:23highlight an important point,
15:24which is that,
15:27the fact that my refusal
15:28of mister Anderson
15:30or miss Parker is conscientious
15:33does that that's good that
15:34it's conscientious because it should
15:35not be otherwise,
15:37but that does not imply
15:38that my refusal is justified.
15:40The conscience as a human
15:42faculty is both limited
15:44and fallible,
15:45just as human vision is
15:47limited and fallible.
15:48That I see something or
15:50I think I see something
15:51does not mean that I
15:52see clearly
15:53or correctly.
15:55And yet, just as one
15:56cannot keep a car on
15:57the road without
15:59driving according to what one
16:00sees,
16:01one cannot practice medicine well
16:04without practicing according to conscience.
16:08Without practicing according to how
16:09one is best one can
16:10tell ought to practice.
16:13And specifically, a physician cannot
16:15discern whether she should accommodate
16:17or refuse
16:18the request of mister Anderson,
16:20miss Parker, or anyone else
16:22except by exercising her conscience
16:25and following its judgments.
16:27So
16:29if refusing patient requests is
16:31part and parcel of good
16:32medicine
16:34and if the conscience is
16:35the faculty of reason a
16:36physician uses when judging whether
16:38she should or should not
16:40refuse a particular request,
16:42then it seems to me
16:43critics cannot reasonably oppose conscientious
16:46refusals per se.
16:49Well, so what then is
16:50the problem? Why all this
16:53why are folks so stirred
16:54out about conscientious refusals?
16:56The problem
16:57as Stahl and Emmanuel put
17:00it is that physicians are
17:01not conscripts.
17:03No one is compelled to
17:04become a physician
17:06and in choosing to become
17:07a physician,
17:08one willingly,
17:09we should be able to
17:10presume, one willingly takes on
17:12the responsibilities
17:13that go with being a
17:15physician.
17:17What Stahl and Emmanuel call
17:18physician's role morality?
17:21We would not countenance teachers
17:23who refuse to grade their
17:25students' work.
17:27We would not countenance attorneys
17:29who refuse to defend their
17:30clients before the court.
17:32Why then would we allow
17:33physicians to refuse what patients
17:35request?
17:37Here we arrive at the
17:38root of the problem.
17:41If conscientious refusals characteristically
17:44involve
17:44physicians refusing to fulfill some
17:46aspect of their genuine obligations
17:49as physicians,
17:50then such refusals indicate that
17:52with respect to that aspect,
17:55they cannot in good conscience
17:57be physicians.
17:59And if that's true,
18:01Emanuel and Stahl seems to
18:02me are right.
18:03They should not be doctors
18:04as they put it, or
18:05they should at least avoid
18:06areas of medicine in which
18:08they can anticipate that patients
18:09will request interventions
18:11that they cannot in good
18:12conscience provide.
18:15If that's true.
18:17To know whether it's true,
18:19we need criteria by which
18:21we can distinguish refusals that
18:22are consistent with physicians
18:24professional obligations
18:26from refusals that contradict such
18:28obligations.
18:30Define such criteria,
18:32we have to figure out
18:33what in fact physicians are
18:35obligated to do. And here's
18:37the rub.
18:39The physician refusals that occasion
18:42controversy
18:43do so precisely
18:45because they unmask
18:46deep disagreements about what medicine
18:48is for.
18:50They they unmask deep disagreements
18:53about what physicians reasonably profess
18:55when they profess
18:57to be physicians.
19:01Now, is there any
19:03agreement, any consensus about what
19:05medicine is for that could
19:07give us a starting point?
19:09Something that we can all
19:10agree physicians simply must commit
19:12to
19:13if they are to continue
19:14being physicians.
19:17Well, it had it has
19:18been self evident, it seems
19:19to me, to people from
19:21virtually every culture and moral
19:23tradition,
19:24religious and otherwise, throughout history
19:27that physicians, if nothing else,
19:29are obligated to care for
19:30the sick and the injured
19:32seeking to restore
19:34their bodily health.
19:37This universally recognized obligation
19:40still provides, I think, a
19:41powerful criterion by which we
19:43can discern that some refusals,
19:45however conscientious,
19:47are incompatible
19:48with being a medical professional.
19:51For example,
19:52suppose a physician refuses to
19:53care for patients with HIV
19:56because the physician doesn't like
19:57homosexuals,
19:59or for black patients because
20:01of racial bigotry,
20:02or for criminals because of
20:04revulsion at their crimes.
20:06Such refusals, it seems,
20:08violate physicians'
20:10constitutive
20:11professional obligation
20:13to
20:14preserve and restore the health
20:16of the one who is
20:17sick
20:17without regard to the patient's
20:19other characteristics.
20:21That seems to me a
20:23genuinely consensus
20:25idea.
20:27This obligation to seek the
20:28patient's health does not, however,
20:31provide a criterion by which
20:32one can
20:33condemn the sorts of conscientious
20:35refusals that have stirred controversies
20:38over the past couple of
20:39decades.
20:40Rather,
20:42over the past two generations,
20:44physicians have come to use
20:45medical technology
20:47in all sorts of ways
20:48that are not obviously
20:51directed to preserving and restoring
20:53patient health.
20:54And the paradigmatic
20:56example of such interventions
20:58is perhaps the least controversial,
21:00namely contraceptives.
21:02In nineteen seventy nine,
21:04two decades after the FDA
21:06approved the first oral contraceptive,
21:08my old mentor, Mark Siegler
21:10and Anne Dudley,
21:12and mentors, I should say.
21:12Mark Siegler and Anne Dudley
21:14Goldblatt
21:15wrote the following. And I
21:16should say they wrote this
21:17having no
21:19ethical
21:20opposition to contraceptives.
21:24They wrote the oral contraceptive
21:26medication was the first prescription
21:28drug that was and is
21:29in effect a self prescribed
21:30treatment.
21:32Patients, I e medical consumers
21:34desiring elective medication
21:36demanded that physicians prescribe the
21:37contraceptive pill. Other popularly self
21:40prescribed medications soon followed and
21:42came to be seen as
21:43appropriate solutions or treatments for
21:45problems previously considered
21:47individual or social concerns,
21:49but in any case, not
21:50biological abnormalities
21:52or specific diseases. I'd say
21:54they could have
21:55that last
21:57clause, they could've said, but
21:58in any case,
21:59not clearly
22:00deficits in or injuries to
22:03bodily health.
22:06Examples of such practices include,
22:07in our time, the practices
22:09of medical aid in dying,
22:11making short children taller or
22:13fast athletes faster,
22:15reshaping buttocks and breasts and
22:17noses and chins,
22:18otherwise changing secondary sex characteristics,
22:21helping bay people have babies,
22:23using in vitro fertilization,
22:26helping them not have babies
22:27in a a number of
22:28different ways, and and so
22:29on.
22:31It's not surprising that
22:33physicians took up these not
22:36so obviously health directed uses
22:38of medical technologies.
22:40Physicians had the expertise
22:42and the legal authority to
22:43manipulate the body,
22:45and patients wanted what the
22:47physicians could lawfully provide.
22:51Along the way, however, minorities
22:53of physicians have refused to
22:54engage in these practices,
22:56arguing that the practices are
22:58not required by or or
22:59even contradict
23:01doctors'
23:02professional obligations
23:03as healers.
23:06Stalin Emmanuel represent a growing
23:08chorus of figures,
23:10within the profession, prominent figures
23:11in many cases,
23:13arguing that these refusals have
23:15just gone on too long.
23:16And the doctors must now
23:18provide or facilitate access to
23:20the full range of legal
23:21and professionally accepted medical interventions,
23:24notwithstanding
23:24their moral obligations
23:26to doing so.
23:29So why then
23:32why then does this course
23:35not condemn the physician's refusal
23:37to prescribe for mister Anderson
23:38the antibiotics he requests?
23:41Why does that not stir
23:42controversy?
23:43Why is it that refusing
23:45miss Parker's request for referral
23:46to the gender clinic stir
23:48more outrage?
23:50Here, critics of conscientious refusals
23:53introduce a new distinction
23:55according to which the physician
23:56who refuses mister Anderson's request
23:59is justified
24:00because he does so for
24:01medical or professional reasons and
24:04thereby upholds the physician's role
24:06morality.
24:08In contrast, the physician who
24:09refuses miss Parker's request for
24:11a referral to the general
24:12clinic
24:13is unjustly, at least presumptively,
24:15is unjustly allowing
24:16personal and private concerns to
24:18intrude upon what should be
24:20a strictly
24:21professional
24:22consideration.
24:24It's difficult to overstate
24:26the importance of this
24:28distinction, this putative
24:30distinction
24:31between the personal and the
24:32professional.
24:33Indeed, every criticism of conscientious
24:36refusals that I have read
24:37and I have read many,
24:38maybe most,
24:40everyone
24:42invokes and leans heavily on
24:43this distinction.
24:46Stalin and Emmanuel capture the
24:47now conventional thinking,
24:51in this way. Physicians may
24:53believe what they will in
24:54their private lives, they write.
24:57But in their role as
24:57health care professionals, they must
24:59provide the appropriate interventions
25:01as specified
25:02by the medical profession.
25:05So in this way of
25:06thinking,
25:07physicians who conscientiously refuse a
25:09patient's request
25:11thereby allow personal biases,
25:14to interfere with their professional
25:15obligations and particularly the obligation
25:17to respect patient autonomy.
25:19But here's the challenge. How
25:21does one judge
25:22whether one is refusing a
25:24patient request
25:25for reasons that are sufficiently
25:27medical or professional
25:29rather than merely personal.
25:32Critics of conscientious refusals
25:34have provided, in my judgment,
25:37no nonarbitrary
25:38standard to guide such judgments.
