Journal ofMedical Ethics, 1996; 22: 115-120

An obligation to provide abortion services:what happens when physicians refuse?Christopher Meyers and Robert D Woods Department of Philosophy and Religious Studies, Califonia State

University, Bakersfield, California

AbstractAccess to abortion services in the United Statescontinues to decline. It does so not because of significantchanges in legislation or court rulings but because fewerandfewer physicians wish to perform abortions andbecause most states now have "conscientious objection"legislation that makes it easy for physicians to refuse todo so. We argue in this paper that physicians have anobligation to perform all socially sanctioned medicalservices, including abortions, and thus that the burdenofjustification lies upon those who wish to be excusedfrom that obligation. That is, such persons should haveto show how requiring them to perform abortions wouldrepresent a serious threat to theirfundamental moral orreligious beliefs. We use current California law as anexample of legislation that does not take physicians'obligations into account and thus allows them too easilyto declare conscientious objection.

The ethics committee at a county hospital inCalifornia recently faced the following dilemma:

The county had a state-mandated legal obligation toprovide abortion services for two population groups -

those incarcerated in the county penal facility andthose deemed incompetent to make their ownmedical decisions. The county had chosen to providethese services through its public hospital, which had,in turn, subcontracted with a local private obstetri-cian to perform most of the abortions.When this obstetrician's services became unavail-

able, the hospital searched in vain for another privatephysician willing to cover the service. Realizing thismeant that his staff would have to fill the void, thechair of the hospital's obstetrics and gynecologydepartment approached the ethics committee,looking "to relieve the residents and faculty of thisburden". Discussion revealed that of the eightresidents on staff, only one was willing to performelective abortions. And, according to the chair, nonewere qualified to perform an unassisted second

Key wordsAbortion; abortion services; physician obligations;conscientious objection.

trimester procedure. Compounding this shortagewas a reluctance on the part of the faculty, a reluc-tance that ranged from "flat refusal" to "strongdistaste".

After obtaining the relevant facts, the committeeproceeded to provide the chair with informationfrom California's "conscience clause" legislation.This legislation allows health care workers to opt outof providing abortion services if they sign a writtendeclaration stating they hold "a moral, ethical, orreligious objection". This information solved thechair's dilemma; he and all the members of his staffpromptly submitted the appropriate statements andwere thereby legally excused from the obligation.

But now the hospital was unable to fulfil its legalduty. That is, the hospital, as the county agency pro-viding state-mandated health care, was obliged tomaintain abortion services but had no one willingand qualified to do so. A local clinic agreed to takethe incompetent patients but not the inmates,fearing the presence of women in shackles beingguarded by an armed deputy sheriff would intimi-date their other clients.2 The only other option wasto transport the inmates to a clinic in a major metro-politan area some two hours away. But this proved tobe prohibitively expensive, given the need for trans-portation and guards.

In short, the hospital and the county were legallystuck between a rock and a hard place. They had onestate law mandating that they provide abortionservices and another state law resulting, in practice,in an absence of physicians willing to perform them.

That there were not enough physicians willing toprovide abortion services is not unique to thishospital. Although the demand for abortionsremains fairly constant, fewer and fewer physiciansare willing to perform them or even to learn therelevant skills; indeed, as of 1991, "eighty-three percent of US counties [had] no abortion provider".3Thus, while the committee was able to resolve theproblem in this case - through creative arrangementswith the clinic and through hiring a faculty memberwilling to perform abortions - it will undoubtedlyarise again, if not at this hospital then at some otherpublic facility.

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116 An obligation to provide abortion services: what happens when physicians refuse?

It will arise again because California's conscienceclause, like similar clauses in other states,4 places thedilemma solely in the context of competing rights,with no inclusion of concomitant obligations. Thatis, the law sees the problem only as an example of aconflict between the right of physicians5 freely tochoose which procedures they can morally tolerateversus the right of access to abortion services. Ananalysis of these rights is no doubt important. Butsuch an analysis will come up short if it does not alsoinclude consideration of how obligations, particu-larly status or role-engendered obligations, weighagainst these rights.

