The President's Council on Bioethics
Thursday, September 11, 2008
Session 3: Conscience in the Practice of the Health Professions
CHAIRMAN PELLEGRINO: Thank you, Robby. We'll now give an
opportunity for the panelists to respond in any way they wish. Dr. Lyerly ,
would you like to go first?
DR. LYERLY: Well, thank you very much for your
thoughtful comments, for reading the position statement so carefully. I
neglect that in my deciding that I'm not going to be able to respond point
by point and particularly to your concerns because in my agreement to attend
and speak at this meeting, I have been - I've agreed also not to discuss the
opinion 385 specifically. So I can only speak on my own behalf.
. . . ACOG's Committee on Ethics is not just a group
of physicians who get together and make moral judgments. We have people
trained in philosophy on our committee, we have people trained in public
health, and we have physicians with a great deal of moral wisdom.
But I will say, though, as a matter of fact is that ACOG's Committee on
Ethics is not just a group of physicians who get together and make moral
judgments. We have people trained in philosophy on our committee, we have
people trained in public health, and we have physicians with a great deal of
moral wisdom. So I think the concern about whether this is a scientific
judgment or a moral judgment should be considered in light of the fact that
the committee is a diverse committee both in terms of expertise and in terms
of views about the sorts of issues that you brought up. Thanks.
CHAIRMAN PELLEGRINO: Dr. Brody .
PROF. BRODY: I guess I would prefer to pass at this
time, if I may, and actually try to hold any comments to questions directed
more at what I said specifically here.
CHAIRMAN PELLEGRINO: Dr. Curlin.
DR. CURLIN: Well, I'll maybe just raise one issue that
might be the first question to Prof. Brody , which is why - you drew a
distinction between mild and strong interpretations of judgments of
conscience or conscientious refusals. You said a mild one would imply
something like standing aside and that a strong would imply some sort of - I
forget the terms you used, but active resistance to or incumbering patients'
choices, and I was curious why you put the refusal to refer - this relates
somewhat to Prof. George's comments - why you put the refusal to refer in
the strong category. How does it constitute an active prevention of someone
else obtaining what they seek?
Okay. Thank you. I'm not happy with those terms. I grasped at something to
call it, and if somebody could come up with some better terms, I would be
grateful. There's a spectrum here, and I think it's a spectrum that - I
think I saw a slide in Dr. Lyerly's presentation that had an arrow with a
thing at both ends of the arrow I think that got at somewhat the same idea.
But there's clearly a spectrum. It's not an either/or.
And at one end of the spectrum I was thinking of actions that primarily
involved the individual health professional standing aside, but that was the
least amount of interference with the patient getting the service that the
patient sought, and at the other end of the spectrum the patient was most
inconvenienced or prevented or coerced from having that service provided by
the action of the health professional.
So the referral was more in the middle of the spectrum. It was not at the
far end of the spectrum, but it clearly put an impediment in the way of the
patient getting the service. If the patient was not as familiar with other
sources of care or other sources of service then the patient would be
relatively more dependent on this provider letting the patient know that
these things existed or that they could help the patient get there.
To the extent that the patient is very well informed and is very
knowledgeable and has the means to go around and to find out other things,
it would be the least amount of impediment. So it might be patient specific
or even social class specific in terms of how much or how little of an
interference that was with the patient's ability to obtain the service.
CHAIRMAN PELLEGRINO: Dr. Meilaender and Dr. Elshtain .
PROF. MEILAENDER: I want to try to just think about a
couple of theoretical questions. I'm more interested in them for the moment
than in the particular issues that get debated here. And I have a question
for Dr. Lyerly and one for Dr. Brody . But first I have a friendly
suggestion, and that is that the use of the language of imposition in these
contexts is always misleading. It suggests the need for complicated
arguments about entitlements that haven't been made.
And if I'm a person who declines ever to use force against anyone else
and you need me to do it in order to protect you and I say, "I'm sorry,
that's something I never do," it would be very peculiar to describe me as
having imposed my values on you. It might be too bad from your perspective,
but I haven't imposed them on you anymore than you would be imposing on me
if you tried to persuade me to do it. So I just think the language of
"imposition" should be gotten rid of.
But my theoretical interest - it's really a very old question. It's just
a form of the "Can a good man be a good citizen" question that philosophers
have been thinking about for a long time. And I have a particular question
for Dr. Lyerly and one for Dr. Brody .
For Dr. Lyerly , you gave us a slide about different ethical
considerations. One of them was conscience, but then there are others -
health, fairness, and respect. And these are all the values in play in the
situation, and they are somehow to be balanced or we're to decide relative
weights or something, and I would like to hear you say more about how one
does that, how this procedure of balancing or weighing takes place. That's
my question for you.
And for Dr. Brody, you had - the fascinating question you raised under
your slide on professional integrity about a professional elevating the - in
this case the patient's needs above his own interests, and then you said
does one's own interest include one's personal integrity. But then you
confused - and I think that's - it's like, you know, "Should I be prepared
to go to hell in order to help somebody," a question which theologians have
But you gave the, to me, puzzling example of physicians who should be
willing to risk their own lives in an epidemic, for instance, to do it, and
then you said, you know, if you'd risk your life, why wouldn't you risk your
But I thought the reason for a physician being
willing to risk his life in an epidemic was precisely that he didn't think
staying alive was the most important thing, that there was something else
that was morally more compelling and obligatory even than preserving his
existence. And that would have something to do with the personal integrity
that you seem willing to think may be - one should be willing to set aside
in embracing what one thinks is evil.
But I thought the reason for a physician being willing to risk his life
in an epidemic was precisely that he didn't think staying alive was the most
important thing, that there was something else that was morally more
compelling and obligatory even than preserving his existence. And that would
have something to do with the personal integrity that you seem willing to
think may be - one should be willing to set aside in embracing what one
thinks is evil. And so I'd like you to just sort that one out for me a
little bit more.
DR. LYERLY: Thank you for your question. I wish had a
truly formulated answer to it because the framework that I presented really
came to me as I was thinking through considerations from the perspective of
the patient, which is I think a perspective that is often not represented in
fine grains to the degree that considerations about conscience itself in the
So as I was thinking about the patient-centered considerations, they
really fell into three categories. Again, one was questions about welfare.
So the harms that might result from the decisions of providers not to
inform, refer, or provide services they find morally objectionable, and I
gave some examples of those potential harms. Some may be palpable,
measurable harms that we as physicians can see. Some may be express harm. So
that's one category that ought to be considered when we're thinking broadly
about the category of patients, the effect of conscientious refusals on
The second is questions about justice and how the decisions that
providers make that lead to differential access to different - to goods and
services. So the degree to which the decisions of providers lead to
differential access - how do we measure that.