25:41Rather than asking whether
25:44doing what the patient requests
25:45is required by a physician's
25:47commitment to the patient's health,
25:50they set aside
25:51the question of what the
25:52patient's health requires
25:55and instead
25:56insist physicians show that their
25:58refusals are not influenced by
26:00personal values,
26:01particularly that not that they
26:03have, say, let's say, some
26:04religious value
26:05that or religious commitments that
26:07might
26:08line up with,
26:10their refusal.
26:13But alleging that a refusal
26:15is based on merely personal
26:16values, it seems to me
26:18only begs
26:19the relevant
26:20question, the relevant
26:22medical ethical question.
26:24And that is, is the
26:25refusal consistent with one's professional
26:27obligations?
26:30In these debates, everything turns
26:32on how we define the
26:33substance of our professional obligations
26:35because
26:36at the heart of every
26:37controversy about what physician
26:39about physician refusals
26:41lies a debate about what
26:42medicine
26:43is for.
26:45Disputes about conscientious refusals reflect
26:47at root
26:49two rival accounts of what
26:51medicine is for and what
26:53physicians
26:53reasonably profess.
26:57On what my colleague, Chris
26:59Tolleson, and I call the
27:00provider of services model,
27:02a medical professional is obligated
27:04to provide interventions
27:05that patients request
27:07so long as the interventions
27:09are legal,
27:10are feasible,
27:12meaning you have the means
27:14to bring them about, they're
27:15technically feasible,
27:16and are consistent with patient
27:18well-being
27:20where well-being
27:21is understood principally in terms
27:23of the patient's considered
27:26informed preferences
27:27being satisfied.
27:29Now if that seems like
27:30a bit of a caricature,
27:32of maybe the way you
27:33practice or the way people
27:34around you practice,
27:36I think it's because
27:37although the provider of services
27:39model has been growing in
27:40influence over the past two
27:41generations,
27:42it still coexists with a
27:44traditional vision of medicine
27:46that still guides physicians'
27:48intuitions and practices in many,
27:50if not most
27:52clinical domains.
27:53According to that traditional vision,
27:55which we call the way
27:56of medicine,
27:58medicine is a paradigmatic
27:59practice.
28:01And we could talk later
28:02if you want about what
28:03makes something a practice, but
28:04it's a practice that's elevated
28:06to a profession because of
28:07its social importance
28:10that aims at the health
28:11of the patient.
28:13On the way of medicine,
28:15a medical practitioner is professionally
28:16obligated to seek the patient's
28:18health
28:19and to refuse to act
28:20contrary to the patient's health,
28:22at least to do so
28:23refuse to do so intentionally.
28:26The way of medicine has
28:27much in its favor. I'm
28:28gonna list five reasons to
28:30prefer it to the provider
28:32of services model.
28:34First,
28:35the way a medicine is
28:36supported by the considered opinions
28:37of wise practitioners of the
28:39art for thousands of years.
28:42Aristotle,
28:42just to pick one example,
28:44Aristotle's whose father was a
28:46physician
28:47wrote, now as there are
28:48many actions, arts, and sciences,
28:51their ends or purposes are
28:53many.
28:54The end of the medical
28:55art is health
28:57as that of shipbuilding
28:59is a vessel.
29:01So Aristotle took this claim
29:03about the end of medicine
29:04that its purpose is the
29:05patient's health,
29:07as a starting point, as
29:08as something that is known
29:10immediately by both, as he
29:12would put it, the many
29:12and the wise.
29:14Similarly,
29:15the Hippocratic oath, as we
29:17saw earlier, includes a promise
29:18to enter homes only on
29:20behalf of the sick. Implying
29:22that medicine's fundamental aim, its
29:24fundamental purpose,
29:25its rise on detre, that
29:26that the thing we should
29:27expect of anyone who puts
29:28themselves forward as a medical
29:30practitioners
29:31is to act so as
29:32to restore the health that
29:33is imperiled in the sick.
29:35Countless practitioners of medicine
29:37before and after have made
29:38the patient's health their goal.
29:41It's the first reason. Second,
29:43and related,
29:44the way of medicine is
29:45affirmed by the practices of
29:46physicians and patients across diverse
29:48moral communities,
29:49religious and otherwise.
29:51As I already noted,
29:53today, medical technologies can be
29:55applied toward many different goals
29:57with respect to which different
29:59moral communities and traditions have
30:01long disagreed.
30:03Questions like
30:04having children or avoiding children,
30:07taking on suffering or avoiding
30:08suffering,
30:09changing one's bodily appearance and
30:11for what reasons.
30:12If medicine were understood as
30:13a practice of pursuing those
30:15goals,
30:16there would be no shared
30:17medical profession
30:18any more than there is
30:20a shared clergy profession.
30:23The commitment to seek healing
30:24for those who are sick
30:25and injured, however, is central
30:26to Judaism,
30:28Christianity,
30:29Islam, and other world religions.
30:31It is championed equally by
30:32those who do not consider
30:33themselves religious at all.
30:35Indeed,
30:37despite having arguments with colleagues
30:38about this this subject over
30:40two decades, I have yet
30:42to meet colleagues
30:43who challenge the notion that
30:45one of physicians central concerns,
30:47central commitments
30:49is the patient's health.
30:52Third, the way of medicine
30:54fits the particular vulnerability to
30:55injury, illness, and death that
30:58patients face.
30:59Those who are clearly sick
31:01or injured
31:02do not need control
31:04so much as they need
31:05help.
31:06And in order to entrust
31:07themselves to medical practitioners,
31:09they must have confidence that
31:11the practitioners will seek to
31:13heal them
31:14and not to harm them.
31:16Without such trust,
31:18seems to me, physicians cannot
31:19do their work.
31:21And I recognize it remains
31:23necessary to define health further.
31:25In our book, we spend
31:26the first chapter considering what
31:28health is. I welcome
31:30you reading the book if
31:31you'd like,
31:32or we can dig into
31:33it in the q and
31:34a. But for the present
31:35purposes, the key distinction is
31:37that in the provider of
31:38services model,
31:40health is only a subjective
31:42and socially constructed
31:43concept.
31:45So so we might say,
31:46well, your health is one
31:47thing, but my health is
31:49another or, you know, your
31:51truth, my truth kind of
31:54thing. Whereas in the way
31:55of medicine, health is meant
31:57in an objective sense
31:59as the sense of an
32:00observable
32:02characteristic of living things,
32:04what Leon Kass describes as
32:06the well working of the
32:07organism
32:08as a whole.
32:09Health so understood
32:11grounds medical practice, we think.
32:13It is the end that
32:15medical practitioners must prioritize
32:17because it is objective,
32:20real, something in the world
32:21that does not is not
32:22just made up by us.
32:24It's the sort of thing
32:25about which medical practitioners can
32:27develop genuine expertise
32:30and can therefore exercise a
32:31certain
32:32valid authority of expertise.
32:37Fourth,
32:38the way of medicine has
32:39a better account of how
32:41the personal and the professional
32:42fit together.
32:44Without any objective standard by
32:46which to determine whether an
32:47action is sufficiently professional,
32:50proponents of the provider of
32:51services model draw idiosyncratic
32:53and arbitrary lines between the
32:55professional and the personal. So
32:57for example,
32:59ACOG
33:00contends that physicians must refuse
33:03policies that require them to
33:04report undocumented
33:06patients to immigration authorities.
33:08By the way, I would
33:09agree with them about that.
33:10But they they they must
33:11refuse that because such policies
33:13conflict with other professional norms,
33:15including as they put it,
33:16the primary principle of non
33:18maleficence.
33:19In the same piece, however,
33:22ACOG takes it for granted
33:23that physicians must refer patients
33:25for abortion
33:26and ignores altogether well known
33:28arguments
33:29that abortion violates the same
33:31principle
33:32of non maleficence. I realize
33:33that's a subject of deep
33:34dispute and argument,
33:36but Aycock just skips over
33:38the argument,
33:39in and I think a
33:40kind of arbitrary,
33:41way.
33:43Stalin Emmanuel
33:44claimed that physicians might
33:46justifiably
33:47refuse assisted suicide,
33:49a practice that Ezekiel Emanuel
33:51happens to have publicly opposed
33:53for decades
33:54because they argue or because
33:56they claim the practice is
33:58currently controversial and subject to
34:00debate about whether it is
34:01medically appropriate. So they say
34:02since for that reason, you
34:03can refuse that. However, they
34:05do not acknowledge that abortion
34:07or medicalized gender transition are
34:09similarly controversial
34:11and subject to similar debate.
34:12And they say, therefore, if
34:13you all refer for those,
34:15you need to be out
34:15of go out of medicine.
34:18Professional responsibilities
34:19thus emerge this concept of
34:21professional responsibilities
34:22emerges as sufficiently malleable
34:25to rule out whatever a
34:26writer dislikes and to require
34:28what the writer affirms.
34:31Similarly, in seeking to say
34:33more about the professional,
34:35proponents of the provider services
34:37model often look to public
34:38and professional opinion in arbitrary
34:40and self contradictory ways, it
34:42seems to me. So on
34:42the one hand, they'll refer
34:44to a standard of care
34:46and a consensus
34:47as establishing the scope of
34:49what physicians must do. You
34:50must refer for this because
34:51that's the standard of care.
34:53In the next breath,
34:54they will refer to the
34:55absence of consensus
34:57as the reason physicians also
34:59must refer
35:00because
35:01they'll say, you may have
35:03personally opposed that, but many
35:04people disagree with you. Therefore,
35:05it wouldn't be right for
35:06you to allow your views
35:07to trump.
35:09In a particularly curious turn,
35:11Stowell and Emmanuel claim that,
35:13quote, health care professionals voluntarily
35:16choose their roles and thus
35:17become obligated to provide, perform,
35:19and refer patients for interventions
35:21according to the standards of
35:23the profession, end quote.
