Oklahoma abortion Bill survives Governor's veto

The Oklahoma State Legislature has overturned Governor Henry's veto of an "omnibus" bill containing abortion regulations. (The veto is explained at the United Kingdom site of Medical News Today. Besides gives the best definition of human embryo that I've seen in legislation:

“Human embryo” means a human organism that is derived by fertilization, parthenogenesis, cloning, or any other means from one or more human gametes or human diploid cells.

Pro-abortion groups are concerned that the bill requires the facility doctor to perform an ultrasound before every abortion, that the girl or woman be allowed to see it, and that the results be explained to her. Not only is there a requirement to post a notice in the facility informing the women and girls that it is "against the law for anyone, regardless of his or her relationship to you, to force you to have an abortion" and the abortionist evidently must actually speak the words out loud before each abortion!

Called the "Freedom of Conscience Act," (The text is here, in a Word document) the bill offers protection to any medical professional who refuses to act in a way that goes against his or her conscience.


The best news article that I've found is here, at the "Daily Women's Health Policy Report" of the National Partnership for Women and Families, a group I'd never heard of before. It appears that the main focus has been legislation to protect women in the workplace.
Robert Cole, an Oklahoma native, writing for Associated Content, has explained the bill in this article. Here's an article from The Feminist Majority, with good links.

Ironically, Democratic Presidential Candidate, Barack Obama, used the objection to abortion by the Senator from Oklahoma, Senator and Obstetrician Tom Coburn, to justify his relationship with the Weatherman bomb-building conspirator and now-college professor, William Ayers. (Ayers is the man who was quoted in the New York Times on September 11, 2001 as regretting that he did not do enough bombing and fighting the US government in the early '70's.)

Gynecology and Obstetrics Policy makers respond to doctors on conscience

It appears that the American College of Obstetricians and Gynecologists and ABOG (the American Board of Obstetricians and Gynecologistsmay be about to abort their efforts to change laws concerning conscientious refusal in Washington. It remains to be seen whether they will deliver on their promise to support -- without limits - the Conscientious Refusal to perform or refer for certain procedures. (I'm sorry, I can't resist obvious puns, even on such a serious subject.)

LifeEthics has been covering the controversy over the American College of Obstetrics and Gynecology's "Opinion #385, Limits of Conscientious Refusal in Reproductive Medicine," which states that,

Providers with moral or religious objection should either practice in proximity to individuals who do not share their view or ensure that referral processes are in place. In an emergency in which referral is not possible or might negatively have an impact on a patient's physical or mental health, providers have an obligation to provide medically indicated and requested care."

First, "medically indicated" should be up to the physician and not dependent on autonomy - the patient's wants and wishes. Remember that Joseph Kennedy, the father of John and Robert, had his daughter lobotomized because she was too wild. At that time, according to Joe, the lobotomy was medically indicated.)

Obviously, this is not a moral obligation - but one that can be enforced by the use of the words "standard practice" and "standard reproductive services." In other words, abort, refer, or face lawsuits and risk your board certification. And the definition of "emergency" varies.

We also reported that the Secretary of Health, Michael O. Leavitt, had written to the Presidents of the American College of Obstetrics and Gynecology, the professional organization that supposedly sets the standard for these professionals, and the American Board of Obstetrics and Gynecology which certifies and tests OB/Gyns Presidents of ACOG and ABOG. He informed them that they were in danger of risking their own funding for training programs and status by any attempt to override the protections for Conscience in Federal funding regulations.


Even NPR noticed and covered the controversy.

The leaders at the Christian Medical and Dental Association have let CMDA members know that the President of ACOG, Kenneth L. Noller, MD, responded to the Fellows (certified OB/Gyns) last week and Norman F. Gant, MD, the President of ABOG, responded to Secretary Leavitt by letter on March 19, 2008.

Dr. Gant doesn't have a clue what the Secretary is talking about:

I am responding to your letter addressed to me asking about the American Board of Obstetrics and Gynecology’s stand with respect or to a physician’s choice to violate their conscience by referring patients for abortions or taking other objectionable action, or risk losing their board certification.” I can only say that I do not know where you came up with any suggestion, much less documentation, that the American Board of Obstetrics and Gynecology has ever asked anyone to violate their own ethical or moral standards.

And Dr. Noller reassures the Fellows that in this case, an Opinion is just an Opinion (and we're supposed to forget the attempts to change the laws):

We want to be clear the Opinion does not compel any Fellow to perform any procedure he or she finds to be in conflict with his or her conscience and affirms the importance of conscience n shaping ethical professional conduct. For example, while this is not a document focused on abortion, ACOG recognizes that support of or opposition to abortion is a matter of profound moral conviction and ACOG respects the need and responsibility of its members to determine their individual position on this issue based on their personal values and beliefs. We want to assure members with a diversity of views on this issue that they have a place in our organization.
Ethics Committee Opinions provide guidance regarding ethical issues. This Committee Opinion is not part of the “Code of Professional Ethics of the American College of Obstetricians and Gynecologists.” This Committee Opinion was not intended to be used as a rule of ethical conduct which could be used to affect an individuals initial or continuing Fellowship in ACOG. Similarly, it is not cited in the American Board of Obstetrics and Gynecology’s “Bulletin for 2008,” and “Bulletin for 2008 Maintanence of Certification” and an obstetrician-gynecologist’s board certification is not determined or jeopardized by his or her adherence to this Opinion.
Conscience has an important role in the ethical practice of medicine. While this Opinion attempted to provide guidance for balancing the critical role of conscience with a woman’s right to access reproductive medicine, the Executive Committee has noted the uncertain and mixed interpretation of this Opinion. Thus, the Executive Committee has instructed the Committee on Ethics to hold a special meeting as soon as possible to reevaluate ACOG Committee Opinion #385.

Secretary of Health Supports Conscience

Secretary of Health Michael O. Leavitt has stepped up to protect the right of conscience and conscientious refusal, specifically in the right not to be forced to commit or be complicit in abortion and other forms of killing. The Secretary has sent a letter to the President of the American College of Obstetrics and Gynecology warning about a possible conflict with Federal anti-discrimination rulings secondary to ACOG's Ethics Statement #385. (that's a pdf)

See the LifeEthics post explaining the origin of the conflict, here.