And the third is questions - and I think it's really - as you said it's
difficult to find the correct word, and I have been searching for one and
trying different ones on. You know, some might call it respect for autonomy.
Some might think more narrowly, especially when we consider questions of
reproduction about bodily dominion, so deciding whether you can control what
happens to your body, what to die for, et cetera.
So those are sort of three areas that I think there may be different
economies with which to measure them. So, again, theories of justice can
help us with the differential access questions. Other theories about utility
measurement or welfare can help us with the questions about harm to patient
But I think the third question, questions about bodily dominion, are
really, really difficult ones. They'll probably need a theory unto
themselves. But I think it may be helpful to think about them separately as
we're balancing. You know, balancing acts are always difficult.
Beauchamp and Childress worked for years to talk about how you might
balance principles. So that's not something I personally have worked out,
but my hope that as the committee thinks through these problems that those
categories would be helpful distinctions for the applications of theory.
. . . the image or metaphor [of] balance, is
entirely uninformative. It doesn't actually tell us anything about what
we're being asked to do in thinking about these things . . . It's sounds
scientific, but it's not.
PROF. MEILAENDER: I don't want to prolong, but I guess
I'll go on record as saying I think that the image or metaphor or whatever
we want to call it, the balance, is entirely uninformative. It doesn't
actually tell us anything about what we're being asked to do in thinking
about these things, and it's not surprising, therefore, that the way we
balance them turns out to be drastically different from one person to the
next. It's sounds scientific, but it's not.
PROF. BRODY: I actually totally agree with you that the
example of the risking of one's life in the face of an epidemic threat may
be more misleading than informative in that case. I raised it purely to
pique the person's interest to go further into it and not with the idea that
I thought it was any sort of conclusive argument.
And I think that if we were to plumb this sort of toward the bottom, we
would need - in addition to our theoretical account of professional
integrity, we would need a theoretical account of the physician's
And I have looked at the literature to try to find that account of the
physician's self-interest because I believe that ultimately if we're going
to teach our medical students that in order to serve the patient you have to
put the patient's interests - which Dr. Pellegrino reminded me needs careful
definition - just what are those interests - above to some extent the
interests - to some degree, at least, the interests of the physician or the
health provider, what does that mean. And until you can define both sets of
terms, I don't think you've gone very far theoretically.
I have been struck by how often the appeal to
professionalism and altruism is completely uninformed by that account of
what are the legitimate interests of the provider . . . which are to be put
in second place.
I have been struck by how often the appeal to professionalism and
altruism is completely uninformed by that account of what are the legitimate
interests of the provider against which - which are to be put in second
place. So I've tried to inform myself on this issue and, frankly, had a hard
time with it. I don't know where that theoretical account lives.
So if somebody knows that, please tell me. Like, for example, how much
money is a reasonable amount of money for physicians to make so that if they
make more than that, they're greedy and they're putting their interests
ahead of their patients' and if they make less than that, they have a
legitimate grievance? How do we draw that line? How do we even think about
that? I don't know of any ethical literature on that subject.
Please come to Galveston in November 5th to 7th - not now, because
November, I hasten to say, is after the hurricane season - and we'll be
doing a conference on the physician's duty to treat in the face of epidemic
threats, and I hope we'll talk about that, because I think it's a very, very
deep and troubling question and I don't believe the existing literature has
as yet put the lid on it.
But certainly it's the case that we could - one reason to give up your
life or to risk giving up your life is because your professional integrity
seems to require it in order to serve the patient. Another reason to give up
your life or risk giving up your life is because your personal conscience
requires it or your faith commitments require it. That's certainly . So you
could have different reasons why you might be obligated to risk your life.
And so, yes, I absolutely did not prove anything by throwing that example
out, other than to just, as I hoped to say, "This needs to be explored
CHAIRMAN PELLEGRINO: Dr. Elshtain .
I want to raise a question . . . that has to do with
whether we are not often faced with a particular rather comprehensive
morality that refuses to name itself and that is often presented in the
guise of a kind of neutral look at the question. . . a scientific view or a
kind of neutral view as between competing possibilities, morally speaking,
when, in fact, it is not that at all.
PROF. ELSHTAIN: Well, I want to begin by thanking the
three of you for your very challenging presentations and also for your very
obvious concern for the people that you treat and that you teach. I want to
raise a question or develop an issue that Prof. George raised in his
commentary, and that has to do with whether we are not often faced with a
particular rather comprehensive morality that refuses to name itself and
that is often presented in the guise of a kind of neutral look at the
question, because I think that's often what's going on when we get a
positioning sort of from the point of view of those who, in a rather neutral
way, want to look at medical and scientific questions without the sort of
taint of extraneous moralities is often presented as, again, a scientific
view or a kind of neutral view as between competing possibilities, morally
speaking, when, in fact, it is not that at all.
Now, there's a mass of literature by now. It's been accumulating over 20
years criticizing this neutrality argument, most of it written by liberal
political philosophers, not conservative political philosophers. I'm
thinking of people like Michael Sandel , people like Charles Taylor ,
William Galston , and a number of others.
And I think what these folks would say is that it's much better to have
these moralities unpacked and laid out than to assume we have a sort of
neutral view and then we've got a partisan view of some kind and that the
neutral view somehow, the sort of scientific view, has to constantly take
care that the partial or sectarian view doesn't insinuate itself.
And let me give you, Dr. Lyerly , some examples from your presentation
that I think are illustrative of what I'm saying, that there's a morality
involved here. I'm not saying that's wrong. I'm saying that it needs to be
unpacked, understood, and named.
In your discussion of the pro-life woman with, I believe, pulmonary
hypertension - was that the issue, the health issue? And you indicated that
her physician, being himself or herself pro-life, might not raise for her
the possibilities of or explain to her the possibilities of abortion given
the health conflict that she has.
And, again, it occurred to me that in calling her pro-life, you already
presuppose a pro-choice position. The pro-life position came into being in
response to the pro-choice position. So we cannot assume this woman knows
nothing about the alternatives.
So it seemed to me that what was, again, sort of percolating in here was,
again, a particular view of the physician, of the patient, of morality that
wasn't being put forward and instead it was seen as a kind of clear-cut
case, which it clearly is not, of a patient not being well-informed. But,
again, to call herself pro-life, as you describe her, means that she
certainly is aware of an alternative.
In the example of - I believe it was the lesbian woman who came in for -
was it an IUD? It was for some kind of reproductive - yes. And there again
it seems to me that what we have is a situation - with everyone's views on
those sorts of issues, we have a situation where a patient is coming in with
an expressed desire that so far as I can tell has very little to do with
what we ordinarily consider medicine or health.