35:25Yet they then,
35:26a few sentences later,
35:28lament
35:29that the organizations
35:31that most authoritatively
35:32establish the standards of the
35:33profession,
35:35quote, all tend to accept
35:36rather than question conscientious objection
35:38in health care. So they're
35:40they're saying we must follow
35:41the standards of profession, and
35:42we'll admit that the standards
35:44of profession tend to allow
35:45conscientious refusals.
35:49ACOG as well as Stalin
35:50Emmanuel acknowledge deep social disagreement
35:53about whether abortion is permissible,
35:55yet both claim that abortion
35:56is standard medical practice and
35:58therefore cannot be refused.
36:00Although abortion is politically and
36:01culturally contested, Stalin Emanuel write,
36:04it is not medically controversial.
36:07So again, in the absence
36:08of clarity about the professional
36:10commitments of medicine,
36:11proponents sometimes rely on and
36:13sometimes disavow claims of consensus
36:16and controversy
36:17adopting, it seems to us,
36:19a kind of whatever works
36:20strategy
36:21in an attempt to press
36:23their desired shape of conformity
36:25onto the profession.
36:27The way of medicine by
36:28contrast
36:29distinguishes not between the professional
36:31and the personal,
36:32but between that which fulfills
36:34the physician's profession
36:36and that which departs from
36:37or contradicts that profession.
36:40And in an important sense,
36:41this merely distinguishes the reasonable
36:43from the unreasonable
36:44with attention to the particular
36:46vocation of practitioners of medicine.
36:49Fifth,
36:50in contrast with the provider
36:51services model, the way of
36:53medicine presents a workable, peaceable
36:55approach to living with disagreement
36:57with the pluralism that defines
36:59our age.
37:00Stalin and Emmanuel speaking for
37:02the provider services model write,
37:04Healthcare professionals who are unwilling
37:06to accept these limits to
37:08conscientious refusals that is,
37:11have two choices.
37:12Select an area of medicine
37:14such as radiology that will
37:15not put them in situations
37:16that conflict with their personal
37:17morality, or if there's no
37:19such area, leave the profession.
37:22If the profession of medicine
37:24follows this logic to its
37:25conclusion,
37:26it will have to drum
37:27out
37:28those who have the audacity
37:30to refuse interventions because
37:32those interventions are not required
37:34by or conducive to the
37:36patient's health.
37:38This is seems to me
37:39a recipe for a homogeneous
37:41and authoritarian health care profession,
37:44One held together by the
37:45forcible imposition of external norms,
37:48the norms of legally permitted,
37:50the technologically feasible,
37:51and what the patient desires.
37:53And physicians unwilling to work
37:55within these constraints would have
37:56to go.
37:58Perhaps paradoxically,
38:00the way of medicine has
38:01much more flexibility.
38:03Seems clear that there is
38:05no way to recover or
38:06forge a new full agreement
38:08on the part of all
38:09physicians regarding the moral obligations
38:11of medical practitioners.
38:13But
38:14if we imagine a profession
38:16structured even minimally on a
38:18commitment to patient's health,
38:19then the then the profession
38:21would allow conscientious refusals
38:23where reason dispute exists about
38:25whether an intervention is consistent
38:27with that goal.
38:29Patients like mister Anderson
38:31and miss Parker then would
38:32would not be surprised to
38:33encounter clinicians who make clear
38:35in so many words
38:37that they do not believe
38:38that what the patient seeks
38:39is what the clinician should
38:40be doing.
38:42Patients in some areas,
38:44particularly rural areas,
38:45may struggle to find clinicians
38:47who will provide interventions that
38:48are available elsewhere.
38:50The profession would sustain in
38:52its ranks an ongoing
38:54debate about what good medicine
38:55requires.
38:57The presence of differences would
38:58push people to consider why
39:00they are making the choices
39:01they make
39:02rather than taking practices for
39:04granted.
39:05And physicians would represent the
39:07diversity of moral communities
39:09found in a society,
39:11religious and otherwise.
39:12And the range of choices
39:13among philosophies of care would
39:14reflect the ongoing moral disagreements
39:16among those communities.
39:18When people like Stahl and
39:20Emmanuel insist that physicians put
39:21their professional
39:22obligations first,
39:24we would insist
39:25that they make an argument
39:26to show how the physician's
39:28commitment to the patient's health
39:30objectively construed
39:31requires physicians to participate in
39:33the intervention and question.
39:36The way of medicine does
39:37not ask physicians to set
39:39aside
39:40their religious or other moral
39:41commitments
39:42because they are punitively
39:44personal.
39:45The practice of medicine, in
39:47fact, has been developed and
39:48enriched by religious communities throughout
39:50history.
39:51And on the way of
39:52medicine,
39:53public and professional authorities would
39:55expect
39:56and would welcome religious and
39:58other moral communities to develop
39:59distinctive medical institutions and practices.
40:02They would tolerate diverse moral
40:04and religious views if those
40:06are not essentially unjust.
40:09That seems a far cry
40:10from the provider services models
40:12service models
40:14increasingly aggressive intolerance of disagreement.
40:21Let me close with just
40:21some brief notes on contending
40:23conscientiously for good medicine in
40:25our time
40:26since I know there are
40:27some students here.
40:29I I propose that health
40:31care professionals should strive conscientiously
40:34to preserve and restore their
40:35patients' health,
40:37And in so doing, to
40:38contend conscientiously
40:40for good medicine.
40:41In some contexts,
40:43practicing
40:44this way will require courage,
40:46even great courage.
40:48Trailblazers
40:48must sometimes walk alone.
40:51As, Martin Luther King Junior
40:53said,
40:55there comes a time when
40:56one must take a position
40:57that is neither safe nor
40:58politic nor popular, but he
41:00must take it because conscience
41:01tells him it is right.
41:04And this does not mean
41:06necessarily setting out to persuade
41:08all of your colleagues that
41:09they are in error.
41:12Some are called to that
41:13task,
41:14but certainly not all.
41:16Nor do I recommend fighting
41:17for one's rights like fighting
41:19for a right of conscience,
41:20which I think is,
41:22too easily interpreted and twisted
41:24into privileging physicians rights
41:26over those of patients.
41:28Rather,
41:29I encourage clinicians
41:31and trainees to practice medicine
41:33according to reason
41:34and to be prepared to
41:35give an account
41:37of why you do what
41:38you do
41:39including
41:40why you refuse to do
41:42what you refuse to do.
41:46Be committed to the central
41:47good of medicine,
41:48the patient's health.
41:50Do nothing contrary to that
41:52good
41:53and align your practice in
41:54harmony with it.
41:56Cultivate the virtues that are
41:58essential to good medicine and
42:02be a physician and a
42:02healer, not merely a technician
42:04or a provider.
42:06In short, be a good
42:08physician
42:09practicing good medicine.
42:11Doing so will bring good
42:12to your patients and good
42:13to yourself.
42:15It may also persuade
42:16your colleagues and patients.
42:19I think the bay most
42:20basic truths like the truth
42:22as I see it that
42:24medicine is
42:26essentially
42:27for the health of the
42:28patient.
42:30These are often better demonstrated
42:31in practice than an argument.
42:34By pursuing their patients' health
42:35in time tested ways that
42:37respect the purposes and limits
42:38of medicine,
42:40clinicians will show forth a
42:41better way,
42:42a way that has an
42:43integrity and even a beauty
42:45that may win over those
42:46who at present
42:48are somewhat captive to the
42:50provider of services model.
42:53I'll stop there, and we'd
42:54be happy to take questions.
43:01There's more of just, like,
43:02capsaicin Sure. Tables.
43:04So,
43:06what we're gonna do next,
43:09is,
43:09Amir and, as Karen, I
43:11got some mics, gonna have
43:12some mics, and I'm gonna
43:13call you. Please wait until
43:15I call you, and then
43:16wait until,
43:17either Amir. So you guys
43:18keep an eye on me
43:19because I wanna kinda mix
43:20it up who gets to
43:21ask a question or make
43:22a comment.
43:24We have a lot of
43:24students here, PA students and
43:26medical students. I wanna make
43:27sure at least some of
43:27these questions and comments come
43:28from you guys,
43:30But there's a lot of
43:31folks here who might wanna
43:31say something.
43:35You know, and and I'll
43:36I'll take the liberty of
43:37of the first comment
43:39and then and then question.
43:41The a comment would be
43:42that that you raise an
43:44interesting concern
43:46that, by using the model,
43:48and I forgive me if
43:49I can't recall the model.
43:50The model that Emmanuel was
43:51proposing, we're we're a bit
43:52more technician
43:53and provider,
43:56that we run the risk
43:57of a monolithic and authoritarian
44:00profession.
44:01And just one comment, which
44:03is that sometimes
44:05the physician
44:06that a patient presents to
44:10may actually, in a in
44:11a grand sense, represent the
44:12profession
44:13and may, in fact, therefore,
44:15be monolithic.
44:16So when that physician is
44:18reluctant or refuses to mention
44:21other options that that physician
44:22can't provide by conscience,
44:25That patient may present may
44:26present
44:27themselves, may see
44:29a monolithic
44:30structure to them, and and
44:32in fact, then not have
44:33access to other things that
44:34they might have. In other
44:35words, they might not proceed.
44:36As you say, it's different
44:37in rural areas versus urban
44:38areas and and so on.
44:41But I I share your
44:42concern about a monolithic
44:44profession, but I worry about
44:45sometimes the individual physician can
44:47present that. Yeah. I don't
44:48know if I'm making my
44:49point clear on that. Well,
44:52I'll respond at least to
44:53one one
44:55aspect of
44:56that. I'm not arguing that
44:59physicians should hide things from
45:01patients.