The American Association of Pro-Life Obstetrics and Gynecology, alerted us to the Press Release sent out by the HHS, most likely due to the fact that the ACOG Ethics Committee is meeting Monday and Tuesday, March 17 and 18.

Here's the news item:

FOR IMMEDIATE RELEASE Contact: HHS Press Office
Friday, March 14, 2008 (202) 690-6343

HHS SECRETARY CALLS ON CERTIFICATION GROUP TO PROTECT CONSCIENCE RIGHTS

Unless changes are made, physicians could be forced to refer patients for abortions even if it violates their conscience

Health and Human Services Secretary Mike Leavitt today expressed disappointment in a new policy put forth by the American College of Obstetricians and Gynecologists (ACOG).He also called on the American Board of Obstetrics and Gynecology (ABOG) to reject this policy and protect the conscience rights of physicians.

In a letter sent to ABOG Executive Director Dr. Norman Grant today asking for clarification, Secretary Leavitt notes, "It appears that the interaction of the [ABOG Bulletin for 2008 Maintenance of Certification] with the ACOG ethics report would force physicians to violate their conscience by referring patients for abortions or taking other objectionable actions, or risk losing their board certification."

In particular, the Secretary expressed concern that enforcement of this ACOG policy by certain federally-funded entities would violate federal laws against discrimination.

Secretary Leavitt continues, "As you know, Congress has protected the rights of physicians and other health care professionals by passing two non-discrimination laws and annually renewing an appropriations rider that protect the rights, including conscience rights, of health care professionals in programs or facilities conducted or supported by federal funds."

The full text of Secretary Leavitt's letter appears below:

Norman F. Gant, M.D.,
Executive Director
The American Board of Obstetrics and Gynecology
2915 Vine Street
Dallas, TX 75204

Dear Dr. Gant:

I am writing to express my strong concern over recent actions that undermine the conscience and other individual rights of health care providers. Specifically, I bring to your attention the potential interaction of the American Board of Obstetrics and Gynecology's (ABOG) Bulletin for 2008 Maintenance of Certification (Bulletin with a recent report (Opinion Number 385) issued by the American College of Obstetricians and Gynecologists (ACOG) Ethics Committee on November 7, 2007 entitled "The Limits of Conscience Refusal in Reproductive Medicine".

The ACOG Ethics Committee report recommends that in the context of providing abortions, "Physicians and other health care professionals have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive service that patients request." It appears that the interaction of the ABOG Bulletin with the ACOG ethics report would force physicians to violate their conscience by referring patients for abortions or taking other objectionable actions, or risk losing their board certification.

As you know, Congress has protected the rights of physicians and other health care professionals by passing two non-discrimination laws and annually renewing an appropriations rider that protect the rights, including conscience rights, of health care professionals in programs or facilities conducted or supported by federal funds. (See 42 U.S.C. § 238n, 42 U.S.C. § 300a-7, and the Consolidated Appropriations Act, 2008, Pub. L. No. 110-161, 121 Stat. 1844, § 508). Additionally, threats to withhold or revoke board certification can cause serious economic harm to good practitioners.

I am concerned that the actions taken by ACOG and ABOG could result in the denial or revocation of Board certification of a physician who -- but for his or her refusal, for example, to refer a patient for an abortion -- would be certified. These actions, in turn, could result in certain HHS-funded State and local governments, institutions, or other entities that require Board certification taking action against the physician based just on the Board's denial or revocation of certification. In particular, I am concerned that such actions by these entities would violate federal laws against discrimination.

In the hope that compliance of entities with the obligations that accompany certain federal funds will not be jeopardized, it would be helpful if you could clarify that ABOG will not rely on the ACOG Ethics Committee Report, "The Limits of Conscience Refusal in Reproductive Medicine" when making determinations of whether to grant or revoke board certifications.

Thank you very much for your assistance in this matter.

Sincerely,

Michael O. Leavitt
cc:
Kenneth Noller, M.D.

The American College of Obstetricians and Gynecologists

"Objectivity is Bias" (meaning, healing, integrity)

Our recent conversation about conscience and medicine and the ongoing conversation about science and controversies is reflected in the NPR "Speaking of Faith" replay of an interview with, and publication of an essay by, Dr. Rachel Naomi Remen. (The outline and much of the story is available in text, here.)

"An answer is an invitation to stop thinking about something, to stop wondering."

Dr. Remen speaks of the stories that we share, the meaning that we need to find in those stories and acknowledges that objectivity is in itself a bias. Scary thought: that some data is ignored in science, medicine and public policy because it doesn't fall within the parameters that we've already decided is acceptable.

There's a description that most of us who have any medical training at all will recognize: the med student looking at the veins of strangers and judging their suitability for drawing blood or inserting IV's:

On one very rare summer afternoon off I remember traveling home to visit my parents on the subway, realizing only after a while that I had been unconsciously scanning the veins of the bare-armed people around me, wondering whether my skills with a needle were good enough to allow me to successfully draw blood from them. This sort of training changes the way you see things, the way you think. Gradually things that had been central in my previous life became vague and faded into the background and other things more heavily rewarded became overdeveloped. After a time I just forgot many important things.

Actually, what seems a demeaning way of looking at the human body isn't necessarily a proof that medical training leads to depersonalization and instrumentalization of our fellow humans, if we recognize the new viewpoint as an outgrowth of our wish as students and doctors to heal, prevent and relieve pain. Finding the underlying meaning or connecting it to a story that has a "better" meaning can inform our conscience, help to maintain our integrity and prevent some suffering of our own as profession.

About 20 minutes into the interview, there's the story of Dietert, who continued weekly chemotherapy injections as the only way to continue the contact - the touch and communication - with his doctor. In the meantime, the doctor was depressed because the "only thing" he had was failing to cure the patient. I worry about this: how often do we only offer and only validate active intervention, science and the material, rather than the passive, spiritual or psychological valuable - the intangible moral worth - like the listening that Dr. Remen offers so generously?

