Sunday, May 24, 2009

Abortion and medical ethics: my rebuttal

Commenter Bob Hunt offers his viewpoint regarding Abortion and medical ethics.

It's long been the case that the reduction in the number of abortions in the U. S., as well as the lack of access to abortions for so many women, has less to do with laws restricting abortion rights and more to do with the difficulty of abortion clinics to find doctors and nurses willing to perform abortions.
I grant that Mr. Hunt, a medical professional, has anecdotal evidence (better than no evidence at all) for his position, but such an assertion requires more and better evidence.

Mr. Hunt offers, but dismisses, an alternative hypothesis:
This is partly, no doubt, because of pressures placed on clinics and their staff by pro-life activists. But, more than that, it is because more and more doctors and nurses have moral reservations about abortion.
It's well-documented that these "pressures" include not only peaceful protests and non-violent direct action, but also personal harassment, death threats, vandalism, bombings, and actual murder, both attempted and achieved. A considerable amount of evidence must be offered for any thoughtful person to exclude these "pressures" as the primary cause of lack of access to abortion.

Mr. Hunt also conflates a reduction in the number of abortions (a generally good thing: abortions are logistically complicated, emotionally disturbing to some women, and pose some medical risk) with a reduction in access to abortion services. As far as the former goes, the most obvious, provably efficacious and scientifically uncontroversial way to limit the overall number of abortions is to provide universal access to contraception and good sex education, a position which seemingly ought to be socially and politically uncontroversial, but sadly is not.

This is why many medical schools, under pressure from abortion rights activists, started requiring that students learn how to perform abortions, because so few were voluntarily learning to do so.
Again, I must challenge the evidence for the truth of Mr. Hunt's assertion here. Furthermore, it seems odd to argue that medical students should a priori have much of a choice about their curriculum: they are there to learn; if they want to express themselves, they can go to art school.

If conscience rights are rescinded [note: "conscience rights" have not yet been granted, so they cannot be rescinded] even more doctors and nurses will take your advice and move to fields where abortion is not an issue, and the dirth of health care workers in the field of obstetrics will only get worse.
At best, even granting arguendo that Mr. Hunt's factual assertions are accurate, he makes nothing better here than an argument from expedience. Such an argument is not necessarily bad, but it is limited a priori: an argument from expedience is never a good argument for a general principle.

I don't think any of my colleagues at my hospital would deny any patient care that is in their [presumably the patient's] best interest. But that is the crux: what, exactly, is in the best interest of the patient[?]
I agree that it's not always trivial to determine the patient's best interest, but Hunt places an invalid condition on this determination: "how far the doctor or nurse is willing to go, or what they are willing to do is one of those variables" affecting the determination of the patient's best interest. This is nonsense: There might be other dimensions in which a medical professional's personal characteristics would be relevant, but they cannot be relevant to or have any bearing whatsoever on a determination of the patient's best interests.

I doubt that any doctor or nurse would agree that the best interest of the patient means providing care "most efficacious to achieve the well-being of the patient in the patient's own terms." There are simply too many variables to make such a vague policy practical or meaningful in any way.
Why not? My construction might be broad, but I don't see how it's vague, i.e. containing ambiguous or undefined terms. Patients typically want to live as long as is practically possible, they want to be free of physical pain and psychological suffering, they want to have maximum physical function and a minimum of inconvenience. In terms of abortion, the patient considers her well-being to consist of not being pregnant. While this construction might not handle every possible case (especially psychological or psychiatric issues), it seems clear and unambiguous in the vast majority of medical situations.

Troublesome and/or horrific consequences of such a policy are legion.
They are not so legion that they have intruded on my attention; I'm unable to think of a single case outside of organic mental illness or profound neurosis of any troublesome — much less horrific — consequence of acting in any patient's self-interest. It seems to me, however, that many troublesome and horrifying consequences spring immediately to mind when physicians arrogate their own personal interests over the patient's: forced sterilization, unethical experimentation, the decades-long psychiatric pathologizing of homosexuality. I invite Mr. Hunt to offer examples (outside of psychiatry) of the "legion" of troublesome or horrific consequences of adhering strictly to the patient's best interest.

No health care worker in his or her right mind is going to adopt a personal standard of practice that requires them to leave their conscience outside the hospital door.
Why not? When I see a physician or any medical practitioner, I want to be able to assume they will act in my best interests, regardless of their conscience. If their conscience is aligned with acting in my best interest, so much the better, but if not, either the conscience or the person needs to be outside the door. I don't want to know if they approve or disapprove of atheism, communism, mixed marriages, and I want to be sure that even if they do disapprove, their disapproval will not affect the quality of my care.

No health care worker regards him or herself as nothing more than a tool of the state, doing the bidding of the state...
There is a substantive difference between being a "tool of the state", i.e. acting in the interests of the members of the government, and being subject to external ethical and legal standards.

No health care worker regards him or herself as nothing more than a tool of ... or any particular patient no questions asked
Why not? If you're in the health care field, you're there to make me better when I'm sick; you damned well better not be there to use your power over my health to enact your own personal agenda. No questions asked? Ask me all the questions you need to to discover my best interests, but in the intended metaphorical sense, no: your "questions" — especially your ethical questions — are simply irrelevant.