In this paper we thus provide a critique of theCalifornia conscience clause and thereby alsoattempt to address the general issue of when it isappropriate for physicians to declare conscientiousobjection. While we strongly support the right of anindividual to opt out of participation in activities sheor he finds morally repugnant, we do not believe theCalifornia conscience clause provides appropriatemeans for doing this. We argue that the law isseriously flawed because, first, it does not takeadequate account of physicians' moral obligations toprovide services and, second, because it simplifiesthe process of moral decision-making to the pointwhere it is rendered, at best, trivial. After consider-ing the benefits enjoyed by US physicians, wecontend that they have a prima facie obligation toprovide services, including abortion services, andthus that the burden of proof lies upon them tojustify being exempted from this duty. We concludewith some suggested changes to the conscienceclause, changes that would include consideration ofphysicians' duties, show greater respect for moraldecision-making, and still protect genuine con-science-based moral decisions.The issues raised here clearly extend beyond

abortion and beyond California. We focus onabortion and California's conscience clause becausewe believe the problems raised in our case serve bestto exemplify the extent to which physicians have anobligation to provide care beyond that typicallyacknowledged. The provision of abortion servicesrepresents a paradigm example of the conflictbetween individual rights and community needs.That is, it involves the conflict between an indi-vidual's right to avoid participating in activities shedeems morally repugnant and the right of thecommunity to have socially sanctioned medicalservices made available. While similar conscience-based dilemmas exist in such issues as right to dieand living will statutes,6 the provision of care toMedicaid patients,7 and the use of physicians toprovide lethal injections in capital punishment,8none of these carry with them such a direct conflictbetween physician rights, patient rights, and physi-cian obligations.9

Also, the number of physicians willing to performabortion services has declined, in part, because it has

become increasingly risky to do so. As the cases ofDavid Gunn and John Britton'° reveal, there is agenuine, if unlikely, threat to personal safety. Andthere is an even greater threat of harassment andintimidation, including anonymous calls andmailings and picketers at both work and home. Thusif an obligation to provide services can be establishedon this issue, it would clearly extend to other, lessrisky but still undesirable - to some - medical proce-dures.

Finally, the problem is exacerbated in California,and a number of other states, by conflicting laws. Inaddition to the conscience clause, there are addi-tional laws and regulations which require counties(and thus typically county hospitals) to make suchservices available to certain populations.

CONFLICTING LAWS AND REGULATIONSWhile US federal courts continue to tinker with theprecise meaning of the reproductive and privacyrights emerging from Griswold," and Roe,'2 theissues have, for twenty-plus years now, been fairlywell settled in California. California law providesboth a negative right against governmental interfer-ence in activities deemed to fall under privacyprotections,'3 and a positive right, at least for certainpopulation groups, to medical services, includingthose related to family planning."'

California thus gives explicit constitutional andregulatory protection to both a negative right ofprivacy and a positive right of autonomy. The statealso thereby explicitly guarantees, at least in theory,that abortion services will be made accessible topersons in the protected classes. Through theseguarantees the state also acquires the correspondingobligation to ensure the availability and timelyprovision of such services.

In competition with these rights, however, is theright of physicians to declare conscientious objectionto engaging in medical procedures that run contraryto deeply held moral or religious scruples. Hence therub. On the one hand, California grants individualsthe right to determine, without state interference,their own family planning activities and furtherstrives to secure access to the appropriate healthcare services for its otherwise compromised citizens;on the other hand, California also allows healthcare workers to declare conscientious objection toproviding abortion services, thereby creating thepossibility, and in our case the reality, that suchservices would not be effectively available.

THE OBLIGATION TO PROVIDE SERVICESPart of the reason the county had no means of fulfill-ing its duty was because none of the physiciansinvolved believed they had an obligation to performabortions. In their minds they were free to choosewhich activities they wished to practise, so long asthere were no laws or regulations to the contrary andso long as in doing so they did not directly endanger

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Christopher Meyers and Robert D Woods 117

others. The principle of liberty, this argument holds,should be the guiding principle, binding unless onejustifies its violation.'5Our contention is that the liberty principle is not

paramount here because an appeal to it ignores thecrucially important social roles and resources thatshape contemporary US medicine and society. Webelieve, in fact, that physicians have a prima facieobligation to provide services. Thus the burden ofproof lies with those who wish to be excused fromthat obligation.