Early in the interview, Dr. Remen speaks of her mystic, Orthodox Jewish grandfather who described the birthday of the world as an accident, when the vessels containing the light of the world were broken and the striving of each of us to heal the world, to reveal the light around us and especially in our fellow human beings. I recognize her grandfather's conversation with the world, and with God, as I was raised surrounded by the knowledge of the love of God.

Now, I am just as guilty as anyone else of deciding that if you don't at least relate somehow to the same meaning that I do. If you don't seem to even live in the same reality that I do, you must be wrong and may even be insane. You'd benefit from my "fixing" you (her word, not just mine), either by inundating you with facts and references and some arguing or by some medical or technological intervention, like a nice shot of Haldol ("vitamin H") or an antipsychotic medication.

But I think - I hope - my best skill is listening, learning your language and meanings, and trying to translate between our two perceptions (even if I have to admit to myself that I really think of it as my understanding and your misunderstanding).


What too many people don't realize is that it's actually easier to interfere than to refrain. (So we end up with drug resistant bacteria, because it was easier to write the antibiotic than to explain viruses and risk your anger. Or it's easier to hook you up to chemotherapy, a ventilator or dialysis than to explain that I'm probably not going to be able to cure or even heal you. At least it looks - it feels - like I'm doing something!)

The interview and the essay point to the need for meaning in the practice of medicine beyond "objective" science and even healing that we can achieve as doctors - and society. I love the how and when, the molecules and causes. I believe in the germ theory and the disease model of Western medicine. I need and love my tests and measurements. But what drives me (and gets me in trouble) are the why's and what if's, what is right or ethical. It's probably what drives you, too or you wouldn't be reading this blog.

(I think Dr. Remen's Orthodox Jewish grandfather and I would have had a nice conversation during this season of Hanukkah and Christmas, when our two traditions celebrate light and dedication, revelation and reconciliation, watching and listening expectantly and generously.)

Doctors, Abortion and Conscience

The debate on medical ethics has definitely moved from "Our Bodies, Our Choice," to "My Choice, You Don’t Have a Choice." Autonomy, the "I want" ethics, trumps the right to life, the right to liberty and the physician's duty to do no harm. Where once laws were written to punish doctors who harmed patients, doctors are now threatened with lawsuits and the loss of our licenses for refusing medications or procedures demanded by patients and their surrogates.

The American College of Obstetricians and Gynecologists ethics statement, "The Limits of Conscientious Refusal in Reproductive Medicine" is a case in point. Abortion is so important to the ACOG Ethics Committee that they deny the right not to be killed and threaten the right not to be enslaved by calling abortion the “standard reproductive care that patients request” and demands that doctors who “deviate from standard practices” (object to abortion) “practice in proximity to individuals who do not share their views or ensure that referral processes are in place” (with a willing abortionist). The President of ACOG then wrote letters asking Congress for laws to force these limits on our consciences: doctors who object to abortion should either change their practice so that they don't take care of women and girls or move close to a willing abortionist.

The Christian Medical Association and 28 other pro-life, pro-family organizations have written a letter criticizing ACOG’s Statement as “a profound misunderstanding of the nature and exercise of conscience, an underlying bias against persons of faith and an apparent attempt to disenfranchise physicians who oppose ACOG's political activism on abortion.”

GrannyGrump posted several reasons conscientious doctors should consider elective intentional abortion bad for the mother. I agree with her that abortion is wrong because it is bad for women. I also believe that she begins from the same viewpoint that I do: Even if abortion weren't bad for women, it would still be wrong.

Elective intentional abortion is immoral because it takes the life of a human being. If the mother's life is in danger, she has the right to self preservation and it is moral to help her save her life. Even then, the child's life should also be protected if at all possible. The intent can never be to produce a dead child.

State officials have mandated that all medical students learn to perform abortions in New York and that all pharmacies stock and dispense contraceptives in Illinois and Washington. ER doctors are forced to dispense Emergency Contraception in Connecticut, California, Massachusetts, New Jersey, New Mexico, New York, Ohio and Washington. How long before autonomy supersedes the physician's right to conscience at the end of life since the American Medical Association has condoned the use of Oregon's "Physician Assisted Suicide" law (now renamed and redefined as "Aid in Dying")?

Laws against the conscience are a poor substitute for medical ethics and will result in the death of those same ethics. The end result of limiting the physician’s conscience is cook book health care written in court rooms by lawyers and judges. The practice of medicine will no longer be a profession, much less a calling, practiced by men and women of conscience. It will become a job done by people capable of following orders, doing what they believe is wrong.

Yamanaka has a conscience

“When I saw the embryo, I suddenly realized there was such a small difference between it and my daughters,” said Dr. Yamanaka.

The New York Times article on Shinya Yamanaka, "Risk taking is in his genes," (free one time registration necessary) should get the headline-writer in trouble for a sad pun.

Instead, Dr. Yamanaka might be in trouble with the objectors to conscience. (No links, just look at today's posts - or the last two months of posts - the subject keeps popping up.)

People like John Gearhart, MD will want to "put pressure" on Yamanaka to write letters to Nancy Pelossi and the rest of the US legislators making the usual reactionary case for Federal funding for embryonic stem cell research in light of the successes with non-destructive research.

The NYT reporter, Martin Fackler, can't be too popular in the next few days for pointing out that the US laws and funding are not nearly as tight as those in Japan, due to moral objections in that country:

In 1999, his career got a break when he was hired by other universities, including Kyoto University in 2004, that were willing to give him a laboratory and more money. At about the same time, he said, he visited his friend’s fertility clinic. That visit inspired him to find a way around the moral issues that had bogged down stem cell research, not just in the United States but also Japan, where the Education Ministry put tough restrictions on embryo use.

In fact, restrictions are so tight that he says he cannot use human embryos at his laboratories here. Instead, research using human embryos is done at U.C. San Francisco, where he maintains a small two-person laboratory. He said he had never handled actual embryonic cells himself, and the American lab uses them only to verify that the reprogrammed adult cells are behaving as true stem cells.

“There is no way now to get around some use of embryos,” he said. “But my goal is to avoid using them.”

For a look at the science and bioethics slant on these revelations, see Wired Science (see the comments on this one), Blog.bioethics.net, Wesley Smith's Secondhand Smoke, and Jennifer Lahl's blog, "The Human Future."

