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Meet the Guest
Ginny L. Ryan, MD MA (Bioethics)
Dr. Ryan is a Professor and REI Division Chief in the Department of Obstetrics and Gynecology at the University of Washington in Seattle, Washington. She also provides subspecialty REI care at the Puget Sound VA. She is current Chair of the Ethics Document Review Panel for the American College of Obstetricians and Gynecologists (ACOG) and former Chair of the Committee on Ethics for ACOG. In her previous faculty position at the University of Iowa, she was Chair of the Hospital Ethics Committee and a consultant on the Ethics Consult Service.
In this episode, we interview Dr. Ginny Ryan, a bioethicist, on bioethics in reproductive healthcare. We sort out the difference between ethics, morals, conscientious practice, and to who autonomy belongs. We also cover the principles of ethics and how to apply them to your practice and the impact Roe v. Wade has beyond abortion care.
Main Questions Asked
- Can you start by explaining to our listeners what are ethics?
- What’s the difference between ethics and morals?
- What are the ethical principles and where do they come from?
- How do these ethical principles intersect with clinician autonomy? Or who does or should autonomy belong to?
- What is conscientious practice and how does this relate to abortion?
- How do ethics, especially as it relates to the clinical practice of sexual and reproductive health, intersect?
- When we think of clinical decision-making and communication, how can we use ethics to inform coming up with “the right answer” or “the best decision?”
- What are the ethical implications of Roe v. Wade, including its impact on infertility and IVF?
- What can providers do if their state bans abortions?
- Where can listeners go to learn more about ethics, especially as they related to sexual and reproductive healthcare?
SisterSong: Reproductive Justice
EP 7: Grassroots Perspective of Reproductive Justice, Abortion, and Religion with Toni Bond Leonard
EP 3: Reproductive Justice with Dr. Aisha Wagner and Dr. Moira Rashid
ACOG Code of Professional Ethics Statement
Clinician approach to clinical and Ethical Reasoning
Hi, everybody, and welcome to the Woman-Centered Health Podcast. Today we are speaking with Dr. Jenny Ryan, a bioethicist and Boar certified reproductive endocrinologist and fertility specialist in the division chief for reproductive endocrinology and infertility in the Department of Obstetrics and Gynecology at the University of Washington in Seattle. She’s just a little busy and wears a few hats. In light of the recent decision from the US Supreme Court, medical ethics or bioethical concerns have been a hot topic for clinicians and reproductive health care. So we thought that bringing in a bioethicist to talk about these ethical issues can help guide other clinicians who might be challenged in providing important health care to people who are pregnant or want to become pregnant.
We also want to let our listeners know that we are undergoing some strategic changes so that we can improve our listener experience and streamline our processes. So we will no longer be offering our traditional show notes and will instead include takeaways resources and transcripts directly on our website. But we would still love and appreciate your support. You can find ways to support us on our website by going to www women-centered health.com and clicking the Support US tab. Also, nurses can now earn ce for listening to the WCH podcast. Just check out myceq.com or download the app the Cehq app, or visit our website www.womancenteredhealth.com to learn more. And always I’m recording with my little tiny person so you may hear some little extra noises.
Hi Jenny, thank you so much for being a guest on our podcast today. The first question we always ask our guests is whether they can share with our listeners some details about your background.
Great to be with you guys. My Background I grew up in Canada, in southern Ontario, except a few years living in England, and I think it’s interesting to reflect on that because I think it has informed my thoughts about national health care and access to care as I’ve gone into medicine subsequently in my adult life. But I did move to the United States for college and so I’ve lived here in the US for longer than I ever lived in Canada by now. And I moved just thinking I would be competing in track and field. But then much of my parents chagrin, especially when things like the Dobbs decision come out, they keep thinking this will be something that will bring her back home. But I’ve stayed ever since college. I first took a course in ethics in college.
I majored in something which at the time was pretty forward thinking, was called Biology and Society. And specifically my area of interest was maternal and infant health in society. So along with that came some really interesting coursework, including a few courses in ethics and science and medicine. And so that really began my interest in ethics. In medical school I was drawn to women’s health, to Obstetric Gynecology. I think that was really a combination of the medicine and the surgery. And honestly, specifically remember the day that I first saw the c section and the amazing uterus and how huge it was, and then how it just began to already become closer to normal size in minutes after the c-section. I just thought, this is the most amazing organ in the world, and I want to work with medicine.
And I also think I came to realize that really, if I could get there to work with women as a surgeon and a physician, it was a really privileged opportunity to work with people in really complicated situations, often fraught and complicated situations. So as far as the interest in bioethics that continued after residence, I was really grateful to be able to pursue my master’s in bioethics early in my faculty career and also got involved where I was previously in my practice at the university of Iowa for 20 years. I got involved in the program in bioethics and humanities, which was a wonderful interdisciplinary group. And through that, I got involved in the ethics consult service, as it just got started up there at the university hospitals.