45:02It seems to me one
45:03of the virtues that's essential
45:04to good medicine is the
45:05virtue of candor,
45:07which would include forth being
45:08forthcoming about the reality of
45:10for example, if one knows
45:12that most of one's colleagues
45:14would offer a particular intervention
45:17that one thinks is not
45:18a good intervention,
45:19it seems to me you
45:20have an obligation to be
45:21honest candid about that. You've
45:23come to see me. You've
45:24asked for that. Let me
45:25explain to you why
45:26in my judgment or or
45:28why I I can't in
45:29good conscience
45:30provide that for you.
45:32And then explain if insofar
45:33as the patient
45:35wants to hear it,
45:36why why you why you
45:37think that's the case. I
45:39appreciate this. So my second
45:40question, and I promise to
45:41open it up after this,
45:42because as the, you know,
45:43the students will gather because
45:44the the students who've been
45:46paying attention, which is, you
45:47know, some some portion of
45:48Two or three of them.
45:49Yeah. I'm I'm sure they're
45:50all paying attention. I've been
45:51paying attention to the things
45:51I've asked them. They'll recognize
45:53that that much of what
45:54you say resonates with things
45:55that I've said and some
45:57of it does not. And
45:58that's that's cool. That's what
45:59makes the world go round.
46:01Your
46:02the notion of conscience,
46:04part of my struggle with
46:05that is so if someone,
46:07out of conscience feels that,
46:09for example, referring a nineteen
46:11year old to a transgender
46:13clinic and conscience feels that's
46:14not, supportive of that patient's
46:16health,
46:19based on conscience.
46:21Sometimes, perhaps, I worry. I
46:23think we all worry that
46:25it may be based on
46:26that that conscience itself may
46:27be founded upon,
46:30not necessarily the patient's well-being,
46:33but rather certain prejudices.
46:35And that we don't want
46:36those prejudices to actually dictate
46:38what the patient is or
46:38isn't,
46:40what's made available to that
46:41patient. I think you've kinda
46:42responded to that. But the
46:43bigger my bigger question about
46:44consciences,
46:45but a little study of
46:46history.
46:47I mean, American physicians in
46:49the nineteenth century,
46:52some had no trouble doing
46:54experimental surgery
46:55on slaves
46:56because they were not really
46:57human beings. And just as
46:59German physicians in the twentieth
47:01century, not all, but some
47:02had no trouble doing similar
47:04things to, Jews and others
47:06in the camps because they
47:07were not really human beings.
47:09And their conscience told them
47:11that this was actually okay.
47:13So and it wasn't that
47:14they thought I I don't
47:15think I don't believe that
47:16they woke up in the
47:17morning and said, these are
47:18actually people, and what I'm
47:20doing here is a horrible
47:21thing.
47:22I think their conscience told
47:23them just like the conscience
47:24of a Yale physician who
47:25does something does an experiment
47:27on a rabbit,
47:28doesn't worry about it the
47:29same way they would if
47:30they did an experiment on
47:31a person. So my fear
47:32is not that they went
47:33against their conscience. They acted,
47:35I think, often
47:36consistent with their conscience in
47:38doing things that some of
47:39their contemporaries and hopefully all
47:42of us now look back
47:43and say, well, that was
47:44really a bad thing to
47:44do.
47:45So
47:46I I worry about just
47:47relying on my own conscience
47:49because I worry that my
47:50own conscience may in fact
47:51be that imperfect just as
47:52those of the American physicians
47:54in the past and the
47:55German physicians in the past.
47:56And I'm sure some physicians
47:57in the present
47:59act according to their conscience,
48:01but in ways that I
48:02would find abhorrent.
48:03Yeah. Well, that that you
48:05put a few things on
48:05the table there first.
48:09The conscience
48:10as I said, that that
48:12a judgment is conscientious,
48:15does not mean it's true.
48:16It can be horrific. I
48:18mean, I think it was
48:19Eichmann who con I think
48:20it was Eichmann who in
48:21the trials
48:22confessed that
48:25he
48:26had let some Jews go
48:28free because of family connections,
48:31and then was troubled by
48:32the fact that he had
48:33not been fully ruthless in
48:36executing the plan.
48:38So consciences can become horribly
48:40formed.
48:41And so the the the
48:43that egg judgment, that you
48:45act according to conscience is
48:47necessary, I think, for moral
48:49action, for ethical action. If
48:50you're doing what you think
48:51you shouldn't do,
48:52you're you're not getting off
48:54the ground ethically.
48:55But it's not sufficient.
48:57And so which is partly
48:58why we all have a
48:59responsibility to form our consciences
49:01according to the truth insofar
49:03as we are able. And
49:04if you think about the
49:05something like the the German
49:07physicians,
49:08it seems to me
49:09from the history, there there
49:11was,
49:14more than
49:15everybody just thought
49:16conscientiously,
49:17sure, we can kill, you
49:18know, we can kill this
49:19whole class of people. There
49:21was a sense of you
49:22are told from outside
49:24what you're supposed to do
49:25to preserve the health of
49:26the Volk,
49:28and then we start to
49:29rationalize our behavior and our
49:30conscious become numb. And pretty
49:32soon, they become
49:33deeply corrupted and and deformed
49:35such that we are troubled
49:37by letting some go free.
49:39That can happen. So I
49:40I'm not putting forward the
49:41conscience
49:43as the only standard to
49:44which we hold ourselves.
49:45I am saying though that
49:47in the end,
49:48the only resource for getting
49:49out of those situations also
49:51is that someone recognizes they
49:53are wrong
49:54and says I'm not gonna
49:55do them just because I'm
49:55told they're everybody says this
49:57is the standard.
49:58I refuse to do it
49:59because as best I can
50:00tell, it is not ethical.
50:03And that's that
50:05having people among our profession
50:07and and having a profession
50:09that welcomes that kind of,
50:11that kind of posture
50:13keeps us
50:14not just taking for granted
50:15practices that may ten, fifteen,
50:17twenty years from now be
50:18things we look back on
50:19and think, how in the
50:20world did we get involved
50:21in that?
50:22Well, that I mean, that's
50:24there's no doubt. I mean,
50:25that's a fair point because
50:26there's no doubt there's something
50:27we're doing now, more than
50:28one thing, that we're gonna
50:30look back in twenty years
50:31and say, well, that was
50:31a mistake. I mean, we
50:32look back now from what
50:33we did twenty years ago
50:34and say, well, that was
50:35a mistake. Not just a
50:36mistake scientifically, but sometimes a
50:37mistake ethically as well. So,
50:40I guess
50:42we have to think about
50:43what then the safeguards are
50:44to consciences that are
50:46formed badly.
50:48That's right. So it seems
50:49to just jump there. In
50:50the end, there through the
50:51political process, we have to
50:53set boundaries.
50:54It seems to me the
50:55reasonable boundaries that are set
50:56by authorities
50:58are ones that are around
51:00the
51:01holding people accountable to act
51:02in ways that are conducive
51:04to patient's health.
51:05Objectively understood.
51:07They should not be setting
51:08boundaries of you must do
51:10everything that people ask of
51:11you.
51:12But when you see a
51:13doctor watching someone bleed out
51:15and just ignoring it, that
51:17that clearly is and then
51:18they they can't say, well,
51:19I conscientiously thought it would
51:21be a good idea to
51:21let them bleed out. That
51:23can't that can't justify that
51:25action. I'm not proposing that
51:26it does.
51:27I hear you. So let
51:28me let me let me
51:28start. This gentleman right here,
51:30we'll start with if we
51:31could bring the mic there.
51:34Thank you for your speech,
51:35doctor. Wait one second. There
51:36you go. Hold it up
51:36close. Thank you for the
51:38speech, doctor. I wanted to
51:39make two points.
51:40First,
51:41you framed,
51:42consciousness
51:43in as a negative freedom,
51:45the right to not do
51:45something,
51:47as a physician, or the
51:48right to withhold a service.
51:49Do you believe your ideas
51:51extend in terms of a
51:52positive freedom, the right to
51:53provide a service, even if
51:55the authorities, perhaps, are not
51:57allowed to make it more,
51:58topical?
52:00Perhaps you are in a
52:01state that is, that has
52:03outlawed gender affirming care abortion
52:05and physician assisted suicide. Putting
52:07aside the legal risks of
52:08doing this, do you believe
52:09that consciousness extends to do
52:11that? And on the second
52:12point,
52:13we often bring up,
52:15American physicians and German physicians
52:17during World War two. I
52:18just wanna we often forget,
52:19the Japanese physicians in unit
52:21seven thirty one, if you
52:22guys wanna look that up
52:23in experimentation on the Chinese.
52:25So just wanna bring that
52:26up as well. Thank you.
52:27And we we should also
52:28mention them in the US.
52:30I I think,
52:31engaging some pretty awful,
52:34behavior with,
52:36forced sterilization of the the
52:38the so called unfit.
52:40North Carolina was one of
52:41the leading states and sterilized
52:43a few thousand women against
52:45their will.
52:46That was supported by our
52:48Supreme Court. Justice Oliver Wendell
52:50Holmes famously said three generations
52:52of imbeciles is enough.
52:54So
52:56the the the answer to
52:57your first question, which is
52:58an important one, is this.
53:01So
53:01first of all, there's the
53:02question the the question of
53:04what is one morally obligated
53:05to do, and I proposed
53:07to you that one is
53:08if is definitely morally obligated
53:11to do all that one's
53:12conscience,
53:16that that one's
53:17conscience
53:18determines and judges one must
53:20do,
53:21and also to refuse what
53:23one conscience judges one must
53:25not do. Again, that's that's
53:27not to say that you're
53:28what decisions you make are
53:29going to be good, but
53:30that's a condition for the
53:31possibility of them being good.
53:33That being said, there's a
53:35second question about
53:37when should authorities
53:39limit what you are allowed
53:40to do.