Do you care at all about having health care that even approaches professional standards when you need to go to the ER for that broken arm that won't kill you (though, in fact, it might)?
Yes, I care about having health care that complies with professional standards. Hence I don't want any deviations from those standards, especially deviations justified only by purely subjective considerations such as individual conscience.

34 comments:

  1. Mr. Hamelin,

    Thank you for your respectful rebuttal. I posted some additional thoughts on the original thread, as I said I would, this morning. Now I have to go home and go to bed. I hope to have a response to your rebuttal tomorrow morning and look forward to furthering our discussion.

    Bob Hunt, RN

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  2. If you've posted anything on the other thread, it hasn't yet shown up on my moderation queue.

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  3. Oh, after I posted my comment on Hunt's essay, I see that you, too, have pretty much concluded that he is just pulling a bunch of conclusory assertions out of his ass without any evidence backing them up.

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  4. Mr. Hamelin,

    Regarding my posting on the original thread: Not sure what happened there. I admit I'm not very computer savvy, so I'll chalk it up to some sort of error I must have made in the attempt to post. I'll either try again or just offer my thoughts here if there is time.

    Given the length limitations of posting on blogs, it's difficult to both make a point and defend it with evidence at the same time. Indeed, even my response to your rebuttal may require two or more postings. I don't have as much room as you do, but I'll do what I can.

    I sincerely appreciate the respectful tone with which we've so far managed to discuss this matter. It's difficult to take seriously accusations that "he is just pulling a bunch of conclusory assertions out of his a** without any evidence to back them up." I've found that people often become their worst selves when blogging. I suppose the anonymity encourages this. This is one of the reasons I always sign my name to my posts. I do not curse, call names, shout (ie: ALL CAPS!), and rarely even use exclamation points. As long as we can keep the conversation civil, I'm happy and even eager to keep it going.

    Well, so much for that. Now, you ask for evidence:

    You wrote, "A considerable amount of evidence must be offered for any thoughtful person to exclude these 'pressures' as the primary cause of lack of access to abortion." I'm not sure what a considerable amount of evidence might be, but the article "Influence of physician attitudes on willingness to perform abortion," which appeared in vol. 93, n. 4 of Obstetrics and gynecology, 1999, concluded that "The most important personal factors influencing a physician's decision not to perform abortions included lack of proper training and ethical and religious beliefs." An article in Family Medicine, 1999; 31(3) entitled "Medical Students' Attitudes Toward Abortion and Other Reproductive Health Services" concluded that most med students intended to include abortion in their practice in spite of "continuing pressure on abortion providers." Both of these studies were done in the late 90s, when violence against abortion providers was at it's peak. "Violence against abortion providers has declined markedly since the 1980s and '90s" - "A Hard Choice," Washington Post, Nov 23, 2008. Jacob Appel, in his article "Do We Need A Pro-Choice Litmus Test for Obstetricians?" (he recommends that only pro-choice candidates be accepted into med school for obstetrics) writes from personal experience: "During my medical training and career as a bioethicist, I have encountered many obstetricians who could never be convinced to terminate pregnancies because they were personally opposed to doing so - often for private religious or philosophical reasons." While I found articles from pro-choice sites that surmised that pressures from pro-life activists was a major reason health care professionals didn't want to do abortions, none offered evidence of such from studies and most that offered comments from abortion providers on the matter spoke of how such pressures (at least violence pressures) were part of the past. Incidentally, your own source for the well documented pressure against abortion providers mentions the contribution pro-life groups have made in the effort to stop violent actions against abortion providers and clinics.

    Bob Hunt, RN

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  5. Mr. Hamelin,

    Next entry.

    You wrote, "Mr. Hunt also conflates a reduction in the number of abortions ... with a reduction in access to abortion services." In point of fact, I didn't. Had I written that there was a lack of access to abortions for many women, and thus a reduction in the number of abortions ... you would be correct in your charge. What I wrote was simply that there has been a reduction in the number of abortions, as well as a lack of access to abortions for many women. It's a reasonable conclusion that the former follows from the later, but not a necessary one, and my statement doesn't imply a necessary conclusion.

    Is there a problem with access to contraception? Or is the problem with proper use of contraception, or of people not bothering to use contraception? I don't know, honestly. It seems to me that contraception is pretty easy to get hold of. Condems are sold in men's bathrooms at gas stations. You'll have to show me evidence that access to contraception is the problem. I've always thought the most obvious way to avoid getting pregnant was not having sex. On that point, we've had sex education in the schools for years now, even decades, and it doesn't seem to have had much of an impact on sexual activity. Maybe it isn't very good, I don't know. I graduated 30 years ago and my children don't attend public school, so I really don't know what the programs are like now. I do know that the Alan Guttmacher Institute has done research on what factors influence teens' decisions to postpone sexual activity, and sex ed programs in schools aren't even on the radar.

    Regarding med schools requiring that med students learn how to perform abortions, you got me on that one. My statement was based on an article read some time ago, that I can't now find. Washington Times columnist Julia Duin, however, does report that The Polling Company/Woman Trend found that 39% of medical personnel reported "experiencing discrimination because of their beliefs." Medical Students for Choice (MSFC) says that 20% of OB/GYN residencies make abortion training available, and 27% of those require it. According to Life News website, New York and California are two states that require training in abortion, but include conscience clauses, thought the Catholic Medical Association says that med students receive pressure not to make use of them.