Text of Letter from CMA to ACOG on Conscience

(The press release is here and the LifeEthics coverage is here.)

December 7, 2007
American College of Obstetricians and Gynecology
Douglas W. Laube, MD, President
PO Box 96920
Washington, D.C. 20090-6920

Dear Dr. Laube:
The undersigned individuals and organizations urge the repudiation and withdrawal of the recently published position statement of The Committee on Ethics of the American College of Obstetricians and Gynecologists (ACOG), "The Limits of Conscientious Refusal in Reproductive Medicine."
The ACOG statement suggests a profound misunderstanding of the nature and exercise of conscience, an underlying bias against persons of faith and an apparent attempt to disenfranchise physicians who oppose ACOG's political activism on abortion.
The paper indicates that ACOG views the exercise of conscience and faith not so much as a cornerstone right in a democracy or as a historic hallmark of medicine, but rather as an inconvenient obstacle to abortion access.
A few excerpts from ACOG's paper illustrate these concerns:

1. "An appeal to conscience would express a sentiment such as 'If I were to do 'x,' I could not live with myself / I would hate myself, I wouldn't be able to sleep at night."

By caricaturing conscience as a pitifully self-centered, subjective feeling, ACOG denigrates the objective sources of conviction. Physicians of faith base decisions of conscience not on personal whims and feelings but
on the objective teachings of Scripture--the same Scriptures that have provided the foundation for the laws of much of civilization. A physician's conscience may also be informed by time-honored ethical standards such as the Hippocratic Oath, which for centuries provided a foundation for medical ethics until abortion advocacy censored its teachings.

2. Physicians may not exercise their right of conscience if that might "constitute an imposition of religious or moral beliefs on patients."

This harshly skewed view of the exercise of conscience would have the practical effect of reducing physicians to pawns of patients, since in ACOG's view, conscientiously declining a prescription or procedure is tantamount to "imposing religious or moral beliefs on patients."

3. "Physicians…have the duty to refer patients in a timely manner to other providers if they do not feel they can in conscience provide the standard reproductive service that patients request."

This assertion contradicts a basic corollary of conscience. The same life-honoring, objective principles—"Thou shalt not kill," and "first, do no harm"--that persuade many conscientious physicians not to perform abortions also persuade them not to recommend someone else to do the deed.

4. "All healthcare providers must provide accurate and unbiased information so that patients can make informed decisions."

Normally no one would question this principle, but in this case, context is everything. Since ACOG has gone to court to fight laws requiring abortion doctors to offer informed consent information to patients on the risks and alternatives to abortion(1), clearly ACOG intends to selectively apply this requirement only to pro-life physicians to force them to offer abortion as an option.

5. "Providers with moral or religious objections should … practice in proximity to individuals who do not share their views…"

It is incredible that ACOG would actually require a pro-life physician to relocate his or her practice to be close to an abortion facility. Besides the fact that this drastic requirement is selectively invoked only against pro-life doctors, it would also have the negative practical impact of removing desperately needed doctors from underserved areas.
ACOG's misguided and uninformed public statement on conscience limits is bound to have the effect, whether unintended or actually intended, of discouraging persons of faith from practicing or choosing obstetrics and gynecology as a profession. At a time when many communities are already suffering the loss of obstetricians and gynecologists forced out of their practices for economic reasons, it seems especially unwise to send such a message of ideological intolerance and religious discrimination.
ACOG's aggressive political advocacy for abortion has significantly impaired its ability to speak for all physicians and to judge matters of medical ethics without bias. We urge ACOG to reconsider and withdraw this statement as a step toward remedying that lamentable loss of respectability and credibility.
Sincerely,

David Stevens, MD
Chief Executive Officer
Christian Medical Association

1 American College of Obstetricians v. Thornburgh, 737 F.2d 283, 297-98 (3d Cir.1984).

Please see the CMDA website for the other signers.

CMDA to ACOG: Stop Attack on Conscience

The Christian Medical and Dental Association has released a statement condemning the American College of Obstetrics and Gynecologists for ACOG's position statement (earlier coverage, here and here) that would require all doctors who object to abortion to either change their practice or make sure that they work next to a willing abortionist:

Physicians call on The American College of Obstetricians and Gynecologists to stop attacking conscience rights

December 11, 2007--The nation's largest faith-based association of physicians, the 15,000-member Christian Medical Association (www.cmda.org), today joined other leading national organizations in challenging The American College of Obstetricians and Gynecologists (ACOG) to stop its attack on the conscience rights of pro-life physicians.

A letter, drafted by CMA and signed by other national organizations, blasted ACOG's Committee on Ethics position statement, "The Limits of Conscientious Refusal in Reproductive Medicine." CMA's letter noted that the statement "suggests a profound misunderstanding of the nature and exercise of conscience, an underlying bias against persons of faith and an apparent attempt to disenfranchise physicians who oppose ACOG's political activism on abortion."

CMA CEO David Stevens, MD said, "ACOG is not only out of touch with conscience-driven physicians, but also with our long-standing American tradition to protect the rights of citizens to not participate in conscience-violating actions—especially when those actions would take a human life. That American tradition rests on constitutional principles of religious freedom and speech."

ACOG's position paper targets pro-life physicians, insisting that abortion-objecting physicians refer patients to get abortions and declaring that physicians who will not participate in conscience-violating procedures and prescriptions must actually move close to doctors who will.

Dr. Stevens added, "Many physicians had been realizing that because of their aggressive abortion lobbying, ACOG officials do not represent the values of most physicians and mainstream medicine. This statement goes a step beyond not representing our life-affirming values to actually advocating policies to prevent us from exercising those values. ACOG's attitude seems to be, 'If you don't toe the ACOG line on abortion, the 'morning-after pill,' and the application of reproductive technology, then you shouldn't be practicing obstetrics--and if you do, we're going to do everything in our power to force you to accommodate our abortion agenda."

CMA Executive Vice President Gene Rudd, MD, an obstetrician and gynecologist, noted, "I have withdrawn my ACOG membership of over 25 years. My conscience can no longer support their lack of conscience. ACOG's strategy seeks to marginalize dissenting opinions. I as an obstetrician have a moral obligation not only to act in my patient's best interest, but also in the best interest of the developing baby, and of society as a whole."

