Conscientious Objection in Medicine

Transcript

• 00:00I think we should get started.
• 00:03Welcome everyone to the to our final
• 00:06seminar of the Year of the academic year.
• 00:10I should say in the Yale School of
• 00:13Medicine program for biomedical ethics,
• 00:15my name is Sarah Hull and I'm one of
• 00:17the associate directors of the program,
• 00:20along with Jack Hughes and on behalf
• 00:23of us and our director Mark Mercurio,
• 00:27who couldn't be with us tonight,
• 00:29I'd like to welcome you all
• 00:32before we get started.
• 00:33I'm I'm sorry that if there's a lot
• 00:35of ambient noise in the background,
• 00:37my washing machine is on the spin cycle now,
• 00:39very unfortunate.
• 00:43I wanted to go over some ground rules
• 00:45before just basic sort of orders
• 00:47of business before we get started.
• 00:48I, I think most people are
• 00:51familiar with our format,
• 00:52but we usually start with about 45
• 00:55to 50 minutes of discussion tonight.
• 00:57We actually have a panel,
• 00:58so we have two discussions
• 01:00discussions which is wonderful.
• 01:01And then we follow with a
• 01:03Q&A session at the end.
• 01:05You're welcome to enter any of
• 01:07your questions through the Q&A box,
• 01:09as the discussants are are
• 01:11presenting their material.
• 01:13And then we'll go over them.
• 01:14At the end,
• 01:16we're going to start with Doctor Ronit stall,
• 01:19who is going to discuss some of the
• 01:22arguments against the exercise of
• 01:24conscientious objection in medicine.
• 01:27And then we,
• 01:28we will hear from Doctor Mark Siegel,
• 01:30who will present some of the
• 01:32arguments in favor of the exercise
• 01:34of conscientious objection medicine.
• 01:36And then we will again open it
• 01:38up for discussion,
• 01:39and I will moderate that that Q&A session so.
• 01:42Without further ado,
• 01:44I think we should get started and
• 01:46and I I just to make sure that we're
• 01:49we're clear and on what what we
• 01:51mean by conscientious objection.
• 01:52In medicine we I've used the
• 01:55definition that conscientious
• 01:56objection in medicine is the refusal
• 01:58to provide requested treatment due
• 02:00to moral convictions that conflict
• 02:02with the action or actions that
• 02:05such treatment might entail.
• 02:06But you know, I,
• 02:08I would encourage our discussants
• 02:09to expound upon that.
• 02:11And, again, I.
• 02:11I hope that we have a rich discussion.
• 02:14And our goal is to really explore this.
• 02:17This often very complex issue in the practice
• 02:20of medicine in in a in a nuanced way.
• 02:23So without further ado Doctor Ronit Stahl,
• 02:28pH D is an associate professor of
• 02:29history at the University of California,
• 02:31Berkeley,
• 02:32and currently a Greenwall Foundation,
• 02:34faculty, scholar, and bioethics.
• 02:36Her current book,
• 02:37project,
• 02:37troubling conscience,
• 02:38religious Freedom and Healthcare
• 02:39in the United States,
• 02:41examines the rise and consequences
• 02:43of institutional conscience.
• 02:44Rights through a history of
• 02:46religious hospitals and government
• 02:48funding as a postdoctoral fellow
• 02:49in advance biomedical ethics at
• 02:51the Perelman School of Medicine
• 02:52at the University of Pennsylvania,
• 02:54she published articles on conscientious
• 02:56objection and conscientious provision
• 02:58of care and medicine in the New
• 03:00England Journal of Medicine and JAMA.
• 03:02Her award winning first book,
• 03:03enlisting Faith how the military
• 03:05chaplaincy shaped religion and state
• 03:07and modern America was published by
• 03:09Harvard University Press in 2017.
• 03:11She earned her pH D in history from
• 03:13the University of Michigan in 2014.
• 03:14And I in social sciences and education
• 03:17from Stanford in 2005 and a BA in
• 03:20English from Williams in 2002.
• 03:21Doctor stall. Take it away.
• 03:24Alright, thank you very much.
• 03:25Thanks to everyone who's joined us today.
• 03:28Thank you for the invitation and
• 03:30thanks to everyone in the background.
• 03:33You of course makes zoom events possible,
• 03:37so I I want to start today by talking about
• 03:40the ways in which ethics exist in context.
• 03:44We live in 2022 United States,
• 03:47or at least that's where I am right now.
• 03:50And as many of you likely know,
• 03:52we're also there for living
• 03:53in a in a rapidly changing.
• 03:55Legal and political landscape in terms
• 03:58of healthcare and healthcare ethics,
• 04:00and you know there's been recent
• 04:02news about the leak of a Supreme
• 04:05Court decision about abortion.
• 04:07There are new laws in states
• 04:10about gender affirming care.
• 04:13There are all sorts of arenas
• 04:16in which healthcare has become
• 04:18political and not just political,
• 04:20but partisan, and in this realm,
• 04:231 dimension has been.
• 04:25Over the past, about 50 years.
• 04:28This question of conscientious objection
• 04:31in healthcare and as was noted,
• 04:34I'm here to make an argument against
• 04:37what's often been called conscientious
• 04:40objection or religious refusal in medicine,
• 04:44and I want to be clear at the outset
• 04:46that sometimes people construe this
• 04:48as an argument that's anti religious
• 04:51or anti morals or anti ethical
• 04:53and I want to be clear that the
• 04:55argument I'm making is an argument.
• 04:56About pluralism and power,
• 04:58an argument that's that's rooted in
• 05:01a deep respect and study of religious
• 05:04institutions and communities,
• 05:05and also a commitment to studying,
• 05:08thinking about,
• 05:09and in the context like these,
• 05:11perhaps arguing over how they
• 05:14function in public serving spaces.
• 05:16And this work emerges from my own
• 05:19research and scholarship as both
• 05:22the historian and a bioethicist.
• 05:24And so when we talk about conscience.
• 05:26In healthcare,
• 05:27we're often talking about values in conflict,
• 05:30and so sometimes, as I noted,
• 05:32this can be an argument that pits kind
• 05:35of religious freedom or conscience
• 05:37against patient centered care or autonomy.
• 05:41And what's tricky about this is
• 05:43that there's no singular religion.
• 05:45There's no singular conscience,
• 05:47and there's no singular notion of what
• 05:50even patient centered care might look like.
• 05:53And so sometimes there are religious and
• 05:56moral views which are in conflict with
• 05:59what might be deemed patient centered care,
• 06:01or in some cases bodily autonomy.
• 06:04But that's not always the case,
• 06:06and I think that's part of
• 06:07what makes this difficult.
• 06:08There's no single notion of what is religion.
• 06:11For what is conscience and I also therefore
• 06:14want to emphasize that you know, many,
• 06:16though not all people hold religious beliefs,
• 06:19but regardless of religious affiliation,
• 06:22commitments or belonging in
• 06:24particular religious communities,
• 06:25everyone has values,
• 06:27and everyone wrestles with
• 06:28ethics based on their values.
• 06:30And it's that these values can change,
• 06:32and some of them come from
• 06:35spaces of religion,
• 06:36some of them come out of deep notions
• 06:39of morals and ethics which may.
• 06:41Again, be connected to religion,
• 06:43but aren't necessarily so.
• 06:46And of course, within healthcare itself.
• 06:49People bring values,
• 06:51providers bring their own values.
• 06:53Patients bring their own values,
• 06:54institutions express values,
• 06:56so part of the reason I think this is a
• 07:01really complicated domain is that when
• 07:03we're talking about what is, again,
• 07:06sometimes called conscientious objection
• 07:08and at other times called religious refusal.
• 07:11And these. Can be you know,
• 07:12overlapping sets of terms so they also
• 07:15can sometimes have different legal,
• 07:18political, or ethical nuances to them,
• 07:21but I think some of the challenges we're
• 07:24talking about this is that we can talk
• 07:26about these questions of conscience
• 07:28and relationship to individuals.
• 07:30We can talk about it about in
• 07:33regard to institutions,
• 07:34and we can think about individuals
• 07:37within institutions and that
• 07:38can be sets of individuals,
• 07:40healthcare providers which
• 07:41could be physicians.
• 07:43Nurses physicians assistants,
• 07:45but also, you know,
• 07:47surgical techs.
• 07:48All sorts of people in who work
• 07:51within healthcare institutions,
• 07:52hospitals and clinics,
• 07:53and so this question of individuals
• 07:56and institutions they're related
• 07:58but different and and sort of.
• 08:00As a side note,
• 08:01I'm going to be focusing mostly
• 08:03on individuals here today,
• 08:04though my book actually looks the book
• 08:06project that I'm currently researching
• 08:08is really focused on institutions,
• 08:10and the questions that arise around
• 08:12different kinds of religious hospitals.
• 08:14And what they therefore express as their
• 08:17values and impose on their employees,
• 08:20which does ultimately then
• 08:22affect what patients can access,
• 08:24similarly to thinking about
• 08:26individuals and institutions,
• 08:28we can talk about both beliefs and behaviors.
• 08:31And here, too, they're not the same thing.
• 08:34People with the same core
• 08:36belief have different,
• 08:38often have different behavioral outcomes.
• 08:40They can choose to act in different ways,
• 08:42and so this question of what's the?
• 08:44Action associated with conscience is,
• 08:47I think, central.
• 08:48And finally,
• 08:49we can also talk about systems
• 08:51and structures or what we might
• 08:53call the context and concepts and
• 08:55contingencies that give certain people
• 08:58and certain perspectives more or
• 09:00less power within specific spaces.
• 09:02Maybe it's in the space of a
• 09:04hospital or a medical school.
• 09:06Maybe it's in a clinic.
• 09:07Maybe it's elsewhere.
• 09:09Maybe it's in a courtroom or in
• 09:11a legislature.
• 09:12And So what I'm going to now spend the
• 09:14rest of my time talking about again,
• 09:16I'm going to focus primarily on individuals,
• 09:18so I'm happy to address.
• 09:20Questions of institutions.
• 09:21In the Q&A and as we're seeing in
• 09:25our current moment institutions,
• 09:26especially hospitals themselves matter,
• 09:28I'm also going to focus on behaviors
• 09:30and this really gets it like what.
• 09:33How are we defining conscience?
• 09:35I want to be clear that everyone has
• 09:37their beliefs and I'm when I'm making
• 09:40an argument against conscientious
• 09:42objection and religious refusal.
• 09:44It's about the behaviors that
• 09:46stem from that belief,
• 09:47not an argument that someone
• 09:49can't have a belief.
• 09:50It's about what you can or
• 09:52can't do with that.
• 09:53Belief.
• 09:53And finally,
• 09:54I want to recognize that of course
• 09:57we're talking about conscience
• 09:59objection and religious refusal within
• 10:02a particular within the United States.
• 10:04First of all,
• 10:05within the US health care system within
• 10:07US legal structures that have emerged,
• 10:09especially over the past 50 years.
• 10:13And so because my focus is on the
• 10:16behaviors that arise from beliefs,
• 10:18the actions people might take or not take.
• 10:21It's also an argument about the structures.
• 10:24And systems that enable or privilege
• 10:27certain behaviors over others.
• 10:29These are structures and systems
• 10:31with a history and as a historian,
• 10:34I'm particularly attentive to
• 10:36how some of these systems are.
• 10:40We're created and constructed,
• 10:42developed, and evolved over over time.
• 10:46So when we talked about this,
• 10:49it's therefore not that it has
• 10:50to be in one particular way,
• 10:52and I and I hope this is what we'll
• 10:54get to in terms of a discussion is that
• 10:56there are always other possibilities,
• 10:58and I've done some work outside
• 11:00of the US context,
• 11:02which also informs my idea that you know,
• 11:05just because we have one system here
• 11:07doesn't mean it has to be the system.