    BTW, on the earlier matter of why doctors and nurses won't do abortions, the above mentioned poll also reported that 82% of 2,865 Christian medical personnel said they were very or somewhat likely to limit their practice if they had to perform abortions. Other religious groups may have different responses, but 75% of the U. S. population identifies itself as Christian, so it's fair to say that the poll represents the views of a fair chunk of medical personnel.

    The matter of whether or not med students should have a choice about their curriculum depends on whether or not abortion services are an essential part of the field of obstetrics. MSFC, who is trying to get more schools to require abortion training, and Mr. Appel mentioned earlier, think so. But I would venture to guess that a lot of OB/GYN students, or at least a lot of Christian ones, get into the field because they want to help bring life into the world, not snuff it out.

    Bob Hunt, RN

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  6. Mr. Hamelin,

    Next entry.

    You wrote that "'conscience rights' have not yet been granted, so they cannot be rescinded." I'm not sure what you mean by that, unless you question the term "conscience rights." Perhaps conscience clauses would be preferred. In any case, NARAL reports that 47 states and the District of Columbia "allow certain individuals or entities to refuse to provide women specific reproductive health services, information, or referrals." Headlines all over the place last December reporting how the Bush administration introduced an HHS regulation "reinforcing protections for doctors and health care workers who refuse to participate in abortions and other procedures based on religious or moral grounds" (Associate Press, Dec. 12, 2008) Eight attorneys general, Planned Parenthood and others have filed a suit to overturn the regulation. Obama has promised to overturn the regulation (though his statements at Notre Dame suggest he's re-thinking the idea). When I spoke of rescinding conscience rights, it was to these laws and regulations I was referring.

    Thank you, again, for the opportunity to discuss these matters. I'll have more to say about the rest of your rebuttal tomorrow or the next day.

    Good night.

    Bob Hunt, RN
    Knoxville, TN

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  7. Mr. Ross,

    I understand the limitations of commenting. You can email me if you wish, and I'll republish your message as a comment. Also, you have to be a little thick-skinned to engage in public debate, especially on blogs. I'll censor anything egregious, but you have to tolerate some snark.

    The evidence as you present it does not seem to strongly support your position. The 1999 Ob Gyn article explicitly mentions lack of training as well as religious beliefs, and the 1999 Family Medicine article seems to directly contradict your position. While it does appear that anti-abortion violence has declined, it is still present, and should never have been there in the first place.

    The Appel article, Do We Need A Pro-Choice Litmus Test for Obstetricians?, asserts fear of violence is an important reason doctors are not performing abortions (and the decline of violence is due to improved law enforcement).

    More importantly, tha Appel article highlights the fundamental problem with the first portion of your original argument: It's an argument from expediency, and the condition of expediency depends on (at best; as noted above your evidence is not strong) the private moral beliefs of the existing practitioners. At every level of health care, the number of qualified candidates far exceeds the number of actual positions; selecting those candidates on the basis of their willingness to comply with professional ethical standards is a valid method to overcome the expedient issue in the long term.

    I am a philosopher, not a scientist or a health-care services administrator; I'm typically neither qualified nor interested in solving short-term, relatively superficial problems (just because a problem is superficial doesn't mean it's easy or trivial).

    My interest is with the more fundamental ethical issues. A standard with exceptions granted on purely preferential grounds is no standard at all. The right of exception by virtue of "conscience" undermines not just the immediate standard of abortion on demand, but also the general standard that all medical practitioners must subordinate any moral or ethical beliefs not aligned with the best interests of the patient.

    You address this deeper issue in the second part of your original comment, and not — interestingly enough — by asserting that a fetus is itself a patient with interests. You assert, rather, that the best interests of the patient — as defined by the patient herself — should not fundamentally control medical ethics.

    The argument from expedience is a non-starter for several reasons: your evidence for an expedient problem is weak; expedient problems are best solved by those with direct administrative authority over the field in question; and arguments from expedience are in principle irrelevant to fundamental ethical issues.

    As a philosopher, I'm much more interested in general, more fundamental ethical issues, and I invite you to comment further on the thesis you assert in the second part of your original comment.

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  8. Given that capital punishment is legal, would it be possible for the government to force a given doctor to perform an execution if no other doctor was willing?

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  9. Alphonsus: While your question is interesting, it's substantively different from the question currently under discussion.

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  10. "Hence I don't want any deviations from those standards, especially deviations justified only by purely subjective considerations such as individual conscience."

    Aren't, at least in some cases, a patient's wishes just as purely subjective as those of a conscientious doctor/nurse? What are your standards for objectivity/subjectivity? I think it would aid the discussion if premises/standards were more clear.

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  11. Alphonsus:

    Aren't, at least in some cases, a patient's wishes just as purely subjective as those of a conscientious doctor/nurse? -

    The patient's best interest is subjective in all cases. The question is not whether the issue should be decided on an objective or subjective basis, but on whose subjective interests should be ethically relevant.

    Objective considerations would include the efficacy of some treatment to achieve a desired result. On objective issues, the physician's scientific knowledge should prevail: A physician may ethically refuse, for example, a patient's demand to treat his cancer with Laetrile.