And I was encouraged to volunteer for the American college of obstetricians and gynecologists committee on bioethics. And then through I also had a wonderful time as a representative of a cod for the American society for reproductive Medicine ethic committee and also the American pediatrics AAP. And so just seeing how ethics was done in sort of different areas of medicine as well. And we interacted with representatives from the American medical association, and their council on ethel and judicial affairs. So one of the most, I would say enriching experiences of my life was being on that committee and really seeing how people were thinking through problem-solving in these tricky areas of women’s health. So that’s kind of how I ended up really interested in this area, partly also because I’m extremely interested in access to care and justice issues.
And that’s something that in policy and that’s something that is very much under the auspices of and should be of bioethics.
The other question we always ask our guests is, what informs your perspective? So in other words, why do you do what you do and what is it?
Most valuable to you both world and especially in healthcare? So I feel like that gift that I’ve been given is the opportunity to try to provide some of that knowledge and insight. Now, I’ve got three daughters, and I just see that in practice as they’re sort of moving through puberty. And so that has informed my perspective both in my civilian life in healthcare and I think really, again, the idea of access to accurate information, to knowledge, to the right providers, to an understanding of the science, is really, I think, what brings me to work every day and what has informed my perspective.
Okay, so like we said today, we’re going to talk about medical ethics. So let’s jump right in. Can you start out by explaining to our listeners we’re going to start out basic here? What are ethics?
Yeah, that’s also a great question and spends a little bit on who you ask. Of course, like so many questions I have had the opportunity to lecture over the years to medical students, and fellows. And I think what it comes down to is basically how one tries to figure out the best course of action. I think some people drill it down to even what’s right or wrong. I think that’s overly simplifying things and I think that’s kind of one of the misunderstandings of ethics. And I think I’ve shared this with you, Stephanie, before, is when people say great, we’ve got an ethicist here, they’ll tell us what’s right and what’s wrong and not at all, and I hope no ethicists out there are proclaiming such an ability.
I think it’s a little bit more accurate to say, to help to peel away the layers and figure out the best course of action or look to some standards, some people, if you look it up, people will see the terms morality and ethics being kind of interchanged. I think it’s often defined as moral philosophy as well. So kind of the branch of knowing where you’re trying to deal with moral principles to help make a decision. It depends a little bit like so many things. And if you’re talking about theory or the practice, the thing I like about bioethics is that it’s much more practical in my mind, sort of the study of what to do when issues arise in things like medicine and health policy.
I think when I took my master’s, we talked about the history of bioethics and history ethics. And of course, you can go all the way back to the very beginning of written history to talk about tool offers, figuring out right and wrong. But the field of bioethics kind of seems to have arisen in the late sixty s and the late 70s. So it’s pretty young that’s the 1960s pretty young. And it’s interesting too, that might just be kind of what I was taught as well as a fairly Judeo-Christian American-centered teaching of the history of bioethics. But that’s kind of classically what’s taught at this point.
So you got into this a little bit, but what is the difference between ethics and morals?
Yeah, I think they’re often used interchangeably. But the way I think about it is again, I think quite practical think of morals as being a personal ethic, something you’ve developed personally. It has a fair religious connotation most of the time. So how you’ve developed your own sense of right and wrong? And that may have a lot to do with if you follow any religious tradition or just your influences, your upbringing, your social context, et cetera. Whereas I feel like ethics is generally again more practically considered sort of how do you figure out again what to do in certain professional situations? So like a code of conduct. So it’s used in, again, medicine, obviously for bioethics. But people talk about business law, you hear about ethics panels in politics, which I think is pretty funny, it seems a little bit of a contradiction in terms.
But anyway, I feel like that’s kind of the difference in my mind between morals and sort of moral underpinnings and ethical underpinnings. When I used to teach this, I haven’t had the opportunity much in the last few years, but I described to young physician providers that you sort of have these different codes of conduct and you have to listen to institutional policy to some extent. You have sort of medical best practices code of conduct, and then you’ve got sort of ethical guidelines code of conduct, and sometimes those are like different voices, potentially conflicting voices in your head. And now of course we’ve got more governmental interference, which is complicating that as well. But that’s generally what I think about when I pull apart ethics and morals.
What are the ethical principles and where do they come from?
Teach about this principle of a pro to doing bioethics I think can be really helpful came from, interestingly, again, the field of bioethics was developing in the late sixty s and early 70s that really came out of the discussions around research ethics and how research had gone very wrong through World War II in the Nuremberg trials and then in the US with the Syphilis trials. So there’s a lot of really terrible history of research without ethics. And so out of that came this Belmont report, which you can look up. It’s really interesting. It was years in the making of course, but I think it was published in about 1974. And in that report, they pretty clearly set down three principles, one of them being respect for persons, one of them being beneficence, and justice. The respect for people.