53:42And it seems to me
53:43that the very possibility of
53:44a free society is a
53:45basic political philosophy issue is
53:48that negative rights, the negative
53:50right of conscience is much
53:51more expansive than a positive
53:53right.
53:54So it seems to me
53:55the states
53:56have good reason to,
53:59be very hesitant
54:00to come in and force
54:02people to do something that
54:03they believe is wrong.
54:05It does not follow that
54:06the state has the same
54:08limitation that the state must
54:09allow people to do the
54:10full range of things they
54:11think are right.
54:13And so this and I
54:14realized that can seem like,
54:15well, you're not being fair.
54:17You're you wanna have your,
54:19you wanna have,
54:20what's the right analogy? Anyway,
54:22you want
54:23yeah. Well, something like that,
54:24but it's I'm actually thinking,
54:25you know, it's good for
54:27what you you some people
54:28would think, well, if you
54:28believe in if you believe
54:30conscience is so important, then
54:31you should support
54:33the state allowing the conscientious
54:35person to provide abortions, let's
54:36say, or to do to
54:38provide assisted,
54:39medical aid in dying.
54:41And it seems to me
54:42that that it doesn't follow,
54:43that that that the negative
54:44right does not imply the
54:46the positive right. But that's
54:48even taking into consideration in
54:49terms of a physician's obligation
54:51for the patient's health and
54:52well-being. If the physician is
54:54convinced
54:55that to do this is
54:55necessary for the patient's health
54:57and well-being, you think that
54:58the prescriptions of the state
54:59should still,
55:01trump? No. No. I think
55:03that there are situations in
55:04which a physician may determine
55:07she may determine that the
55:09state has told me I
55:10cannot do this, but I
55:11must.
55:12And and and, hopefully,
55:14in those cases, she's using
55:16good judgment. Her conscience is
55:17well formed. And and and
55:19usually, if that's happening, that's
55:21a sign that the state
55:22policy there's something wrong with
55:23it. It's it's an unjust
55:24policy if that's happening very
55:25often.
55:28So but then the question
55:30the question kinda becomes what's
55:32the substance? I mean, is
55:33she right or wrong? What
55:34is the state right or
55:35or is that doctor right?
55:36And that that
55:37in that case, it matters,
55:39you know, what the ethical
55:40issues at stake are. Thank
55:41you.
55:43UNC is in the house
55:44here, doctor Hughes. Absolutely.
55:46Thank you.
55:48You've already
55:50allowed that you, want
55:52people who may have a
55:53conscientious objection to providing a
55:56particular procedure
55:57to
55:58inform the patient,
56:00of what the what the
56:01world is like out there,
56:03what their choices are, what
56:04their options are.
56:05And I'd like to just
56:07get you to elaborate on
56:08that a little bit further.
56:09You in your in the
56:10paper that you published some
56:12time ago, you
56:14surveyed doctors about what their
56:16obligations were or what the
56:17obligations of the profession should
56:19be. So
56:20would would you be willing
56:22to
56:23to say,
56:24for example, that a
56:27a physician who conscientiously
56:29objects
56:31to, say,
56:32a gender transformation
56:35would still be obligated, and
56:37it sounds like that person
56:38would be obligated to provide
56:40information
56:41or would be
56:43obligated to,
56:45to note
56:46that there are other people
56:47who would be supportive.
56:50Is that conscientiously
56:52objective
56:53objecting
56:54physician
56:55obligated any further? Are they
56:57obligated
56:58to refer?
57:00Are they obligated to provide
57:02more specific
57:03information in addition to the
57:05information,
57:06perhaps, about why they object?
57:09But just so that there
57:10would be,
57:13just so we know what
57:15your standards would be, your
57:16requirements
57:18for those who are conscientiously
57:20objecting. And then,
57:23depending on what your response
57:25is,
57:25how would you distinguish
57:28the end result of your
57:29recommendations from the end result
57:32of Emmanuel and his colleagues'
57:35position?
57:36Okay. Thank you.
57:38The late, Dan Brock
57:41of medical office at Harvard,
57:43wrote a piece in a
57:44collection that I had the
57:45privilege of editing
57:47about twenty years ago
57:49and
57:50in which he talked about
57:51the conventional compromise,
57:53which he was for. And
57:54he said the conventional compromise
57:56is that
57:57we we we socially
57:59and and politically and publicly,
58:02value
58:04people having space to act
58:05according to conscience.
58:07We don't wanna be
58:09coercing people into doing things
58:10that they believe are wrong.
58:11It's generally good for the
58:13body politic.
58:15But
58:16we have the the professional
58:17medicine has a social contract,
58:20at least implicitly,
58:22that requires
58:23the profession to make available
58:25the full range
58:26of interventions
58:27that the law permits and
58:29that people, the public may
58:30want. So the conventional compromise
58:32is you don't have to
58:33do the thing
58:35that's being asked, but you
58:36do have to refer. And
58:38the referral,
58:39Brock argued, is a way
58:40of honoring that
58:42social contract.
58:44I think that's not I
58:45think that's wrong. And here's
58:46why here's why I disagree
58:48with with,
58:49professor Brock.
58:51It seems to me that
58:52the social contract,
58:53insofar as there's a reasonable
58:55social contract, is not that
58:57we must provide all
58:59legal things that are possible,
59:01all the things that the
59:02state has not taken the
59:03time to outlaw.
59:06But in fact, that what
59:07what we have a social
59:08contract to do is to
59:09show up for
59:11and discipline ourselves to be
59:12able to
59:14care for those who are
59:14sick or injured
59:15in a reasonable way using
59:17the means available, seeking to
59:18preserve and restore their health.
59:19That's what the public expects
59:21of us as doctors.
59:22So
59:23to answer the first part
59:24of your question, it seems
59:25to me that I have
59:26an obligation, first of all,
59:28to all patients as I
59:29do to all persons to
59:30be a truth teller.
59:32So in my interaction with
59:33the patient, I should neither
59:34be I should not be
59:35acting in a way that's
59:36deceptive,
59:37and I should not fail
59:38to say things that I
59:39think a reasonable person
59:41should would would want to
59:42know.
59:43How far you go in
59:44that, it seems to me
59:45as a matter of judgment
59:46as is the case in
59:46much of medicine. What's a
59:47reasonable person standard?
59:49I don't think a doctor,
59:52for example, I'm a hospice
59:53and palliative medicine doctor. When
59:55people are facing the end
59:56of their life and they
59:57say, I don't know what
59:57what are my options. I
59:59don't tell them one of
60:00your options is to drive
01:00:01to California and be be,
01:00:03undergo assisted suicide or drive
01:00:05to Canada and be euthanized
01:00:06or fly to Switzerland and
01:00:07be I don't tell them
01:00:08that because I don't think
01:00:09that's
01:00:10belongs in the reasonable person
01:00:12standard. Now if they said
01:00:13what about as my patients
01:00:14have?
01:00:15What about that, you know,
01:00:16anything you can do to,
01:00:17like, make things go faster?
01:00:19I'll say, tell me, are
01:00:20you talking about,
01:00:22you know,
01:00:23hastening your death intentionally? Yeah.
01:00:25I'd like that. Then I
01:00:26then I explain to them,
01:00:28well,
01:00:29why I won't do that
01:00:30and and why, you know,
01:00:31the fact that it's not
01:00:32legal in North Carolina. If
01:00:33someone asks about assisted suicide,
01:00:35I'm candid about the fact
01:00:36that that is legal in
01:00:37a number of states.
01:00:38You can pursue that if
01:00:39you like.
01:00:40Here's why I'm not going
01:00:41to
01:00:42cooperate with you in that
01:00:44and why I hope you'll
01:00:45reconsider.
01:00:46So it seems to me
01:00:47we're we're held to the
01:00:48standard of, again, act in
01:00:49a way that's consistent with
01:00:50their health,
01:00:52and
01:00:53and then we owe them
01:00:54the things we owe to
01:00:55all human beings like truthfulness,
01:00:58candor,
01:00:59being forthcoming,
01:01:02and that that seems to
01:01:03be what we what we
01:01:03owe.
01:01:04So one potential problem
01:01:06with that
01:01:08is is is,
01:01:10is the, you can give
01:01:11that to to doctor Siegel
01:01:12to ask next, would be
01:01:14what I've called the savviness
01:01:15requirement. So here's the trouble
01:01:16with that example. So the
01:01:17guy who's savvy enough to
01:01:18know to ask about that,
01:01:20he gets more information about
01:01:21that option. Right? He gets
01:01:23to he because he asks
01:01:24you, well, is there countries
01:01:25where it's legal? Then you're
01:01:25gonna tell them about the
01:01:26countries where it's legal. The
01:01:27guy who's not savvy enough
01:01:28to ask that question. Maybe
01:01:30he doesn't,
01:01:30you know, not as good
01:01:32with the Internet. He doesn't
01:01:32have a cousin who's in
01:01:33the medical profession. The guy
01:01:35who's not savvy enough to
01:01:36ask the question
01:01:37gets fewer options
01:01:39than the guy who's got
01:01:40who's well read.
01:01:42It strikes me as an
01:01:43injustice that one man gets
01:01:44more options than the other.
01:01:46Yeah. Well,
01:01:48I mean, are you aware
01:01:49ever of
01:01:50there being physicians who are
01:01:53practicing in ways that you
01:01:54don't think are good, but
01:01:55that patients could see?
01:01:58My guess is you are.
01:01:59At least I am.
01:02:00And I've talked to surgeons
01:02:01who know there are surgeons
01:02:02who will do a procedure.
01:02:02I think I just don't
01:02:03I think they're
01:02:04they shouldn't be doing that.
01:02:07If if that's the case,
01:02:08are you obligated to tell
01:02:10people this is one of
01:02:11your options?
01:02:13You're supposed to, like, take
01:02:14in the full scope of
01:02:16possibilities?