• 11:09So when we're talking about.
• 11:10Health care conscience in the United States?
• 11:13We're often talking about legislation and
• 11:16specifically healthcare conscience clauses,
• 11:19which are statutes that have been written
• 11:22that insulate professional in this case,
• 11:24healthcare providers from any
• 11:27consequences of performing tasks
• 11:30that they deem personally,
• 11:32they personally deem objectionable.
• 11:35Which is to say it immunizes them.
• 11:37It protects them from facing any harm,
• 11:40for refusing to provide.
• 11:42Care this has most often been in
• 11:46reproductive healthcare and LGBT healthcare.
• 11:49In end of life healthcare,
• 11:51but it can be in other arenas as well,
• 11:54so I think it's important also
• 11:56to note that you know.
• 11:58Sometimes people will talk about
• 12:00this and again say it's you know
• 12:03it's about it's anti religious or
• 12:04it's about particular perspectives,
• 12:06but it's it's really.
• 12:08It's about particular domains of
• 12:10healthcare where these arise most often.
• 12:12And there are lots of different kinds
• 12:15of healthcare providers and over
• 12:17time these conscience causes have
• 12:19moved from just physicians and nurses
• 12:22directly involved in particular care
• 12:25to a larger array of pharmacists,
• 12:28therapists.
• 12:29Tax on even janitorial or secretarial
• 12:33Staffs within hospitals,
• 12:34but not just hospitals.
• 12:36Also insurance companies and other.
• 12:39You know the sort of vast kind of octopus,
• 12:43the tentacles of healthcare in the United
• 12:46States and and yet within healthcare.
• 12:49I think one thing that's really important
• 12:52and important for my thinking about
• 12:54conscience is that this is a profession.
• 12:57These are different professional roles.
• 12:59Just to take for example,
• 13:01physicians and nurses.
• 13:02These are, you know, and pharmacists.
• 13:03These are distinct professions,
• 13:05but they are all professions
• 13:06and they all come, therefore,
• 13:09with professional standards.
• 13:11With professional expectations,
• 13:13people have to get degrees credentialed
• 13:16accredited to work in these positions and
• 13:20all of them share at least one thing,
• 13:24which is a notion of a professional.
• 13:27The morals of the profession.
• 13:29A professional role morality
• 13:30is a sociological term in which
• 13:33patients well being is the primary
• 13:35interest of these professions.
• 13:37It's it's enhancing patients well being.
• 13:41Despite this common role,
• 13:44there's of course debate and discussion
• 13:47over what is a patient's well being,
• 13:50and that's where a lot of
• 13:52the issues around conscience arise.
• 13:54And in some context, it's who counts
• 13:57as the patients and others, it's about
• 13:59what counts as a patient's well being.
• 14:01I want to argue, though, that that
• 14:03patients themselves play a role here,
• 14:05and one of the challenges of working this
• 14:08out is that patients understand themselves.
• 14:12Professionals have certain expertise
• 14:13that patients are trying to access,
• 14:16but patients most often they know it.
• 14:18They know what they want, and especially
• 14:20in these contested arenas of care,
• 14:23and so these healthcare conscience clauses,
• 14:26which again are legislative,
• 14:28have been used to create structures that let,
• 14:33for the most part it's objectors, to care,
• 14:35or people who want to refuse to provide care.
• 14:38Professional medical associations
• 14:40have their own.
• 14:42Codes of ethics or the American
• 14:44Medical Association has a code
• 14:46of ethics for physicians.
• 14:47There are codes of ethics for specific,
• 14:50and there are stances of
• 14:53specific subspecialties like the.
• 14:56OB GYN or the American Thoracic
• 14:58Society nurses have a code of ethics.
• 15:00Pharmacists have a code of ethics and
• 15:03all of them have also wrestled with
• 15:05conscientious objection as a legal
• 15:08structure that exists and then kind
• 15:10of tentatively tried to work out what
• 15:13does it mean to provide ethical care.
• 15:16While people can object and I'm not going
• 15:18to get into all the technicalities here,
• 15:21but I think one thing that's
• 15:22interesting is most of these codes
• 15:24of ethics have evolved over time.
• 15:26And I think one thing you can track
• 15:29is this wrestling with what does
• 15:31it mean to object or refuse care
• 15:34when again in general the duty is
• 15:36to provide care and so again,
• 15:38my critique of the way conscience is
• 15:41deployed and in fact employed in medicine
• 15:44is about these policies and actions,
• 15:47not about people's beliefs and my concern
• 15:49with the way conscience is used to deny
• 15:52or refuse care is that it highlights
• 15:55the ways in which there's an incredibly.
• 15:58Problematic negotiation of power and
• 16:01that negotiation of power is both
• 16:03within a pluralistic society in which
• 16:06peoples beliefs and values differ
• 16:08but also within a healthcare system
• 16:11that at least ostensibly in 2022,
• 16:14claims to be patient, centered and
• 16:18invested in certain ethical ideas,
• 16:21especially around patient autonomy,
• 16:25beneficence, nonmaleficence,
• 16:27and most of all.
• 16:28And I think this is really important
• 16:31justice and so the problem of the
• 16:33way conscience has arisen as a
• 16:35system in Healthcare is that this
• 16:37power is lopsided and asymmetrical.
• 16:39The law in this sense allows the
• 16:43imposition of personal beliefs on patients
• 16:46in the form of refusing to provide care.
• 16:50And yet, and this is an argument
• 16:53I've made in in writing,
• 16:55health care professionals
• 16:57voluntarily chose their profession.
• 16:59They had choices about
• 17:01what they wanted to enter,
• 17:04and so to deny something
• 17:06to deny patients care.
• 17:07That is part of a standard part
• 17:09of the profession is, in my view,
• 17:12a problem, and indeed, to me,
• 17:15unethical,
• 17:15and this has been allowed for in
• 17:18many informally for a very long time.
• 17:21That formally,
• 17:22starting in 1973 in 1973, is important.
• 17:26It's not about Roe versus Wade and the
• 17:29legalization of abortion nationally,
• 17:31but actually about the church amendment,
• 17:33which is a federal statute
• 17:35that arose in the context,
• 17:38certainly of Roe V Wade,
• 17:40but actually was prompted by the denial
• 17:44of of a tubal ligation or sterilization
• 17:47to a woman having a C-section,
• 17:49and it was denied because.
• 17:52She was in Montana and there
• 17:54had been a hospital merger.
• 17:56The only hospital left was
• 17:58a Catholic hospital and they
• 18:00said they wouldn't provide it.
• 18:02And when a Montana judge said actually
• 18:05you can't discriminate there,
• 18:07they're at least to a lot of lobbying
• 18:09and ultimately the church amendment,
• 18:11which is named not for the
• 18:12church but for Frank Church.
• 18:13The then Democratic senator from Idaho,
• 18:16and he thought this was a tidy,
• 18:18easy solution.
• 18:19A solution to what he thought.
• 18:22It's also not a huge problem, he said.
• 18:24You know, if you allow in the context
• 18:26of abortion and sterilization,
• 18:28the ability to deny care
• 18:30institutions can deny this care.
• 18:33But providers can deny it
• 18:36without any legal consequences.
• 18:38That's like it's a way of kind
• 18:40of putting this off to the side,
• 18:42and if brackets it so that it
• 18:44won't become a larger issue.
• 18:46And in that sense,
• 18:48he was very wrong.
• 18:49But in the course of working out.
• 18:52About his conscience clause would look
• 18:55like one of the arguments that arose then,
• 18:58and is still often made today.
• 19:00Is that conscientious objection
• 19:02in Healthcare is a parallel or
• 19:05an analogous to conscientious
• 19:07objection in in the military,
• 19:09and I've done that.
• 19:11Actually a lot of work on conscientious
• 19:13objection in the military,
• 19:14and I think there are some
• 19:16really significant differences
• 19:17between conscientious objection.
• 19:18Again as a practice in healthcare
• 19:21and conscientious objection.
• 19:22As a practice in the military and
• 19:24I'm just going to quickly list these,
• 19:27but happy to talk about them more.
• 19:30First conscientious objection as
• 19:31deployed in health care is about an
• 19:34objection to a professional standard
• 19:36of care or professional practice.
• 19:38It's not to state mandated conscription,
• 19:41so it's an objection to something
• 19:43within the profession itself.
• 19:44Second, it occurs, as I noted,
• 19:46within the context of a freely
• 19:48chosen profession,
• 19:49and that is different from conscientious
• 19:51objection in the military,
• 19:52which was which was a system that
• 19:55emerged in response to conscription or
• 19:57forced participation in military service.
• 20:003rd Conscious an objection in
• 20:03Healthcare is incredibly selective
• 20:05and allows an individual to
• 20:07make very discrete decisions.
• 20:11Two professionally accepted practices,
• 20:13whereas in the military context
• 20:15it was an all or nothing.
• 20:17You objected to war or you didn't,
• 20:20but you in fact,
• 20:20and there are legal cases about this.
• 20:22Could not selectively object and
• 20:23that was and I'll get to this,
• 20:25but that was for reasons of equity.
• 20:29In healthcare, conscientious
• 20:31objection is a system that emerged
• 20:34that has no external scrutiny.
• 20:36You don't have to prove anything about your
• 20:39objections or that you've held them for a
• 20:42long time or that you apply them evenly.
• 20:44It's simply you invoke it,
• 20:46and you're protected and that again
• 20:48is quite different from draft boards.
• 20:50Assessing ones objections to war.
• 20:545th it Shields the objector from all
• 20:57repercussions and costs there is by law.
• 21:00There is no permitted employment consequences
• 21:03for refusing care for providers.
• 21:06The costs are all put on the
• 21:09patients who can't access the care,
• 21:11and so finally six.
• 21:12It's one sided.
• 21:13It protects those who refuse
• 21:15to treat who deny care,
• 21:17but not those whose conscience
• 21:19compels them to provide medically
• 21:21accepted but politically contested.
• 21:23There, and I'll note, this wasn't.
• 21:26It wasn't supposed to be this way.
• 21:27The church amendment does actually
• 21:30include protections for conscientious
• 21:33providers of sterilizations and abortion,
• 21:36but legally that what's a developed
• 21:39has been a lopsided system in
• 21:42which refusers are protected.
• 21:44But providers or not,
• 21:45and so I really want to emphasize
• 21:48that in in a in a space of a
• 21:50voluntary professional choice.
• 21:53People have accepted who enter this
• 21:55field except a professional obligation
• 21:57to place the well being and the patient
• 22:00at the center of professional practice,
• 22:03and indeed the sort of notion of
• 22:06patient autonomy as well as a patient
• 22:08Bill of Rights and the notion of
• 22:10patients having rights and contact
• 22:12in healthcare context is emerging at
• 22:14the same time in the early 1970s,
• 22:16and so I think it's central that
• 22:20you know that it really.
• 22:23Get punched subjection and healthcare
• 22:25really pits a provider against a patient
• 22:28who has much less power in this system.
• 22:31Often an argument is made that these
• 22:34politically contested areas of care
• 22:36like reproductive health, LGBT health,
• 22:39are kind of lifestyle choices,
• 22:41and so it's not about medical care.
• 22:43It's about peoples lifestyles.
• 22:45But I think this substitutes
• 22:47cultural and political judgments
• 22:49for professional medical knowledge
• 22:51where there is in fact research.
• 22:54People do know what people's options are,
• 22:56and there's been an,
• 22:57you know,
• 22:58a move in particular in a lot of these
• 23:00domains toward nondirective counseling,
• 23:03in which the healthcare provider has the
• 23:05expertise to know what the possibilities are,
• 23:08but gives the patient the ability to make
• 23:10the choice that's best for themselves,
• 23:12and indeed,
• 23:14professional standards require
• 23:16conveying accurate information,
• 23:18performing professionally accepted
• 23:20and indicated procedures,
• 23:22and providing timely referrals.