Physicians have this obligation, we contend,because the image ofthem as unbeholden free agentsis a myth. Physicians are, in fact, deeply indebted tosociety, an indebtedness that brings with it a strictobligation to provide vital and socially sanctionedmedical services.'6 With this obligation comes theneed to justify why one should be exempted fromproviding such services.The obligation to provide service comes from two

sources: 1) The ways in which physicians receiveextraordinary social benefits, and 2) The socialharms that would be suffered should the service notbe provided. Addressing the second reason first,while we acknowledge that our society has notreached anywhere near unanimity of opinion onabortion rights, there has long been a strong majorityopinion that women should have the right to deter-mine the course of their pregnancies, at least withincertain, mainly developmental, parameters. Thereseems also to be a consensus, confirmed in recentcourt rulings,'7 that undue obstacles should not beplaced in the path of women attempting to exercisetheir reproductive rights. Should abortion servicesbecome wholly unavailable to certain segments ofsociety, particularly for relatively trivial reasons, anundue burden clearly would be present, and thus asubstantial social harm would accrue.

With regard to the extraordinary social benefitsphysicians currently enjoy, there are at least fiveworth noting. First, all physicians trained in theUnited States receive considerable support intaxpayer-provided educational dollars. For example,in 1990 the US Department of Health and HumanServices alone provided $236,300,000 in fundingfor college and postgraduate programmes in healthand professional training.'8

Second, as the California Business and ProfessionsCode explicitly states, professional licensure is a"privilege", not a "right" or "entitlement".'9 And, asa privilege, it is subject to appropriate state oversightand regulation.

Third, in part because of the state licensingprocess, physicians have been granted a monopolyon most types of medical care. With such amonopoly comes an enhanced obligation to providethose services society has deemed valuable. In thecase of abortion, as our example acutely reveals,women have no alternative source for treatmentshould physicians succeed in acquiring exemption.20

Fourth, physicians enjoy both economic benefit -

in 1994 the mean net annual income for obstetri-cians in the United States was $221,800 5-18 - andlofty social status. With this wealth and prestigecomes a special commitment to the society thatconfirms, and pays for, those advantages.And fifth, in this case the physicians were all

employed at a taxpayer-funded institution; ie, theyreceived their salaries, in part, from some of the verywomen they refused to treat.

While not all physicians work for public hospitalsor clinics and not all receive compensation in therange of a quarter of a million dollars a year, all dononetheless receive social benefits far beyond thoseof the average person. We therefore propose thatthere must be correspondingly powerful justifica-tions given in order to be exempted from the obliga-tion to provide socially valued and legally sanctionedmedical services, including abortion services.Accepting this does not negate physicians' right tomake free, conscience-based choices regarding whattypes of care they shall provide and to whom. Ourclaim is simply that the burden falls upon the physi-cian to show that her conscience is indeed threat-ened. It is she who appeals for exception to anotherwise existent duty and thus it is she who mustjustify her position.

PROBLEMS WITH THE CONSCIENCE CLAUSEWe contend that California's conscience clause hasthree fundamental flaws. The first is that the clausedoes not acknowledge physicians' obligations toprovide abortion services. Rather, it appears to begrounded in the sort of "free agent" myth discussedin the previous section, ie, that physicians should beable to do whatever they wish. The arguments in theprevious section, we hope, reveal why this approachis misguided.The clause's second flaw is that it makes the

process of declaring conscientious objection sosimplistic as to trivialise moral decision-making.Recall the requirements of the law: If a health careworker wishes to declare conscientious objection sheneed only sign a form stating "a moral, ethical, orreligious objection" to the procedure. She does nothave to give reasons to show that this belief is con-sistent with other beliefs she holds and practises.Nor is she challenged, made to justify her stance.Rather, she need only do the equivalent of statingthat she holds an opinion that the activity is wrong.The implication of this approach is that, at least

on the question of abortion, all beliefs are equallyvalid. Accepting this subjectivity of values produces,as Langdon Winner argues, "a loss of attention paidto shared reasons for action. When values are lookedupon as subjective, ... when basic moral and politicalideas are bypassed with such alacrity, any hope offinding a rational basis for common action vanishes.... [This inevitably results in] a scandalous incom-petence in dealing with fundamental, recurring

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118 An obligation to provide abortion services: what happens when physicians refuse?