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  12. If you want to know more about my position regarding subjectivity and objectivity in ethics, you can read my series on Meta-Ethical Subjective Relativism.

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  13. "You assert, rather, that the best interests of the patient — as defined by the patient herself — should not fundamentally control medical ethics."

    My understanding of Hunt's position was that patients are not necessarily the best at determining their own interests. In psychiatry, for instance, one might face situations in which patients would clearly be unable to distinguish what is in their best interest. Should a doctor be legally bound to follow the dictates of an individual with severe depression or schizophrenia? In such situations, it seems that the doctor's prescription for treatment might at times go against the stated wishes of his or her patient.

    Although cases of mental illness as described above are unusual, I think they still highlight the principle that no doctor should be forced to perform medical procedures which they, in their medical opinion, find unnecessary and/or harmful.

    It seems that one of the key questions involving conscience clauses involves what degree of latitude exists for acceptable medical opinion. To ban pro-life doctors from obstetrics would be to make it a matter of policy that all obstetricians must hold that direct abortion can, at certain times, be a medical necessity. Problematically, such a policy leaves undefined what exactly constitutes an abortion and ignores the spectrum of practices and informed beliefs which are involved. For instance, even a staunch Catholic philosopher like Germain Grisez held (tentatively) that one could crush the skull of a fetus (killing it) in order to deliver it to save its mother's life. Although some conservative Catholic thinkers (e.g. William May) reject Grisez's conclusion, I think few Catholic doctors would disagree with treating an ectopic pregnancy in a way that led, unfortunately and indirectly, to the death of the fetus.

    Should these doctors be barred from practicing obstetrics because they would not perform first trimester abortions? Second? Third? One of the major problems with the abortion debate in America is the way that few people distinguish between different kinds of abortion (for more on this and the way the media contributed to it, see John Noonan's book "A Private Choice"). This lack of nuance creates a lot of barriers to moderation in public policies. I imagine that there are some doctors who wouldn't object to a first trimester abortion but would refuse to participate in a third-trimester/post-viability abortion. Should these doctors be forced to leave their field? If not, why?

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  14. "Objective considerations would include the efficacy of some treatment to achieve a desired result. On objective issues, the physician's scientific knowledge should prevail: A physician may ethically refuse, for example, a patient's demand to treat his cancer with Laetrile."

    Should a doctor who refuses to perform an abortion because he thinks it is medically unnecessary be forced to leave obstetrics?

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  15. Mr. Hunt: Your earlier comments finally arrived in my moderation queue, and I immediately approved them.

    Note: You can select the Name/URL identity option to add your name to the comment (the URL is optional). Since you sign your comments anyway, it's not a big issue, but it helps readers follow the discussion, and it also makes moderation more convenient for me, since I'm presently approving your comments immediately.

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  16. Mr Hunt: Since you've given me permission to post your first comment, may I routinely assume I have general permission to post your comments? I will, of course, promise to reproduce your comments in whole and unedited (you might, however, want to give me permission to correct trivial typographical errors).

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  17. Alphonsus:

    My understanding of Hunt's position was that patients are not necessarily the best at determining their own interests. ...

    Although cases of mental illness as described above are unusual. I think they still highlight the principle that no doctor should be forced to perform medical procedures which they, in their medical opinion, find unnecessary and/or harmful.
    The difficulties with mental illness lie in determining the patient's best interests; once those interests have been determined, there is no ethical question about acting in those interests. This is again a substantive difference with abortion: in abortion it's crystal clear that the abortion is in the woman's self-conceived best interest.

    To ban pro-life doctors from obstetrics would be to make it a matter of policy that all obstetricians must hold that direct abortion can, at certain times, be a medical necessity. -

    This is an entirely uncontroversial assertion: if a woman is pregnant, and it is in her best interests to not be pregnant, it is a physical, medical necessity that she receive an abortion to fulfill her best interests.

    Problematically, such a policy leaves undefined what exactly constitutes an abortion...You obviously lack even a layman's knowledge of reproductive medicine. There is only the most trivial and peripheral medical or scientific controversy at all over what constitutes an abortion: the only matter of "controversy" is whether the inability of a fertilized egg to implant in the uterus constitutes contraception or abortion. This controversy is not at all relevant to the ethical question at hand.

    ... and ignores the spectrum of practices and informed beliefs which are involved. -

    Yes, yes it does: my argument is that we should ignore those beliefs, since they have nothing to do with determining or acting in the best interests of the patient.

    Should these [Catholic?] doctors be barred from practicing obstetrics because they would not perform first trimester abortions? Second [trimester abortions]?You have not read my work carefully if you do not quickly understand that I would say "Yes" to both.

    Third?A whole 'nother can of worms. By the third trimester, a fetus has enough of a nervous system to make plausible considerations of its own objectively existing interests.

    Again, the point of this particular conversation, which you seem very obtuse in understanding, is not whether the fetus has interests, but rather whether the physician's moral interests can take precedence over the best interests of the patient, i.e. the pregnant woman.

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  18. Should a doctor who refuses to perform an abortion because he thinks it is medically unnecessary be forced to leave obstetrics? -

    Under what sense would an abortion not be medically necessary to end an unwanted pregnancy? We are talking about the real world, not possible worlds where the laws of physics or biology are substantively different from our own.