• 23:24To ensure patients receive care,
• 23:26but the current system of conscientious
• 23:29objection in health care as built
• 23:32in through legislatures and through
• 23:34decisions by judges and courts,
• 23:37has not enabled patients to access
• 23:40the care they seek.
• 23:42And you know,
• 23:43I won't get into extensive detail here,
• 23:46but you know one thing that's also
• 23:48happened is the church amendment was
• 23:51really focused on direct provision of care,
• 23:53but it's often been.
• 23:55Ancillary provision of care that's affected.
• 23:57So there's currently I've been
• 23:59talking to doctors in the
• 24:01University of California system,
• 24:03where it's a nurse,
• 24:05wouldn't even admit a patient to a
• 24:09floor because they didn't, you know,
• 24:12approve of a procedure they were getting,
• 24:15and they were sort of just left,
• 24:17sitting in a wheelchair, in a hallway, or.
• 24:21Operating room staff refused to, you know,
• 24:25Prep an OR and that delayed care.
• 24:28So it's not just the
• 24:30immediate people involved,
• 24:31but really it's become a quite extensive
• 24:35ability to opt out of providing care.
• 24:38And to me that rejects the
• 24:41fundamental obligation of healthcare,
• 24:42the duty to ensure patients continued
• 24:45well being as patients themselves seek
• 24:48to live their life and it places then.
• 24:51The individual beliefs of the provider
• 24:54over not only professional standards,
• 24:56but also the patients sense of
• 24:59themselves and their interests.
• 25:01So in that sense,
• 25:02I think we can think of it
• 25:03as a conflict of interest,
• 25:05not a financial one,
• 25:07but a conflict of a conflict of
• 25:11interest over beliefs and so.
• 25:14And I really want to emphasize in my
• 25:16final few minutes here that I think
• 25:18this matters for several reasons.
• 25:19I think it matters generally for medical.
• 25:21Ethics and where the patient
• 25:24sits in healthcare.
• 25:25I think it matters for notions
• 25:28of professional integrity and the
• 25:30ability of patients to understand
• 25:33and expect that they will get care.
• 25:35That is up to the accepted
• 25:38professional standards of care,
• 25:39which of course change and evolve over time,
• 25:43but that patients should be able
• 25:45to expect that they are going to
• 25:48see a professional who will offer
• 25:51them the care that the profession.
• 25:54Dean's right,
• 25:55I think there's a question of
• 25:57institutional trust and just trust
• 25:59in providers when people do not get
• 26:01access to information and in the
• 26:03course of working on this project,
• 26:05one of the things that has really
• 26:07become clear to me is the way in
• 26:09which people are surprised by moments
• 26:12where they're not getting care.
• 26:15A big issue arises in the reproductive
• 26:17health around around miscarriage,
• 26:19management and expectations that.
• 26:21Their provider will be able to help them,
• 26:25and then there's a refusal and
• 26:27it creates all sorts of not just
• 26:30challenges for the patient,
• 26:31but real distrust and mistrust in the system.
• 26:34And so finally I think it matters
• 26:36for reasons of justice and equity
• 26:38that access to care matters.
• 26:40That patient should be able to
• 26:42expect to receive high quality care
• 26:44up again to the standards of the
• 26:47profession at which the provider is.
• 26:49The is the expert and the patient
• 26:51is trying to access that.
• 26:53Expertise and and so to create a
• 26:56system that doesn't enable patients
• 26:59to get full information necessarily
• 27:02timely referrals.
• 27:03But most of all the care they seek
• 27:06that meets professional standards
• 27:08to me is the central problem
• 27:11of conscientious objection,
• 27:13especially in a system where
• 27:16people don't always have so many
• 27:19choices and where they have to.
• 27:23And they're trying to navigate a lot
• 27:26of complexity without full information,
• 27:28and we know about inequities
• 27:31in the healthcare system and
• 27:33as the current system exists,
• 27:36it allows, in my view, the perpetuation
• 27:39of inequities in these domains.
• 27:42With that I will turn it over and
• 27:45look forward to continued discussion.
• 27:49Thank you so much doctor stall,
• 27:51that was a really nice overview of some
• 27:53of the issues with with conscientious
• 27:55objection and in particular you know I'd
• 27:58like to bring to light the the question of
• 28:00autonomy and the question of of freedom,
• 28:02because often we hear that term
• 28:05freedom or religious freedom used
• 28:07to to justify permissive provisions
• 28:09for conscientious objection.
• 28:11But it's noteworthy that you know,
• 28:13it's not necessarily a net
• 28:15increase in freedom,
• 28:16but rather it actually tends
• 28:17to exaggerate the gradient of.
• 28:19Of power between clinicians and and patients,
• 28:22and and also, as you noted,
• 28:24often the cases that that are most commonly
• 28:28contentious from a conscientious objection,
• 28:31standpoint or cases involving
• 28:33reproductive care, gender,
• 28:35affirming, care and care.
• 28:37At the end of life and therefore involving
• 28:40particularly vulnerable populations,
• 28:42including often you know, women,
• 28:45the elderly and LGBTQ plus folks
• 28:48who who already.
• 28:49Uh, don't have HealthEquity
• 28:51in in many different domains,
• 28:53so so to your point it's if there's
• 28:55a a justice concern as well,
• 28:58so thank you very much for that.
• 29:00I'd like to now transition
• 29:02to Doctor Mark Siegel,
• 29:04who's going to argue in in defense of
• 29:07of the the the judicious application or
• 29:11exercise of conscientious objection.
• 29:13Just as an introduction,
• 29:14although I know many people know,
• 29:16Doctor Siegel already Mark Siegel.
• 29:20Hang on one second.
• 29:21I just lost my screen there.
• 29:22Mark Siegel graduated from the
• 29:24Columbia University of Physicians
• 29:25and Surgeons in 1988 and completed
• 29:27his residency in internal medicine
• 29:29at the Hospital of the University
• 29:31of Pennsylvania in 1991.
• 29:32He was a pulmonary and critical
• 29:34care fellow at Yale from 1992 to
• 29:371995 and has been a full-time
• 29:38Yale faculty member since then.
• 29:40Doctor Siegel is board certified in
• 29:42internal medicine, pulmonary medicine,
• 29:44and critical care medicine.
• 29:46He was previously Co chair of
• 29:48the Hospital Bioethics Committee.
• 29:49His major clinical focus is in
• 29:51the intensive care unit and he
• 29:53attends in the MCU and on the
• 29:54general Internal Medicine services.
• 29:56Doctor Siegel serves on the editorial
• 29:58boards of critical Care Medicine Chest,
• 30:01the Annals of the American Thoracic Society,
• 30:03and the American Journal of Medicine.
• 30:05He is the recipient of several
• 30:06teaching awards and has participated
• 30:07in several multi center trials
• 30:09investigating new therapies for
• 30:10the treatment of critical illness.
• 30:12He currently serves as program
• 30:13director of the Yale Traditional
• 30:15Internal Medicine Residency and
• 30:16course director of the Internal
• 30:18Medicine sub internship.
• 30:19Doctor Siegel take it away.
• 30:24OK, thank you Sarah and and
• 30:25thank you for the organizers.
• 30:26For this invitation.
• 30:28I I really appreciated what
• 30:29Doctor Stahl had to say.
• 30:31As as expected,
• 30:32she is articulate and passionate and
• 30:35I think she has really showed us
• 30:38what can go wrong in this important
• 30:41area in the few minutes that I have,
• 30:43I I want to make the case that
• 30:45it is essential to preserve the
• 30:48opportunity for clinicians to maintain
• 30:51conscientious objection and so let me.
• 30:54Dive in and before I do that,
• 30:56let me just give you just a
• 30:58couple of other words of that.
• 30:59My background so is as Doctor Hall said,
• 31:03I am a medical intensivist so I spend a
• 31:06lot of my life in the intensive care unit.
• 31:09I was also the Chair of the American
• 31:14Rescue Society Ethics Committee and
• 31:16sat on a committee that created a
• 31:19document providing guidelines for the
• 31:21exercise of conscientious objection.
• 31:24I am not particularly religious I I
• 31:27come from a Jewish background and I
• 31:30don't consider myself particularly religious,
• 31:32really more secular,
• 31:33and I just want you to know
• 31:35that I am pro choice.
• 31:36I have some views that about end of
• 31:40life care in the ICU and I think
• 31:43that that practical background
• 31:44doesn't form the comments that I'm
• 31:46going to share with you today,
• 31:48so I'd like to start with a
• 31:51couple of case scenarios.
• 31:53These are made up.
• 31:54But but I I think they're realistic.
• 31:56So scenario number one,
• 31:58let's imagine it's June 2022.
• 32:01You are a Catholic medical student
• 32:03and personally opposed to abortion.
• 32:06The Supreme Court has overturned Roe, V.
• 32:09Wade,
• 32:09and abortion is now legal in
• 32:11the state where you live.
• 32:13You've been deciding what
• 32:14specialty to enter and believe
• 32:16OBGYN might be right for you.
• 32:17And given the change in abortion laws,
• 32:19you're relieved that you can now
• 32:21become an OBGYN without having to
• 32:23be asked to perform abortions.
• 32:24Since your religion perfectly firmly
• 32:28opposes your participation in that procedure,
• 32:31now imagine it's five years later
• 32:34and it's 2027 and you've graduated
• 32:36from residency and you're entering
• 32:38the practice of OBGYN and over
• 32:40the past five years,
• 32:41the Supreme Court has suddenly
• 32:42become more liberal,
• 32:43and Roe V Wade is reaffirmed,
• 32:46so abortion will be allowed.
• 32:48And a pregnant woman comes to your
• 32:49clinic and asked you to perform an abortion.
• 32:51And the question is,
• 32:53are you professionally obligated?
• 32:55To do so,
• 32:56just going to throw that out there
• 32:58as a question.
• 32:59Scenario number two it's June 2022
• 33:02and you're a medical intensivist and
• 33:04you're not religiously affiliated.
• 33:05You've been in practice for 30 years.
• 33:08A patient in the ICU is dying
• 33:10from widely metastatic cancer,
• 33:11but death is not imminent on palliative
• 33:13care is helping to treat her,
• 33:15but despite their efforts,
• 33:17she remains symptomatic.
• 33:18She's cognitively intact and has
• 33:21no psychiatric diagnosis.
• 33:22The patient states repeatedly
• 33:23that she wants to die and ask you
• 33:26to inject her with something to
• 33:28enter life quickly.
• 33:29You tell her that you continue
• 33:31to work with palliative
• 33:32care, but you can't enter life because
• 33:35youthanasia is illegal in your state and
• 33:38you are morally opposed to the practice.
• 33:41Five years later, 2027,
• 33:43a similar situation arises,
• 33:45but now Connecticut has adopted
• 33:47law laws allowing youth in Asia,
• 33:49modeled on practice in
• 33:51Belgium and the Netherlands,
• 33:52and you remain morally opposed to euthanasia.
• 33:56But are you obligated on
• 33:58professionally ethically?
• 33:59To offer euthanasia now that it is
• 34:02legal and allowable in your state.
• 34:05So I'm just posing those questions which
• 34:08I think are are reasonably realistic.
• 34:11So what I hope to show is why.
• 34:14I believe clinicians should be allowed
• 34:16to opt out of care that conflicts deeply
• 34:19with their deeply held moral beliefs.