01:02:16To me, the person who
01:02:18doesn't bring this up
01:02:19is not owed
01:02:21the suggestion you might wanna
01:02:23go die by suicide
01:02:24because that's not the sort
01:02:26of suggestion the doctor owes
01:02:27in out of her commitment
01:02:28to act in a way
01:02:29that's conducive to patient health.
01:02:31If the physician asked me
01:02:32about it, I'll tell them
01:02:33what I know.
01:02:36But
01:02:37I don't think as a
01:02:38physician, I owe people
01:02:40knowledge about things they can
01:02:41do that are not good
01:02:43things to do or and
01:02:45particularly not things that are
01:02:46that are consistent with their
01:02:47health.
01:02:49That that so there is
01:02:51a
01:02:52large dependence
01:02:53on the definition
01:02:55on the definition of health
01:02:57in in your scheme. Yeah.
01:02:59Absolutely. And and it because
01:03:01health can be the term
01:03:02can be defined. It's interesting
01:03:04that in these debates, if
01:03:05you'll pay attention, people tend
01:03:06to use the language of
01:03:07well-being when they're criticizing conscientious
01:03:09refusals.
01:03:10I think that's telling.
01:03:12They almost never will say
01:03:14you're obligated to act in
01:03:15a way that's consistent with
01:03:16the patient's health and that's
01:03:17why you must refer them
01:03:18for medical aid in dying.
01:03:20They don't say that. They'll
01:03:21say who are you to
01:03:22say what's consistent with their
01:03:23well-being?
01:03:24Their well-being is something that
01:03:26only they could say and
01:03:27you're obligated to support their
01:03:28well-being
01:03:29and that's why you should
01:03:30refer them if they ask
01:03:31you, etcetera.
01:03:33So but if you define
01:03:34health such that it is
01:03:35open ended
01:03:36and includes
01:03:38things that are contrary to
01:03:40the health defined more
01:03:42narrowly as a kind of
01:03:43bodily well working,
01:03:45then you're right. It you
01:03:46then it would it would
01:03:47change things. Yes. So the
01:03:48next the next question will
01:03:49be doctor Siegel, and then,
01:03:51I'm looking for a medical
01:03:52student. Are you a PA
01:03:53student?
01:03:54Outstanding. If you would get
01:03:55give her the next mic,
01:03:56and then after that,
01:03:58doctor Latham, please. So let's
01:03:59start with doctor Siegel. Yes.
01:04:00Then this lady here, then
01:04:01doctor Latham. So we'll try
01:04:03and and I have and
01:04:03I'm grateful. Be brief in
01:04:04our response. You know what?
01:04:05You're not the problem. I'm
01:04:06I'm the one who's talking
01:04:07too much up here, not
01:04:08you. So so I'll I
01:04:09will ask you guys from
01:04:10now. Now that I've talked,
01:04:11now everybody's gotta be
01:04:13brief. So so, yeah, please
01:04:14keep the questions relatively brief.
01:04:16I I will.
01:04:17So a few years ago,
01:04:19you I don't know if
01:04:19you remember, but you and
01:04:20I served on a committee
01:04:21for the American Thoracic Society
01:04:23Yes. Where we,
01:04:25wrote a set of guidelines
01:04:27for,
01:04:28structures and policies to follow
01:04:30to when issues of conscientious
01:04:33objection come up.
01:04:35And and at the time
01:04:36when we were doing this,
01:04:37I I thought this is,
01:04:37like, one of these nice
01:04:38things to put in place,
01:04:39but I don't think it's
01:04:40really gonna come up that
01:04:41often.
01:04:42And and as you spoke
01:04:44about,
01:04:45the issue of, well, you
01:04:46shouldn't be in the profession
01:04:47if something happens. I realized
01:04:49that that the standards
01:04:51of society and the standards
01:04:53of medical care
01:04:54might, in fact, change quite
01:04:56rapidly
01:04:57before we know it. Right?
01:04:58So if you work in
01:05:00UK
01:05:01right now, gender affirming care
01:05:02for children isn't a thing,
01:05:04I think, anymore That's right.
01:05:05Contrast to the US. And
01:05:07fifteen states have medical aid
01:05:08in dying. Connecticut happens not
01:05:11to be one of them,
01:05:11but it could be,
01:05:13sometime. And, of course, who
01:05:14knows what's gonna happen with
01:05:15abortion,
01:05:17in the weeks ahead.
01:05:19So I I'm I'm hoping
01:05:20that you might talk a
01:05:22little bit about structures that
01:05:23we could put in place
01:05:25that would specifically
01:05:26allow physicians and the institutions
01:05:29they work in to navigate
01:05:31issues of conscience as they
01:05:32might come up on a
01:05:34daily basis in practice.
01:05:37Well,
01:05:41is there something you have
01:05:42in mind as a place
01:05:43to Okay. So let's say
01:05:44let's say you you wake
01:05:46up tomorrow morning and you're
01:05:48a palliative care physician,
01:05:50and you are
01:05:51deeply morally opposed to
01:05:54medical aid in dying, but
01:05:55you happen to be on
01:05:56the faculty at a medical
01:05:57center,
01:05:59where you live, work, own
01:06:01a house and family.
01:06:03And now you're gonna have
01:06:04a whole series of patients
01:06:05come to you
01:06:06and ask for medical aid
01:06:08in dying. And so the
01:06:10question is, what do you
01:06:11do now? Yeah.
01:06:12So good.
01:06:14As part of the American
01:06:16political experiment,
01:06:18for better and worse, we
01:06:20have had
01:06:22stronger than in most even
01:06:24including Western nations, a stronger
01:06:25emphasis on
01:06:27the state,
01:06:28on religious freedom, which has
01:06:30been interpreted to mean
01:06:32in the law to mean
01:06:33the state cannot compel or
01:06:34coerce people to do things
01:06:36they believe are wrong. So
01:06:37there's a strong tradition of
01:06:39that. And interestingly,
01:06:40if you look at when
01:06:42when some practice that's controversial
01:06:44like medical aid in dying
01:06:45is passed
01:06:46invariably in these states, say
01:06:47California,
01:06:48Oregon, others,
01:06:49they include language that says
01:06:51effectively you don't have to
01:06:52do this. Doctors don't nurses
01:06:54don't have to cooperate in
01:06:55this. It's only an option,
01:06:57not something to be required.
01:06:58But when what happens is
01:06:59shortly after that, people start
01:07:01to argue it's
01:07:02maybe the state didn't require
01:07:03you to do it, but
01:07:04it's wrong for you not
01:07:05to do it. As a
01:07:05profession, we should we should,
01:07:08push that. I I think,
01:07:14the challenge that I encourage
01:07:16is is
01:07:18is to practice
01:07:21reasoning about and talking about
01:07:22with your colleagues and your
01:07:24patients
01:07:25why you practice the way
01:07:27you practice. And and I
01:07:28and it doesn't require
01:07:30a long discourses
01:07:31on lots of deep things.
01:07:33I will tell you I've
01:07:34told patients for for years
01:07:36when these issues come up
01:07:37about can't you make this
01:07:38go faster for for my
01:07:40mom. I don't like watching
01:07:41her like this. This is
01:07:42taking too long.
01:07:44Ways that are respectful and
01:07:45don't
01:07:46don't suggest, you know, you're
01:07:48some kind of horrible person
01:07:49because you're asking to do
01:07:50something I can't in good
01:07:50conscience do. But just just
01:07:52explain to them,
01:07:54as I understand it, I
01:07:55need to make sure I
01:07:56act in a way that's
01:07:57consistent with your mom's health.
01:07:59And here's why I don't
01:08:00think that is is something
01:08:02that I can do or
01:08:03I'm I'm willing to do.
01:08:04And I have found that
01:08:07patients,
01:08:08family members,
01:08:10trainees that I'm training as
01:08:11bedside teaching all these years
01:08:14and colleagues
01:08:15get it.
01:08:16They may not agree with
01:08:17it always, but they get
01:08:19it and they see that
01:08:20I'm still committed. And this
01:08:21I always encourage people, make
01:08:23clear you're committed to fulfilling
01:08:24your obligations as a physician.
01:08:26You're not saying I wanna
01:08:27be a physician, but I
01:08:28don't wanna do what I
01:08:29know physicians ought to do.
01:08:30You're saying I wanna be
01:08:31a physician, and now physicians
01:08:32some physicians are doing something
01:08:33that I I don't think
01:08:34is a good thing physicians
01:08:35do.
01:08:36People get that. They respect
01:08:37that. And if and if
01:08:38you continue in that way,
01:08:41then you become a witness
01:08:42to a different way. So
01:08:43that means that people around
01:08:44you have to ask themselves,
01:08:46should I go go with
01:08:47that doctor's
01:08:48way? They don't they don't
01:08:49they don't participate. Or do
01:08:50I just go with the
01:08:51other? And that's that's healthy
01:08:54to avoid a situation where
01:08:56we just do things that
01:08:57maybe judge thirty years later
01:08:58as wrong because everybody's doing
01:09:01it. A practical thing would
01:09:02be, say, our health care
01:09:04group had some physicians who
01:09:06do, some physicians who don't,
01:09:08you
01:09:09would presumably want the patients
01:09:10who come here to know
01:09:12which physician they're getting. Yeah.
01:09:13You might have to don't
01:09:14really give patients those choices.
01:09:17You might you might have
01:09:18to you might have to
01:09:19some way communicate that. Yeah.
01:09:21Yes. Yes, please.
01:09:24Hold it up close.
01:09:26So, I think we can
01:09:27all agree that there are
01:09:29some cases when
01:09:31health we can all agree
01:09:32that it's in someone's advantage.