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  19. "This is an entirely uncontroversial assertion: if a woman is pregnant, and it is in her best interests to not be pregnant, it is a physical, medical necessity that she receive an abortion to fulfill her best interests."

    By assuming that abortion is automatically and always in her best interest, you're begging the question. The issue of whether or not said abortion is automatically in her best interests in the crux of the matter we're discussing.

    "Again, the point of this particular conversation, which you seem very obtuse in understanding, is not whether the fetus has interests, but rather whether the physician's moral interests can take precedence over the best interests of the patient, i.e. the pregnant woman."

    No, its about whether an obstetrician has a right to say, with an informed and clear conscience, that he finds a medical procedure (in this case abortion) medically unnecessary and may refrain from taking part in it. Most abortions are sought for economic reasons, so it's debatable whether they are necessary from a medical/scientific perspective.

    "You obviously lack even a layman's knowledge of reproductive medicine."

    Perhaps it will be more clear if I better explain myself. I realize that no one debates what an abortion is. What I am trying to say is that no one seems to be making the distinctions when it comes to conscience clauses. From a purely medical standpoint, an abortion at one month is different from on at eight months. In the discussion of conscience clauses, however, it seems as though doctors would be unable to choose what kinds of abortions they support and what kinds they reject. Although you might be against it, late term abortions do take place and, without any kind of conscience clause, it would seem that all qualified obstetricians would, theoretically at least, need to be willing to perform them.

    "Third?A whole 'nother can of wor"ms. By the third trimester, a fetus has enough of a nervous system to make plausible considerations of its own objectively existing interests."

    Under the current abortion law in the US, though, your statement is not entirely uncontroversial. Vaguely defined health exemptions basically allow for abortions at any time up until birth. All one generally has to do is find a doctor (not necessarily one who can perform abortions) who is willing to support a claim of emotional/psychological distress. In many European nations, for instance, such late-term abortions would require an appeal to a committee/board of doctors.
    http://news.bbc.co.uk/2/hi/europe/6235557.stm
    America's abortion laws are actually very permissive by international standard. Again, see the Noonan book.

    To use an analogy, would a plastic surgeon who wants to work with burn victims have to be willing to perform (assuming he's capable) transgender surgery? The patient feels it is in his best interest to change his sex. Should the plastic surgeon, in order to maintain his career, be press-ganged into having to perform operations which he believes to be medically unnecessary?
    I think the wall we're hitting on the abortion question stems from the question of whether or not any given abortion is medically necessary/in the best interests of the patient. If, as you believe, abortion is a medically necessary solution to any unwanted pregnancy, then it is difficult to argue in favor of conscience clauses. If there are at least some cases of unwanted pregnancy where abortion is not necessary from a medical/scientific point of view, then it seems that reasonable conscience clauses should be maintained to protect the rights of responsible physicians to practice as they see fit.

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  20. Mr. Hamelin,

    The discussion with you today has been civil and enjoyable. I may not be able to stop by to post future responses, so I thought I might make some suggestions on where to go if you're interested in exploring the other side of the abortion debate. As I've mentioned, Noonan's book is helpful. Francis Beckwith, Patrick Lee, Russell Hittinger and Robert George have also wrote books and monographs on the abortion issue, so you might be interested in checking them out, if only for refutation.

    in all things charity,
    Alphonsus

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  21. Marcus Tullius Cicero5/26/09, 1:51 PM

    "Under what sense would an abortion not be medically necessary to end an unwanted pregnancy?"

    Should every OBGYN be tasked with undertaking training for providing abortions. It seems like you're arguing that every obstetrician must be trained and willing to participate in abortions or he will somehow be unable to fulfill his professional responsibilities. What if delivering babies is all he wants to do? It seems somewhat absurd to insist that every member of a rather broad medical field must be ready and willing to perform any given specialized task within that field or be thrown out. To turn the question on its head: must every abortionist be willing to deliver babies, on pain of losing his license/certification?

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  22. By the way, here's the source on why women choose to have abortions, in case you were curious.
    http://www.google.com/url?sa=t&source=web&ct=res&cd=1&url=http%3A%2F%2Fwww.guttmacher.org%2Fpubs%2Fjournals%2F3711005.pdf&ei=zkgcStrpNYXAMtyGyZMP&rct=j&q=most+common+reason+for+abortion&usg=AFQjCNElFws7Yw8B1FPWx9opGB2uXDJgbw

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  23. By assuming that abortion is automatically and always in her best interest, you're begging the question. -

    No. The original question is: given that not being pregnant is in the best interest of a woman, should a physician be permitted to refuse to perform an abortion because of the physician's own moral beliefs?

    You asked a different question: would an abortion be medically necessary in the sense of the safest, most efficacious procedure to fulfill the best interests of the patient. The answer, from an objective view is an unqualified "Yes".