It's a desire that turns on a particular understanding of the self, a
particular understanding of ethical and social relations, a particular
understanding of where physicians should be in relation to patients'
articulation of what it is they want.
So, again, an example, but lifted out of this whole world view, and I
don't think it helps us very much. It's better to articulate the cluster of
presuppositions that lead to this kind of instance, this kind of example. So
more clarification on that I think would be extraordinarily helpful - you
know, what kinds of moralities are we talking about here, who's imposing
what on whom?
Although I agree with my colleague, Dr. Meilaender, that the language of
imposition is tremendously misleading, because no society has ever existed
anywhere at any time that didn't mandate certain things and that was not
coercive in the implication of those things. Every time we enforce a law,
there's an element of coercion. So I think we have to be clear about that.
I think the language of imposition isn't
tremendously helpful. We need to think of another way of talking about this
because we cannot live with the issue of some kinds of mandates and certain
forms of coercion. Liberal societies try to reduce the coercion as much as
they can, but it's there, although we often don't like to talk about it very
There are all kinds of things that you and I are prohibited from doing
every single day, and we're glad that society imposes for the most part.
I've got to stop at a red light. It's an imposition. So I think the language
of imposition isn't tremendously helpful. We need to think of another way of
talking about this because we cannot live with the issue of some kinds of
mandates and certain forms of coercion. Liberal societies try to reduce the
coercion as much as they can, but it's there, although we often don't like
to talk about it very much.
Dr. Brody , in your case, I wanted to just - a couple of questions. They
tie into the issue of conscience and the kind of Rawlsian position that you
adopt. And I'll try to make this as quick as possible.
In your discussion of conscience you argue that the popular account of
conscience, inner moral sense, et cetera, cannot accommodate inner conflicts
of conscience. I think that's true only if you are approaching conscience
from a strictly deontological point of view. It seems to me that within
other alternative understandings of conscience, there is indeed the
recognition that conflicts of conscience are going to occur, both within the
individual, between the individual and what society mandates, and so forth.
If you look at the whole great tradition of casuistry that we heard
something about this morning, the presupposition is that there are going to
be some mandates of conscience, if you will, that may at times be overridden
because other mandates of conscience trump at a particular point in time.
So, again, it's the adoption of a particular moral philosophy that leads to
that particular view about conscience and doesn't cover the whole at all.
On the issue of Prof. Rawls and the RLPRG - I have no idea how you would
say that - RLPRG, something like that - the group of people that you freely
choose. I certainly didn't freely choose Ms. McCarthy in the seventh grade,
but she's in my head. I mean, the notion that you could simply at one point
sort of say, "I choose you special five people. You're going to be my
reference here," that could become entirely narcissistic.
You know what you would wind up with is a nice group of people validating
you and some of that horrible language. And I want my parents out of it
because they don't like the fact that I've chosen to be a happy-go-lucky
beach bum. So, you know, I don't want them saying anything to me. I want
other happy-go-lucky beach bums who are going to second my motion.
So I'm not sure that this is again a tremendously helpful way to think
about especially moral formation, because most of our - and I'm sure you
won't disagree with that. Most of moral formation takes place before we
start picking who we want to be with in the world.
So I'm afraid these are more comments than questions, but I thought they
might be worth putting on the table for your consideration. Thank you.
CHAIRMAN PELLEGRINO: Next is Peter Lawler .
PROF. LAWLER: Right. And thanks to you all for some
wonderful presentations. They're very thought-provoking. I thought the most
challenging thing Dr. Curlin talked about was this challenge to the
distinction between personal ethics and professional ethics, which you are
to assume, that personal ethics is somehow religious or comes from the group
which affirms your rational life plan. And we have this. We have to take it
seriously; nonetheless, it often conflicts with professional ethics, which
is more objective, rooted more in health.
So you knock yourself out to not want to privilege professional ethics
over personal ethics, but you still did finally, because one seems rather
subjective and arbitrary - you know, who knows where this group comes from -
and the other seems more real and scientific. Prof. Curlin said it. I just
don't see that going on.
When I see conscientious objection, I see doctors giving reasons and
they're giving reasons about health. When doctors conscientiously object to
performing an abortion, because they don't see how abortion contributes to
health. And the same with contraception and the same when they refuse to
prescribe Prozac for ordinary unhappiness and so forth.
And so Robby's objection to abortion is not religious. It may conform
with his religious belief, but he writes book after book showing how it's
rooted in science, the facts about health. This is a matter of legitimate
controversy. And Dr. Curlin had this great quote from Leon Kass where he
says, "As medicine gets more powerful, we become more unclear about the ends
of medicine because it becomes more unclear what health is," and when we
enter the era of enhancement where we'll be able to satisfy people's desires
and call that medicine, when we enter the era of biotechnology, it's going
to become more and more unclear what health is.
So let's give our - Dr. Curlin gives our doctors more credit. They give
reasons. Their objections are rooted in the legitimate controversy - to the
legitimate scientific controversy over what health is. So the more powerful
medicine becomes, the more the domain of conscientious objection should be
allowed to expand because the domain of reasonable controversy over what
health is is going to expand. So I wonder if you diminish unreasonably these
conscientious objectors by calling them merely religious or merely - you
know, referring to whatever that initial group is.
PROF. BRODY: To whom was that question asked?
PROF. LAWLER: I wondered whether you now agreed totally
that Dr. Curlin was right in his criticism of you on that.
PROF. BRODY: I will elect to respond, then, if I may. I
disagree with Dr. Curlin in one way, and I would want to just add a
qualification to what Dr. Curlin said in another way.
The way I disagree with Dr. Curlin is I believe Dr. Curlin has confused
two very different concepts. He's confused conscientiousness with appeals to
conscience. And there are many, many things in life that I could do
conscientiously, and one thing I can do conscientiously is give you moral
reasons in defense of my judgments.
. . .I would want to have a very clear distinction
between simple conscientiousness and an appeal to conscience.
That does not necessarily mean that I have appealed to conscience in the
way I would define - or I take it Prof. Paris would define conscience. So I
would want to have a very clear distinction between simple conscientiousness
and an appeal to conscience. So that would be my main disagreement.
My qualification I would add to what Dr. Curlin said is that I understood
the primary focus of the discussion and came essentially prepared to talk
about, when a professional says, "I don't want to do something," and the
main reason they give for not wanting to do it is, "It offends my personal
conscience," which doesn't have to be religious, but may be religious.
Now, another reason you could give - which I agree is totally legitimate
and should be investigated deeply - is, "I object to this because it's not
professional. It's outside the bounds of the goals of medicine" or the goals
of nursing or pharmacy or whatever. That's a perfectly legitimate line of
argument. It deserves very careful scrutiny.