One, it talked about also protecting those without agency. So respecting persons with agency and protecting those without agency. That was again directly kind of coming out of the research, the mismanaged research that had been happening with really the most vulnerable people being charged with being the research subjects and the benefits going to the already privileged. Out of that respect for persons came autonomy. She’s sort of now one of the principles that aren’t talked about optimizing wellbeing and avoiding harm. And so out of that one came the beneficence and nonmaleficence, which are two then of the principles. And then finally there was justice. And so again the four principles now are considered autonomy, nonmaleficence, and justice also. That is in the Belmont report.
And then these four principles also have all been informed by the oath that our various medical professions have taken over the years. So you hear at first do no harm. That’s coming from the Hippocratic oath. All of that also informs this idea of these four principles which are supposed to be equally considered when one is weighing ethically fraught situations. But anyway, again, that’s basically what it’s caught as the primary response to these situations is this for principle approach, I.
Think it’s important to just make a quick reminder too, and you had said this, that these ethics are coming from a place where there were no ethics, kind of how they are born out of those situations. It’s important to think about where these come from as well. Then my next question is how these ethical principles intersect with clinician autonomy.
Autonomy, again, these four principles are supposed to be considered equally, but most people can understand this and see in practice that generally autonomy is considered. We act as if it’s first among equals. So it’s kind of given especially in, again, our sort of western biological approach and it’s focused on individualism. But autonomy is really about centering the patient or the research subject and making sure that the patient is fully informed and has the right to self-determination and bodily integrity. And again, it’s very much an individualist approach. Sometimes, I suppose, it is misunderstood to also apply to physicians or providers and say that they also have autonomous rights to make decisions about what they do. And that’s a misunderstanding or a misreading of the principles.
As you can imagine, having grown out of research ethics and the Spellmont report really had nothing to do with the provider in that position of power having a right to their own autonomy. So instead, when we talk about physicians or providers still having some rights to live comfortably with their decisions based on their own needs and preferences, cultural, religious background, et cetera, that’s considered a separate thing. But it’s called conscientious practice where some people kind of talk about conscious or conscientious practice, but again, different, but definitely something to weigh in this kind of calculus of what’s the best thing to do.
So you’re kind of saying like clinician autonomy. People are thinking of that as like I don’t have to do anything that I don’t agree with. But you’re saying that’s more conscientious practice. Am I understanding that? Right, right.
I just saying that there really isn’t such a thing as physician autonomy. It shouldn’t be considered a principle. It’s not one of the principles. Autonomy is very much about protecting the patient in an unequally powered situation, protecting the research subject. And so it’s just been, I think, misused. But there is, again, the AMA code of ethics drives conscientious practice. There is a very well accepted and I think appropriate discussion of providers having some rights to make decisions within limitations about what they do in their practice. But I just want to pull it apart from the principles and what autonomy really means.
Yeah, that’s really interesting. I hadn’t actually heard it like that before, but it makes sense to separate that a bit because I know that’s always, especially in the media, sometimes they kind of act like, oh, what if the providers don’t agree with specific to abortion? What if you don’t agree with abortion? Or what if you don’t agree with birth control? I’ve worked with physicians who don’t believe that women should take birth control, but then what are you doing to the patient? Are you centering the patient or are you centering your own self?
I think going back to history and figuring out why some of these fundamental foundations of bioethics were developed makes you kind of understand there really wasn’t and still isn’t really the need to give much more power to the providers. They already have a lot of power not to say again that there shouldn’t be some. You have to go through life as a provider feeling comfortable with your own morality as well. So not to say that’s not a consideration, but it certainly doesn’t need to be given that power. And so it’s interesting to read the AMA code of ethics and how they describe the conscientious practice. Right?
But the ACA Committee on Ethics has a really nice article that I think was last affirmed in 2016, where they talk about conscious refusal or conscientious refusal and as you say, Stephanie, that is often used comes to abortion and refusal for abortion. But yeah, as you say as well, there are issues with contraception. And so they describe it as I just looked it up recently in preparation for this. To just look at their verbiage again. And they described it as being important but limited. That these conscientious refusal rights shouldn’t impose religious or moral beliefs on patients. They shouldn’t negatively affect the patient’s health. They should not be based on scientific misinformation. And they should not create or reinforce racial or socioeconomic inequalities. I think that was just really well stated.
I think the thing I love about considering bioethics and your decision-making is that it should really pull you away from, ideally this sort of societal biases and your cultural biases that you may be subconsciously applying to your health care decisions. So I think they’ve done a good job in that piece to try to really highlight those issues.
Can we go into a little bit more than about abortion and conscientious practice? So we take a note a bit about how they’re related. Do you have any kind of other things that you would say about that specific to abortion?