    People are ordinarily able to introspectively determine their own best interests. If an ordinary woman wants to not be pregnant and says that she doesn't want to be pregnant, we can conclude that not being pregnant is in her own best interests, unless we can demonstrate good reason to believe she has some other psychiatric or psychological condition.

    its about whether an obstetrician has a right to say, with an informed and clear conscience, that he finds a medical procedure (in this case abortion) medically unnecessary and may refrain from taking part in it. -

    Medical necessity -- in the objective sense -- consists of safety and efficacy in fulfilling the best interests of the patient. It is a matter of scientific truth, not personal opinion. As far as abortion goes, the scientific truth is crystal clear, and if you wish to dispute it you must first show me your MD and provide links to the scientific studies. Note that allegations of post-abortion depression or the link between abortion and breast cancer have been adequately proven false and I treat such assertions as lies.

    The only place where opinion enters into the medical necessity is where the scientific evidence is not yet conclusive.

    (continued)

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  24. In the discussion of conscience clauses, however, it seems as though doctors would be unable to choose what kinds of abortions they support and what kinds they reject. -

    Such distinctions are not relevant to the fundamental ethical principle under discussion here. We are not discussing which procedures are susceptible to choice, we are discussion one particular basis, i.e. personal moral belief, on which a physician might refuse to honor the patient's best interest.

    Although you might be against it, late term abortions do take place and, without any kind of conscience clause, it would seem that all qualified obstetricians would, theoretically at least, need to be willing to perform them. -

    Third term abortions form a minuscule fraction of all abortions, are almost always performed either if the life of the woman is in immediate jeopardy and/or if the fetus is moribund or nonviable. No competent, qualified physician should refuse to perform an abortion under such circumstances.

    Furthermore, it is objectively, scientifically true that a third-term fetus has enough of a nervous system to actually have interests, so the ethical debate regarding third-term abortions -- balancing competing interests of multiple patients -- is very different from the debate regarding first and most early second term abortions, where there is (at least arguendo) only the interests of one patient to consider.

    We are not presently discussing whether or not first and early second term fetuses have any interests whatsoever, because that is not the claim raised by "conscience" clauses. Capisce? If you want to write a comment or email discussing that issue, and if it meets my editorial standards, I'll be happy to discuss that issue. But it's not what we're talking about right now.

    If there are at least some cases of unwanted pregnancy where abortion is not necessary from a medical/scientific point of view, then it seems that reasonable conscience clauses should be maintained to protect the rights of responsible physicians to practice as they see fit. -

    Actually no, even taking your premises arguendo. A physician should never perform a procedure that is not medically necessary to achieve the best interests of the patient. Period. End of story. If some abortions are not in the best interests of the patient, they should not be performed at all. It is equally a violation of the principle of the patient's best interest to perform a medically unnecessary (i.e. not efficacious) procedure as it is to refuse to perform a necessary procedure.

    Again, the only point where the subjective judgment of the physician is concerned would be in areas where the efficacy or safety of a treatment was a matter of scientific controversy. This is simply not the case regarding even third trimester abortions.

    Also, I will reiterate: trying to frame the abortion debate in terms of the tiny fraction of third-trimester abortions, only a tiny fraction of which are in any sense elective, pushes the bounds of good-faith debate.

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  25. It seems like you're arguing that every obstetrician must be trained and willing to participate in abortions or he will somehow be unable to fulfill his professional responsibilities. -

    I'm neither qualified to nor interested in commenting on the scope of medical specialties. There is some specialty which includes abortion; we are assuming for the sake of discussion that that specialty is labeled "obstetrics" and its practitioners "obstetricians".

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  26. I don't see anything about the Finer paper, Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives, that's particularly relevant to this discussion. From the abstract:

    RESULTS: The reasons most frequently cited were that having a child would interfere with a woman’s education, work or ability to care for dependents (74%); that she could not afford a baby now (73%); and that she did not want to be a single mother or was having relationship problems (48%). Nearly four in 10 women said they had completed their childbearing, and almost one-third were not ready to have a child. Fewer than 1% said their parents’ or partners’ desire for them to have an abortion was the most important reason. Younger women often reported that they were unprepared for the transition to motherhood, while older women regularly cited their responsibility to dependents.

    CONCLUSIONS: The decision to have an abortion is typically motivated by multiple, diverse and interrelated reasons. The themes of responsibility to others and resource limitations, such as financial constraints and lack of partner support, recurred throughout the study.

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  27. Bob Hunt, RN5/26/09, 11:20 PM

    Mr. Hamelin,

    Thank you for your response. I'll try the Name/URL option. I wish my fourteen year old daughter were here to show me what I need to know about computers. Thanks, too, for the option to e-mail. Unhappily, it's not available to me just now, since our home computer crashed some weeks ago and I don't have access to e-mail. I'm forced to use the computer in the library of my hospital (after I've finished my shift and clocked out or on my days off, of course.) Yes, you have my permission to post all of my comments and are very gracious to offer to correct any typos.

    I didn't have high expectations that my evidence would impress you. Nevertheless, it works for me. As far as why doctors are refusing to do abortions, I think it's safe to say that pressures from pro-lifers and ethical/religious reasons both contribute. As to which contributes more, perhaps the evidence for that answer just isn't there.