• 34:21I want to address some of the
• 34:24potential arguments against
• 34:26conscientious objection on many of
• 34:28which back to stolen nicely outlined,
• 34:31and I'd like to conclude at the end
• 34:34by suggesting reasonable compromises
• 34:36that might address the needs of
• 34:40clinicians while protecting patients.
• 34:42So what is conscientious objection anyway?
• 34:44For the purposes of my remarks,
• 34:47I consider the refusal to provide
• 34:50standard medical care which
• 34:52conflicts deeply with moral,
• 34:54deeply held moral beliefs.
• 34:56So an example might be an OBGYN who
• 34:59is opposed to abortion and refuses to
• 35:02perform one or an MD who refuses to
• 35:05participate in physician assisted death.
• 35:07That comes in many varieties.
• 35:09You've been Asia is 1.
• 35:11Example,
• 35:12conscientious objection does not include
• 35:15refusal to provide non standard care,
• 35:19so it if it's sort of off off the rails.
• 35:23If somebody wants you to inject
• 35:25something that they found at the
• 35:28at the drug store or something
• 35:30that you don't necessarily hold
• 35:32a deep moral opposition to,
• 35:34it's just a personal opinion.
• 35:36That's not what we're we're
• 35:37talking about today.
• 35:40So there's a history of
• 35:42moral challenges in medicine.
• 35:44In the past there was a history of eugenics.
• 35:47It was perfectly common for American
• 35:51physicians to sterilize people who were
• 35:55thought to be unfit to be parents.
• 35:57There's a history of matching
• 36:00physicians where certain horrendous
• 36:02practices were condoned by physicians
• 36:04and Nazi Germany and, and, of course,
• 36:07the history of this Kiki study,
• 36:10which withheld care for syphilis
• 36:14from vulnerable individuals,
• 36:16and the physicians involved
• 36:17in a lot of that work,
• 36:19were highly prominent individuals
• 36:21in American medicine.
• 36:23In the future, you know,
• 36:25there's a lot changing when it comes to
• 36:28whether abortion will be allowed or not.
• 36:30Euthanasia and will be will be a latter, not.
• 36:33And I, I want to highlight this just to
• 36:36recognize that many of us enter these
• 36:39professions for a very long time, we.
• 36:41Enter our professions at a point where
• 36:44certain practices are deemed acceptable,
• 36:47and then during the course of your career
• 36:49that may change and so the question is,
• 36:52if standard practices change
• 36:54and your moral beliefs don't,
• 36:55are you obligated to change along with
• 37:00your professional societies expectations?
• 37:04Clinicians are also moral beings.
• 37:07Morality is intrinsic to
• 37:09our professional identity.
• 37:11We're committed deeply to patient welfare.
• 37:14We're committed to honesty and integrity,
• 37:17and I hope everybody here agrees that
• 37:20we want clinicians to take their moral
• 37:23and ethical obligations seriously.
• 37:25The hazard of though,
• 37:26is that if you ask clinicians to
• 37:29deliver a morally discordant care,
• 37:30in other words,
• 37:31to do something that they are
• 37:33morally opposed to doing.
• 37:34And there is a risk that you would
• 37:37induce severe moral distress,
• 37:38and in turn that might lead to
• 37:41decisions to leave the profession.
• 37:43Or perhaps not even enter the
• 37:45profession in the 1st place.
• 37:47And I have to imagine that that
• 37:49would not be helpful for patients.
• 37:54You know Doctor Stall was talking
• 37:56before a little bit about
• 37:58religion in the United States.
• 37:59You know this is a some data
• 38:01that I found from far Curlin,
• 38:03published in 2005.
• 38:04Looking at a 1988 survey of the
• 38:08distribution of religions among
• 38:10physicians in the United States and it's a
• 38:13little different than the US population.
• 38:15But you can see a distribution of
• 38:19Protestants and Catholics and Jews
• 38:21and not affiliated Hindus, Muslims.
• 38:23Etcetera and it it's just to
• 38:26highlight the fact that that
• 38:28physicians like a lot of people
• 38:30in our society come to work with
• 38:33religious backgrounds and beliefs,
• 38:35which I'm sure to a great extent
• 38:38informs their care.
• 38:42So what's the problem with not
• 38:46allowing conscientious objection?
• 38:48This these questions were
• 38:49raised a number of years ago,
• 38:52and an excellent article
• 38:53by by White and Brody,
• 38:56and their concern is that if we don't
• 38:58allow conscientious objections that
• 39:00it might have a negative influence
• 39:02on the types of persons who enter
• 39:04medicine and a negative influence
• 39:06on the way clinicians attend to
• 39:08their professional obligations.
• 39:09You know, if.
• 39:10If people have more of a lease start,
• 39:13are thought to be disposable,
• 39:15that would be problematic.
• 39:16It could promote callousness.
• 39:19If you don't believe that moral that
• 39:23you can practice your your profession
• 39:26in concert with your moral beliefs,
• 39:28it might be that physicians would become
• 39:30less willing to be sympathetic to and
• 39:32accommodating of patients moral beliefs.
• 39:34So.
• 39:34So if moral beliefs are important for
• 39:38patients, why not for clinicians too?
• 39:40And? And if we don't allow?
• 39:41Clinicians to follow their
• 39:42own core moral beliefs,
• 39:44how can we expect them to adhere
• 39:47to professional responsibilities?
• 39:48And there are two different
• 39:51types of morality.
• 39:53As as Doctor Stoll said,
• 39:55you know the federal government has for
• 39:59a long time supported conscience rights.
• 40:02Among practicing clinicians,
• 40:04you can see the website for Health and
• 40:08Human Services on the bottom with the link.
• 40:11If anybody wants to look at this in
• 40:13more detail but just to enumerate some
• 40:15of these conscience rights conscience
• 40:17protections apply to healthcare
• 40:19providers who refuse to perform,
• 40:21accommodate or assist.
• 40:22In certain healthcare services
• 40:24on religious or moral grounds,
• 40:27federal statutes protect healthcare
• 40:29provider conscience rights and
• 40:30prohibit recipients certain federal
• 40:32funds from discriminating against
• 40:34healthcare providers refused to
• 40:36participate in these services.
• 40:38Again,
• 40:38based on moral objections or religious
• 40:40beliefs and their instructions on
• 40:42how someone could file a complaint
• 40:45under the Federal health care provider
• 40:47conscience protection statutes.
• 40:49If you believe that you have
• 40:51been discriminated against,
• 40:52either because you refuse to participate in.
• 40:55During medical procedures such as abortions,
• 40:57sterilization were coerced into
• 40:58performing procedures that are against
• 41:01your religious or moral beliefs or
• 41:03refused to provide health care items
• 41:05or services for the purposes of causing,
• 41:07assisting in or causing
• 41:08the death of an individual,
• 41:10such as by assisted suicide or euthanasia.
• 41:13So these are baked in to federal statutes.
• 41:17They include the church amendments as
• 41:19Doctor Swallow and into subsequently
• 41:21public Health Service Act,
• 41:23the Weldon Amendment and the Affordable
• 41:25Care Act, and I just want to.
• 41:26Quote a couple of lines from
• 41:29the Affordable Care Act.
• 41:31You know one that no qualified health
• 41:34plan offered through an exchange may
• 41:36discriminate against any individual
• 41:38healthcare provider or health care
• 41:40facility because of its unwillingness
• 41:42to provide pay for provide coverage
• 41:44of or refer for abortions so can't
• 41:48be discriminated against.
• 41:49If that's the belief,
• 41:50and also that the federal government,
• 41:52then any state or local government or
• 41:55healthcare provider that receives.
• 41:56Federal financial assistance under
• 41:58this act or under any amendment of
• 42:01this act or any healthcare created
• 42:04under this act may not be subject
• 42:06an individual or or institutional
• 42:08healthcare facility to discrimination on
• 42:11the basis of the entity that the entity
• 42:13does not provide any health care item
• 42:15or services furnished for the purposes
• 42:17of causing or the purpose of assisting
• 42:20in causing the death of an individual,
• 42:22such as by assisted suicide,
• 42:24euthanasia, or mercy killing.
• 42:25So that was a mouthful.
• 42:27It's just to say that these are statutes
• 42:30that are protecting moral objections
• 42:33to providing abortions or various
• 42:35forms of physician assisted death,
• 42:37including euthanasia.
• 42:41So I I completely agree with Doctor
• 42:45Saul that there are practical
• 42:47concerns that we need to account for.
• 42:52Yes, we do enter into the
• 42:55healthcare professions voluntarily.
• 42:57I I would argue, though,
• 42:59that that we enter into these
• 43:01professions at an early age,
• 43:03not necessarily knowing
• 43:04what we're agreeing to,
• 43:06and also recognizing that there is
• 43:09potentially a changing moral landscape.
• 43:11There is a real concern about
• 43:14interfering with patient access to care,
• 43:16and I would argue that any support
• 43:18for conscientious objection
• 43:19has to deal with that.
• 43:20There is a concern about discrimination
• 43:23against vulnerable patients,
• 43:25including LGBTQ, and again,
• 43:27I think that any support for
• 43:30conscientious objection has to
• 43:31make sure that vulnerable patients
• 43:33get the care they are entitled to.
• 43:36There is our concerns about imposition
• 43:38of burden of care on colleagues,
• 43:40so if I were to refuse to.
• 43:42Care for a patient in the ICU?
• 43:44That would mean that that one
• 43:45of my colleagues would have to
• 43:47take care of that patient,
• 43:48and that's potentially a burden.
• 43:50There are concerns about the
• 43:52failure to respond to emergencies,
• 43:53and we have heard horrendous
• 43:55stories about women with atopic
• 43:57pregnancies where they couldn't
• 43:59get a timely abortion and suffered
• 44:01health consequences because of that,
• 44:03and that,
• 44:04you know,
• 44:04I think that that is clearly something
• 44:06that we can't allow to happen.
• 44:07There is a power differential between
• 44:10clinicians and patients and like.
• 44:12You should acknowledge that that the
• 44:15politicians hold power over patients and
• 44:18we need to recognize patients rights
• 44:20and there's the potential for abuse.
• 44:22I'm using moral objections as a
• 44:24smokescreen for deterioration
• 44:25and I'm just I'm discrimination.
• 44:28It's not.
• 44:28Maybe it's not really moral belief
• 44:30that you just don't want to take care
• 44:32of a person from a vulnerable group,
• 44:34and there are very few mechanisms
• 44:36in place and I'm aware of that
• 44:39provide the necessary process
• 44:40and oversight to make sure that.
• 44:43Punches objection is exercised in a
• 44:45way that is not going to be abused.
• 44:47It doesn't mean it can't be done,
• 44:49but I think Doctor Stall is right that
• 44:53that at this point the structures
• 44:55are not where they should be.
• 44:59Professional standards evolved.
• 45:00Abortion appears to be going from
• 45:02the legal to legal and back again,
• 45:04and it's likely to vary by state
• 45:07in the years ahead. And of course,
• 45:09people move states as as their lives evolve.
• 45:14End of life care is evolving too,
• 45:16with growing acceptance of DNR status,
• 45:18withdrawal of life support,
• 45:19and physician assisted
• 45:21death rules vary by state,
• 45:22and certainly rules vary by country.
• 45:24So so to my knowledge in Israel,
• 45:28it's still not.
• 45:29And considered appropriate to
• 45:30withdraw life sustaining therapy
• 45:32once it's already been applied so
• 45:34the patient is on a ventilator.
• 45:36Taking them off is a difficult thing to do.
• 45:39And then at the other end of the spectrum
• 45:40in places like Belgium and the Netherlands,
• 45:42euthanasia is allowed.