questions of human existence: How are we to livetogether? How can we live gracefully and withjustice?"2"We readily grant there is no moral consensus on

abortion. We grant also that requiring justificationfor beliefs implies that valid standards exist for eval-uating that justification. And we acknowledge theclear danger that exists in appealing to suchstandards, ie, that in practice they will simply be theones held by the society's powerful elite. But toretreat therefore, as we believe the conscience clausedoes, to the position of no standards, to the view thatany moral position is as good as the next, is both todeny the importance and difficulty of careful,rational decision-making and to denigrate our natureas moral agents.Our culture's rejection of a subjective approach to

ethics is revealed, ironically, in the federal lawallowing a declaration of conscientious objection toparticipation in violent military activities.22 Thisstatute is considerably more demanding than theCalifornia conscience clause; it includes strict guide-lines as to what counts as a justifying belief and itdemands substantial proof from the petitioner as tothe actual existence of this belief. For example, thecode specifies that the belief must be strictly reli-gious and may not include "essentially political,sociological, or philosophical views, or a merelypersonal moral code". And on the question of proof,the courts have uniformly held that each conscien-tious objection applicant must persuade the draftboard that his religious beliefs are personally and, inessence, passionately held. Merely belonging to areligion which holds that war is immoral is insuffi-cient justification.23 Instead, the applicant mustarticulate the basis for his scruple and must demon-strate "sincerity" of belief and consistency in beingopposed to all war, not merely this or that war.24No similar test, indeed no test at all, exists in the

California conscience clause. No actual justifica-tion need be given, only a bare statement that onepossesses a scruple against abortion. One need noteven specify whether that scruple is moral or reli-gious. Rather, all one must do, in essence, is justsay no

Indeed, this simplistic process of declaring con-scientious objection leads to the clause's third majorflaw - that it is too easy to import mixed motives,thereby circumventing the original intent of the lawand also thereby enhancing the potential for the legal"Catch 22" described in our case.The clear, and we believe appropriate, intent of

the conscience clause is to protect health careworkers from having to perform services which trulywould violate their conscience. It is not intended toprotect those who would avoid providing abortionsout of economic considerations or mere distaste. Inpractice, however, the bill's broad language allowsexactly these kinds of considerations to play a pre-dominant role.

In the case described above, the committee hearda variety of justifications given for why the physiciansdid not wish to perform abortions, none of which, inour minds, satisfy the intent of the law. For example,one physician viewed participation as creating apotential economic conflict for his private practice infertility; he worried that his private patients wouldquestion his commitment to their goal of producinga child if he was at the same time willing to end thelife of another. A second physician saw himself, andwish to be perceived, as a specialist in gynaecologyrather than obstetrics. A third candidly admittedthat he did not wish to be considered an abortionprovider since such services are typically not lucra-tive. The only protest that came close to meeting thelaw's intent was the comment that second trimesterabortions are "complex and frankly ugly. They aremost unpleasant for everyone involved". Even here,though, while there is a hint of a conscience-basedscruple lurking in the background, the complaint ispresented as an aesthetic, rather than as a moral,objection.We do not mean to suggest that these physicians

were venal, manipulative, or deceitful. They allsincerely did not want to perform abortions and, asthe above comments reveal, they were quite candidas to their reasons. The broad language of theconscience clause allows that such a negative desire,combined with a written statement using thestatutory language, was all they needed.

A NEW MODEL FOR JUSTIFYING EXEMPTIONGiven these weaknesses in California's conscienceclause, a new model is needed which would allowphysicians to declare conscientious objection whenthere is a true crisis of conscience, but which wouldat the same time take into account both the obliga-tion to provide services and the importance ofcareful moral decision-making. According to thismodel, then, a determination of whether an exemp-tion claim is justified would involve a process ofascertaining and weighing the duties and goodsextant in the situation. In our case, the cost ofallowing exemption entailed both an abrogation ofthe physicians' obligation to treat and the practicalnegation of a socially and legally recognised right, aright whose fulfilment, or lack thereof, had thepotential for profound impact upon many persons'lives. Thus, we believe, there needed to be a cor-respondingly profound justification given by thosewishing to declare conscientious objection.

While other conscience-based exemptions fromsocial obligations rely upon an institutional processfor scrutiny, the existing conscience clause providesno mechanism for determining whether a particularexemption claim is justified. Borrowing, in part,from the guidelines established for the draft board,we therefore recommend a review board be estab-lished to evaluate claims of moral objection toproviding abortions.