    I agree that arguments from expedience are not strong arguments for general principles, at least in philosophy class. I'm not a philosopher, however. I'm a nurse, working on the front lines of health care (though not in obstetrics) and very conscious of the fact that fewer and fewer of the generation behind me are entering heatlh care, and too many who have are leaving. Abortion rights activists are concerned about the practical matter of too few doctors being willing to perform abortions. Their answer is to convince more medical students to become abortionists, convince more med schools to require the training, and rescind conscience clauses. I'm not concerned in the least that too few doctors and nurses are willing to participate in abortions. I rejoice in the fact. I am concerned that too few med students and nurses are interested in entering obstetrics. Anything that will convince a med/nursing student who is hopeful about obstetrics not to enter the field, or anyone not to enter health care in general, is a concern to me. (A big reason I didn't become a labor and delivery nurse was my concern that I may one day be expected to assist with an abortion and the consequences, despite the law in Tennessee, of refusing to do so.) If that's an argument from expedience, so be it. I'm the one who has to take on more patients and shifts because we don't have enough nurses to carry the load.

    In my next entry, I hope to address the meet of the ethical question of health care professionals having the right to refuse to participate in procedures for reasons of conscience.

    Bob Hunt, RN
    (I'll try the Name/URL, but I signed anyway -- just in case)

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  28. Bob Hunt, RN5/27/09, 1:18 AM

    Mr. Hamelin,

    Next entry.

    In my original post, I made reference to your statement that the best interest of the patient means providing care "most efficacious to achieve the well-being of the patient in the patient's own terms." Perhaps it was assumed, but in your rebuttal you regularly referred to the obligation of health care workers to act in the best interest of the patient, but failed to include the phrase "in the patient's own terms." Again, perhaps this was assumed, and you did say, "In terms of abortion, the patient considers her well-being to consist of not being pregnant." Nevertheless, this is a crucial distinction, and the heart of my objection. The health care worker is always ethically obliged to act in the best interest of the patient. We agree here. We agree, too, that what is in the patient's best interest is not always easy to determine. But, as I mentioned in a comment on the capital punishment thread, "in the patient's own terms" is a big wrench to throw into the equation.

    You asked for examples of when acting on this construct of a "patient's best interest in his own terms" might be troublesome, or even horrific. On the capital punishment thread, I mentioned the case in Montana of Mr. Baxter who sued for the right to have a physician assist him in killing himself. He won the right, but no physician in Montana is willing to assist him. If approached by Mr. Baxter, who regards his own death to be in his best interest, would a physician be obliged to assist him? Would a nurse be obliged to assist the doctor in this case?

    Betty Coumbias of Vancouver, who is healthy, wants to die with her husband, George, who has severe heart disease (the article I found doesn't say if George is terminal). Clearly, Mrs. Coumbias regards it to be in her best interest to die with her husband. In such a case, is the doctor obliged to act in the patient's best interest on her own terms? Are the nurses obliged to assist in the suicide of a healthy woman? In fact, what if George is not terminal, just very ill? How far does the "right" to assisted suicide go?

    A man who considers himself a sex addict (not currently recognized as a sexual disorder by the APA), though he is not a sex offender, asks his doctor to perform surgical castration because the patient is convinced it is in his best interest. Is the doctor obliged to act according to the patient's best interest on the patient's own terms in this case? Are the nurses obliged to assist?

    The potential cases are multiplied in cases where the patient is a child or otherwise under the legal guardianship of another.

    Remember, we're not talking about whether the doctor is obliged to investigate and work with the patient to discern his best interest. Let's be gracious and assume the doctor has done that. We're discussing whether the doctor is obliged to act according to the patient's best interest as defined by the patient's own terms, even if the doctor disagrees with the patient about what is in his best interest.

    To summarize, then: "In terms of abortion," you write, "the patient considers her well-being to consist of not being pregnant." Your argument is that if a woman is pregnant and wants to not be pregnant, that means abortion is medically necessary. If a procedure is medically necessary, then health care professionals are obliged to provide and/or assist in the procedure. Abortion, (limited for the sake of this discussion to elective abortion in the first and second trimesters) is always medically necessary, because it is in the patient's best interest in her own terms. Health care workers, then, are obliged to provide and/or assist in abortion.

    It's late, so I need to go home. I thought this might be a good place to stop. I want to make sure I do understand your position correctly before I proceed with my response. Please correct me if my above summary is wanting in any way.

    Bob Hunt, RN

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  29. Bob Hunt, RN5/27/09, 6:07 AM

    Mr. Hamelin,

    I'm going to leave the abortion issue aside for now. Abortion is but one example of a case where health care professionals might want to opt out on grounds of conscience. There are others, so a discussion of one particular example isn't necessary to the core argument.

    As such, I would like to take the liberty of paraphrasing what you wrote in one of your responses to Alphonsus in a way that I think summarizes well the question at hand:

    Given that a particular procedure or therapy is in the best interest of the patient (that is, most efficacious to achieve the well-being of the patient in the patient's own terms), should a health care worker be permitted to refuse to perform or assist in a procedure or therapy because of his or her own moral beliefs?

    Based on statements you made in your rebuttal to my first post, I take it your answer to the above would be: no, a health care worker should not be permitted to refuse because of his or her own moral beliefs.

    As a nurse, I certainly agree that health care workers are ethically obliged to provide services that are in the best interest of the patient. Where we disagree is in your construct that the best interest of the patient as determined by his or her own terms trumps the conscience of the health care worker. There is nothing, either in the ancient or modern versions of the Hippocratic Oath or in the Nightingale Pledge, that binds the health care worker in this way. To do so would be to entrap the consciences of health care workers within the consciences of their patients.

