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    Here’s what happens when freedom to speak meets intolerance to listen

    Are some views unfit to be aired at medical school? Tensions over critical social issues spur heated objections but also open room for thoughtful discussion.

    There is a person on the left side with a speech bubble. The bubble is being painted over by another person on the right side on a ladder.

    Editor’s note: This article is part of a series on freedom of speech, misinformation, and medicine. Other articles in this series include stories about increasing threats to academic freedom and balancing a physician’s right to free speech with the harm caused by medical misinformation.

    The University’s fundamental commitment is to the principle that debate or deliberation may not be suppressed because the ideas put forth are thought by some or even by most members of the University community to be offensive, unwise, immoral, or wrong-headed. — the Chicago Principles

    On many campuses, the question of how students should respond to speech that offends them has been settled. Free speech codes have proliferated at American universities over the past decade, with more than 100 adopting some form of the Chicago Principles, created by the University of Chicago (UChicago) in 2014 in the wake of conflicts at several schools over controversial speakers.

    Yet the current social climate is putting the ideals of free expression and tolerant listening through a stress test.

    At the University of Michigan Medical School (U-M Medical School), in Ann Arbor, incoming students petitioned to replace the chosen keynote speaker at the white coat ceremony in 2022 because she had spoken out against abortion. She spoke anyway; several dozen students walked out.

    At the Medical College of Wisconsin (MCW) this past Spring, an in-person symposium organized by critics of racial diversity policies was moved online because school officials worried that student and faculty efforts to get the event canceled — on the grounds that it was “not rooted in evidence” and could make students feel unsafe — had created a risk of disruption on campus.

    At UChicago in 2018, students in the Pritzker School of Medicine were among those who argued that Steve Bannon, the controversial former advisor to President Trump, should not have been invited to speak there because he promulgated intolerant extremist views.

    These are just the most visible examples of a growing tension around free expression and tolerance at some medical schools. The tension plays out most frequently out of public view, as administrators increasingly hear students and teachers declare that certain points of view are antithetical to the mission of medical care and education, and should not get a platform on campus. On the flip side, other students say they do not feel safe expressing opinions that cut against mainstream views for fear of provoking cancel culture hostility from peers and teachers.

    “This idea of free expression comes up more and more,” says David McIntosh, PhD, vice dean for justice, equity, diversity, and inclusion at the David Geffen School of Medicine at UCLA, in Los Angeles. “Sometimes students come to our office frustrated that other students have expressed views that they think are out of bounds for a medical school.”

    “We’re seeing increasing rates of self-censorship, increasing rates of intolerance toward opposing ideas” at colleges overall, says Zachary Greenberg, senior program officer for campus rights advocacy at the Foundation for Individual Rights and Expression (FIRE), a nonprofit civil liberties organization founded in 1999 that monitors free speech suppression.

    Educators and free speech advocates see the phenomenon as the trickle-down impact of cultural polarization and the coarsening of public discourse. Students arrive at medical school today having grown up hearing many political, media, and social leaders demonize their foes, delegitimize opposing views, and spread scientific misinformation.

    “Students see this intolerance of opposing beliefs in society, they see leaders trying to destroy their adversaries,” Greenberg says.

    To be sure, civil discourse about divisive issues goes on among students and teachers every day, often through lectures and discussions planned for that very purpose. But more and more, students on some campuses see certain issues — primarily involving abortion, immigration, gender identity, sexual preferences, and public health mandates — as settled on the grounds of medical science, ethics, and health care outcomes.

    At the same time, there appear to be insufficient forces pushing to instill the value of free expression and tolerance in a multicultural, pluralistic society. That’s long been the role of elected leaders, journalists, and teachers, but such civic tutoring seems to be both less common and less embraced. In an opinion piece about the growing intolerance on college campuses, published in The New York Times last month, two Stanford University professors blamed “the failure of higher education to provide students with the kind of shared intellectual framework that we call ‘civic education.’ It is our responsibility as educators to equip students to live in a democratic society whose members will inevitably disagree on many things.”

    In what might indicate the sensitivity of the subject, of the 13 medical school faculty and communications offices contacted by AAMCNews for interviews about the state of free expression and tolerance on their campuses, seven declined.

    Sensitive issues

    School administrators have found several ways to navigate challenges that arose when objections to certain messages clashed with the value of free expression.

    In 2018, when an outspoken pro-life advocate was scheduled to speak at an event run by a Christian-based club at University of Colorado School of Medicine’s Anschutz campus (CU Anschutz), in Aurora, a group of pro-choice students argued that the speaker should not be allowed.