If I take the first line of argument, "It offends my personal
conscience," I don't believe logically I'm saying anything that necessarily
impacts on any other professional, except those who happen to come from the
same philosophical, moral, perhaps religious tradition that I come from.
. . .if I say it in terms of "This violates my
professional integrity because it's outside the bounds of dealing with
health, it's not a health issue," then I'm implying that no physician of
integrity, no nurse of integrity, no pharmacist of integrity really ought to
do that either.
On the other hand, if I say it in terms of "This violates my professional
integrity because it's outside the bounds of dealing with health, it's not a
health issue," then I'm implying that no physician of integrity, no nurse of
integrity, no pharmacist of integrity really ought to do that either.
They're misguided if they think that they should be doing that.
So those are very different kinds of arguments and they deserve - each
one could be a very serious argument and each one could be accompanied by a
lot of reasons in addition to the appeal to conscience or the appeal to
professional integrity, all of which would then need to be carefully sorted
out. Some might be empirical claims; some might be moral claims. Most in one
way or another, I agree, are going to be value laden, and we deserve to sort
out the value laden features.
So had we wished to, we could have gone in that other direction. We could
have said, "Let's look at what do you mean by professional integrity, what
do we mean by the goals of medicine, the goals of pharmacy, et cetera." And
those are heavily, heavily value laden ethical concepts - what is health.
And we could have gone that way had we elected to do so.
CHAIRMAN PELLEGRINO: Dr. Curlin , did you want to
DR. CURLIN: I think that what Prof. Brody is doing is
defining an appeal to conscience, in my judgment, too narrowly as an appeal
that will not give a further reason and then defining as conscientious
reasoning those appeals that give a reason. And I guess I would say that
certainly I would agree that a physician who says I am not going to provide
this thing that other people think I should provide by virtue of being a
physician or because of my position as a physician needs to give some
account as to why they don't think being a physician implies providing that
Again, in my understanding with respect to all these areas of controversy
those reasons are given. Some people are not as articulate about it, but
reasons are given. These are not arbitrary refusals.
And I think I do agree with Prof. Elshtain that
there's a lot that's hidden - and Prof. George - a lot that's hidden under
the language of standard versus not standard or personal versus professional
or private versus public or objective versus subjective or all that language
- are hidden in this debate about what, in fact, we're obligated to do as
And I think I do agree with Prof. Elshtain that there's a lot that's
hidden - and Prof. George - a lot that's hidden under the language of
standard versus not standard or personal versus professional or private
versus public or objective versus subjective or all that language - are
hidden in this debate about what, in fact, we're obligated to do as
And my last thought on that would be just that medicine would not be a
profession of such prestige historically if people were having to - if the
profession we make implied putting aside things that we think are very good,
but rather the reason it's been seen as a noble profession as it's always
been understood as a professing upward - in effect, taking on new
commitments that are higher, not lower than the ones you had before.
And so the notion that you have a professional integrity and a personal
integrity seems to me wrong-headed in the sense that of course you have
commitments that are specific to your professional role and those that are
not, but having integrity is to know how to act in light of both of those,
it seems to me, not to give up one form of integrity for another.
CHAIRMAN PELLEGRINO: I have a problem. We have lots of
commentators and questions, so we may at some point ask you to just hold it,
and then when you have an opportunity, get it. Prof. Gómez-Lobo .
PROF. GÃ“MEZ-LOBO: Thank you. I want to go back to the
very notion of conscience that underlies part of our discussion. And the
reason why I do this - and I'm addressing this to Prof. Brody - is because
of that claim that certain dictates of conscience ought to lead certain
individuals not to choose a health career. I was really worried about that,
not because I'm about to embark on a health career - it's too late in life
for that - but I think that there's a deep misunderstanding there.
And let me start with the ACOG committee opinion where conscience is -
first it says it expresses a sentiment, such as, "If I were to do X, I could
not live with myself, I would hate myself, I wouldn't be able to sleep at
night," and then the opinion piece goes on to say "according to this
Now, I find that incredible. I mean, it's such a misunderstanding of
what's going on. It may be a consequence of that conscience that I cannot
sleep at night, but conscience is a particular practical judgment as to
whether what I'm going to do is morally right or morally wrong, which means
whether I'm going to harm a human good or benefit a human good.
And in that regard I totally agree with Dr. Curlin . It is in a very
important sense a public judgment. I have to give reasons. I cannot just say
my conscience tells me to do this. I have to go on and give reasons.
And in that regard, for instance, it seems to be absolutely natural and
even a duty of a doctor who refuses to perform abortions to say why he or
she refuses to perform an abortion. I mean, that has to be clear and up
front. It's a human good that is going to be harmed.
Now, if we view it in this way, then there's no
conflict between integrity of the physician or the care giver and the
benefit of the patient. On the contrary, the judgment of conscience is a
judgment about the good of the patient. It's not a judgment about my
Now, if we view it in this way, then there's no conflict between
integrity of the physician or the care giver and the benefit of the patient.
On the contrary, the judgment of conscience is a judgment about the good of
the patient. It's not a judgment about my integrity. It's a judgment about
what objectively I would be doing if I did it and that's why it is such a
Now, I would want to add this on the balancing question. There's a very
serious problem there for the following reason. It ultimately seems to me
judgments of conscience can be modified. In other words, I can be led to
change my judgment of conscience. For instance, if there's empirical
evidence about emergency contraception, for instance. That's seems to me
absolutely natural. Again, that shows that judgments of conscience are
public in a very important way.
But once I have all of the available evidence, once I have decided that
it be wrong for me to do it, I have no further way of judging the truth of
my - of passing judgment on the truth of my conscience. Now, what does that
entail? It entails that there are no occasions in which it would be rational
to force someone to act against their conscience because that person would
always be doing something morally wrong if she would act against her
conscience. So integrity is a derivative of acting in accordance with one's
conscience, but conscience itself stands in a quite different position with
regard to the patient and with regard to health and the basics of the
So I would plead with Prof. Brody , please don't exclude from a medical
or a health career someone who thinks along those lines. On the contrary.
PROF. BRODY: Yes. If I thought that by saying that there
might come a time when one would be forced to suggest to a person of
conscience that because you're a person of conscience you ought not to seek
a career in health care - I would be horrified if that was a common sort of
However, I gave one example, which I think typifies the sort of very
extreme case I had in mind where that might come up and that was the example
of the Jehovah's Witness anesthesia resident who would not give a blood
transfusion to a non-Jehovah's Witness patient even if the consequence might
be the death of the patient.
Now, I believe that someone - I can't remember where I read this - but
someone gave the example of would a Quaker, for example, or a pacifist seek
a commission to West Point . At some point, practically speaking, there's
such a conflict between what you feel required to do as a matter of
conscientious commitment and what you know is a role responsibility normally
expected of people who undertake that kind of career that there's a serious
question of practical wisdom or prudence of saying that's the field of work
I want to go into. So that was the kind of extreme case, exceptional case,
that I had in mind.