Yeah, I mean, just reflecting in general about the sort of ethics in women’s health care or reproductive health care, definitely abortion is the one that comes up the most. I guess if you were to just ask the panel of selected books out in the community or even in healthcare, there’s a lot in reproductive health care. I was part of a panel of authors that published some work we did when I was in Iowa. We were meeting with the medical students every six weeks and having them write up some cases, any cases that caused them sort of feel some angst about what happened, and sort of try to process that in these cases. And we would go through them. They were de-identified cases and we’d go through them and talk about the issues that would arise.
And I would say maybe half the time somebody would write about an issue with abortion, but there are a lot of other things. And when we publish the data, we’re looking at the same type of process that the medical students did in their internal medicine and their pediatrics rotations and they would consistently describe their rotation in obstetrics and gynecology is the most fraught than they had in the rest of their medical school training. So it was really interesting to hear that and to see what came up for them.
As far as the issues, it’s really across the lifespan and when you think about when you’re providing reproductive health care, it involves the end of life care, which is sort of your classic kind of bioethics issues and where you have most of your bioethicists in medicine or palliative care providers or looking at end of life issues. But it also starts with, again, early embryonic development and that’s why I became so interested in bioethics, doing reproductive endocrinology, but it involves, again, power and gender politics and bodily interference, and then this whole issue of is it maternal versus fetal interests or are those ones in the same what’s the age of Viability? And that goes to the abortion issue as well, but also involves a lot of issues of technology and the body.
And are we introducing this is also an area in Rei I’m super interested in? Are we introducing new technologies, typically without full consideration of their impact? So there are a ton of complicated challenges in reproductive health and I think abortion obviously gets a lot of press, but I think it’s easier to even think through if you situate it in this kind of broad context.
I’m just kind of curious about this research that you did with the students, did you have any kind of common themes between them? And I don’t know if you have any more examples of ethical issues that students have that you could speak to.
Yeah, one of the things that came out too, which is an important thing when you’re thinking about working through clinical ethical reasoning, is also to consider how much is a communication issue versus a true ethics issue. So that actually came up quite a lot, that there’s just a failure of communication and a lot of what we do in health care that might seem like an ethical issue, but is not that interesting, came up quite a bit when we actually honed in on what we would consider ethical issues. There’s a real issue with also student involvement in reproductive health care and so the pelvic exam issue comes up all the time.
That’s a super common one, as you can imagine, from brains and learners who feel that they have a right to do some pelvic exams on patients, on women in the operating room, and in the clinic. The interesting thing about that is that really changes as you move away from being a student yourself. I sort of was on the very forefront of that. I was like, yes, we need full access, this is a learning institution, we should just get to do pelvic exams on everybody. It’s just part of medicine and why are we Exceptionalizing women’s bodies?
But then as you experience more of healthcare over the years and trauma that you’ve seen that women have gone through, then you start to really kind of understand that’s not necessarily a right that should just be automatically given and it’s much more important that there’s fully informed consent even for pelvic exams. So anyway, because that came up a lot and there’s a really interesting conversation to have with other subspecialty providers as well and to think through, there’s really no similarity. I mean, people talk about, well, what about the erectile exam and prostate exam? But there’s really no similar exam that is taught in medicine to the pelvic exam.
And then also then when you think about exams under anesthesia and the general practice of not getting consent because it’s just a standard part of exams and then you talk to patients about you understand that there may be exams under anesthesia that you weren’t aware of a pelvic exam anyway. So that’s something that came up a lot inappropriately in these cases as well. So it’s really fascinating, it’s always really helpful for me to hear the student’s reflection and then we would also have rotating other physicians and providers come in to help me and to see them sort of being like, oh, I didn’t even think maybe I’ve been in practice too long. I didn’t even think about that, I had no idea. And there’s a lot of it. I know it’s near and dear to your hearts as well.
There’s a lot of obesity stigma that comes up in women’s healthcare as well. And in parenting, the sort of judging value around the ability to parent also comes up. So, anyway, just super fascinating. I could go on and on.
Well, I’m just seeing such an intersection between the things that we talk about all the time on the show with biases and how those intersect with ethics and it almost seems like I’m putting this together now, the things that we have biases on, then we’ll kind of take this moral high ground or we might call ethical high ground. But as you’re saying, there’s a difference. That’s really interesting, right, exactly.
I was thinking that too. As I was thinking through this particular conversation, I was thinking this is exactly what these issues are, and yeah, so I agree.
Yeah, like if a patient is we’ve labeled that patient as obese. That doesn’t give the provider an ethical or moral I would say moral high ground to say you’re obese, I’m going to put you on a calorie restriction diet. I mean, that’s kind of an extreme example, but really even just what I see all the time just saw something on TikTok, like a patient lost £80 and her provider weighed her and said, we still need to lose 20 more, and didn’t acknowledge anything about her kind of big behavior change. And so it’s almost like it’s like you have a moral high ground to just kind of say whatever you want because you think that patient should lose more weight based on your own belief system.