• 45:47So there was an interesting article
• 45:49published back in 2017 by colleagues in in
• 45:53critical care and I would encourage anybody
• 45:56who's interested to read this article,
• 46:00but they were doing is they wanted to get
• 46:03a group together of people with diverse
• 46:06viewpoints on on euthanasia, in the ICU,
• 46:11and they asked 4 core questions and actually
• 46:14we're not able to reach any consensus.
• 46:17On three of these questions,
• 46:18one was are there patients
• 46:20for whom death is beneficial?
• 46:23So would the patient be better off dead than
• 46:26alive because of their underlying condition?
• 46:29Is physician assisted suicide or euthanasia
• 46:32morally equivalent to withholding or
• 46:35withdrawing life sustaining therapy?
• 46:37So is the act of ending their life the
• 46:40same as simply taking equipment away?
• 46:42And 3rd question,
• 46:44is it morally acceptable for physicians
• 46:46to cause death intentionally so to
• 46:50perform an act where the intent is
• 46:53for the person to die so as opposed
• 46:57to removing equipment and just?
• 46:59Letting nature take its course,
• 47:01whatever that might turn out to be.
• 47:03The important point was that this this
• 47:05group of of Intensivists couldn't agree
• 47:08on the answers to those questions,
• 47:10but there was a fourth question
• 47:12and that was what is a reasonable
• 47:14accommodation between the right of
• 47:16patient access to physician assisted
• 47:18suicide and you can Asia and the right of
• 47:21conscience conscientious objection and.
• 47:23And this is where the group had consensus.
• 47:26They all supported conscientious
• 47:28objection and I want to quote.
• 47:30That we unanimously agree that accommodation
• 47:32for the matter of conscience is necessary
• 47:35on patients should respect the fact
• 47:38that physician assisted suicide in Asia
• 47:40and ethically controversial topic is a
• 47:43controversially as a controversial topic,
• 47:45and they should expect many physicians to
• 47:48be unwilling to provide it upon request
• 47:50and to all participants in the position.
• 47:53Patient physician covenant must
• 47:55recognize that conscientious objection
• 47:57is an instrumental means of promoting
• 47:59the integrity and.
• 48:00Quality of medical care.
• 48:02So a strong endorsement of
• 48:04conscientious objection,
• 48:06no matter what side of the argument you are
• 48:08on with respect to physician assisted death.
• 48:13So the American College of Obstetrics
• 48:16and Gynecology has specific
• 48:18recommendations on conscientious
• 48:20refusal just to quickly review them.
• 48:22That patient well being must be paramount.
• 48:24That healthcare providers must impart
• 48:26accurate and unbiased information
• 48:28that clinicians must provide potential
• 48:30patients with accurate and prior
• 48:32notice of their personal commitments
• 48:34that commissions have the duty to
• 48:36refer patients in a timely manner
• 48:38to other providers if they can
• 48:40provide the standard reproductive
• 48:41services their patients request.
• 48:43Setting an emergency where referral
• 48:44is not possible or might negatively
• 48:46affect the patient's physical or
• 48:48mental health that providers have
• 48:50an obligation to provide medically
• 48:52indicated and requested care regardless
• 48:54of their personal moral objections.
• 48:57That in resource poor areas.
• 48:58Access to safe and legal reproductive
• 49:01services should be maintained and that
• 49:03lawmakers should advance policies
• 49:05that balance and protect providers.
• 49:07Conscience is with the critical
• 49:09goal of ensuring timely,
• 49:10effective evidence based and
• 49:12safe medicine to all women.
• 49:13Seeking reproductive services.
• 49:15So the bottom line is that the ACOG
• 49:19did not object to the notion of
• 49:23conscientious refusal categorically.
• 49:25What they wanted to do was to make
• 49:28sure that it was done in a way
• 49:30that respected these core concerns,
• 49:32particularly to make sure that
• 49:35patients still had access to the
• 49:39care that they needed.
• 49:41Similarly for the Americans Thoracic Society.
• 49:45This is the committee that I said on.
• 49:47We recognize that there are important
• 49:50arguments in favor of conscientious
• 49:52objection to protect clinicians,
• 49:54moral integrity,
• 49:55clinicians, autonomy,
• 49:56quality of medical care,
• 49:58and the need to be able to change has
• 50:01with professional norms and practices
• 50:03while still recognizing that we need
• 50:05to hunt that their arguments against
• 50:07we need to recognize that their need
• 50:09to honor professional commitments.
• 50:11Protect vulnerable patients.
• 50:12Prevent excessive hardship for other
• 50:15clinicians or our institutions,
• 50:17and to avoid invidious discrimination
• 50:20against patients so so.
• 50:22This policy statement which we
• 50:25put out back in 2015,
• 50:27basically made four recommendations,
• 50:30one that conscientious objections
• 50:31in the ICU should be managed
• 50:33through institutional mechanisms.
• 50:35In other words,
• 50:36it shouldn't be at hoc that
• 50:38institutions should accommodate
• 50:39conscientious objections in the ICU.
• 50:41As long as certain criteria are met
• 50:43that it doesn't impede a patient
• 50:45or surrogates access to medical
• 50:47services or information that the
• 50:50accommodation won't create excessive
• 50:51hardships for other clinicians and
• 50:54that it's not based on discrimination.
• 50:56The third recommendation was that a
• 50:59clinicians consciences objection to
• 51:01potentially inappropriate orthopedic
• 51:03medical care should not be considered
• 51:06a sufficient justification on its own,
• 51:09So what they were trying to do
• 51:10is to distinguish between.
• 51:11Request for feudal care,
• 51:13separate from some of the other topics
• 51:15that we're talking about today,
• 51:17such as physician, assisted death,
• 51:20and euthanasia, and finally,
• 51:22the recommendation that institutions
• 51:24should promote open world dialogue and
• 51:27advanced measures to minimize moral
• 51:29distress and create a culture where
• 51:31diverse values are respected in the
• 51:34critical care setting so you know,
• 51:36just finally the ideas that we
• 51:39should advance identification.
• 51:42Clinicians having an obligation
• 51:44to identify and notify others
• 51:47of anticipated conscientious objections
• 51:49that should be done in a timely
• 51:52manner that they should disclose
• 51:54all medical options and make sure
• 51:56that patients have uninterrupted
• 51:57medical care that there should be a
• 52:00protocol for transferring care from
• 52:021 physician to another one position
• 52:04to another if there is an objection,
• 52:06there should be a process for appeals
• 52:08that there should be consequences for
• 52:10clinicians who refused to provide.
• 52:12Medical service when a conscientious
• 52:14objection can't be accommodated,
• 52:16so you can't just walk away from the
• 52:19patient and leave them without care and
• 52:22that there should be periodic review of
• 52:25conscientious objective objection cases.
• 52:28So in summary,
• 52:29I hope I've made an argument that
• 52:31we should allow clinicians to
• 52:34invoke conscientious objection,
• 52:36accommodate the the needs of
• 52:38physicians and other providers,
• 52:40and we hope that this may improve
• 52:42the quality of medical care provided.
• 52:45But to do so, we have to have safeguards,
• 52:47including transparency,
• 52:48advanced planning and oversight
• 52:50that ensures that that beliefs
• 52:52are deeply held and consistent,
• 52:55and that patients rights are protected.
• 52:58So with that I will stop and
• 53:00I'll turn it back over to Sarah.
• 53:02Thank you.
• 53:04Thank you so much.
• 53:05That was a really nice overview and
• 53:07I just like to highlight a couple
• 53:10points before we open up to the Q&A.
• 53:13You know, I, I think that it's important
• 53:15when we talk about deeply held beliefs
• 53:17to understand the seed of those beliefs.
• 53:20Because I I do think it makes a difference
• 53:22whether those are beliefs according to
• 53:25one's personal versus professional morality.
• 53:27So you know, sort of as as an an
• 53:29example that I've cited before,
• 53:31is that you know, it's my.
• 53:32It's my personal,
• 53:34deeply held belief that that factory
• 53:37farming is deeply unethical and problematic.
• 53:40And you know that the way that that we eat.
• 53:43In this country is is wrong,
• 53:46but that's not.
• 53:47That really is completely divorced from
• 53:49my professional duties as a physician,
• 53:52and therefore it would be unacceptable
• 53:53for me as a cardiologist for example,
• 53:56to deny a patient a prescription for
• 53:58a statin because I perceive that you
• 54:00know his or her hyperlipidemia is
• 54:02only due to his or her meat eating,
• 54:04and I don't want to enable that meat
• 54:05eating that that in my opinion you know,
• 54:07even though that's a very deeply
• 54:09held belief of mine,
• 54:10that's a belief that would interfere
• 54:11with my duty to care for my patient.
• 54:13According to the best cardiology
• 54:15evidence out there,
• 54:17and therefore that that would be
• 54:19unacceptable and and similarly,
• 54:21you know that's not a religious belief.
• 54:22But I don't.
• 54:23I don't think religion automatically
• 54:25therefore shield someone just because
• 54:27they you know they have a religious
• 54:29belief in my belief is is secular that
• 54:31that doesn't allow physicians to sort
• 54:33of force their beliefs upon patients,
• 54:35but to your point,
• 54:36there are a lot of professionally
• 54:38very contentious topics,
• 54:40such as as providing physician
• 54:43assisted suicide.
• 54:44For example,
• 54:45where it seems very reasonable that
• 54:47someone could hold a professional
• 54:49belief that that hastening the
• 54:51death of a patient violates their
• 54:53professional duty to do no harm
• 54:55because they perceive death as a harm,
• 54:57and indeed one of our first comments
• 54:59in the Q&A touches upon this point,
• 55:02I'm just going to read it because
• 55:03I think it was nicely stated it
• 55:04is worth highlighting that not all
• 55:06health practitioners feel that some
• 55:07legal procedures such as abortion,
• 55:09euthanasia,
• 55:09accord with the doctor's goal of
• 55:10working toward a patient's health if
• 55:12inducing death doesn't accord with an
• 55:14orientation of health and it's a misnomer.
• 55:15To say that such practitioners refuse care.
• 55:18Rather,
• 55:18such practitioners refuse to participate
• 55:20in a procedure that doesn't lead to health.
• 55:22Again,
• 55:22this is not denying care,
• 55:23so I I think that's for me.
• 55:25That's a very key distinction to be made.
• 55:28You know where that conscientious
• 55:29objection is coming from?
• 55:30Is that coming from a seat of a
• 55:31of a personal belief,
• 55:32whether religious or secular?
• 55:33Or is that from a professional belief aright,
• 55:36arising from the duties that
• 55:38we've sworn to uphold,
• 55:39such as as promoting health
• 55:42and and promoting flourishing,
• 55:44alleviating suffering?
• 55:45And and avoiding death when possible,
• 55:49and realizing that that there may
• 55:50be a lot of room for debate there.
• 55:52And and then the the other thing
• 55:54that I would just note that I would
• 55:56highlight that you said that I
• 55:57thought was was really helpful.
• 55:58There were a few key points of consensus
• 56:01that I think we can all agree upon,
• 56:02which is that you know,
• 56:03even that there are certain certain core
• 56:07standards or or baseline standards such
• 56:10as no deceit or withholding information.
• 56:12So for example,
• 56:14even someone who's morally opposed.
• 56:16To providing an abortion because
• 56:18they have a metaphysical belief.
• 56:20Whether that's religiously seated or
• 56:22secularly seated that that that would
• 56:25terminate what they believe is a life
• 56:27they're not allowed to not counsel
• 56:29someone about abortion as an option,
• 56:32and that that they're they're allowed to to
• 56:34decline to participate in that procedure.
• 56:37But they're not allowed to
• 56:39lie to patients or to withhold
• 56:41information to patients about the
• 56:43the possibility of that procedure.
• 56:45And I think that that's an important point.
• 56:47And another point that you made that I
• 56:49think is really critical is the idea
• 56:51that an emergency overrides the the
• 56:53the practice of conscientious objection.