    “As a woman leader in medicine, how can you allow this to happen?” one student demanded of Shanta Zimmer, MD, senior associate dean of medical education.

    “This is free speech,” Zimmer replied.

    The controversial nature of the speaker is immaterial — speech cannot be restricted based upon whether the university agrees or disagrees with a speaker’s viewpoint. — CU Anschutz Freedom of Expression policy.

    When Zimmer suggested that the students attend the event to listen and to hold their own event in response, “They said, ‘We don’t even want to talk to them,’” Zimmer recalls. Pushing back on their refusal to discuss different points of view about medical matters, she told them, “That might be an option in your political life outside of school, but as a burgeoning physician, that’s not acceptable.”

    Zimmer says several of the students accepted her admonition to attend the event without disruption and to present pro-choice materials outside the venue.

    Perhaps no issue has spurred as much conflict over free expression at medical schools as abortion, and the U.S. Supreme Court decision last year that overturned the constitutional right to abortion has heightened tensions. Students and guest speakers who advocate for bans on abortion often draw particularly emotional reactions from the vocal majority, who say that abortion access is a critical form of medical care for women and that physicians need to honor the patient’s choice regardless of their personal views.

    “If you're trying to communicate an anti-choice agenda, that abortion shouldn’t be taught in medical schools, or saying that it’s not essential health care, then there’s no place for that discussion in an institution of science,” says Danna Ghafir, a student at a medical school in the south and president-elect of the board of Medical Students for Choice.

    Ghafir says she knows medical students who oppose abortion personally, but, as professionals, they need to ensure that their patients have access to safe abortions if that is their preference and need.

    Austin Clark, on the other hand, believes that strong pro-life views should be aired on campus. In 2018, when Clark was a student at the University of Louisville (UofL) School of Medicine, he expressed his conservative opinions and organized a speaking event on campus with Alex McFarland, an author and evangelist who writes about conservative Christian views on such issues as gender identity and abortion. While university leaders expressed some concern about the need for extra security at the event, Clark says the presentation went on.

    UofL will not stifle the dissemination of any idea, even if some members of our community think it offensive or hateful. UofL free speech policy

    After the event, Clark says, he felt ostracized by students and teachers. “There was definitely a shift in how people interacted with me,” he says.

    (The school declined a request to discuss free expression and tolerance on campus, citing a lawsuit by Clark alleging that he was expelled in 2020 because of his outspoken views.)

    Discussions about diversity and inclusion are another common point of conflict. Last May, at MCW in Milwaukee, a chapter of the National Association of Scholars (NSA) was to hold a symposium about “the uses and abuses of government-sponsored Diversity Equity and Inclusion (DEI) programming in universities generally and specifically in medical, scientific, and technical education.” The NSA is a conservative-leaning advocacy organization that says it supports “freedom from ideological imposition,” including from diversity requirements, in higher education.

    Students and faculty demanded that the event be canceled, with some signing a petition to MCW President and CEO John Raymond Sr., MD, stating that “discourse that is politically motivated” and the presence of the NSA would affect students, “especially those who are routinely subjected to discrimination and the effects of racism.”

    The objections to the symposium “were not temperate,” Raymond says, and he was concerned about opposing sides facing off at the site of the event, which was slated for the day before commencement week and close to MCW partner medical facilities.

    “It was creating a lot of friction on campus,” Raymond says. “It was just too disruptive.”

    The school postponed the symposium, which Raymond says was eventually held off-campus and online with assistance from MCW. The school is developing principles for freedom of expression, using the Chicago Principles as one model, Raymond says.

    These incidents illustrate a typical (albeit not exclusive) pattern in free expression conflicts at colleges: liberal majorities allege that conservatives are promoting policies based on their personal beliefs rather than on science, while conservatives say that liberal students and faculty who dominate the mainstream opinions are not willing to hear opposing views.

    “I’ve had conservative students come to me and say, ‘The school clearly favors things that are against my values. I’m not allowed to be myself here,’” Zimmer says, in an observation expressed by administrators at other medical schools.

    As a result of such feelings, some conservative students censor themselves on socially touchy matters. “Our politically conservative students will say, ‘I don't feel comfortable talking about my views,’” Zimmer says — another observation shared by administrators at other schools.

    Sensitive discussions

    Intolerance and self-censoring worry school leaders, who say students need to learn how to connect in meaningful ways with patients from diverse backgrounds, beliefs, and lifestyles. Faculty confront that concern through individual discussions and organized events.

    At UCLA, McIntosh tells students who express discomfort with the school’s progressive environment, “Whether you like it or not, you’re going to have patients in your clinic who identify as LGBTQ, or identify as Black, Hispanic, Latinx, Native American, etcetera. You have to understand their lived experiences as well as the science” in order to provide proper care.