Yeah, I think so. I think there’s so much of this feeling in medicine, it’s very slow to change where somehow we have the right to judge somebody’s ability or to be pregnant. So I’m just thinking about it since I’ve been doing this rei. It’s a long time now, I guess, but policies have changed around helping a single person get pregnant or unmarried people, and oh my God, and what about gay, lesbian, bisexual, transgender people? That has finally been changing. But it took forever. And it had nothing to do with medicine. It had to do with value judgments about being able to parent or be pregnant or what you deserve.
And so it’s really and I think then that is reflected now in obesity stigma when it comes to reproductive endocrinology, where there are so many BMI limits out there and it’s kind of people just fall back on, well, it’s just not medically the best place to be if you’re going to be pregnant. And I think that’s just exactly just an excuse to just perpetuate these biases. So it’s quite frustrating.
So when we think about clinical decision-making and communication, how can we use ethics to inform those conversations, including coming up with the correct answer or the best decision, quote unquote?
I think so many providers in healthcare are actually very concrete thinkers, right? You start throwing in philosophy and it just gets like, I just want to know what to do. Somebody teach me what to do that’s me too. I’m very practical and concrete. So former colleague of mine who’s at the University of Iowa, I believe still Loris Calgon, and he published in 2005 this really helpful, concrete, but open for a lot of this approach. The title of the article is A Clinician’s Approach to Clinical Ethical Reasoning template or Guideline for how to Approach Clinical Ethical Reasoning. When you have a problem or you think you’ve got a problem, that’s kind of acquired an ethical basis. And it’s called the Clinicians Approach to Clinical Ethical Reasoning. And interestingly, I’ve just continued to use that in the way I think about ethical problems in healthcare.
When we were developing at the university, our ethics consult service, we used this. And in fact, we had sort of a notes template that used the guideline as well. So I found it really helpful. And so it talks about beginning, it’s sort of like cheap complaints, state your problem, what’s the problem? And then sort of gather the different data, the medical facts, and goals, but also importantly the patient’s goals and preferences and other stakeholders. I think what I’ve pulled into this, which wasn’t necessarily in the original article, was the idea that patients don’t function in a vacuum. So there may certainly and are almost always other stakeholders as well.
And so whether that’s family or community and then also very importantly bring in a context that is there and that’s sort of outside of medicine, but another context about their sort of their personal goals, their personal definition of flourishing, that sort of thing important to think about. As I mentioned earlier too, is this problem ethical or maybe it drills down to it’s actually a medical decision-making problem that people can’t agree on or it’s actually just communication that hasn’t been clear, that’s important to figure out and real name. And then the next part was do we need to get more information? And whether that again is more expert medical advice or are we talking about do we need more dialogue, do we need to talk to more of the stakeholders?
And that’s where I think one of the things that I didn’t really anticipate with being an ethics consultant was this idea that learning how to be a mediator is really helpful, a good listener, and a reflective listener. And that’s often what an ethics consult service will do is to try to promote dialogue between the stakeholders and just try to sort of have the right answer come up. Again, you’re not necessarily the one who’s identifying that, but I’m trying to just bring that out. And then so then the final step is to look at sources of ethical values that are out there and help them to determine the best course of action again.
So that’s where you start to look at things like the four ethical principles or the issue of sort of a consequentialist approach, right, where you’re looking at what are the differences, what are the likely outcomes and which one is a better outcome. So that’s one way of approaching things as well. And also very related to thinking about medical issues is looking at cases that have happened in the past. Are there published cases or cases that people are familiar with where they’ve reasoned through this? And you can do a sort of a similar thing so that’s even got a name like Casuistry. But anyway, just looking at comparable cases, and then of course it’s important to look at professional guidelines that are out there again through your own subspecialty or through the AMA.
And this is also where your consideration: are there any conscientious practice considerations in there as well? So it’s really kind of. A nice stepwise approach that I continue to use. And I think after having written enough notes using that approach, it kind of just comes a little bit more naturally. But it’s the way that you think about medical problems too, again, and so it falls nicely in the way that often providers are thinking through problems.
I don’t know if you know but do most hospitals have this, ethics consult service?
Do most hospitals have that you’re aware of?
It’s a good question whether most have it. There was definitely a feeling that when we were developing this at the University of Iowa that was in the minority of similarly sized institutions that did not have one. It was really interesting to develop the service because we first sort of did a needs assessment and it turns out that when you don’t have a consulting service individual programs, departments, and clinical services will just develop their own system of how to figure these things out. And it often is sort of a consultative or group of experts type of thing that has developed. For example, before we had the ethics consult service at Iowa, we would in our rei practice there if we’re thinking of introducing a new and potentially fraught service like our gestational surrogacy program.
