Conscientious Provision of MAID and Abortion: Robert Brody, Lori Freedman, Mara Buchbinder
Today\u2019s podcast may be a stretch for our listeners.\xa0 Please stick with us.\xa0 No matter what your position on medical aid in dying (I\u2019m ambivalent) or abortion (I\u2019m pro-choice), this is a bioethics podcast, and I hope that we can all agree that the ethical issues at stake deserve a critical re-think.\xa0 All three of today\u2019s guests are well established bioethicists.\xa0\xa0
Let me start by quote/paraphrasing one of today\u2019s guests, Mara Buchbinder, who puts her finger on the issue we talk about today:\xa0\xa0
\u201cTypically when we think about conscience in medical ethics we think about it in terms of\xa0 a negative claim of conscience, where a clinician refuses (or objects) to provide care.\xa0 But what we know from my research and those of others, people also articulate a positive claim of conscience: they feel compelled to provide a service - whether it\u2019s abortion provision or medical aid in dying -\xa0 because of a deeply held conviction that this is the right thing to do.\u201d\xa0\xa0
I\u2019ll continue by quoting Lisa Harris, who wrote in the NEJM:
Bioethicists have focused on defining conditions under which conscientious refusals are acceptable but, with rare exceptions, have neglected to make the moral case for protecting the conscientious provision of care. Indeed, there is a real asymmetry between negative duties (to not do something) and positive duties (to do something) and, accordingly, between negative and positive claims of conscience. Violations of negative claims are considered morally worse than violations of positive ones.However, as bioethicist Mark Wicclair argues, the moral-asymmetry thesis does not provide adequate ethical justification for current conscience law, which protects only conscience-based refusals. Moral integrity can be injured as much by not performing an action required by one's core beliefs as by performing an action that contradicts those beliefs.
Lisa was writing about providing abortion care, but she just as easily could have been writing about providing medical aid in dying in states where it is illegal.\xa0\xa0
Today we wrestle with this issue of conscientious provision.\xa0 We start by talking with Robert Brody, an internist who recalls physicians helping patients die during the height of the AIDS epidemic in San Francisco.\xa0 Robert was first asked by one of his own patients for assistance in dying in 1991, far before aid in dying was legalized in California in 2016.\xa0 Robert went on to be the founding chair of the board of Compassion and Choices, the major national advocacy organization for medical aid in dying.\xa0 Today, medical aid in dying is legal in some 10 states, and illegal in others.\xa0\xa0
Also today, in the wake of the Supreme Court\u2019s recent Dobbs decision, some 13 states ban abortion.\xa0 To examine how clinicians might act in the face of such bans, we turn to Lori Freedman, who wrote a book about clinicians (primarily Ob-Gyn\u2019s) who work in Catholic Hospitals.\xa0 She describes the \u201cworkarounds\u201d these clinicians used to skirt the rules in order to provide reproductive care for women.\xa0\xa0
We talk about the parallels between these issues at the beginning and end of life, and areas in which these parallels fall apart.\xa0 For example, Jack Kevorkian excepted, clinicians have not been prosecuted for providing aid in dying in states where it is illegal. In contrast, there is a justified fear of prosecution of providing abortion care in states where it is illegal.\xa0\xa0
It took contemplation on a bike ride to put my finger on why I \u201cwrestle\u201d with the notion of conscientious provision.\xa0 On the one hand, when I hear of Ob-Gyn\u2019s in Catholic Healthcare systems using \u201cworkarounds\u201d to provide reproductive care, I\u2019m standing up and cheering on the inside.\xa0 On the other hand, when I hear of workarounds to assist patients to die, or even euthanize them, I worry that we\u2019ve gone back to a time when the doctor or nurse knows best - and should be morally permitted to do whatever they think is right, according to their conscience.\xa0 Do we really trust all doctors and nurses so far?\xa0 Would you, with your parents, trust any doctor or nurse to make such life or death decisions, regardless of the law?\xa0 There have to be limits to conscientious provision, just as there are limits placed on conscientious objection. In conscientious objection, there are general rules, such as: the patient must be given time to seek a clinician who is willing to provide the treatment; and clinicians can only object to specific treatments under specific circumstances.\xa0 And yet, I worry about explicitly creating ethical rules for conscientious provision. Ought we, in bioethics, create ethical rules for providing care that is illegal?\xa0 Who will follow them, and what would be their incentive for doing so?\xa0 Would such ethical guidelines foster or feed suspicion of the motivations of bioethics?\xa0\xa0\xa0
We could have talked for hours. We may reconvene for another podcast as we see how these issues continue to unfold.
Oh life. It\u2019s bigger. It\u2019s bigger than you and you are not me.
-@AlexSmithMD
Many links:
Mara Buchbinder\u2019s book - Scripting Death: Stories of Assisted Dying in America
https://www.ucpress.edu/book/9780520380202/scripting-death
Lori Freedman\u2019s book (forthcoming) - Bishops and Bodies: Reproductive Care in American Catholic Hospitals
https://www.rutgersuniversitypress.org/bishops-and-bodies/9781978828865
Lisa Harris piece mentioned on podcast
https://www.nejm.org/doi/full/10.1056/NEJMp1206253
Alta Charo piece mentioned on podccast
https://www.nejm.org/doi/full/10.1056/nejmp058112
Yvonne Lindgren article mentioned on podcast
https://dc.law.utah.edu/cgi/viewcontent.cgi?article=1002&context=ulr
Art Caplan piece mentioned on podcast
https://www.thehastingscenter.org/abortion-law-lessons-from-medical-aid-in-dying/
George Annas piece mentioned on podcast
https://dsc.duq.edu/cgi/viewcontent.cgi?article=3090&context=dlr
https://muse.jhu.edu/pub/1/article/722811
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SPONSOR:\xa0 \xa0
This episode of the GeriPal Podcast is sponsored by\xa0UCSF\u2019s Division of Palliative Medicine, an amazing group doing world class palliative care.\xa0 They are looking for physician faculty to join them in the inpatient and outpatient setting. \xa0To learn more about job opportunities, please click here:\xa0https://palliativemedicine.ucsf.edu/job-openings
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