    For students of all political persuasions, the messages are less about freedom of expression than about what James Woodruff, dean of students at the Pritzker School of Medicine, calls “the more important, other side of the coin: willingness to listen to people who have different opinions than yours.”

    Some schools drive home that lesson through lectures and group discussions about civil discourse, through student orientations, first-year medical courses, and seminars about issues in medical care, education, and science. One goal is making students feel comfortable expressing views that cut against the mainstream.

    “We spend a fair amount of time [with incoming students] setting up the environment so that people feel comfortable being vulnerable, trusting each other, and having hard conversations,” says David Muller, MD, dean for medical education at the Icahn School of Medicine at Mount Sinai, in New York.

    A longer-term goal is to instill habits in future physicians and researchers of listening thoughtfully and seeking out other points of view.

    The core message, says Woodruff: “Varied opinions, disagreements — those are fodder for improving patient care. One needs to actually seek out those people who have different perspectives, because in complex systems, no one person has the right answer to the problems we face. You need alternative opinions in order to actually come to the best decisions.”

    Toward that end, the Pritzker School of Medicine periodically holds civil discourse gatherings where faculty lead about 20 students in discussion and debate about such issues as affirmative action and whether health care is a human right. These events served as a handy model after news broke in 2018 that Bannon had received an invitation from a business school professor at UChicago to participate in a debate about immigration and globalization. Students from around UChicago held protests against the invitation. Eventually, Bannon did not participate, but many students remained distraught that he was even asked.

    “There was a lot of discussion here at the medical school, along the lines of, ‘How could this possibly happen? That in an educational environment, we invited somebody who is so intolerant?’” Woodruff recalls.

    Although members of the University community are free to … criticize and contest speakers who are invited to express their views on campus, they may not obstruct or otherwise interfere with the freedom of others to express views they reject or even loathe. — the Chicago Principles

    At Woodruff’s invitation, the professor who had invited Bannon came to one of the civil discourse gatherings to say why it was vital to have open discussions with people whom we think are extremists. As Woodruff recounts, the professor explained his concern about the rise of Trumpism in America and the response of its opponents. He had grown up in Italy, where his father taught him that one reason fascism arose there after World War I was that “society dismissed the ideas of the fascists as absurd, instead of confronting the merits of their arguments.”

    “The students who had come in ready to argue with this person realized that they had mistaken impressions of his intent,” Woodruff says. “It was a wonderful experience in understanding that there should be humility in approaching conversations with people who we disagree with.”

    At MCW, Raymond is eyeing similar conversations through a speaker series on freedom of expression, covering “ideas that may be uncomfortable or go against dogma, that may even be viewed as anti-scientific.”

    Administrators are striving to instill the value of “parrhesia,” a term from ancient Greece meaning candid, uninhibited speech. In a recent AAMCNews interview, human rights lawyer Jacob Mchangama, author of Free Speech: A History From Socrates to Social Media, touted parrhesia as “a commitment to broadmindedness and tolerance of dissent.”

    What defines tolerance? Under the various free speech statements at universities, shouting down a speaker is intolerant. How about walking out during a speech in protest, as some U-M Medical School students did when faculty member Kristin Collier, MD, welcomed them at the white coat ceremony last year?

    First, the students submitted a petition for the school to replace Collier as a speaker. Although Collier did not plan to discuss abortion, the petition stated that having “an anti-choice speaker as a representative of the University of Michigan” lends support to a “theology-rooted platform to restrict abortion access, an essential part of medical care.”

    The belief that an opinion is pernicious, false, or in any other way detestable cannot be grounds for its suppression. — U-M Freedom of Speech guidelines

    When Collier’s speech went ahead, students conducted the walkout not with the aim of suppressing her talk, but as a form of counter-speech. Their protest was similar to heckling and displaying signs, which the U-M policy allows as long as the speech can continue. And the action garnered attention on campus and in the national news media for the protesters’ cause.

    U-M Medical School declined to discuss the walkout or the state of free speech and tolerance on its campus. It issued a statement saying, in part, that Michigan Medicine “unequivocally stands behind the principles of academic freedom and freedom of expression. Free expression of views is essential to dynamic dialogue and debate.”

    How can faculty and students foster dynamic dialogue and debate at a time when uncivil discourse is so prevalent? Medical school leaders find hope in the constructive conversations they’ve organized to help people gain insight into opposing views and tone down hostile intolerance.

    “If only our students and our colleagues would learn some of those things about one another,” says Zimmer at CU Anschutz, “I think we’d find a little more of that common ground and be able to have these discussions but not hate each other.”