We brought in some outside stakeholders from pediatrics and from the community, and we would have meetings where we would talk about the issues and sort of try to drill down. So that was happening and continues to happen all around within hospitals and healthcare institutions. And I would say that it’s quite common in large institutions to have ethics consult service of some sort or there may be one that you can contact for a broader health system. And so we would have our annual conferences and people would be coming from across the state and would represent some sort of similar service that they might provide for that whole region of the state or their whole system of hospitals or health care facilities, including it’s pretty common to have something for nursing home types of institutions as well as rehab facilities.
So I’m sure there’s data out there to answer that question more accurately.
We talked about practically how clinicians tend to be pretty concrete or practical thinkers. Could you just walk us through the best way to sort of communicate with a patient? When you see an ethical issue come up, like, how do you sort of decide that this is probably an ethical issue and then how do you kind of talk to the patient? Like, I need to consult with somebody else on this?
Yeah, well, interestingly, the consult service we very clearly wanted to be open to, it had to be patient based on a particular patient issue because there’s also obviously institutional ethics policy issues for that. We had the ethics subcommittee to work on, but the consult service specifically had to be sort of a problem and patient base we wanted it to be open to family members, patients themselves, and any staff in the hospital. So we made sure there were ways to get in touch with us that weren’t just sort of a burrow through the electronic medical record or Paging system but fairly frequently it was from some kind of clinician, nursing staff, somebody on the care team.
And I think we did a fair number of just sort of curbside and wanted to be very open to that where it was sort of like well, I think this is really more of an issue to talk to sort of safety and security about because sometimes it was the quote-unquote difficult patient type of thing. So we would try to be that liaison to other resources in the hospital as well, what we thought might better address those issues or like palliative care. Sometimes it was end-of-life support and just sort of moral distress and we would get connected with those folks. So I think that ideally in one’s practice you have access to that sort of cure sighting so that you’re not even sure if it needs whole ethics to consult. Do I just need somebody else’s eyes on this?
And that I think being a third party is really helpful again to kind of reflect some of those things and offer resources. But it is interesting because one of our first questions was always was a patient aware of this concern that you have? Interestingly too. And this is a whole fodder for a whole other conversation but we would also make sure that the attending provider, in that case, was aware, and sometimes the issue was really about power dynamics within the care team and so that was kind of could be an awkward we would sort of do a curbside but not put in a full console because that person reporting the issue didn’t want to get the attending physician involved.
I think it’s always fair to and that’s part of working within a team is to feel like you have somebody just within your team or you bring something to the team’s attention to help pull out your own biases, right? And hopefully, that’s what every working team has is that they have care conferences where they can really bring in different voices within their own team. Don’t necessarily have to elevate it to whole ethics consult service but I think that’s really important to check your biases and try to figure out why am I responding so emotionally, potentially or so strongly to this particular patient.
Do you have any advice on how would a clinician who’s having a concern frame this for a patient? Like is that something that you say, hey, I’m specifically having this issue, or is this usually going to happen, quote-unquote, behind like closed doors, and then you loop in the patient, or what does that look like?
Probably requires some reflection. I’m just thinking about my own practice with this. We have issues that come up fairly frequently with age and the pursuit of fertility treatment. That’s been interesting. It has changed over the years as well. Where we used to think, oh my goodness, 43 is just an age where we’re going to be feudal in our it was like 41 and then 42 and then 43 and now we’re treating women into their later forty s and even using egg donation IVF to treat women up to 65. And so it really brings up issues of ageism and sort of, again, gender equity and what it means to be a parent and what it is owed to your child. And again. Really interesting discussions. But I find myself in those conversations with women especially interestingly here in Seattle. We have just a more diverse population.
I would say. And we have a fair number of black women coming to see us and talking about how they’ve very truly been abused by the system. Not had good access to care. And are finding themselves in a position now at 45. 46. 47. Where they’re feeling like they’re wanting to parent and bring up a lot of great questions of equity and bias. And so I find myself saying, well, this is something that’s rapidly changing. I need to talk to my team about this. I really appreciate you sharing where you’re coming from right now. We can point to sort of standards of care within our field, but then like to develop our own sort of team policies. And it’s interesting to consider how a policy may both protect against bias but also perpetuate bias.
Because when we start to individualize care, we sometimes then perpetuate our own biases when we start to listen to the voices that are louder and make exceptions for those people. So I think it’s an interesting thing and hopefully when a clinician is dealing with an issue that gives them kind of angst or that they’re able to step back and just talk to the patient and say, I really appreciate our relationship, I need to think about this and I need to talk to our team and just be really open and honest in the communication about it.
Yeah, thanks. That makes sense. I know that a lot of people are interested now that the Supreme Court has overturned Roe v. Wade and really talking about the ethical implications of that IVF. And since as a bioethicist and an infertility specialist, what do you see as the potential ethical implications versus legal implications of this new decision?