Wesley Smith on Toronto Conference on End of Life

Wesley's report is at his blog, Secondhand Smoke.

The medical interventional suicide or "Physician Assisted Suicide" (PAS) offers a false sense of control to people who are actually the healthiest of the patients who know that they are nearing the end of life.

It's false because before legal medical regulations can be used to "help" terminal patients to control the "time and manner of their death," the laws are actually being sold to voters who aren't sick, who are encouraged to think "there but for the grace of God, go I." Instead of giving dignity to patients in pain, talking about the indignity of having others care for our bodies and the horrors of uncontrollable pain increases the revulsion toward physical weakness and dependency.

Mr. Smith says that in Toronto ( as at the Houston Holocaust Museum last month), he focused the bulk of his talk on "Futile Care Theory."

Calling all cases of withdrawal of care "Futile Care Theory" and eugenics is also false. It denies any acknowledgment that doctors act on their conscience. By denying that doctors and medical ethics committees -a group of peers and lay people, clergy, and ethicists - can be acting in good conscience, even when it goes against the wishes of surrogates and families condemns us all. If we can't trust these people, how can we trust a judge or a jury to act in good conscience?

I hope everyone reads what Wesley says about another speaker, Ms. Frazee:

She told the audience that there are two general veins of opposition to assisted suicide; political and spiritual, with people in each camp disagreeing with each other on other issues. She suggested that the best way to work together would be to develop a philosophical approach that would include all and permit people to also pursue other agendas when not working against assisted suicide.

Too often, the only common ground is the hatred of the control that doctors seem to have. Suicide proponents and "futile care" activists declare doctors the bad guys who diagnose and couldn't cure, who bring the bad news of unavoidable death and who won't "do everything."

As I reported after Wesley spoke at the Houston Holocaust Museum, the risk is to squeeze doctors between two extremes.

I suggest that the doctrine of double effect can help us make the distinction. Doctors may not act with the intended result of death, but we know that some of our actions may cause death, unintentionally. In all cases, the intention and the act must be ethical, but sometimes - as when we poison the body with chemotherapy or radiation to fight cancers - only medical knowledge and experience can inform our conscience.

Laws and the legal process are a poor substitute for medical ethics and will result in the death of those same ethics.

The logical result is an end to all laws protecting the conscience of doctors, pharmacists, and nurses, in favor of laws leading to court and cookbook algorithms. The practice of medicine won't be a profession - much less a calling - with peer review, judgment and conscientious men and women. It will be a job done by people capable of following orders, even when it goes against their best medical and moral judgment.

Who will you trust? Lawyers and judges like Blackmun and Greer? Juries who live in a society that forces medical professionals to act in a way they believe is wrong? Legislatures and referendums that give us Oregon's assisted suicide? Or doctors and pharmacists who are prescribing and dispensing the potassium, heart stimulants or blood pressure control in the IV, adjusting the ventilator, dialysis machine and the dosage of pain meds under the watchful eye of nurses and the rest of their community?

Colorado's Human Life Amendment

Although Time Magazine, the Denver Post and the blogs insist on calling it the "fertilized egg rights" law, Colorado's State Supreme Court has approved the wording for a proposed "Human Life Amendment." The proponents of the amendment need 76,000 signatures in order to get the initiative on the November, 2008 ballot.

The Chicago Tribune reporter at least understands that after fertilization we are talking about an "embryo." The Trib even found three ethicists who agree that the human embryo is alive. Which puts them in opposition Justice Blackburn’s opinion ( which medical school did he go to, anyway?) in Roe v. Wade that no one knows when life begins.

Unfortunately all three of those ethicists are much more worried about the definition and description of the qualities and abilities of those living humans they deem worthy of “personhood” than whether or not it is acceptable to discriminate between which humans are persons or not. Their main objection seems to be that protection of the inalienable right not to be killed, enslaved or treated as research material “would cause a lot of problems." (I'll bet that they disagree with the Dred Scot opinion, though. Overturning that one sure caused a lot of problems.)

U.S. law, based as it is on “unalienable rights” mentioned in the Declaration of Independence, should absolutely prevent courts, laws and ethicists from infringement of the right not to be killed or enslaved. Ethicists – of all people – shouldn’t need a lawyer to understand that the full exercise of unalienable rights affects infants, children, the mentally disabled and the mentally ill. Parents have special duties to their children and children can't claim the same expression of liberty (drinking, driving, entering into contracts) that their parents do. There are legal precedents for dealing with the “problems” posed by the varying abilities of the mentally ill and disabled as well as for minors – including very young infants who can legally be restrained against their will (in a crib, playpen or car seat).

The “ethicists” in the Tribune article, as well as readers' comments in both papers and in blogs all over the internet, bring out every pro-abortion objection except the coat hanger. They warn us that fertile women will be “monitored,” that women who miscarry or who drink a glass of wine will be prosecuted. They insist that if State law recognizes the human being as a person from fertilization, we’ll have to decide whether to try to save every child at miscarriage and ectopic pregnancy or fail to enforce the law. Elective intentional abortions and manipulation that is intended to end the organization of an embryo - are acts which may be prohibited under law and the State Medical regulations. Spontaneous abortions (miscarriages), and stillbirths, like so many natural deaths, are impossible to prevent and cannot be prohibited.

Since US Supreme Court rulings (Roe v. Wade and Casey, among others) all base the “right” to an abortion on the autonomy of the mother and while affirming the right of the State to protect the child in certain cases, the “extracorporeal” embryo should be protected, somehow, even in current law.

It might be worth noting that the law requires determination of the cause of death of everyone who dies, and that Texas requires a special review of children under 6 and those of any age who die within 24 hours of admission to the hospital. Texas also names a “person” as living human individual from fertilization to natural death through our Penal Code. The 2003 Prenatal Protection Act allows criminal charges when a third party causes the death of an unborn child while exempting the actions of the mother or deaths due to legal medical procedures with the consent of the mother.