01:09:34Right? Like you mentioned, someone
01:09:35bleeding out, we all know
01:09:37you need to stop the
01:09:37bleed. There's some blurry parts
01:09:40where it's transgender health care,
01:09:41abortions
01:09:42where
01:09:44who are we to make
01:09:45a judgment on someone's health
01:09:47when there is no concrete
01:09:49evidence saying that it goes
01:09:51against their health
01:09:53when we might even have
01:09:54evidence that refusing someone
01:09:57transgender affirming care goes against
01:09:59their
01:10:00mental health being?
01:10:02Isn't it slightly patronizing then
01:10:04if we do refuse them
01:10:08some sort of health care
01:10:09because we don't think it
01:10:11is good for them, but
01:10:12there is no concrete evidence
01:10:13saying that.
01:10:14And how would you then
01:10:16go about? Because we all
01:10:17try and not have that
01:10:18patronizing physician concept where who
01:10:20are we to determine that.
01:10:23Yeah. I I'm glad you
01:10:24raised this question. So
01:10:26who are we to decide
01:10:28that? It seems to me
01:10:29we are the ones who
01:10:30are being asked to act
01:10:31in a certain way. And
01:10:33so we must
01:10:34judge whether the way we
01:10:35are acting
01:10:37is consistent with how we
01:10:38ought to act.
01:10:39And in this case, it's
01:10:41consistent with what we expect
01:10:43of ourselves as medical practitioners.
01:10:45That's a judgment each of
01:10:46us has to make.
01:10:48And just as a patient
01:10:50has to make a judgment
01:10:51about whether
01:10:52they ought to, in fact,
01:10:54seek some kind of intervention.
01:10:57So that's the who are
01:10:58we part.
01:11:00It is true that there
01:11:02are hard
01:11:03that there are there are
01:11:04obvious cases. You know, you
01:11:05have cancer,
01:11:07generally wanna get rid of
01:11:08it.
01:11:09You're bleeding out, generally wanna
01:11:10stop that. Your septic, generally
01:11:12wanna kill the the bacteria.
01:11:14There are things that are
01:11:15really straightforward, and there are
01:11:16areas where it's blurry.
01:11:18What
01:11:20health requires, whether there's a
01:11:21dimension of health
01:11:23that's really at stake with
01:11:24a certain practice or not.
01:11:27It seems to me where
01:11:28it's blurry, we all the
01:11:29more
01:11:30need to both
01:11:33allow for clinicians to to
01:11:34have different come to different
01:11:36judgments.
01:11:37And
01:11:38as clinicians,
01:11:40be be,
01:11:42act in a way that
01:11:43recognizes the blurriness and potentially
01:11:45be be willing to flex,
01:11:47you know, where you where
01:11:47you're not certain that something
01:11:49is problematic with respect to
01:11:51someone's health.
01:11:53So something like referral for,
01:11:55you know, the gender clinic,
01:11:58I brought that up in
01:11:59these cases just because it's
01:12:00it's a live question that's
01:12:01being debated as as was
01:12:03noted here. And I I'll
01:12:04just say I'm on the
01:12:05record as one who thinks
01:12:06it's a the the gender
01:12:08medicine
01:12:09project has been a mistake,
01:12:11particularly for young people. I
01:12:13think it is not the
01:12:15evidence is pretty clear
01:12:17that
01:12:18we don't have evidence that
01:12:19medicalized gender transition
01:12:21improves mental health outcomes, which
01:12:23is the point of it
01:12:24in young people. And it
01:12:25clearly does medical harms,
01:12:28to people insofar as it
01:12:29blocks
01:12:30their maturation
01:12:31and makes people sterile while
01:12:32they're on cross sex hormones
01:12:34or puberty blockers and so
01:12:36on.
01:12:36That's my that's that's my
01:12:38judgment. But that I and
01:12:39I realized a lot of
01:12:40people disagree with that, particularly
01:12:41in the United States.
01:12:43Whether you agree or disagree,
01:12:44it seems to me the
01:12:45physician has got to
01:12:47has got to think and
01:12:49try to make a good
01:12:49judgment.
01:12:50And if if the physician's
01:12:52judgments
01:12:54become so clearly at odds
01:12:57with
01:12:58the collective's judgments about what
01:12:59health requires, then the collective
01:13:01has got to discipline the
01:13:02physician. I acknowledge that. But
01:13:04it seems to me they
01:13:05should do so. If they're
01:13:06doing it reasonably, they'll do
01:13:08so on the basis that
01:13:09that action is not is
01:13:10not consistent with a commitment
01:13:12to the patient's health. Does
01:13:13that answer your question?
01:13:14Sort of. It doesn't make
01:13:16it I mean, it doesn't
01:13:17resolve the disagreements, you know,
01:13:19about these things.
01:13:21Yes. Doctor Nathan.
01:13:25So I guess I have
01:13:26a kind of it in
01:13:27a way, it's a vocabulary
01:13:29question,
01:13:31but it's probably more than
01:13:32that. Suppose I agree with
01:13:34you, which I don't, about
01:13:35your definition of health,
01:13:37and I,
01:13:39am
01:13:40a gerontologist
01:13:41at a hospital in California.
01:13:43And it's a religious hospital
01:13:45where for explicitly religious reasons,
01:13:48certain services are not provided,
01:13:49like medical aid and dying
01:13:51or for that matter vasectomy.
01:13:54K?
01:13:55And suppose that I
01:13:59want to break the rules
01:14:00of the hospital where I
01:14:01have admitting privileges
01:14:03and tell my patient
01:14:05about the opportunity
01:14:07at hospitals elsewhere in the
01:14:08area
01:14:09to get some of those
01:14:11services.
01:14:13And, again, supposing as I
01:14:14do not that I'm agreeing
01:14:16with you on your definition
01:14:17of health. Am I allowed
01:14:19to say
01:14:21that what I'm doing then
01:14:23in telling my patient about
01:14:24this
01:14:26is
01:14:27exercising my conscience?
01:14:30Because it doesn't seem to
01:14:31be referred to your model
01:14:33of medicine that is advancing
01:14:35health.
01:14:36It
01:14:37can I say that for
01:14:39reasons of conscience,
01:14:40I'm violating the Catholic hospital's
01:14:44rules
01:14:46in order to tell people
01:14:47about procedures that are legal
01:14:49in my state? Or can
01:14:50I not or do I
01:14:51have to call it something
01:14:52else
01:14:53because I'm not thinking about
01:14:54advancing my patient's health when
01:14:56I want him to get
01:14:57a vasectomy?
01:14:58I want him to be
01:14:59able to get one if
01:15:00he wants it. No. Okay.
01:15:01I'm glad you brought this
01:15:02up. So
01:15:04if you believe
01:15:06as all things considered
01:15:08that you must that it
01:15:09is right, that you have
01:15:10an ethical obligation to tell
01:15:11the patient about these services
01:15:12offered at other hospital, then
01:15:14you must do that.
01:15:16That that is that is
01:15:17you have I think that's
01:15:19a sort of But would
01:15:20you call it a matter
01:15:21of conscience? Yeah. Absolutely. You
01:15:23should say as a matter
01:15:24of conscience,
01:15:25I I have to break
01:15:26this rule by this hospital.
01:15:28That is I mean, that
01:15:29the conscience is that that's
01:15:31this the example you give
01:15:32just highlights that
01:15:34you can have
01:15:35conscientious people coming to judgments
01:15:37that are completely contradictory,
01:15:39and they could still be
01:15:40conscientious judgments. But what make
01:15:42what makes it conscientious is
01:15:43that it is your judgment
01:15:44about how you ought to
01:15:45act or not not to
01:15:46act.
01:15:47Now the separate question is
01:15:49whether the hospital owes you
01:15:50some deference about that, you
01:15:52know, which is separate. No.
01:15:54I was I was just
01:15:55really concerned because through your
01:15:56talk, you seem to be
01:15:57pinning the idea of conscience.
01:16:00What makes it
01:16:02a matter of conscientious objection,
01:16:05you seem to be pinning
01:16:06it to
01:16:07this concept of advancing the
01:16:09patient's health. Oh, no. That
01:16:11I I'm that's a mistake
01:16:12that I if I did,
01:16:13I I certainly did not
01:16:14intend to apply that.
01:16:17I think that
01:16:19the the the conscious as
01:16:20I would described, and then
01:16:22the question comes for people
01:16:23trying to maintain a profession
01:16:25that has some coherence in
01:16:26order and trying to make
01:16:27sure people get what they
01:16:28should get and that people
01:16:30have the kind of freedom
01:16:30they should have.
01:16:32They have to
01:16:33ask, well, what what sorts
01:16:35of refusals should we allow?
01:16:37Consciousness refusals should we allow
01:16:38and what sort of shouldn't
01:16:39we?
01:16:40And it seems to me
01:16:41that the standard they should
01:16:42use if they're being reasonable
01:16:44is is that refusal compatible
01:16:46with a person's commitment to
01:16:48to act according to the
01:16:49patient's health what the patient's
01:16:50health requires?
01:16:52That if you if you
01:16:53say we're going some other
01:16:54standard like, well, they that
01:16:55refusal is only acceptable if
01:16:57it's
01:16:59if it's
01:17:01a really
01:17:02you know, it's a it's
01:17:03for a medical reason
01:17:05where you then define medical
01:17:07reason in this arbitrary ways
01:17:08that I described,
01:17:09then you're gonna end up
01:17:10with, as I think is
01:17:11the case now, a kind
01:17:12of unjust and arbitrary
01:17:15picking and choosing
01:17:17that is
01:17:19that it basically just reflects
01:17:20whatever peep the general sensibilities
01:17:22are of the people in
01:17:23power
01:17:24rather than
01:17:25a principled recognition that some
01:17:27things are clearly required
01:17:29for
01:17:30attending to people who are
01:17:31sick and injured.