It is something that you can imagine that as soon as they start to say that life begins at whatever conception means egg meat firm, then we are dealing with that all the time. And so I would say I think this is probably overused, but it’s really accurate. It has this chilling effect on patients and on providers and everybody’s pretty concerned about what that’s going to mean. I think what the American Society for Reproductive Medicine is saying in their statements and what they’re doing besides strongly standing with others with ACOG and all sorts of professional organizations to speak out about this is that they’re trying to identify where within each state law there might be an issue. And most of the states, I think all of the states to this point have at least said that this is not going to impact IVF.
But it’s hard to believe that it won’t if you’re talking about it because we just routinely embryos freeze and they may not all get used and patients may decide to discard them or donate them to research and we do genetic testing on embryos and decide whether an embryo is chromosomally normal or not. We just type those chromosomally abnormal embryos. And so there are most interestingly, most of the long-term storage facilities for embryos are in states that have fallen or will abortion rights will fall soon. And that’s kind of interesting, I think to look into that and say well, why is that all these states that have long-term storage for the list but anyway, it’s bad news.
And so we have had a lot of patients asking to ship their embryos to Washington now obviously because they have proactively come out to protect reproductive rights? And we’ve had a few people, at least two that I know of, who have said with this happening, I am worried about being a person who is pregnant in this world, in the US. And so I’m not doing fertility treatment anymore. It’s a real problem. And just as a general as a reproductive health provider and a woman and a mother of three daughters awful. And I think a part of the concern that we all have too is the impact on rights, contraception rights to gay marriage, and transgender care and which are things we take care of as well in Rei.
So it’s really concerning and we just need to keep up on what’s happening legally and politically and keep standing with our colleagues.
It’s such a hard situation to be in when you think of ethics and you’re a bioethicist and are thinking about ethics and those four principles and how those are going to compete against the law and I’m sure this isn’t the only time but it seems like for health care this is really the end of life stuff is similar.
But yeah, there aren’t a lot of being hard pressed to find any laws that restrict laws, in general, should not impinge on sort of professional where professional societies in medicine right, should have control over sort of what’s best practices but you have a few odds out there like empower or whatever that’s sort of telling the patient’s right to healthcare. But it’s very hard to find anything that creates a law against providing evidence-based appropriate medical care. Right? I mean, so it’s revolutionary in that sense. And I think about what I was reading from the conscientious practice documents from ACOs and thinking this is exactly what all of these states are doing.
These limitations to practice should not be limited by they shouldn’t impose religious or moral beliefs on patients, they shouldn’t negatively affect health, they shouldn’t be based on scientific misinformation, and they shouldn’t create or reinforce racial or socioeconomic inequalities. I mean, that’s exactly what these laws are doing. And so it’s been forcing clinicians in those states to not do what they need to do, to not provide evidence based care and to not provide care to the most underrepresented people in our society. And it’s hard to believe, and I feel both credibly privileged and grateful that I’m in a state where that’s protected and I’m not concerned, but also I am in a country where that’s the case. And I also feel for my colleagues and the women in the states not so far away, we’re so affected by.
Do you have or what can providers do if their state does ban abortions, need pearls for them?
When I’m most angry about it, I feel like just revolt, right? Just do what you’re meant to do. I mean, I think practically, obviously, speaking out is readily important. A huge number of voices and providers have clinicians and providers have really powerful voices. It’s really interesting actually, that Roe v. Wade was really about a provider rather than actual women. I don’t know. There was a really interesting daily that came out recently where they were talking to a lawyer who was trying to get her case to the Supreme Court in the late sixtys and early 70s, right before Roe v. Wade was passed, and how that was all about the patient voice. And so I think while it’s important for clinicians to raise their voices, I think they really need to elevate the patient’s experience. And the patient’s voice is super important.
I think working with our professional group to figure out what they’re doing, to advocate, to support that and get the word out about that and the state boards to see, try to be savvy about what is out there and what might come down the pike and how to become politically active there, to try to either shore up or to change things that are happening. I think similarly, on an institutional level, just to figure out my institution going to protect me, where are they? If I’m in a state where it’s going to be illegal, what’s going to happen to me when I provide care that I feel that I need to provide, or how do I do that? I think connecting nationally right, is super important to know what people need in other states. How can we work with that?
What we’re thinking about here in Washington, is how can we provide care closer to the border, and provide funding for people to care in Washington. How do we deal with licenses that might not apply in other states? And I think obviously, to donate to the organizations that are doing the good work as well are just some ways to try to help.
I’m curious about your opinion on this too, is when people think Roe v. Wade, it’s all just framed from abortion access, and it’s a win if we women can no longer get an abortion. And I think what’s being lost is Roe Vs wade is more than abortion access. So I’m curious if you could also kind of spell out, like, what other ethical implications of this. I know you hit on some beyond just that abortion piece of Roe v. Wade that maybe people aren’t really thinking about.