In fact, 3 men have been convicted of capital murder under our 2003 Prenatal Protection Act. The convicted men were abusive, the father, and intended to kill the child(ren). One killed twins at 5 months gestation but not the mother, the other two each killed mother and child. One man received the death penalty for killing a teenaged girl he'd gotten pregnant. There are charges pending in at least one more case, a drive-by shooting that caused the death of a pregnant woman.

Last month, the Texas Court of Criminal Appeals ruled in favor of the conviction of a man who killed one of two women he was sleeping with after the first told him she was pregnant. He told his second girlfriend that he would take care of the pregnancy of the first, and shot the first woman 3 times with a shotgun, once in the face.

As for "monitoring the actions of women:" a couple of county District Attorneys in Texas have tried to turn the law into an excuse to lock up mothers for endangering their unborn children. The outcome was similar to the cases in South Carolina a few years ago, when women were arrested after being tested as part of their pregnancy screening, required by that State’s Medicaid regulations. One lawyer made a speech to a group of lawyers that the Act could be coordinated with our State's Consent Laws to charge doctors with capital crimes. Texas State Attorney General has given an official statement on the intent of the Legislature that exempts mothers and doctors.

The handling of an ectopic pregnancy is well established under the doctrine of self-defense. With our current medical technology, the child cannot be saved and he or she is a direct danger to his mother’s life.

While we can’t verify the soul, we can verify which embryos are organisms: techs do it all the time in labs. The embryo, unlike the sperm, egg, and transplanted organs, is an organized organism. It's easy to tell within a day whether the oocyte is fertilized and which are not. It's also easy to tell the difference between embryonic stem cells and an embryo.

Ethics, Conscience and Cheating

Is there a difference between matters of conscience and things you shouldn't do? If there is something that would just get you in trouble but you don't believe it's wrong, how do you decide what to do?

The blog, Adventures in Science and Ethics, is one of the ScienceBlogs that I follow. (I love her "Friday Sprog Blogging" about her kids and the discussions about being a woman and having a family in Academia.)

There's a conversation on morality and cheating:

A reasonable ethical decision is one that you can defend -- to others, not just to yourself. You can give reasons why, of the choices available, this was the right way to go.

A course of action that you are taking pains to hide -- one which you would not want to have to defend to others -- is a red flag, ethically speaking.

Being able to justify a course of action to others is a more stringent requirement than being able to justify it to yourself. Folks who see themselves as living up to a high moral standard ought to keep that in mind and make sure their deeds can meet this requirement.

I was raised on the Bible, being taught to respect the authorities and to understand that a sin is a sin is a sin. However, I have a sense of "that's not fair" when I think of putting highway speed limits on the same plane as hurting someone else or even cheating on a test.

CNN objects to conscience

This subject again.

CNN, that bastion of upstanding plants ethics, objects to doctors with morals - or at least the ones who act on them.

The CNN video (not a "news piece") shows interviews with a woman who was refused contraception by one doctor and a second interview with another doctor who is Catholic and who does not believe that contraception is moral and so he does not prescribe it.

The reporter is shocked that 60% of doctors feel that it's okay to tell patients our moral views.

The reporter asked the patient whether she felt "rejected." The woman said that she did and that she felt that the doctor was judging her and imposing his morals on her. She said that any doctor who would not do what his patients wanted should not be in practice.

The woman isn't judging or imposing her morals on every doctor, is it?

Doctors make "judgments" all the time. We are not simply dispensers of products that people want. We must "impose" our judgment on patients who smoke (a perfectly legal drug) and drink (ditto) or who have become overweight from eating legal food and choosing not to exercise enough to burn off calories faster than they take them in. We are responsible for determining whether a patient is becoming addicted to pain medications, asking for a note for missing work when they were never sick, or a handicapped parking sticker when they're not disabled.

Much more often, we make judgments about the cause of a patient's symptoms or disease and how best to treat it. Our job is not to make the patient feel good about themselves, although most doctors I've met prefer to do so. What we do is diagnose and treat in order to help the patient be as healthy as we are able.

While I don't object to non-abortifacient contraception, it is an elective service in most cases. It is very rarely necessary to maintain the health of the body of patients. It is truly a "choice."

As I've said before, it would be simpler for people who feel that contraception is important to arrange to pay doctors who will write and dispense those medications and devices to go around to the areas where they are needed.

The alternative is to find a way to trust a doctor who will act against his conscience - to do what he considers the wrong thing for your pet issue - to do the right thing every other time.


Hat Tip: Blog.bioethics.net

Governments threaten physicians for anti-abortion policy

In our Nation, with our First Amendment, why doesn't someone threaten all the bodies placing restrictions on conscience clauses and against religious-based practices?

In Portugal, the Health Minister has been threatening to take the Portugal Medical Association to Court for its policy that states that doctors should respect human life from fertilization to natural death.

More here, here, and here.

Then, there's the woman doc in England, who is being threatened with charges of "unprofessional conduct" and being removed from the National Health Services, for telling women to "think twice" before they have an abortion.

The American College of Obstetricians has a new statement on ethics, #385, entitled, "The Limits on Conscientious Refusal in Reproductive Medicine."

Worse, according to the American Association of Pro-Life Obstetricians and Gynecologists, ACOG ACOG sent a letter to Senators in Washington:

"Dr. Michael Mennuti, writing as the President of the American College of Obstetrics and Gynecology (ACOG), has requested the United States Congress to “require doctors with moral objections to refer for abortions.” Urging the Senators to alter the current Abortion Non-Discrimination Act, Mennuti states, “Doctors who morally object to abortion should be required to refer patients to other physicians [for an abortion].”"

Any ethics statement by ACOG carries the weight of "standard of care," and places all doctors, nurses and other medical professionals at risk of legal penalties if we do not follow the guidelines.

Even though I haven't delivered a baby in 10 years, I may still be the primary care doc for a woman who sees an obstetrician for her pregnancy and I still care for a women in the first 20 weeks of pregnancy, as far as diagnosing the pregnancy and caring for threatened miscarriage and tubal pregnancies. I am careful to meet the guidelines of ACOG, because I know that I could be sued - and it would be a slam dunk for the patient if I am ever accused of varying from them.

ACOG now says that I shouldn't care at all for women who might be or are pregnant unless I am willing to make arrangements for an abortion if the woman wants one. That organization also says that hospitals shouldn't offer emergency care for rape victims or maternity care if the organization has objections to elective abortion or sterilization.

