Disputes about conscientious refusals reflect, at root, two rival accounts of what medicine is for and what physicians reasonably profess. On what we call the "provider of services model," a practitioner of medicine is professionally obligated to provide interventions that patients request so long as the interventions are legal, feasible, and are consistent with well-being as the patient perceives it. On what we call the "Way of Medicine," by contrast, a practitioner of medicine is professionally obligated to seek the patient's health, objectively construed, and to refuse requests for interventions that contradict that profession. These two accounts coexist amicably so long as what patients want is for their practitioners to use their best judgment to pursue the patient's health. But conscientious refusals expose the fact that the two accounts are ultimately irreconcilable. As such, the medical profession faces a choice: either suppress conscientious refusals, and so reify the provider of services model and demoralize medicine, or recover the Way of Medicine, and so allow physicians to refuse requests for any intervention that is not unequivocally required by the physician's profession to preserve and restore the patient's health.
Peipert et al. (1) claim that restorative reproductive medicine (RRM) originated as a political and religious movement with the purpose to limit access to in vitro fertilization (IVF). In so doing, they mischaracterize the origin, development, and aims of RRM, as articulated by the International Institute for Restorative Reproductive Medicine, founded in 2000. They do not refer to any peer-reviewed medical literature published by clinicians and researchers working to develop RRM. Objecting that certain political or economic interests promote RRM (or, alternatively, IVF) does not constitute the basis for an evidence-based scientific critique or discussion. Thus, their editorial falls short of a serious effort to understand RRM scientifically.
Segarra I et al., 2023·Front Med (Lausanne)·
Open Access
Hormone-based contraception disrupts hormonal balance, creating artificial states of anovulation and threatening women's health. We reviewed its main adverse effects and mechanisms on accelerated ovarian aging, mental health (emotional disruptions, depression, and suicide), sexuality (reduced libido), cardiovascular (brain stroke, myocardial infarction, hypertension, and thrombosis), and oncological (breast, cervical, and endometrial cancers). Other "collateral damage" includes negative effects on communication, scientific mistrust, poor physician-patient relationships, increased patient burden, economic drain on the healthcare system, and environmental pollution. Hormone-sensitive tumors present a dilemma owing to their potential dual effects: preventing some cancers vs. higher risk for others remains controversial, with denial or dismissal as non-relevant adverse effects, information avoidance, and modification of scientific criteria. This lack of clinical assessment poses challenges to women's health and their right to autonomy. Overcoming these challenges requires an anthropological integration of sexuality, as the focus on genital bodily union alone fails to encompass the intimate relational expression of individuals, complete sexual satisfaction, and the intertwined feelings of trust, safety, tenderness, and endorsement of women's femininity.
Professional bodies such as the American College of Obstetrics and Gynecology recognize the impact of conscience-based decisions. The first time such decisions affect patients and providers is in residency. Our study sought to determine the attitudes of program directors towards various conscience-based refusals in potential applicants to obstetrics and gynecology programs. An eight-question survey was sent to 279 directors of U.S. obstetrics and gynecology residencies in 2019. The survey proposed hypothetical conscientious refusals of common aspects of obstetric and gynecology practice. The survey asked respondents to categorize their reaction to these choices and choose from a list of factors which could modify their reaction. Univariate analysis and multivariate logistic regression were performed. 97 program directors (35%) responded. A majority of PDs reported that the inability to prescribe or counsel on birth control, to provide methotrexate, to counsel on abortion, or to clearly enumerate refusals was impossible to work around, likely to lower an applicant's rank, not compatible with training, or not good for patients; collectively, these responses were grouped as "negative reactions" (73-99%). Female program directors had more negative reactions to applicants who refused to prescribe birth control (aOR 15.8, 95% CI 1.7-99.5) and counsel on abortion (aOR 3.6, 95% CI 1.2-10.8). Directors from different locations and program types did not have significantly different responses. A few program directors identified that academic strength could mitigate otherwise negatively-viewed choices. Illustrative comments of directors' attitudes are provided. Program directors agree that conscientious refusal to participate in certain activities is problematic for obstetrics and gynecology residency. There are very few subjective or regional differences on this stance, and few aspects of an application modify directors' reactions.
Restorative Care and Assisted Reproduction · Outcome Comparisons
La progresiva medicalización de la infertilidad en las últimas tres décadas se corresponde con una creciente difusión de las Tecnologías de Reproducción Asistida (TRA), que han dejado en la sombra, casi por completo, otros enfoques más fisiológicos del tratamiento de la infertilidad, que tienen menos riesgos, son más económicos y, a la vez, igualmente efectivos. Este trabajo presenta un enfoque sistemático e integrado: la NaProTecnología (NPT), que tiene como objetivo optimizar las condiciones fisiológicas en cada ciclo menstrual, para permitir, de esta forma, una concepción por métodos naturales. Este método se postula como una mejor solución para el tratamiento de la infertilidad, desde un punto de vista que no sólo es más ético, sino que, además, es compatible con otros puntos de vistas religiosos, médicos, sociales, legales y ambientales. Los gobiernos deberían promover y financiar la NPT y, al mismo tiempo, las sociedades médicas y científicas deberían diseñar estudios para comparar de una manera justa la tasa de éxito, los costos y las complicaciones de la NPT en contraposición al método TRA tradicional.