I also thank you for highlighting the question about how your conscience
could be wrong and you'd want to give reasons and why it's a public act of
giving reasons to correct the conscience if the conscience is mistaken
because I think I just heard a minute ago Dr. Curlin say that I said that
when you appeal to personal conscience, then you don't have to give any
reasons. So I hope I didn't say that.
I certainly did not intend to say that, and I hope that by saying
conscience can be corrected and could be wrong, I specifically made that
point, that, yes, you could be called upon to give reasons. And often giving
reasons is a part of the exercise of conscience.
CHAIRMAN PELLEGRINO: Paul McHugh .
PROF. MCHUGH: I also join in the chorus of thanks to all
of you for your thoughtful presentations, and my comments are really
comments that come in part out of ignorance of the philosophy, but out of a
lot of experience dealing with patients who say they have needs. I'm very
worried about "needs" when a patient comes in and tells me that and so
therefore I was a little concerned about this little diagram that overlapped
conscience with patients' needs.
Most patients' needs turn to out to be wants, wishes, and sometimes
fantasies, and our job is to sort them out. But where I come to want to ask
a question and relate to what's been said, Dr. Brody , it begins with you,
this very helpful distinction that you are making between what were private
commitments and publicly made commitments, and particularly in oaths. You
made that point.
I took an oath. I took the old Hippocratic Oath, the plain old
straightforward, no abortions, no physician suicide, the old, hard line
things like that and stick to to this day. And the point that you were
making in drawing that sharp point I thought - and I might be wrong about
this - is that you said that usually the public commitments were related to
a public - to a given public stance where, at least in our society, things
were settled on those public issues.
And I want to remind you that you could make a public statement like the
public Hippocratic Oath and be at war with what the public stance became.
And I want to remind you - I might make reference to three books that have
been written in the last five years on each one of these matters that proved
how often the physician publicly committing himself to the views of the
Hippocratic Oath that was both private and public in that sense - you get
up, say it, and do it - proved that they had that public commitment, really
meant something that was driven by his real private sense.
And the three books - one was the book by Kevles on eugenics, where 35
states in the union sterilized people because they thought they were
mentally retarded. And many of those people were not, and many of them
weren't even told that they were going to be sterilized and were distressed
to learn later in life that their failure to conceive had been done to them.
Okay, and that's the first one. [Daniel Kevles, In the
Name of Eugenics: Genetics and the Uses of Human Heredity (Cambridge,
Mass: Harvard Univ. Press, 1998).]
The second arena that has just been recently was a book by a historian at
Columbia - H. Scanlan , I think. The title of the book, the fascinating
title of the book, is Fatal Misconception. It's a marvelous book on the
imperialism of American contraception imposed upon the people of India and
China and other places of this sort where what ultimately has come - because
we had no - we were so committed to our view on population and had no reason
to - we're not going to be held responsible are now held responsible for
having done things like enforced sterilization amongst those people.
[Matthew Connelly, Fatal Misconception: The Struggle to Control World
Population, Harvard University Press, 2008.]
And then the final book written only a year or so ago is Helen Epstein's
book entitled The Invisible Cure [NY: Picador, 2008] where our
medical services going into Africa to try to help in HIV totally refused to
listen - thinking in mechanical terms refused to listen to the women of
Uganda who had demonstrated unquestionably that the partner reduction
approach was the correct approach to the ending of it, whereas, we, running
our zeal for the condom method, continued to have a huge a death rate for
HIV in young women in other African countries.
Again, you made a point that you - this might not have been where you
were going to come in, but I want to ask you that question, why you would
think that a public commitment that was voiced in terms of care of patients
might not sometimes run against the public stance on matters related to
services to people.
PROF. BRODY: Thank you for the challenging question,
because I think you've - frankly, I think you've wrapped up a number of
very, very important issues, and I am going to have a very hard time
disentangling them in order to be able to say anything at all wise.
Let me be very simplistic in responding to just one point, which is what
is the big deal about the public promise. And what I'm saying is when
physicians get up together and say the oath - and what I meant by that was
less the content of the oath, but the idea of we all get up and say the oath
- is the ability of the public then to trust physicians to have made some
kind of promise to them for which we are accountable.
And my willingness - if I am hit by a car on the way across the street to
get back to the Metro and I am whisked to an ER here in Washington and I
don't know the doctors, I don't know the nurses, on what basis am I going to
trust that they will be looking out for my health.
And a very important piece of the reason I'm going to trust them and I'm
going to not demand that I see their biographies and did they really get
their diploma, et cetera, et cetera, is because I imagine they have engaged
collectively in this commitment to the well-being of the patient, that I'm
now a patient and I'm going to take advantage of their commitment to my
So it's really that ability of the public to respond to this public act
with the bestowal of trust. And to have that trust be merited, not just, you
know, a mistaken trust on the part of the public, but a merited trust in us
because we've taken this commitment is what I frankly - was at the root of
this appeal to the public.
Now, then, I would just simply add to that - if I go back to my example
of should a pacifist seek a commission at West Point, I would imagine that
there are folks at West Point who believe, for example, that American
military policy today is very misguided and that if they ever were to rise
up far enough into the - there may be only a few of them, but if they were
ever to rise up high enough in the hierarchy, they would do what they could
to change that policy.
And it is good and it shows that we are a vigorous and lively profession
if there's this active dissent in our ranks about what do we mean by our
commitments, what did we promise the public, what is health. These are all
questions that are potentially contested, these are all questions on which
some scientific facts are pertinent and moral values are pertinent and
social policy is pertinent. As you point out, international relations are
even pertinent. And so we should be having a vigorous debate about this
And so whatever I get up and promise the public that I'm going to do - I
may have my personal doubts about it. I may carry out internally a dissent
within medicine about it, but I have to be careful of when I treat my
patients to be sure that I don't confuse my personal take on this
contentious issue with the larger commitment made by the whole profession.
So there are some things where we can have a lot - it just so happens
that we have a lot of agreement within the profession about what we ought to
do, and there are other instances where there's a lot of disagreement about
what we ought to do, and I at least ought to be clear on that.
I ought not imagine that if I'm a minority of just a very small number of
physicians who believe something that I speak on behalf of all of medicine
when I get up and say that thing. That's what I think we need to guard
CHAIRMAN PELLEGRINO: I have five members of the Council
who wish to comment, and we're checking on seeing whether we need to
evacuate this room at 5:00 . I don't know. We'll be finding out shortly. So
Dr. Carson .