The ACOG statement essentially mandates that all of us must offer abortion and/or referral for abortion - and that if we don't offer abortion ourselves, we probably should either practice "in close proximity" to some one who does and/or that we shouldn't practice in areas that don't have easy access to an abortion!

Family Practitioners and other pediatricians are more likely to be religious and those who practice in Rural areas are more likely to be from a rural area. If ACOG's policy is followed, there would be an acute shortage of primary care doctors for women of childbearing age.

The Position Statement mixes "emergency" and "reproductive" care, and severely goof in calling the conscience an inner voice that tells us that we couldn't live with ourselves if did so and so. As Dr. Robert Orr (a Family Physician and ethicist) says in his rebuttal written for the Christian Medical and Dental Association, the conscience is much more - the conscience cannot be separated from the world view of the person and people of faith often consider the knowledge of right and wrong and the conscience that leads us to follow it to be part of what we call the "Image of God."

Non-believers can be "pro-life" and they also have consciences which they should not be forced to violate.

Again, a person who will go against her or his conscience is a person who will do what he knows is wrong

I still think it would be simpler for all the proponents of abortion to pay to move the abortionists around than for them to try to force docs to act against our conscience.

Limits on "I want" ethics

While we're all waiting for the announcement that Shinya Yamanaka's lab has or has not published on human embryonic-like stem cells dedifferentiated from adult stem cells . . . (The press releases hit while I was writing this post.)


Wesley Smith's blog, Secondhand Smoke has a good discussion titled, " Just Because Someone Wants Something, Does That Mean Doctors Should Do It?," that goes along with the conscience and limits on science debates that seems to be the theme of this blog over the last couple of weeks.


The limits should probably be based on the individuals' right to life and liberty as in, "Is it permissible for a person to infringe on his own rights?" and "Does the desired event risk life and liberty of others?" These themes are what I consider the basis for "First, do no harm."

There are questions that need to be asked.

1. Nothing should be allowed that is designed to intentionally kill a human being. (The Nuremberg Code says "except, perhaps, in those experiments where the experimental physicians also serve as subjects,” but I don't believe that even doctors are allowed to infringe our own right to life and liberty.)

2. Will society be asked act to make special accommodations for the the intentionally mutilated (or the obese, the smoker, the Jehovah's Witness or vaccine denier, etc.)? (How much of my life, liberty and property do you claim?)

3. Will the rights of certain individuals be infringed upon by a demand for an action from someone else that is repugnant to the one being forced to act? (Traditional ethics that society may restrain, but not compel, action except in limited situations such as parents' duty to their children, doctors' and lawyers' duties to their patients and clients. )

Christian Medical Association on Right to Conscience

If the scientist or doctor is driven by curiosity (and a desire for her own set of money making patents?) or because "it's legal" and patients want it, where do we draw the line between preference, opinion and conscience?

We've been discussing the significance of ethics and conscience at here at LifeEthics.org, the Women's Bioethics Blog and Bioethics.net (The latter two "bioethics" sites, emphasize laws and science at all cost, almost to the point of dismissing ethics and, especially conscience, at all. The subject is also the theme of posts at Bioethics.com, the blog of the Center for Bioethics and Human Dignity.

Now, the weekly email newsletter of the Christian Medical and Dental Association has dedicated an issue to the subject, in light of the statement (opinion?) on conscience from the The American College of Obstetricians and Gynecologists. There are links to the statement, itself, and rebuttals by Dr. Robert Orr, and Dr. Edmund Pellegrino.

Give me liberty or give me condoms!

Where are the condom squads who go around making sure that every grocery store, drug store, and 24 hour convenience store stocks latex condoms and the appropriate lubricants, "at all times"? Condoms are a much more basic public health issue than Plan B, which only works (when it works) for about 5 days in the woman's cycle.

Siricou Raven is keeping the conversation alive as to whether or not pharmacists should be forced to stock and dispense all legal medicines. She asks,

What is the difference between a pharmacist refusing to distribute contraception because it offends his own morality, and one refusing to dispense HIV medication because it offends his own morality?

Treating disease has never been controversial. Have you ever heard of a doctor or pharmacist who refuses to treat syphilis, gonorrhea or chlamydia? Have you noticed any that have ceased doing Pap smears since we learned that abnormal Paps are due to a Sexually Transmitted Disease, Human Papilloma Viruses that are only transmitted by sexual contact?

(I do know a pulmonologist - a lung specialist - who will not take on patients who smoke. I could draw all sorts of parallels between sex and smoking, but I'll leave that to you.)

At issue is the very basic question is that of the "unalienable" individual right to liberty, expressed as following the conscience.

As Judge Lawrence wrote in the Injunction, the Washinton State law is very clear on the right to conscience and freedom to practice religion.

There is no reason to carve out contraception and "reproductive health" (a Newspeak term, if I ever heard one) as a special, protected class of medicines, devices and procedures.

For that matter, why on earth would any woman who doesn't want to become pregnant have sex without two or more contraceptives in hand/body before the act itself and/or know her fertile periods? If men didn't have the back up insurance of abortion, I'd bet they would be more careful, too. (Rape is an Emergency Room issue - the ER doc and SANE nurse can dispense and counsel on fertility risk, right along with prophylaxis for STD's).

While I'm ranting:

Ethics lesson 1: Life trumps liberty, since pretty much everything else depends on being alive.

Ethics lesson 2: The only reason the State should force action from a citizen is in cases of life and death. Each law that is enforced puts the citizen's life and liberty at risk, since the enforcement will involve the real and virtual guns of the State. There is a long history of recognizing the relationship between the right to own property and the right to liberty. If the State may take the property or restrict the livelihood of a person, the person is at risk of prison or hunger and is not free.

Ethics lesson 3: People who will do acts that they believe morally wrong for any reason other than to save lives (to stay out of jail, keep their jobs or avoid controversy) are either unethical people or insane. And I'm not too sure about the people who would force them, either.

Some Bloggers shouldn't reproduce

They shouldn't reproduce their thoughts in writing, that is.