01:17:32And then there are areas
01:17:33of
01:17:34disagreement and margin, which is
01:17:36not obviously required. And in
01:17:38those areas, we should
01:17:39we should allow people to
01:17:41refuse to do things they
01:17:42don't think are consistent with
01:17:43medicine.
01:17:44So let me ask a
01:17:45question from
01:17:47the, Zoom audience, please.
01:17:49In the way of medicine
01:17:50model, how do patients who
01:17:52disagree with their physician
01:17:54move toward
01:17:55preserving their health?
01:17:59Good. Well, so
01:18:03in the model,
01:18:04they they if if they
01:18:05encounter a physician who's practicing
01:18:07according to the way of
01:18:08medicine, they they encounter a
01:18:09physician who's committed to acting
01:18:11in a way that's consistent
01:18:11with their health, but they
01:18:12can have a disagreement about
01:18:14that. I mean, that frequently
01:18:15happens.
01:18:16And then I think the
01:18:17patient makes their case,
01:18:19and the physician, if she's
01:18:20a good physician,
01:18:21listens attentively and is willing
01:18:23to reconsider
01:18:25if if there's new information
01:18:26that is relevant that might
01:18:28change her calculation.
01:18:30And they negotiate
01:18:33a way to afford that
01:18:34they both can live with,
01:18:35that they both
01:18:38you know,
01:18:39Mark Seager used to call
01:18:40it the physician patient accommodation.
01:18:41I think it was a
01:18:42helpful concept. They try to
01:18:44negotiate a way forward that
01:18:45they both think is involves
01:18:46both of them acting in
01:18:47a way that's sensible. That's
01:18:49that's good. And sometimes they
01:18:51can't.
01:18:52And in those cases, they
01:18:53peaceably sometimes have
01:18:56to separate, and the patient
01:18:57tries to find a different
01:18:58doctor.
01:19:01Yes. Alexis.
01:19:06Up here. Raise your hand
01:19:07up high so we can
01:19:07find you.
01:19:13I'm wondering,
01:19:15you know, as people have
01:19:16said, it seems like a
01:19:17lot of this depends on
01:19:18this definition of health.
01:19:19I'm wondering what happens,
01:19:22in a case where,
01:19:24say, the science has settled
01:19:25the matter on a certain
01:19:26procedure or intervention
01:19:28being necessary for someone's health
01:19:30and yet still
01:19:31somebody's religious beliefs or conscience
01:19:35is an objection? How how
01:19:36then do we
01:19:37move forward?
01:19:39So this is where I
01:19:40think really the the details
01:19:42matter. Because there's wait. Go
01:19:43ahead, Alexa. Is there is
01:19:44there some is there an
01:19:45example that come to your
01:19:46mind? Well, I mean I
01:19:48think the issue of abortion
01:19:49perhaps I especially in America
01:19:52I think,
01:19:54it's becoming clear like health
01:19:55like a pregnancy is is
01:19:57not a health neutral event.
01:19:58Right? Like it could be,
01:20:02there are many cases where
01:20:03pregnancy could be highly detrimental
01:20:04to someone's health and yet
01:20:07an abortion,
01:20:08you know, is potentially a
01:20:10settled matter as a necessary
01:20:11intervention. And yet still potentially
01:20:14somebody's religious
01:20:15beliefs about abortion,
01:20:18could come in conflict with
01:20:19that.
01:20:21Yeah.
01:20:23So
01:20:24I will I I spent
01:20:25a lot of time
01:20:26working in the area of
01:20:28abortion for
01:20:31I personally have not met
01:20:33or encountered a an OB
01:20:35GYN,
01:20:37or other physician frankly that
01:20:38would not act as necessary
01:20:41to preserve a woman's health
01:20:42including by ending the pregnancy.
01:20:44If there was a in
01:20:45in their judgment,
01:20:47a proportionally grave threat.
01:20:52That being said,
01:20:53abortions that are not medically
01:20:55required, that are not matter
01:20:56of medical emergency,
01:20:58lots of people will not
01:20:59do. And it seems to
01:21:01me that they have
01:21:03a reasonable
01:21:04argument
01:21:05that they do not do
01:21:06that because
01:21:08pregnancy
01:21:09is a state of health.
01:21:10It is a it is
01:21:11brings it does bring real
01:21:12health risks. No question about
01:21:14it. People die from giving
01:21:16birth.
01:21:18But it is also
01:21:19a reflection of health and
01:21:21a state of health. And
01:21:21when someone is pregnant, continuing
01:21:23the pregnancy is what
01:21:25what we expect
01:21:26to happen in someone who's
01:21:28healthy.
01:21:29And then, of course, that's
01:21:30that's before you get to
01:21:31the question of whether what
01:21:32obligations we owe to the
01:21:33fetus,
01:21:34which,
01:21:36if you could you'd consider
01:21:37the fetus a second patient,
01:21:39then you have a problem
01:21:40of acting in a way
01:21:41that's consistent with the fetus'
01:21:42health.
01:21:43So I I think in
01:21:44principle,
01:21:46if there's an area
01:21:47where clear there's really clear
01:21:49what health requires,
01:21:52then just it just that
01:21:54far,
01:21:55authorities
01:21:55have,
01:21:58they have good reason to
01:22:00make sure that that's happening
01:22:01by all the people who
01:22:02put themselves forward as medical
01:22:03practitioners.
01:22:04But
01:22:06when you have a bunch
01:22:06of medical practitioners saying, I
01:22:08don't think that's a good
01:22:08idea, it's usually because it's
01:22:10not so obvious.
01:22:14But yeah.
01:22:15So if so just to
01:22:16follow-up in that little bit.
01:22:17So if pregnancy is a
01:22:18a reflection of health and
01:22:20and I and I don't
01:22:21disagree, then it seems it
01:22:22would fall that infertility
01:22:24is
01:22:25a reflection of
01:22:28a deficit in health.
01:22:30And then for, you know,
01:22:31since infertility treatments, which you
01:22:33which you cited earlier in
01:22:34the talk, where this is
01:22:35not something would necessarily be
01:22:36needed to promote the patient's
01:22:38health. If pregnancy is health,
01:22:40then infertility strikes me as
01:22:41treating infertility is
01:22:43promoting a patient's health. Yeah.
01:22:45And I I think this
01:22:46gets,
01:22:47into this issue. I think
01:22:48you're right insofar as what
01:22:50you're doing is seeking to
01:22:52preserve or restore some aspects,
01:22:54some dimension, some feature of
01:22:55health
01:22:56that would make
01:22:57pregnancy more possible.
01:22:59What I spoke about was
01:23:00in vitro fertilization,
01:23:02which is actually in I
01:23:04think doesn't end around health
01:23:06to achieve a baby, which
01:23:08is a good thing. Babies
01:23:09are good things. But it's
01:23:10not it doesn't go.
01:23:12IV
01:23:13IVF doesn't go about,
01:23:15restoring an aspect of health.
01:23:16It goes about working with,
01:23:19you know,
01:23:20the
01:23:21the whatever
01:23:23limits of health that a
01:23:24person has
01:23:25to try
01:23:26to, you know, generate,
01:23:29a baby.
01:23:33We have this gentleman right
01:23:34here. We'll have the final
01:23:35question of the day, please.
01:23:36And I apologize to everybody
01:23:38else. Yeah. Please, the fellow
01:23:39in the gray
01:23:40shirt. And then I apologize
01:23:42to many others who had
01:23:43something they wanted to ask.
01:23:44Go ahead, please. Hi. In
01:23:46your model,
01:23:49how would, like, something like,
01:23:51for example, COVID vaccines, a
01:23:52lot of people had religious
01:23:53problems with COVID vaccines because
01:23:54of the way they were
01:23:55developed.
01:23:56How would the science that
01:23:57is used
01:23:58to come to treatments,
01:24:00like if a physician
01:24:02objects the way that like
01:24:03a treatment that is objectively
01:24:05beneficial to patients
01:24:07is discovered,
01:24:08would your model allow for
01:24:09a physician to object it
01:24:11on those grounds? That's a
01:24:12good question.
01:24:16So
01:24:19the question of whether an
01:24:20action is consistent with or
01:24:22conducive to
01:24:23a patient's
01:24:24health, I think is a
01:24:26a central
01:24:27criterion
01:24:28in physician's judgment about how
01:24:29they ought to act. It's
01:24:30not the only criterion.
01:24:32There can be other criterions
01:24:33like fairness,
01:24:36you know, truth telling,
01:24:40fulfilling obligations you have that
01:24:41are you have particular kinds
01:24:43of obligations to certain groups
01:24:44and not to others.
01:24:48The the question of, like,
01:24:49the provenance of a vaccine
01:24:51I know in in the
01:24:52COVID thing, there was the
01:24:53there was the concern by
01:24:55some that it was using,
01:24:58you know,
01:24:59effectively
01:25:00the product of stem cells
01:25:01that were originally harvested from
01:25:02a from a aborted fetus.
01:25:09It seemed to me in
01:25:10that case that
01:25:12the
01:25:13the way the way these
01:25:14are often thought of by
01:25:15people who care about these
01:25:16sorts of things is a
01:25:16question of does your action
01:25:18involve a kind of cooperation
01:25:20that makes you complicit in
01:25:21the evil that was done?
01:25:22And in that case,
01:25:25it seemed to me pretty
01:25:26clear that it didn't,
01:25:28personally.
01:25:31And I don't know. I
01:25:32mean, I haven't seen a
01:25:34case where a doctor is
01:25:35refusing to provide vaccines based
01:25:37on that. There probably is
01:25:38someone out there,
01:25:39but
01:25:43I'm not sure quite how
01:25:44that'd be handled, honestly.
01:25:47Good question.
01:25:48Well, this has been an
01:25:50incredible session. Thank you so
01:25:51much, Scott, for us.
01:25:53Thank you.