PROF. CARSON: Just a short comment with perhaps a short
rhetorical question associated with it. First of all, I thank the three of
you very much. I think most of what was said has general applicability to
the medical profession and is very wise; however, when it comes to what I
call 50/50 issues, things like euthanasia and abortion where you have very
substantial portions of the population that have varying opinions, I wonder
if maybe our energies could be better spent looking for ways to be able to
I sometimes feel on these kind of discussions that we're in Congress, you
know. You can't get anything done. It's my way or the highway. And, in fact,
even going to an extreme example, such as the Jehovah's Witness - and, you
know, obviously as a surgeon, I give plenty of blood, but let's say someone
was a Jehovah's Witness anesthesiologist - you know, I run into a lot of
Jehovah's Witness patients who don't want any blood. Maybe we compare those
people - the point being that perhaps if we spent a little extra time
figuring out ways to accommodate as opposed to exclude, we could get further
along in this argument.
CHAIRMAN PELLEGRINO: Next I have Dr. Hurlbut .
DR. HURLBUT: I want to continue in the line of discussion that Alfonso
and Paul had initiated and I wanted to ask Dr. Lyerly, is it impossible to
put the slide with the quote from Julian Savulescu back up?
DR. LYERLY: I don't know.
DR. HURLBUT: As you try to do that, let me go to where I
want to go here. What I want to try to get at here is - first of all, I want
to ask you a question and then I want to make a comment on it, depending on
what you say, of course. But I want to get at the challenging dimensions of
what we're actually doing here, because it's easy to focus on a single issue
like abortion or sterilization and miss the larger context of the drift of
medicine across time and culture and so forth, and we need to seek a very
broad foundation for the future of medicine.
And so I want to just specifically ask you, Dr. Lyerly, in your report
what principle of professional obligation did you - where did you draw -
more specifically I'm a little troubled by what's already been brought out -
the emphasis on conscience being sort of a personally driven thing, and then
just a page later you say, "By virtue of entering the profession of
medicine, physicians accept a set of moral values and duties that are
central to medical practice." And where do you see those as coming from, I
guess is the chief question.
DR. LYERLY: I'm not at liberty to comment on 385.
DR. HURLBUT: Okay, your own opinion, then, on those
DR. LYERLY: I mean, I've been asked not to comment or -
I've been asked not to comment on the document, and so I really can't do
that. I'm sorry.
DR. HURLBUT: Okay, let's forget about the document.
Let's go back. We're talking more broadly about the very crucial issue that
Dr. Curlin has raised about professional obligation, and I think he's zeroed
in on the key question here. What are the professional obligations? They're
clearly not just individually decided on from somewhere or nowhere. What
would be our sources for this - for understanding these parameters?
DR. LYERLY: How might we understand the professional
obligations of doctors and other health professionals?
DR. HURLBUT: Right. Where do we go?
DR. LYERLY: I mean, I think that's a wonderful question
for this group to start thinking about. I mean, what I would add and what I
tried to reinforce today is that conversations about health and the aims of
health need to engage the perspective of the people who will be benefited or
be harmed by its provision.
So it is not just the providers of health care or even theorists about
health and its meaning that should be at the table, but it needs to be
people that live in these bodies, experience the impact or not of
conditions, technologies, living in the world, living in cultures, and we
need to incorporate those views as we think forward about what the aims of
DR. HURLBUT: In other words, the good of the patient. I
mean, that's what you're saying?
DR. LYERLY: Right. I think that's part of it, but what -
for us to understand what health is and what the goals of medicine are, we
need to hear how people experience what we do. So that's an important part
of the equation that I don't think has been there.
I think in the last ten, fifteen years we've been much better at
gathering data about that. We've gathered beautiful empirical data about how
people experience end-of-life care and it's transformed the way that we
provide it. We're beginning to collect data to listen to people about how
they experience care during the process of birth, and I expect that that is
also going to change the way that we think about pain in labor, support, et
So in crafting what we think is good health care, we cannot do so and we
can't think about whether it meets ethical standards unless we listen,
unless we take a moment to listen. So I just - I would urge the brilliant
people who are deliberating about this to consider the views of people who
experience patient -
DR. HURLBUT: Is the quote possible to show or no?
PROF. ROWLEY: Come on, now.
DR. HURLBUT: Can you read it?
PROF. GOMEZ-LOBO: "If people are not prepared to offer
legally permitted, efficient, and beneficial care to a patient because it
conflicts with their values, they should not be doctors."
DR. HURLBUT: So, look, I can certainly agree with you
about listening to the patient, but it seems to me there are other things we
have to listen to and not - and these are very serious issues, because we
want to transcend time and we want to transcend culture as we deliberate on
And the quote that was read seems to - there's something wrong in it, and
I can feel it. It's excluding people from the dialogue by saying, "If you
don't like it, don't go into this profession." And so what I'd just like to
briefly lay out is a couple of parameters that have not been mentioned.
It seems to me that the examples that are given in the paper -
sterilization, artificial insemination for a lesbian - one might add issues
you didn't bring up like face lifts or growth hormone. How do we decide
these kind of issues?
Now, quite apart from whether or not they should be legal or not, there
ought to be some reference to - in grounding medicine to the natural
standards of health and the eminent powers of the body. And I can't see that
some of the issues that you've raised as sort of moral controversies qualify
I mean, whether or not it should be legal for a lesbian to be inseminated
is quite different from the question of whether a physician should feel like
that's part of his profession obligation. It doesn't seem to me that that's
part of the natural eminent powers of the body to be inseminated without the
act of sexual intercourse.
Now, maybe I'm wrong. Maybe you could make an argument for that, but it
seems to me that by saying in the text that you supplied that she was
prompted - this physician was prompted by religious beliefs and some
disapproval of lesbians having children - I mean, that doesn't seem to me
necessary to label that a religious belief. There's an attitude there that
might say, "Well, that's not a natural phenomenon that I'm trying to heal."
Do you see what I'm saying?
DR. LYERLY: Again, I'm not at liberty to comment on the
paper, but I will say it sounds like you are making an important
contribution to thinking about how we're going to define health. And there
is a claim that it has to do with - I don't want to misquote here, but
having to do with the body's natural functioning. Is that correct?
DR. HURLBUT: Some reference to natural functioning, yes.
DR. LYERLY: So I think an argument can be made for that,
certainly, but I don't think that we can take that as truth anymore than any
of the other considerations on the table without a moral argument for it. So
I think that would be an important thing to think about, but I don't think
we need to presume it is or it's not at this point.
DR. HURLBUT: But just to make a brief conclusion of
this, it seems to me that - I mean, we're talking about an issue - say just
the abortion issue alone. There's an enormous history on this issue. I mean,
here just for example from the physician's oath in the declaration of Geneva
in 1948, "I will maintain the utmost respect for human life from the time of
conception, even under threat."