• 56:55So for example,
• 56:56someone presenting with an atopic pregnancy,
• 56:59first of all,
• 57:00that almost seems silly,
• 57:01because that's a completely
• 57:03nonviable pregnancy,
• 57:03and so that there's no way that
• 57:06that pregnancy will end in in in a
• 57:08a baby in a healthy baby that's born
• 57:11that's independent of of the mother.
• 57:13But you know,
• 57:14even let's say that it's a pregnancy
• 57:16that may be questionably.
• 57:17Viable if if a if a woman is
• 57:20presenting in extract in distress
• 57:21and bleeding out or I should say
• 57:24potentially viable in the future.
• 57:25But before the date of any viability,
• 57:27so and you know an earlier pregnancy
• 57:29that that to you know to decline
• 57:32to provide a life saving procedure
• 57:35to that woman,
• 57:36I think would would just be
• 57:38pretty clearly unethical.
• 57:39Regardless of 1's views.
• 57:40And you know,
• 57:41if someone really is going to have
• 57:42a problem with doing a procedure
• 57:44under those circumstances,
• 57:45then there needs to be
• 57:47adequate institutional.
• 57:47Staffing to ensure that that never happens
• 57:49and that goes to one of your next points,
• 57:51which I think is is that rather than
• 57:54being an ad hoc individual basis,
• 57:56there should be institutional norms
• 57:58and standards to codify what what
• 58:01situations are appropriate for the
• 58:04exercise of conscientious objection.
• 58:06Because it does sound like,
• 58:07even though there may not be it,
• 58:09it sounds like those very areas where
• 58:11there isn't professional consensus as
• 58:12to the morality of a certain action.
• 58:14Those are the areas where we need
• 58:16to allow for.
• 58:17Different viewpoints,
• 58:18but also have the institutional
• 58:20supports such that patients still
• 58:22receive the care that they need and
• 58:24and that also respects clinicians
• 58:27as moral agents.
• 58:28So I think that was a a really nice summary.
• 58:33I I'd like to allow doctor stall
• 58:34to offer any
• 58:35final thoughts and then offer Doctor
• 58:37Siegel a chance to offer final thoughts
• 58:39after that just so that everyone
• 58:41gets a second chance to quickly do
• 58:42a wrap up if they if they desire.
• 58:45I think equity in terms of speaking time
• 58:46is important and and I want to have.
• 58:48Come back and forth,
• 58:48but I I want to get to the questions too.
• 58:50And and then we'll open it
• 58:52up to some more questions.
• 58:53If that sounds good to everyone.
• 58:56Well, thank you and that's yeah,
• 58:58sounds like a good plan.
• 59:00You know, I I, you know,
• 59:02I really appreciate the.
• 59:05The the way it actor Siegel
• 59:07kind of laid out the A case for
• 59:11allowing conscience objection.
• 59:13And I guess from you know,
• 59:14it raises some curiosities and
• 59:16one is one is like I you know,
• 59:19I think right,
• 59:20we do have the shared agreement
• 59:21that like there the system as it
• 59:23currently exists right now, right?
• 59:25It doesn't create a process or oversight
• 59:28or really capacity to to manage
• 59:31conscience objection effectively.
• 59:33And I'm I'm just curious.
• 59:35From your perspective,
• 59:36both just the work in a hospital system but
• 59:39also right from the perspective of you know,
• 59:42you're obviously part of other
• 59:44professional societies and whatnot.
• 59:45Do you see spaces where this
• 59:47has been done well?
• 59:48Because the question,
• 59:49like empirically it, is great.
• 59:51What would a vision that allowed
• 59:54this look like that did not?
• 59:57Right that did not compromise patient
• 60:00care that didn't offload work on,
• 01:00:02you know,
• 01:00:03and burden others because.
• 01:00:05For me,
• 01:00:05one of the real this really gets
• 01:00:07at one of the real tensions and
• 01:00:10challenges between fewer like designing
• 01:00:11from the ground up a system that
• 01:00:14allowed this with the commensurate
• 01:00:16laws that allowed that allowed it.
• 01:00:18I think it would look very
• 01:00:20differently than it does right now,
• 01:00:22and I've been part of conversations.
• 01:00:23People who kind of get to the point
• 01:00:25of just like throwing up their hands
• 01:00:27because a lawyer has told them well,
• 01:00:29you can't ask, or you can't do this,
• 01:00:31or you can't do that. So you know.
• 01:00:33And then what does it become?
• 01:00:35You know there there are real
• 01:00:37inequities and then and unfairness
• 01:00:39built into the system so that that's I.
• 01:00:42I mean I'm truly curious if you've
• 01:00:44seen you know a version of this
• 01:00:47that and you think functions in a
• 01:00:49way that is especially seamless
• 01:00:51seamless both operationally internally
• 01:00:53to the clinicians but also that
• 01:00:56does not give patients the the.
• 01:01:01The experience of being, you know,
• 01:01:03refused care or told they're wrong,
• 01:01:05or you know not,
• 01:01:06not even able to have a discussion
• 01:01:09with accurate information,
• 01:01:11because these are all things
• 01:01:13that that do happen,
• 01:01:14so that's that's that's one question I have,
• 01:01:16and I'm also curious.
• 01:01:19You know, I.
• 01:01:20I think it's.
• 01:01:21I understand intuitively why the
• 01:01:24argument emerges.
• 01:01:26You know,
• 01:01:26as you were saying,
• 01:01:27people have made the argument that
• 01:01:30if you prohibit conscience objection
• 01:01:32that you're negatively influencing
• 01:01:35who enters the profession and
• 01:01:37negatively influencing kind of the
• 01:01:40relationship or connection between a
• 01:01:43professional integrity professional
• 01:01:45responsibility and morality.
• 01:01:47But what's curious to me is that it.
• 01:01:51And to me it seems the opposite is true.
• 01:01:53Is that by allowing kind of a constant
• 01:01:56sort of unfettered and unsupervised
• 01:01:59opt out situation that's actually
• 01:02:02harming elements of professional integrity?
• 01:02:05Whereas sort of saying at the
• 01:02:09outset these are expectations,
• 01:02:12doesn't?
• 01:02:12I guess to me,
• 01:02:13like I understand the intuitive appeal,
• 01:02:15but on on pushing it,
• 01:02:17it doesn't quite strike me as right,
• 01:02:19and I guess the analogy
• 01:02:20because it was brought up.
• 01:02:21Right, if I sincerely morally opposed
• 01:02:24eating meat and factory farming
• 01:02:26and all the rest like I don't get a
• 01:02:29job at the slaughterhouse, right?
• 01:02:31But should this slaughterhouse
• 01:02:33actually want to employ like me
• 01:02:36feel like anti factory farming,
• 01:02:38anti meat person in in the sense that
• 01:02:41the food industry might ultimately
• 01:02:43benefit and I realized it's,
• 01:02:45you know, it's a philosophical,
• 01:02:48philosophical hypothetical,
• 01:02:49but I do think it gets.
• 01:02:51But it it's curious to me the
• 01:02:54way arguments have emerged that
• 01:02:56tend to assume that refusal
• 01:03:00should be understood to be good,
• 01:03:02and I guess I I don't find
• 01:03:05that particularly compelling
• 01:03:06when empirically we see,
• 01:03:08we see inequities and we see
• 01:03:11interference with patient care,
• 01:03:13so I just I'm.
• 01:03:15I'm just curious your answers,
• 01:03:17I think. Is it OK if I go exactly so?
• 01:03:21So I think you're asking the key questions,
• 01:03:24and I'm going to give you an example
• 01:03:26of a system that I think works well.
• 01:03:30I, I know that there are some obstetricians
• 01:03:32in the audience or at least one that I saw,
• 01:03:34so they can tell me I'm wrong,
• 01:03:36and this may actually be the exception
• 01:03:39that proves the rule so so a few years ago
• 01:03:42he owned Heaven Hospital basically merged
• 01:03:44with a Catholic hospital in New Haven.
• 01:03:47The hospital See Rapids which
• 01:03:49is now called our same reveals.
• 01:03:52Campus and part of the deal was that for.
• 01:04:00Reproductive care that potentially would
• 01:04:02interfere with with Catholic law would have
• 01:04:06to take place on the York Street campus.
• 01:04:08So even to this day,
• 01:04:10many years after we merged to my knowledge,
• 01:04:13if if you need to have a termination
• 01:04:17of pregnancy or even get birth
• 01:04:20control prescriptions,
• 01:04:20I think it occurs on one campus
• 01:04:22and not the other.
• 01:04:23Now this is, I presume,
• 01:04:26a relatively minor inconvenience when
• 01:04:28the hospitals are six blocks away from.
• 01:04:31Each other and the hospital that
• 01:04:33provides the care and the city is
• 01:04:36filled with physicians who are able to
• 01:04:39provide patients with standard care.
• 01:04:41But that said, you know,
• 01:04:43there is one local place that has the rules.
• 01:04:45It's well known and and the system
• 01:04:48has been set up, but I,
• 01:04:50but I think you're right though,
• 01:04:51that that isn't necessarily the way
• 01:04:55it would normally happen, right?
• 01:04:58Like you,
• 01:04:58you could potentially find your way in a.
• 01:05:01In a big you can be in a town where
• 01:05:04the only hospital is a hospital
• 01:05:06that refuses to provide reproductive
• 01:05:09care and the nearest place might
• 01:05:12be very very far away,
• 01:05:14and so the question then becomes
• 01:05:16what do you what do you do now?
• 01:05:19And and I think that if if I take
• 01:05:22characterize what I think are two
• 01:05:24arguments are in terms of putting
• 01:05:27it into a category I I think that
• 01:05:29I am trying to make the case.
• 01:05:31That that there's a principle here, right?
• 01:05:34Like the principle being that if
• 01:05:37that if a clinician has a a deeply
• 01:05:41held moral belief that they should,
• 01:05:43that that belief should be respected,
• 01:05:46with the caveat that that there are.
• 01:05:50There are hazards that need to
• 01:05:52be accounted for.
• 01:05:54And I think you've beautifully
• 01:05:55outlined those hazards, right?
• 01:05:57Like all the things that could happen
• 01:06:00if if this whole system is at hoc and
• 01:06:04and and we don't have a system to monitor it,
• 01:06:07and we don't have even commonly
• 01:06:09accepted definitions of what
• 01:06:11constitutes a moral belief or what
• 01:06:14consequences there would be,
• 01:06:16you know.
• 01:06:16And then the the the last thing
• 01:06:18that I think you mentioned,
• 01:06:20I I I I basically agree with you,
• 01:06:22but I I want to get back into the issue.
• 01:06:24Reproductive care,
• 01:06:25which again is not my field,
• 01:06:28but I think it's I think
• 01:06:30it's a helpful paradigm
• 01:06:31to think about.
• 01:06:32I think it would be ridiculous for
• 01:06:36somebody opposed to abortion to try to
• 01:06:40get a job at Planned Parenthood, right?
• 01:06:43Knowing that that is fundamentally
• 01:06:45what that organization is about.
• 01:06:48That that said, I would also think that
• 01:06:52knowing that we have a sizable portion
• 01:06:56of our population of physicians who
• 01:06:59are personally opposed to abortion,
• 01:07:01that I would hate to think
• 01:07:03that none of them would be able
• 01:07:06to go through OBGYN training.
• 01:07:09Because they would not be able to opt out
• 01:07:13of of having to perform procedures OK,
• 01:07:17and because you say, well,
• 01:07:19you can you even get through OBGYN
• 01:07:21training at a place like Yale.
• 01:07:24If you're going to say I,
• 01:07:25I'm not willing to to participate
• 01:07:29in this aspect of training,
• 01:07:32which presumably would be the
• 01:07:34consequence if you said that they're
• 01:07:35not allowed to to have doubts.