    A person does not surrender his or her own conscience or moral compass when he receives a medical, nursing or pharmaceutical license. Why should he? For the sake of the patient? But it's for the sake of the patient that the health care worker holds on to his conscience. If the patient and doctor disagree on what is in the best interest of the patient, the patient is free to go to another doctor. Why should the doctor be expected to violate his conscience or turn to another profession?

    Part of the difficulty is that you seem to equate conscience with political or social ideology. Your examples of atheism, communism and mixed marriage suggest this. Consciense is not ideology. Conscience is a function of the intellect that guides us in choosing to act for good or for evil.

    You say that, if your doctor's conscience is out of line with what is in your best interest according to your own terms, then either the doctor's conscience or the doctor himself needs to be outside the hospital door. I argue that you are the one who needs to be outside the care of this doctor. Find another one who agrees to do what you want him to do. It is unconscionable to demand that a person act contrary to his or her certain conscience.

    Austin Fagothy, SJ, wrote in Right and Reason that, "Conscience may ... be defined as the practical judgment of reason on an individual act as good and to be performed, or as evil and to be avoided." He further wrote, "If a man is firmly convinced that his action is right, he is choosing the good as far as he can; if he is firmly convinced that his action is wrong, he is choosing what he thinks is evil, whether it really is so or not." To insist, therefore, that health care professionals abandon their consciences at the hospital door would be to demand that they be willing to choose what they are firmly convinced to be evil. No one has a right to place such a burden on another, not the state, and certainly not someone who has come to that person for help in attaining their best health and well-being. To demand such would be to demand that the health care worker become something other than an individual: a robot, a tool or a machine, but not a person. This is why health care workers will not abandon their consciences at the hospital door, or surrender their consciences into the hands of another, be that the state or a patient, to be played like a puppet on a string. To do so would be to surrender one's very self.

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  30. Mr. Hunt,

    Part of the difficulty is that you seem to equate conscience with political or social ideology. -

    Well, they're definitely related: on what basis other than a her conscience — informed to some extent by scientific truth, philosophical argument, and social and familial context — does a person construct her political and social ideology?

    It is unconscionable to demand that a person act contrary to his or her certain conscience. -

    I will state unequivocally that I understand your position and I disagree completely. I assert that it is entirely conscionable in well-defined circumstances, to demand that an individual act contrary to his certain conscience.

    I will write on the justification for this position as time permits.

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  31. Mr Hunt,

    If conscience really is a function of the intellect, then it should not be necessary to rely on the brute fact of an element of conscience to object to meeting some obligation or refraining from some prohibition. The intellect is concerned with reasons: a person making a reasonable objection must offer those reasons as justification; the mere fact of his conclusion might be mistaken or fallacious.

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  32. Bob Hunt, RN5/29/09, 2:56 PM

    Mr. Hamelin,

    Then we will have to disagree.

    As a function of the intellect, conscience is the capacity to discern how I ought to act in any particular circumstance: if my conscience is certain that an action is good, I can perform that action; if my conscience is certain that an action is evil, I must not perform that action. This demands the use of one's reason.

    What it doesn't mean is that my conscience is always correct. One could have an ill-formed conscience for any number of reasons, including wilful ignorance, laziness, being exposed to a pervasive culture of death, etc... An ill-formed conscience often leads to erroneous conclusions, the idea that it is legitimate to kill human life in the womb being just one example. One's conscience can be deformed by insanity, or other mental illness. The person who is convinced that his duty is to murder his mother, for instance. Certainly it is the community's responsibility to stop such a person from acting. Error has rights; evil has none. Given that, it is certainly possible for a person to act according to a certain conscience, even if that conscience has come to an erroneous conclusion. Even entire cultures have been led astray by charismatic leaders committed to a culture of death and moral relativism. Truth is objective, but one's conscience is not infallible. It is, however, inviolable. Again, I'm not philosopher, and I'm sure that there are others who could put it far better than I. That's the best I can do in my limited time.

    Applying the above practically on the matter of conscience clauses for health care professionals: if a doctor or nurse possesses a certain conscience that performing a particular procedure is evil, he or she must not perform it, for it would be, for him or her, an evil act -- even if he or she is wrong as a result of an ill-formed conscience. Neither the state nor a patient can ethically require a person to perform an act if that person possesses a certain conscience that that act is evil.

    I understand we disagree. We obviously approach the matter from two very different worldviews. As I understand it, then, it is your position that the doctor would be required, ethically, to participate in the act of assisting Mrs. Coumbias in killing herself. Perhaps you would let him off if he gave reasons you found convincing. But what reasons could there possibly be, given your definition of the patient's best interest being defined by his or her own terms? How would you punish the doctor or the nurse for refusing to participate? How would you recommend that the state of Montana punish it's doctors for refusing to assist Mr. Baxter in killing himself? And how do you think this might impact health care in Montana?

    These aren't rhetorical questions. I would really like to know.

    Bob Hunt, RN

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  33. Mr. Hunt: I hope you've read my newest essay on this topic: Unconscionable interference with conscience; I discuss there in more detail some of the points you raise in your latest comment.

    I'll address other issues later.

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