I mean, this is very different from the prevailing sentiment that's going
on right now, and there seems to be a sort of social pressure that's being
imposed on the medical profession as a whole to accept this kind of realm of
things as though it has no past. And it seems to me if we're going to enter
a profession, as your document says, with moral beliefs and values that echo
our profession, we should look more seriously at history.
We've got a very challenging era ahead with
biomedical technology. It's knocking off balance. The new paradigm for
medicine seems to be liberation, not a reference to what would be called
restoration or healing of the body. This is going to challenge us very
deeply, and if we don't have any grounding in this, if we simply say, "If
you don't like it, don't join the profession," that seems to me setting us
for some big problems. It's like closing the conversation rather than
We've got a very challenging era ahead with biomedical technology. It's
knocking off balance. The new paradigm for medicine seems to be liberation,
not a reference to what would be called restoration or healing of the body.
This is going to challenge us very deeply, and if we don't have any
grounding in this, if we simply say, "If you don't like it, don't join the
profession," that seems to me setting us for some big problems. It's like
closing the conversation rather than opening it.
And just to emphasize this, before we had the session I went back - and
admittedly this is heavy-weighted and maybe disproportionate - but I went
back and I read a couple of papers on medicine under the Nazi dictatorship,
and, boy, they're powerful things. I mean, it's hard to believe that some of
us in this room were alive when this was going on.
And just to give you two brief quotes, it says, "The chief of the medical
institution Hjalmar was responsible for the murder of over a thousand
patients. He personally opened the containers of gas and watched through the
peephole the death agonies of the patients, including the children."
And then at the Nuremberg trials he stated, "I was of course torn this
way and that. It reassured me to learn what eminent scientists partook in
the action." And then Leo Alexander , who wrote part of the Nuremberg Code,
warned us. He said, "Whatever proportions these crimes finally assumed, it
became evident to all who investigated them that they had started from small
beginnings. The beginnings at first were merely a subtle shift in emphasis
in the basic attitude of the physicians. It started with the acceptance of
the attitude basic in the euthanasia movement that there is such as thing as
a life not worth living."
Just to conclude, let me point out that the guy whose quote you used,
Julian Savulescu, who would like to say some people shouldn't join the
profession if they just can't get along with the standards, has himself
advocated the creation, gestation, and harvesting of cloned human embryos.
And this is a quote. He says, "Indeed it is not merely morally permissible,
but morally required that we employ cloning to produce embryos or fetuses
for the sake of providing cells, tissues, and even organs for therapy
followed by abortion of the embryo or fetus."
I think the last thing we need right now is to be telling people that
they shouldn't go into medicine. If anything right now, we need some
diversity of views and take this issue of conscience very seriously.
DR. LYERLY: I absolutely agree with you. I think it's
wonderful that this committee is taking on this issue. I spoke to one of the
committee members earlier and I - in addition to recognizing how important
this issue is, I actually think it's a place where there's a potential for
good, valuable, deeply rich deliberation.
I was asked by Dr. Pellegrino and Dr. Davis to demonstrate a range of
views that's out there right now. They fall on a spectrum. I was asked not
to advocate for a single position, but to demonstrate a range of views. I
used Savulescu's quote word for word because I think it does show a view on
one end of the spectrum, which is a very - a view that is very impermissive
of conscientious refusals, which I agree with you are - the role of
conscience has a critically important place in medicine and bioethics.
So as we think forward, I think that dialogue is absolutely important. I
think to engage in that dialogue with respect for people that don't hold the
same views as you that bring to the table different conceptions of health,
that bring to the table different ideas of what matters in how we should set
professional standards, how we should treat our patients and the like - I
think that conversation is absolutely vital.
Its tenor goes up several notches when we're talking about elective
abortion, but it's important to a range of issues that arise in medicine. So
I think - just in closing I think - I agree with you this is an important
conversation. It's not going to serve anyone to shut people down on either
edge, but in order to understand that there's a range of views - I mean,
it's helpful to look at the edges.
And there has been some conversation today that we weren't
contextualizing conversation, but that was partly what I was attempting to
do with my introductory remarks. And I think we all come to the table with
certain moral views, some of which we are wearing on our sleeve and some of
which are very deeply held and we may not recognize it as starkly. So that
being said, I appreciate your view and I think that thoughtful deliberation
on this is exactly what we should be doing.
CHAIRMAN PELLEGRINO: I'm going to use the chairman's
prerogative. We have three more members of the Council who would like to
speak. We'll give them an opportunity to make their comments and then afford
the opportunity of a response on the part of our panelists. I have Dr.
Rowley , Dr. Dresser , and Dr. Landry in that order.
DR. ROWLEY: Mine is going to be very short, and it was
just somewhat similar to a concern of Dr. Brody's that Dr. Curlin seems to
me to have - in his early examples, they were people who - physicians who
disagreed with one another on various aspects of the appropriate medical
care, and I think that's very different than the matters of conscience that
we are discussing in this particular session. And those I would have
classified as more differences amongst clinical judgment. And I think that
they have to be separated out from matters of conscience.
CHAIRMAN PELLEGRINO: Thank you, Janet . Dr. Dresser .
PROF. DRESSER: Well, we have this pluralistic country
and practice of medicine and it's also organic in that it's changing and we
- and I'm sure in a hundred years we'll look back on things we approved of
today and shake our - people will shake their heads, so on and so forth.
. . . I would like . . .to talk about accommodation,
more about what institutions, professional organizations, medical schools,
and so forth can do in terms of procedures, systemic approaches to allow
people who have objections of conscience to act accordingly and at the same
time to meet the standard of care.
So I guess I would like to second Ben 's statement about - to talk about
accommodation, more about what institutions, professional organizations,
medical schools, and so forth can do in terms of procedures, systemic
approaches to allow people who have objections of conscience to act
accordingly and at the same time to meet the standard of care.
I agreed with Howard Brody 's comment about how many of these can be
settled within institutions. You just have to plan. People who come in who
have objections need to - have a duty to state them and others need to be
aware and there needs to be arrangements made. Perhaps in some cases it's
not possible, for example the Jehovah's Witness, but it seems to me it's
easy to get very polarized and rigid and say, "Oh, patients need them,
personal conscience and so forth," but this is a social/professional
problem, as well.
And so it's perhaps not as interesting to talk about things like
scheduling and so forth, but it seems to me that's where a lot of this will
live out and you can minimize the damage on both sides by working on that
CHAIRMAN PELLEGRINO: Thank you, Rebecca . And Dr. Landry
PROF. LANDRY: I'd just like to say thank you to the
panelists, and just some quick comments about conclusions. Dr. Brody , in
yours you look at mild versus strong interpretations, and perhaps that's a
way. There's wiggle room to sort of get by. And the idea is that willingness
to refer will be mild and unwillingness will be strong.