I think that, again, daily the way that they describe the approach that the legal system has taken to try to somehow cobble the Constitution around what are really some fundamental rights, right? So the approach that was taken with Roe was the right to privacy as a constitutional right, which obviously was at least temporarily successful. But I think about it, instead of sort of equal rights by sex or equal rights to all people perhaps would have been a more long-lasting approach legally. But again. I’m not at all a legal expert. But I think when you do think about this issue of the right to privacy. How that’s basically been basically no. That’s not in the Constitution. This fundamental right to privacy. You can just imagine what that means and why. If you read Clarence Thomas his words in this ruling.
He’s already called out again. Rights to contraceptive access and rights to same-sex marriage. So it doesn’t take much to start to see what could fall. And if you look at, like, the Hastings Center is a nonprofit organization that focuses on bioethics and they’re very concerned, it’s interesting to look at their website. They are not as concerned about sort of reproductive rights access with Roe v. Wade being overturned, but they’re more interested in what that means for end-of-life care. And so I think that there are profound implications with physicians having less agency over helping people and their life in what a patient might describe as a good way. So I totally agree. We need to be thinking just as a whole country that this is not just about abortion, clearly, and that this could really have an impact on so many things.
And I think that is important because a lot of people we know that even women who have had abortions sometimes don’t think that this applies to a lot of people sort of other these things, and they really need to personalize that this is impacting so many things.
Yes, thank you for saying that. I shared this on my social media, but when I worked at Planned Parenthood in the abortion clinic, just seeing one time a protester brought his daughter in, your old daughter in for an abortion, and somebody asked, Why are you here? And he was like, well, this is different. And he really did think that, but it’s like we know it’s not. I don’t know what they think, but I don’t know where it was going with that. It just is really yeah, we have to stop thinking that’s exactly right.
Yeah. I mean, it’s interesting to see, again, with so many things that happen in this country and has been outside of the country recently for a long time, it’s really interesting to see how others reflect on what is happening in this country and to see all the countries, not all the countries, but many countries, the UN and Canada, and coming out against this is a real human rights violation. Right. It’s not so clear if you can try to appreciate their point of view, which is really important to do. Yeah. It’s not just about abortion. It’s about human rights.
We want to be respectful of your time. I know we could talk to you for the entire day, probably, about all of this. So if our listeners want to know more about ethics, especially as it’s related to sexual and reproductive health care, where are some places they can go? I know you mentioned the one thing that was created here in Iowa.
My bias has been associated and taking part as a volunteer in these committees. But I really think they do amazing work is that the American College of Obstetricians and Gynecologists. Their Committee on Ethics documents are all they’re accessible on their website. But also through the Green Journal. Which is what we call Eccentrics and Gynecology Journal. Those are publicly accessible. The American Society for Reproductive Medicine. Also, their Ethics Committee documents are publicly accessible on their website as well. Those are published in Fertility Instability. And so those are good, specific sort of our field and our considerations. The Achilles ones cover things like basics like informed consent as well, as conflicts of interest in medical practice and technology. And some really nicely written and considered opinions. I love the Gutmacher Institute. That’s typically more policy, but they’re really up to date on what’s going on.
And I think ethics informs policy a great deal. So they certainly wouldn’t describe themselves as an ethics group. But I think that’s really those are also really thoughtful and timely. I mentioned the Hastings Center that, again, I was interested to see it’s sort of, again, talking about more concerns with end-of-life care and how dos may affect that. But it is a good site for looking at some really well-reasoned ethics. I actually really liked the Code of Ethics, the AMA Code of Ethics, because it’s just again, it’s really nice to see sort of the underpinnings, at least for again, from the standpoint of physician group and see what they’ve got in there. There’s an interesting nonprofit organization called Hypatia, and that’s a feminist bioethics group that has done some really interesting work.
That one you have to be a member of to access their information. But they’re doing a lot to try to be inclusive and reflective of underrepresented groups in health care. And then I think just these days, searching reproductive justice is a great way to kind of find what some excellent groups are doing out there. And there’s a real focus. Again, I talked about the four principles of injustice. And I think that a really important component of an ethical approach to practice in reproductive health is to have that reproductive justice lens. So I’m sure if you ask if some of these organizations are your specific ethics group, they would decline to say that they were. But I think that’s really what they’re doing. Those are just some ideas.
So, Ginny, I would personally like to thank you so much for your time and commitment to advancing sexual and reproductive health care through communication. Do you have any last thoughts you would like to add before we end?
It Was such a pleasure to talk with you both and brought up a lot of related issues that I hadn’t really thought about. And again, I think your podcast is awesome. Everybody should listen to it all the time.
Well, thank you for being such a big supporter of it.
Yes. Thank you.