Take a look at the comments on "Laws, conscience, medicine and bloggers," for a perfect example of "they just don't get it."

Freedom of conscience is part of the Washington State law. The Governor threatened to replace the members of the State Pharmacy Board if they voted against an invalid law. The pharmacists do not have to dispense over the counter medications.

All sorts of red herrings have been raised to defend the law, including accusations that someone might refuse to prescribe medicines for HIV patients and insulin for diabetics.

This is also a good example of my editorial style. You would be shocked by some of the answers I've typed and erased.

Laws, conscience, medicine and bloggers

In contrast to the hype that you might read on blogs and in the press, the Federal District Court judge in Washington has upheld the law of that State. The basic right to not be forced into action that one considers unethical or immoral - the right to liberty - was upheld first, by the Washington State Legislature and affirmed by the Court.

According to the Seattle Times article, there will be a trial next year and the "rules were meant as a compromise after long, contentious hearings and intervention by Gov. Christine Gregoire, who threatened to replace members of the Board of Pharmacy who didn't vote to protect women's rights." (Emphasis mine, BBN.)

The judge ruled in favor of State Law and overturned regulations passed by the Washington State Board of Pharmacy which were changed in July of this year to require that "pharmacies must maintain at all times a representative assortment of drugs in order to meet the pharmaceutical needs of its patients." The plaintiffs, two individual pharmacists and a corporate pharmacy were asking to be allowed to follow their previous practices "refuse and refer."

The Court's ruling is posted here at the Seattle Times website, which also has a fairly good review of the case to this point, here. (I've saved copies of each, so let me know if they disappear).

Judge Ronald B. Leighton issued an injunction that delays the force of the regulation, since it appears that the regulation violates laws passed by the Washington State legislature to protect the rights of individuals:

"As a part of the Health Care Access Act, the legislature expressed the recognition “that every individual possesses a fundamental right to exercise their religious beliefs and conscience.” RCW 70.47.160(1). The Legislature further acknowledged that “in developing public policy, conflicting religious and moral beliefs must be respected.” RCW 70.47.160(1). Accordingly, the Legislature provided that “no individual health care provider, religiously sponsored health carrier, or health care facility may be required by law or contract in any circumstances to participate in the provision of or payment for a specific service if they object to so doing for reason of conscience or religion.” RCW 70.47.160(2)(a). No person may be discriminated against in employment or professional privileges because of such objections. RCW 70.47.160(2)(a). The right of conscience, however, is not intended to result in a patient being denied timely access to any service included in the basic health plan. RCW 70.47.160(2)(b).

"An identical right of conscience was included within the Insurance Reform Act adopted by the Legislature in 1995. RCW 48.43.065."

(emphasis in italics are mine, BBN)


The regulation itself was poorly written.

The phrase "at all times" is a big problem. Would that mean that all pharmacies must change their hours so that they are open or on call 24/7? As to the phrase, "representative assortment," that might mean different things to different people. The wording open to the widest interpretation, however, is the phrase, "pharmaceutical needs of its patients." (Let's forget that pharmacies don't have patients, pharmacists do.)

The "pharmaceutical needs" of patients is wide open to interpretation, especially in the case of Plan B. I've covered the evidence (here) that indicates that Plan B only works to prevent ovulation and fertilization the 5 days or so of the month before and the day of ovulation and the lack of evidence that it acts in any way as an abortifacient. Unfortunately, this isn't acknowledged in the court's ruling or by any of the other parties in the case.

I depend on pharmacists to evaluate the prescriptions I write for my patients. They have often helped me by catching and refusing to fill scripts because they knew about drug interactions, allergies, and fraudulent prescriptions when I didn't. I would like for them to notify me if they refuse to fill my scripts, but their professional judgment is the very thing we physicians and patients are depending on, isn't it? If we force them to do what they believe to be wrong, the only pharmacists we'll be left with will be people who will do wrong because they were "only doing their job." (Where have we heard that before?)


There's an especially over-wrought emotional discussion over at the Women's Bioethics Project blog. No posts are published without the permission of the author, who evidently has some pretty strong feelings involved. I added to the intensity of the silliness and self-righteousness with my comments, I'm afraid. (So far, they haven't posted my remarks from 12 hours ago about cigarettes as a legitimate treatment for priapism [an old remedy - no longer advised - that was actually used as late as the '80's], prescribing of wine as a relaxant, and the fact that I make it a policy not to prescribe medications until they are on the market long enough to be proven by lots of other doctors' patients.)


As Mick Jagger sang, "You can't always get what you want. . . but you can try sometimes to get what you need."

(edit - typos fixed at 5:30 PM CST 11/14/07)

Catholic Bishops to Allow Plan B in Emergencies

Can anyone be forced to act against his conscience? Do religious convictions have any weight in the law? How far can the courts go to make a person do an act that he believes is unethical or immoral?

I hope these questions are not ignored due to the sensationalism that surrounds emergency contraception.

The Catholic Bishops of Connecticut have decided to allow the doctors in Emergency Rooms at the Catholic hospitals in their State to prescribe Plan B for rape victims. (More here.) The courts had ruled that the hospitals would be required to follow state law mandating that all emergency rooms prescribe the pills, even those belonging to religious organizations which object to contraception and abortion.

The law requiring all hospitals to prescribe Plan B to rape victims, which passed in June and takes effect Monday, does not allow for an ovulation test. Instead, it requires a pregnancy test.

Barry Feldman, a spokesman for the Connecticut Catholic Conference, said that since the bill passed, the bishops have questioned the feasibility of the original policy because of "further revelation by them about the state of existing science and the lack of definitive teaching by the church and the fact that there are many who are affiliated with the church that believe the ovulation test isn't necessary."

Feldman said the bishops' decision to allow Plan B to be used for all rape victims in the hospitals does not mean that the bishops' personal beliefs have changed. Also, they still believe the law is seriously flawed and should be changed to allow an ovulation test.

In June, Bridgeport Bishop William E. Lori said the new law violated religious liberties and suggested that politicians might force Catholic hospitals to perform abortions or euthanasia.

Sen. Jonathan Harris, D-West Hartford, who worked to negotiate a compromise bill with the church, said lawmakers have no interest in taking such steps.

"Our efforts had only one