But then there was an aside about rural areas, and I got the feeling that
if you're in a rural area and there was no one else to do it, then
willingness to refer might end up being strong because to be mild you really
have to perform it. And so maybe these aren't such absolute categories.
They're sort of relative.
And the bottom line is you can object to the extent to which it doesn't
have an effect. If it doesn't effect, then you're in sort of the other
category. If you don't regard that as entirely fair, you can comment.
And, Dr. Curlin , you made an appeal that physicians who have their range
of conscientious objection narrowed would be reduced to technicians, but
isn't it more likely that they'll just be driven out. Some specialties will
soon become hostile work environments and you'll get sort of the equivalent
of ethnic cleansing. It will be sort of a ethics cleansing, and you'll get
to the homogeneous view with potential on the other side.
I mean, I think a 38-year-old woman in New York or LA who becomes
pregnant actually gets a lot of pressure for amniocentesis, and with a
Down's diagnosis a lot of pressure for abortion, which would then harken to
the issue of this being simply a matter of politics and political views and
not really a science driven enterprise. So those are my comments.
CHAIRMAN PELLEGRINO: Thank you very much. Now we'll give
an opportunity for each of the panelists to make what comment they would
like to make. I'll start with Dr. Curlin .
DR. CURLIN: If I can begin with the last comment, I
think that they would be both driven out as well driven being technicians in
this sense. And I don't want to make it overdramatic. At this stage most
people of a wide range of moral views can effectively practice and are not
being driven out, although there seems like there's a growing sense of a
But they would be, of course, driven out if they were required to do
things that they could not in good conscience do. They would have to, to
live with understanding and live with integrity, leave the profession.
But they would also, I think - the profession is driven toward a
provider/consumer model because the impulse that leads - and it comes out in
all these essays - that leads to the judgment that we should constrain
conscientious refusals is something on the order of "Doctors have no
business making judgments about whether that thing is good for patients or
they don't have the authority to make that judgment, or if they do make that
judgment, that's a threat."
And so to the extent doctors retreat from - and Prof. Brody in that essay
about , I don't need - if I'm misinterpreting how it would apply to this
situation, I'll let him to speak that, but it said that what you don't want
is doctors retreating from making recommendations, retreating from seeing
themselves as responsible for your good, responsible for your health. And to
the extent you say, well, you're responsible so long as you are willing to
do these things that you think are not ethical, then I think that drives in
And with respect to Prof. Rowley 's comment, I do think there is a
difference between disagreements that you described as clinical judgment.
You said some are clinical judgments versus appeals to the conscience. They
are different, but the difference is in some cases you have an agreement
about what the ends of medicine are, about what we're after here, and a
disagreement about how best to pursue it.
The difference is not that one is conscientious and one is not. The
difference is that some are disagreements about what the ends of medicine
are and some are disagreements about how to achieve those ends. And then
within the former - about what the ends of medicine are - sometimes these
disagreements track onto religious teachings and some don't.
And it seems to me that in our culture, because of these rubrics of
private versus public and whatnot, those that can be seen as tracking more
directly onto religious disagreements are seen in a kind of prima facie way
and I think in an incorrect way as being less valid to be considered in
one's making decisions about one's practice.
CHAIRMAN PELLEGRINO: Dr. Brody .
PROF. BRODY: Specifically in response to Dr. Lawler's
comment, which was quite helpful, I would ask you that if you wish to
consider what I said to see whether it's of some value for your
deliberations here, please keep in mind the title "Two promises."
The reason I say that is because - if I may give an analogy - it may be a
very, very imperfect analogy - I believe today I made two promises. I made
an implicit promise to my wife that if our home were to be threatened, I
would be at her side and would not go running away to some academic thing
that would take me away from my home responsibilities, and I made a promise
to the President's Council on Bioethics to be here at this hearing.
Whether I'm able to keep both promises has a lot to do with how fast a
certain hurricane is moving across the Gulf of Mexico and which direction
it's going. I may find tonight that I was able to get home in plenty of time
and do what I need to do and all will be well. I may discover that I was too
late and I'm trapped in Washington and she's trapped in who knows where. And
a lot of practical things will get in the way of whether I'm able to keep
both promises or whether I find that my commitment to one promise interfered
with my ability to keep the other promise.
So it may seem cute or sort of begging the question if I said, well, the
rural circumstances may be different, but sadly, I think, if you look at it
from the point of view of these are two promises - and I believe - the
reason I said two promises is because I happen to share the concern people
have with the idea of balance.
I wanted to avoid the idea that we're trying to balance something, and so
I was looking for another way to say that, that I hoped would be more
enlightening. And I chose the two promises, and maybe it worked, maybe it
didn't, but I think your comment gets right to the heart of what might be of
value or might not be of value in making that analogy of the two promises.
And just to complete, since we are looking back at slides, I would like
to read my last slide, because I believe it very much fits with what Dr.
Dresser said and what Dr. Carson said. My last slide was titled "Personal
"In the future we will see more examples of conscientious objection dealt
with by local accommodation in the spirit of mutual respect and few
instances of the use of political or financial power to favor only one
CHAIRMAN PELLEGRINO: Thank you, Howard . Dr. Lyerly .
DR. LYERLY: Well, that would have been a beautiful way
to end on hope, but I just want to take a minute to address a worry that
seems to have surfaced today, which I find interesting and not one that had
struck me particularly, and I wonder if it's just the way that we think
about things, namely that limitations or potential accommodation of
providers' rights of conscientious refusal necessarily are going to
translate into a provider/patient relationship in which one is the
technician and one is the consumer of goods.
I think what the concern is on the side, too, of individuals that are
worried about the expression of conscience is also silence in that
relationship between doctor and patient, that not talking about options, not
exploring the ways in which those options might have meaning for somebody,
but instead refusing to talk about things and refusing to make sure that the
patient's needs - and I don't consider the patient's needs frivolous. I
consider them deep and concerning and oftentimes not intuitive - you know,
how to make sure that those things are met.
And so in some ways it may have to do with the idea of what sorts of
things a conversation can do. So if we're only talking about conversations
being an exchange of information or the provision of - or attempts to
persuade people to do one thing or another, then I can see where that
concern comes from. But conversations do a lot more.
Conversations between patients and their physicians establish trust, they
help shape options for people, they make people feel cared for, and my sense
is that that is and continues to be a goal for people who are concerned both
about maintaining providers' rights to conscience and also about individuals
who are concerned about the impact of expression of conscience on patients'
Thank you very much. You three
panelists really put on a heavy afternoon, and we really appreciate it.