• 01:07:37So a lot of people would would.
• 01:07:39Afford not have access to that
• 01:07:41specialty which which I think in
• 01:07:43turn might hurt patients, right?
• 01:07:45If you knew that that lots of
• 01:07:47people couldn't enter that,
• 01:07:49enter that specialty so so that
• 01:07:50that would be my response to
• 01:07:52the points that you're making.
• 01:07:55And thank you both,
• 01:07:57you know I I would just add,
• 01:07:59I think there are a couple key
• 01:08:01differences in in sort of teasing
• 01:08:02apart some of these examples
• 01:08:04that have been brought up.
• 01:08:05You know first the first one being
• 01:08:09that that you know abortion is
• 01:08:11healthcare and I think there's a
• 01:08:13big difference between someone who
• 01:08:15would never provide an abortion
• 01:08:17under any circumstances versus
• 01:08:18someone who has nuanced views about
• 01:08:21abortion and say would feel deeply
• 01:08:24uncomfortable terminating a pregnancy.
• 01:08:26That were just because a child of
• 01:08:29a different gender were desired,
• 01:08:31for example and and it seems
• 01:08:33it seems reasonable even even
• 01:08:35if I don't agree with it.
• 01:08:37And you know,
• 01:08:38I will fully disclose that that
• 01:08:40I I am staunchly pro choice.
• 01:08:42But you know that that there are
• 01:08:44nuanced opinions out there and
• 01:08:46that that someone who objected,
• 01:08:48perhaps to you know,
• 01:08:49devaluing babies of one or fetuses.
• 01:08:52I should say of 1 gender versus
• 01:08:54another might might have have a
• 01:08:56professional a concern that that
• 01:08:58violates a professional duty of
• 01:09:00theirs to to terminate that fetus.
• 01:09:02That's very different from someone who
• 01:09:04would be unwilling to terminate a pregnancy.
• 01:09:07When the mother's life is at risk
• 01:09:09and I actually would argue that
• 01:09:11that someone who would never be
• 01:09:13willing to terminate under any
• 01:09:14circumstances probably isn't,
• 01:09:16isn't best suited to to providing
• 01:09:18reproductive care because I and and
• 01:09:20I think again the the intent matters
• 01:09:22and the consequences matter in.
• 01:09:24In this case, you know,
• 01:09:26and then the the other question
• 01:09:28about contraception at I I I will
• 01:09:30say and and I you know this,
• 01:09:33this.
• 01:09:33This may be a hot take,
• 01:09:35but I don't really see any any real.
• 01:09:38Professional duty objection
• 01:09:40to providing contraception.
• 01:09:42You know if if you have a personal
• 01:09:44objection to non procreative sex,
• 01:09:46that's fine.
• 01:09:47You don't have to participate in it,
• 01:09:49but I'm not sure where there's a
• 01:09:51professional duty in the practice of
• 01:09:52medicine or nursing that says that
• 01:09:54you you need to make sure other people
• 01:09:56don't engage in that, so I don't.
• 01:09:57I don't actually think there's any valid,
• 01:10:00conscientious objection to approach to,
• 01:10:04saying to denying someone access
• 01:10:07to contraception that that.
• 01:10:09To me, seems deeply unethical.
• 01:10:10Now,
• 01:10:10if someone requests a method of
• 01:10:12contraception that could cause them harm,
• 01:10:14for example,
• 01:10:15someone you know with a significant
• 01:10:16history of venous thromboembolic disease
• 01:10:18and they request hormonal contraception,
• 01:10:20that's going to increase their risk.
• 01:10:21That's a different story right now
• 01:10:23that now you have this professional
• 01:10:25duty of first do no harm.
• 01:10:27If your concern is that providing
• 01:10:29a certain medication might put
• 01:10:31your patient at at grave harm,
• 01:10:33that's very different.
• 01:10:34But just saying I don't.
• 01:10:35You know,
• 01:10:36I don't want you to have this because
• 01:10:37I don't think that it's right to have.
• 01:10:39That's when you're not intending
• 01:10:40to bear a child.
• 01:10:42I don't frankly think that that's
• 01:10:43any of our business as as physicians,
• 01:10:45and there's really no professional
• 01:10:46duty that that can justify
• 01:10:48that, so I think it's really
• 01:10:50important to sort of tease apart.
• 01:10:52You know, again, not where where
• 01:10:54that objection is seated is
• 01:10:56that seated in ones professional
• 01:10:58morality or ones personal morality?
• 01:10:59Because we, we all have a duty to to
• 01:11:02uphold the morals of our profession,
• 01:11:03which sometimes can be interpreted in
• 01:11:05different ways as as doctor Stall stated,
• 01:11:08but. But if it's not,
• 01:11:10if it's seated in our own personal morality,
• 01:11:12that really is is very much not
• 01:11:14related to those professional duties.
• 01:11:16I think we have to be very careful not
• 01:11:19to force our beliefs onto onto others.
• 01:11:24My colleague Doug White, who's written
• 01:11:27about this topic in a number of places,
• 01:11:30address one of the important issues that you
• 01:11:32brought up and he said that conscientious
• 01:11:35objection should be a shield, not a sword.
• 01:11:38And what he meant by that is so,
• 01:11:41so you you you have no right to interfere
• 01:11:44with the patient's ability to get care.
• 01:11:47Even while you might want
• 01:11:49to recuse yourself, right?
• 01:11:51So so if I wasn't in the business of of
• 01:11:55writing contraception prescriptions,
• 01:11:57I would it would not be appropriate for
• 01:12:00me to to tell to prevent that patient
• 01:12:02from going to somebody else who who
• 01:12:04could give them that prescription.
• 01:12:06And, and I think that's an
• 01:12:08important distinction.
• 01:12:09To make right this is this is
• 01:12:11about you as a clinician who
• 01:12:14feels personally morally opposed.
• 01:12:16It's you don't have a right to prevent the
• 01:12:19patient from getting standard medical care,
• 01:12:22so that's the argument I'm making.
• 01:12:26But it's different.
• 01:12:27You know if if it's one thing if someone
• 01:12:30never prescribes contraception, for example.
• 01:12:31So again, as a as a cardiologist,
• 01:12:33I don't prescribe contraception.
• 01:12:34If a patient asks me to prescribe it,
• 01:12:37I will say no, but that's not because I
• 01:12:39have a problem with contraception because
• 01:12:41it's outside of my scope of practice.
• 01:12:43Just like I say no to antibiotics,
• 01:12:46you know, unless someone has
• 01:12:47a prosthetic valve and it's,
• 01:12:49you know, before a dental cleaning,
• 01:12:51you know so that,
• 01:12:52but that's very different than.
• 01:12:53Let's say I'm a PCP and I.
• 01:12:56Let's say I prescribe
• 01:12:58contraceptives to married people,
• 01:13:00but I don't think that I should prescribe
• 01:13:02them to unmarried people because I
• 01:13:03don't think that because I I personally
• 01:13:06object to sex outside of marriage,
• 01:13:07or let's say that you know and
• 01:13:10and any number of those things.
• 01:13:12Those are also very different circumstances,
• 01:13:15so you know, I think that I think
• 01:13:17it's it's important to sort of.
• 01:13:18Keep in mind you know what?
• 01:13:20What are the duties that play that
• 01:13:23are informing how how we act.
• 01:13:26Let me I'm going to get into some of
• 01:13:27the questions just because we're we.
• 01:13:29I do want to make sure that our
• 01:13:31audience has a chance to participate.
• 01:13:33So our first question,
• 01:13:34Doctor Stahl.
• 01:13:35What place does implicit,
• 01:13:36racial or ethnic bias play in
• 01:13:38those who choose to object to
• 01:13:39giving care to a patient?
• 01:13:43I think this is a great question
• 01:13:46and also a troubling element of not
• 01:13:49just contemporary, but you know,
• 01:13:51historical healthcare in the United States
• 01:13:52and and I think what's so challenging.
• 01:13:55Of course about implicit bias
• 01:13:56is is that people are not,
• 01:13:58of course, standing up and saying,
• 01:14:00of course, because I'm racist,
• 01:14:01I will not care for this person
• 01:14:04or because I'm a homophobic.
• 01:14:07I'm not going to prescribe prep for,
• 01:14:10you know, to prevent HIV.
• 01:14:13And so one of the things that I think
• 01:14:16really tricky and and and Doctor Siegel
• 01:14:18mentioned is that these kinds of
• 01:14:21objections can be used as a smokescreen.
• 01:14:23They can be used as a sword,
• 01:14:25and so you know,
• 01:14:27as we think about the systems of
• 01:14:30healthcare and the interlocking ways in
• 01:14:33which you know professional training,
• 01:14:36professional expectations,
• 01:14:38and then institutional standards work.
• 01:14:41I think we have to be really attentive
• 01:14:43to the ways in which implicit bias.
• 01:14:46Is. Often undergirding if not.
• 01:14:53You know, under girding both some of
• 01:14:55the choices people make and then the
• 01:14:58outcomes that derive from them and and
• 01:15:00it's why I think we have to be very,
• 01:15:02very careful about assuming that
• 01:15:05you know any claim that that someone
• 01:15:08says is moral is inherently moral.
• 01:15:10And because I do think it both has
• 01:15:13been and continues to be used in ways
• 01:15:16that are discriminatory and, again,
• 01:15:20not necessarily because the person.
• 01:15:23Is ever going to claim it or even realize it?
• 01:15:25Which is, of course what makes
• 01:15:28implicit bias even more challenging.
• 01:15:31Absolutely thank you, the next question.
• 01:15:35It's actually there are a few
• 01:15:37questions that I'm going to combine
• 01:15:39for Doctor Siegel, which is.
• 01:15:41Could you expound a bit on
• 01:15:43conscientious objection,
• 01:15:43perceived feudal care?
• 01:15:45And similarly,
• 01:15:46I'm wondering your thoughts on cases
• 01:15:48when the patient is unable to make
• 01:15:50their own decisions and surrogate
• 01:15:51decision makers are felt to be
• 01:15:52pursuing care that is futile and
• 01:15:54medical providers want to object.
• 01:15:57Yeah, so that that's that's that's
• 01:16:00that's dominated important our
• 01:16:02part of my professional career.
• 01:16:03So I thank the questioner for asking that,
• 01:16:07you know, at least from the
• 01:16:09critical care perspective,
• 01:16:10the approach to request for feudal care
• 01:16:13have been placed in a a separate category.
• 01:16:17And while I think you could think
• 01:16:20about this from the perspective
• 01:16:23of having a deep seated religious.
• 01:16:26Or even secular moral objection
• 01:16:28to to fetal care.
• 01:16:31You know, I don't think that
• 01:16:33that necessarily stems from
• 01:16:35a religious or moral belief,
• 01:16:37and as much as it stems from concerns about
• 01:16:40being asked to provide non standard care.
• 01:16:43So for example,
• 01:16:46to provide CPR when you know it's not
• 01:16:50going to work or operate on a patient
• 01:16:53for cancer when the cancer is incurable.
• 01:16:57And So what?
• 01:16:58What people in my field have done is
• 01:17:01they've come up with a really almost
• 01:17:03a parallel set of recommendations
• 01:17:05for dealing with what is now often
• 01:17:08called potentially inappropriate care
• 01:17:10and and so basically the idea is.
• 01:17:14That there would be a system for asking,
• 01:17:17you know,
• 01:17:18is the care being provided or
• 01:17:21being requested standard?
• 01:17:23And if not then it goes
• 01:17:25down one pathway if it.
• 01:17:27If the care being asked for was
• 01:17:29standard then it might be more about
• 01:17:31what we're speaking about tonight.