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Christopher Meyers and Robert D Woods 119

We recognise that different groups have differentmeans for communicating that a belief is profoundlyheld; thus the board should be structured so as torepresent a diversity of racial, ethnic, and religiousbeliefs and academic training. Furthermore, so as toreduce the potential power asymmetry between theboard and petitioners, it should also include a rangeof disciplines - medicine, nursing, mental health,social services, chaplaincy - and representativesfrom the community, including, hopefully, lawyersand ethicists.The process should begin at an informal level.

The board, or perhaps a committee of the board,would meet with the petitioner to discuss the basisand reasons for the claim of exemption. Should thecommittee not agree, or should the petitioner be dis-satisfied with the outcome, the matter would betaken up formally by the full board, at which pointthe petitioner would have the option to use profes-sional counsel. Finally, in cases of serious dispute,the board's decisions would be reviewable by a courtof competent jurisdiction.We believe such a process would allow for a valid

evaluation of petitioners' claims, while also protect-ing a genuinely conscience-based right to exemp-tion.To assure uniformity, review boards would need a

consistent set of criteria, specific enough to provideguidance, yet with sufficient flexibility to allow forthe range of religious and moral beliefs. We, tenta-tively, propose the following25:

1. The applicant must have a sincere scruple-basedobjection to the procedure;2. That scruple must fit within an otherwisecoherent system of moral or religious beliefs;3. The scruple must be consistent with other beliefsand actions with respect to, in particular, activitiesrelated to the taking of innocent life;4. The scruple must be a key component of the peti-tioner's moral or religious framework, such that itsviolation, and the concomitant violation of herautonomy, represents a greater moral harmn thanwould the corresponding restriction of abortion rights;5. All reasonable alternatives must be explored, forexample, finding another physician to perform theprocedure, with the petitioner merely providing sub-sequent care and follow-up; and6. Especially in those cases of public employment,and perhaps in all cases, when exemption is grantedsome alternative form of public-benefiting profes-sional service should be substituted.26

We recognize this is an extensive list, one thatrequires the petitioner to have and to be able to artic-ulate a well developed and sophisticated moralposition. Given the competing rights at stake, wenonetheless contend that the petitioner should beable to satisfy these criteria if her claim of exemptionis in fact based on a true crisis of conscience.

We recognise also that the process will likely resultin a reduction of the number of health care practi-tioners who would otherwise claim exemption. Ourcase suggests that such a result would hardly beunfortunate, since few of the physicians involvedappeared to have genuine moral or religious objec-tions. But for those who did, requiring them to artic-ulate the basis of their position seems a minimalimposition, one clearly outweighed by the compet-ing goods at stake.

AcknowledgementsWe wish to thank the participants at variousmeetings where earlier versions of the paper wereread for their many excellent suggestions. We aregrateful also to the Kegley Institute of Ethics for pro-viding support for the project and to LegislativeIntent Service, Inc for donating time in the collec-tion of legislative historical material.

Christopher Meyers, PhD, is Associate Professor ofPhilosophy and Director of the Kegley Institute ofEthics.The Revd Robert Woods, J7D, is Lecturer in Philosophy,and an Associate of the Kegley Institute of Ethics.

References and notes1 California Health and Safety Code: section 2595.2 Approximately two years after this issue was first pre-

sented to the ethics committee, the clinic was destroyedby an as yet unidentified arsonist. It reopened abouttwo months later in a new location.

3 National Abortion Federation. Who will provide?National Abortion Federation, with funding from theAmerican Council for Obstetrics and Gynecology,1991: 4.

4 See, for example, Alaska Statutes, title 18, Health,Safety and Housing sec 18.16.010; Arizona RevisedStatutes, title 36, Public Health and Safety, sec 36-2151;Louisiana Statutes annotated, title 40, Public Healthand Safety, sec 1299.31; Michigan Compiled Laws(ann), Public Health Code, sec 333.20182; WashingtonRevised Code, title 9, sec 9.02.100.

5 The clause actually applies to all California health careworkers. For reasons of space and clarity we restrict ourdiscussion to the rights and obligations held by physi-cians. Many, but not all, of the arguments below,however, would apply to other health care workers aswell.

