Conscientious Objection in Medicine

June 17, 2022

Information

June 8, 2022

Sarah C. Hull, MD, MBE
Assistant Professor of Medicine (Cardiology)
Associate Director, Program for Biomedical Ethics
Yale School of Medicine

Ronit Stahl, PhD
Associate Professor, University of California, Berkeley, Department of History

Mark David Siegel, MD
Professor of Medicine (Pulmonary)
Program Director, Internal Medicine Traditional Residency Program
Yale School of Medicine

ID7915

To CiteDCA Citation Guide

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&amp;A session at the end.
01:05You're welcome to enter any of
01:07your questions through the Q&amp;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&amp;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&amp;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&amp;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&amp;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.