• 01:17:32So a request for an abortion or
• 01:17:35or request to have life support
• 01:17:38withdrawn is is actually well in the
• 01:17:41domain of standard care in the in
• 01:17:44the guidelines from the Americans.
• 01:17:45Ask society I didn't show it,
• 01:17:47but there was actually an algorithm
• 01:17:49that specifically addresses this.
• 01:17:51Questioners question OK,
• 01:17:53which is step one you know,
• 01:17:56is the request standard for,
• 01:17:58not if it's not standard,
• 01:18:00it goes down one pathway,
• 01:18:01which is like this utility pathway.
• 01:18:03If it is standard,
• 01:18:04then the question is is the
• 01:18:06objection seated in some moral
• 01:18:08objection so so that would be the
• 01:18:10the way I would approach that.
• 01:18:13Great thank you. This next question.
• 01:18:16I will throw it out to either of you
• 01:18:18or both of you given the codification
• 01:18:20of rights to conscientious objection.
• 01:18:22Are there currently any states or
• 01:18:24institutions where declaration of
• 01:18:26conscientious objection is part
• 01:18:27of the credentialing process?
• 01:18:32Well, I'm not 100% sure what sort of
• 01:18:35part of the credentialing process means,
• 01:18:38but what I will say,
• 01:18:39and this is alluded to in Doctor Siegel's
• 01:18:42point about the Yale Hospital situation,
• 01:18:45is that in Catholic healthcare and
• 01:18:48Catholic hospitals are run according
• 01:18:49to the ethical and religious
• 01:18:51directives for Catholic Healthcare,
• 01:18:52which is a document that's
• 01:18:54now in its sixth addition.
• 01:18:56So it too has changed over time,
• 01:18:58but it does have very specific rules.
• 01:19:02Not just about abortion,
• 01:19:03but around sterilization around
• 01:19:05end of life care and it is part
• 01:19:08of an employment contract,
• 01:19:10so like this gets into the
• 01:19:12tricky legal terrain,
• 01:19:13which is that a per the church amendment,
• 01:19:16conscientious providers of abortion
• 01:19:18or sterilization actually should
• 01:19:20be protected by law in the sense
• 01:19:23of they shouldn't not be hired.
• 01:19:25They should not be fired.
• 01:19:26They should not be at face any sort of
• 01:19:27employment repercussions if they were
• 01:19:29saying moonlighting at Planned Parenthood,
• 01:19:31right?
• 01:19:31They they worked for.
• 01:19:32Saint Vincent's and Moon and,
• 01:19:34you know, took some shifts elsewhere.
• 01:19:36They shouldn't.
• 01:19:37According to federal law face consequences,
• 01:19:40but employment law changes the dynamic
• 01:19:43and the employment contract which
• 01:19:45requires adherence to the ethical
• 01:19:48and religious directives which then,
• 01:19:50and there's a directive.
• 01:19:51One of the directives is
• 01:19:53about that any sort of.
• 01:19:56Connection with abortion care is
• 01:19:58under this kind of scandal provision,
• 01:20:01so so it's multi layered and complicated,
• 01:20:04but that's a space where the
• 01:20:07requirement to adhere to the
• 01:20:10ethical and religious directives.
• 01:20:12It is a way of sort of forcing
• 01:20:16a type of what might in other
• 01:20:19contexts be conscious objection to
• 01:20:21a practice or an other you know,
• 01:20:24or sort of forces a stance on
• 01:20:27on care that is not tied to
• 01:20:30the professional standards,
• 01:20:31but rather to the churches.
• 01:20:33I'm not 100% sure if I understood
• 01:20:36the question in terms of what
• 01:20:38the questioner was getting at,
• 01:20:39but that's a place where we
• 01:20:41can see an institution.
• 01:20:43Requiring something separate from,
• 01:20:45you know,
• 01:20:47being licensed and you know
• 01:20:49being board certified or other
• 01:20:51types of employment conditions.
• 01:20:56You know, I think I can only speak to
• 01:20:59the issue of end of life care in the ICU,
• 01:21:02which is the world that I live in.
• 01:21:06I have no recollection of ever being
• 01:21:09asked a question of about whether I
• 01:21:12would ever refuse to withdraw life
• 01:21:15sustaining therapy from a patient,
• 01:21:17and that is such standard care,
• 01:21:19you know like so, but but I I could at
• 01:21:23least imagine that somebody on our faculty.
• 01:21:27Could come from a religious background
• 01:21:28where they would be uncomfortable
• 01:21:30doing something like that.
• 01:21:31Like what if?
• 01:21:32What if we hired somebody who previously
• 01:21:35worked in Israel where that was never
• 01:21:38done and they immigrated to the United
• 01:21:40States and joined the Yale faculty
• 01:21:42and and so I actually don't know that
• 01:21:46we're positioned to ensure that that
• 01:21:49a a clinician advertises their their
• 01:21:53potential concerns preemptively in
• 01:21:56a way that would allow us to plan.
• 01:21:58Actually think it moreover,
• 01:21:59could become a a crisis, right?
• 01:22:01Like like a patient asked for this and
• 01:22:04then hopefully one of the other members
• 01:22:06of the team takes over the patients care.
• 01:22:09So it would be, I think,
• 01:22:11a gap in in our system that would need
• 01:22:13to be addressed should that come up.
• 01:22:16Great,
• 01:22:16I got just to that point.
• 01:22:17I mean, it's a conversation I've had,
• 01:22:19particularly with chairs of
• 01:22:21maternal fetal medicine programs,
• 01:22:24particularly fellowships,
• 01:22:24whether or not allowed to ask
• 01:22:27about views on termination,
• 01:22:28which comes up in maternal fetal medicine.
• 01:22:31And so you know.
• 01:22:32And this gets that kind of because
• 01:22:33so much is tied to employment law and
• 01:22:36then the perception of either you know,
• 01:22:38hiring or not hiring.
• 01:22:40For these reasons,
• 01:22:41it gleaning the information,
• 01:22:43at least for some hospital lawyers,
• 01:22:45starts to seem like it might get into.
• 01:22:48You know setting the groundwork for
• 01:22:50an employment discrimination case,
• 01:22:51so which again,
• 01:22:54I think just highlights the
• 01:22:56complexity of developing an
• 01:22:58infrastructure where the knowledge
• 01:23:00and the oversight can actually.
• 01:23:04Emerge in a way that can be effectively.
• 01:23:07Handled like transparent where it
• 01:23:10needs to be transparent and in fact
• 01:23:13shielded where it needs to be shielded.
• 01:23:17Great, thank you. We have a hard
• 01:23:20stop at 6:30 so we're that.
• 01:23:22Time is rapidly approaching and so
• 01:23:25I think there's one quick question
• 01:23:27that I'm going to to address.
• 01:23:29And then there's a final question.
• 01:23:32Sort of with an economics focus that
• 01:23:33I'm going to pose to both of you.
• 01:23:35So one of the questions said,
• 01:23:37could it not be said that physicians
• 01:23:40must exercise judgment in providing care,
• 01:23:41but they should never stand as judges
• 01:23:43on the behaviors of their patients?
• 01:23:45And well, I think that's very nicely.
• 01:23:47That, and in most cases does apply.
• 01:23:49I will say that you know there are certain
• 01:23:50patient behaviors that aren't acceptable,
• 01:23:52namely when those those behaviors
• 01:23:54threaten the autonomy of others.
• 01:23:56So one context in which I've argued
• 01:23:58that conscientious objection is also
• 01:23:59allowable even though different
• 01:24:00people may debate whether this really
• 01:24:02counts as contentious objection
• 01:24:04versus just general refusal of care,
• 01:24:06is that you know if a patient who isn't,
• 01:24:09you know critically ill obviously and
• 01:24:10and to whom something terrible won't
• 01:24:12happen if they aren't cared for urgently,
• 01:24:14or someone who is, you know,
• 01:24:16in a mental health crisis and
• 01:24:17isn't aware of what they're doing,
• 01:24:18but if.
• 01:24:19If someone comes to the office
• 01:24:21and for routine visit and is being
• 01:24:23really abusive and violent,
• 01:24:25I think it's within the rights of
• 01:24:27that clinician team to to decline
• 01:24:29to care for that patient.
• 01:24:30Out of this, you know,
• 01:24:31respect and concern for the safety
• 01:24:34of the health care team and actually
• 01:24:37violence against against healthcare workers,
• 01:24:39particularly nurses,
• 01:24:40is a huge problem in this country,
• 01:24:43and so I think that you know we do.
• 01:24:46There is certain patient behavior that
• 01:24:47I think we absolutely can and should.
• 01:24:49Judge and you know,
• 01:24:51violence and and abusive behavior
• 01:24:53absolutely should not be tolerated
• 01:24:55and our grounds for dismissal.
• 01:24:57You know again,
• 01:24:58with appropriate guardrails such as
• 01:25:00obviously critical illness and or
• 01:25:02mental illness that renders patients
• 01:25:05really unable to understand that what,
• 01:25:07how they're acting is,
• 01:25:09is is not OK, so I I see nodding,
• 01:25:12I think that that's I think we can
• 01:25:14move on because I do want to get to
• 01:25:15this last question a little bit of time.
• 01:25:17We have.
• 01:25:18Do you envision any implications
• 01:25:20of conscientious objection?
• 01:25:21On payment Slash,
• 01:25:22is there any role for payers to
• 01:25:24become involved in establishing
• 01:25:25guidelines for conscientious objection?
• 01:25:27For example,
• 01:25:28if a patient's PCP refuses to provide
• 01:25:30contraception on the basis of personal
• 01:25:32moral convictions and the patient
• 01:25:33therefore must see another clinician
• 01:25:35and therefore incur additional
• 01:25:37cost to acquire contraception,
• 01:25:38is it right that the PCP be allowed to
• 01:25:40charge full price for the visit despite
• 01:25:42refusing to offer full standard care?
• 01:25:48That's a really good question.
• 01:25:51You know, probably don't have
• 01:25:52time to to do it justice,
• 01:25:54but but I I would keep coming back to that.
• 01:25:57It's not appropriate to place
• 01:25:59the burden on the patient who is
• 01:26:02simply seeking standard care,
• 01:26:03and I think the for the physician
• 01:26:06or other clinician who's looking to
• 01:26:09exercise conscientious objection rights.
• 01:26:11There is certain responsibility
• 01:26:12burdens that they have to bear to make
• 01:26:15sure that patients don't suffer as.
• 01:26:18Doctor still has said many times tonight.
• 01:26:20I think the problem is with the
• 01:26:23details and and and I could easily
• 01:26:24see that this is another issue
• 01:26:26that needs to be addressed.
• 01:26:29Great, thank you so much.
• 01:26:31Well it looks like we are
• 01:26:33at our time and again.
• 01:26:35We do have a hard stop at at 6:30
• 01:26:37so I would like to thank Doctor
• 01:26:39Stahl and Doctor Siegel for
• 01:26:41coming tonight to speak with us.
• 01:26:43I think this is a really robust
• 01:26:46and thoughtful discussion about the
• 01:26:47pros and cons of the exercise and
• 01:26:50conscientious objection and medicine
• 01:26:51and I and on behalf of the program,
• 01:26:54I'd like to thank everybody for attending,
• 01:26:56not just this session but also all of our.
• 01:26:59Seminars this academic year I wish
• 01:27:01everyone a very happy and healthy
• 01:27:04summer and hopefully everyone gets
• 01:27:06a little bit of a chance to rest
• 01:27:09and we look forward to seeing you
• 01:27:11in the fall for a new and exciting
• 01:27:13lineup of Evening seminar series
• 01:27:15in in our ethics program.
• 01:27:17So thank you so much and good night everyone.