6 See, for example, California Civil Code, sections2430-44 concerning durable powers of attorney forhealth care.

7 See Massachusetts Medical Society v Dukakis (1978) 484US 896.

8 Bonnie RJ. Medical ethics and the death penalty.Hastings Center Report 1990; 3: 12-8.

9 Right to die and living will issues centre on withholdingmedical services and Medicaid patient care has a pri-marily economic focus. Lethal injection cases are fewerin number and therefore less likely to carry with themthe strong community need for services.

10 David Gunn and John Britton were physicians whoprovided abortion services at a number of different

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120 An obligation to provide abortion services: what happens when physicians refuse?

clinics in various states in the United States. Each wasshot and killed, in separate incidents, by anti-abortionactivists.

11 Griswold v Conn (1965) 381 US 479, in which the courtfound a constitutionally protected right to privacy withrespect to family planning practices.

12 Roe v Wade (1973) 410 US 113, in which the courtfound a constitutionally protected right, based in parton privacy, to abortion.

13 The California Constitution, in article I, section 1,expressly includes the right to privacy. California courtshave consistently interpreted this right as constitution-ally guaranteeing protection against governmental orsocietal intrusion into, among other things, health caredecisions.

14 This right is exemplified in two regulations - section5325.1 of the Welfare and Institutions Code (whichgives wards of the state access to their family planningneeds, including abortions) and title 15 of theCalifornia Code of Regulations (which grants, withcertain qualification, incarcerated pregnant women theright to receive, at public expense, an abortion or otherfamily planning service).

15 Under some definitions, this situation would not evenqualify as one requiring conscientious objection. (See,for example, Rawls J. A theory of justice. Cambridge:Harvard University Press, 1971: 368-71.) We rejectsuch an approach as being too narrow in its conceptionof what qualifies as an obligation to society.

16 The locus of current debate regarding the extent ofphysicians' obligations to provide services is centred inwhether they have a duty to treat HIV-positive patients.Although the issues here vary somewhat from ourconcern, the discussion does provide general insightinto the problem. See, for example, multiple authors.AIDS: The responsibilities of health professionals.Special supplement to Hastings Center Report 1988; 2.See also the follow-up essay by Daniels N. Duty to treator right to refuse. Hastings Center Report 1991; 2:36-46. For a broader discussion of conscience-basedappeals in medicine, see Blustein J. Doing what thepatient orders: maintaining integrity in thedoctor-patient relationship. Bioethics 1993; 4:289-3 14.

17 Planned Parenthood of Southeastern Pennsylvania vCasey, (1992) 112 US 2791, specifically with referenceto the spousal notification clause.

18 Anonymous. Statistical Abstract of the US. WashingtonDC: Department of Commerce, Bureau of the Census,Economics and Statistics Administration, GovernmentPrinting Office, 1991. Washington DC.

19 Sections 2051ff. See also Lawton v Board of MedicalExaminers (1956) 143 Cal app 2d 256.

20 Mary Anne Warren, among others, contends that de-monopolising these services represents the best solutionto the problem. (Warren MA. Unpublished observa-tions presented in response to this work during thePacific Division Meetings of the AmericanPhilosophical Association, 1992, Portland, Oregon).We believe that this would reduce, but not eliminate,the problem, since other health care workers could andlikely would also declare conscientious objection. Also,we do not believe the American Medical Associationwould accept such a de-monopolisation and the prece-dent it would represent.

21 Winner L. The whale and the reactor: a search for limits inan age of high technology. Chicago: University ofChicago Press, 1986: 159, 162.

22 Fifty United States Code appendix, section 456(j). Werecognize that military conscription is not a perfectanalogy to abortion services. We contend, though, thatthey have key similarities. Both involve issues of deepmoral import, both involve large segments of the popu-lation, and both involve decisions with life or deathconsequences.

23 Gillete v US (1971) 401 US 437; and Sicurella v US(1955) 348 US 395.

24 Sicurella v US and US v Spiro (1967, 3d Cir) 384 F 2d159, cert den at 390 US 956.

25 Taken in part from the California Supreme Court testof whether proposed restriction of rights is supportable,rooted originally in Comnnittee to Defend ReproductiveRights v Myers.

26 The goal here is to require some service that is both ofcomparable social benefit and, to most physicians, sim-ilarly "distasteful". Thus our tentative suggestionwould be for twenty hours per year of indigent medicalservices. on 14 M

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