Forget conscience - go straight to mandate

Human Events has an editorial from Christian Medical And Dental Association's Jonathan Imbody.

Here's an excerpt:

A national poll showed that Americans favored the “conscience clause” regulation and the civil rights laws it enforced by a two-to-one margin. During a 30-day public comment period, an astounding 340,000 comments and petitions poured in favoring the regulation.

The White House and Congress ignored public opposition, and instead moved even more aggressively to evolve abortion from a choice into a mandate.

Besides the House bill opening the door to mandated abortion coverage in all health insurance plans, the House of Representatives in July voted to force taxpayers to fund abortions in the District of Columbia. The Senate is now eyeing publicly funded abortions under the eight million-member Federal Employee Health Benefits Program.

In each of these actions, the President and Congress tacitly assert that abortion ideology trumps the conscience rights of taxpayers, patients and health professionals like Katrina Belova.

"I became very concerned when I learned about President Obama’s plan to rescind the conscience clause," Katrina said. "It made me uneasy to think that my adopted country, which was always proud of its democratic heritage, had begun to remind me of a communist country my family fled ten years ago.

"If the conscience rule is rescinded and I am obligated to choose between performing an abortion or losing my job, I will choose the latter. And then where will I flee next?"[vii]

Robin Alta Charo named FDA advisor

The University of Wisconsin at Madison has announced that Robin Alta Charo has been named senior adviser to the Commissioner of the Food and Drug Administration.

You'll remember lawyer/ethicist-for-sale Charo. She's the one who sees no problem with sex-selection abortion and who called President Bush's Council on Ethics the "endarkenment." She protests anyone following their consciences, especially religious physicians.

Texas Medical Association doesn't support conscience

This TMA press release/"Alert" is a shallow statement which ignores the history and facts behind the ruling and addresses the right to conscience as though it is dependent on circumstances and can be "rescinded."

The individual right not to act is called "Liberty." As an inalienable right, liberty cannot be given away or taken. It cannot be "balanced" by actions of the State or by organized medicine, only infringed.

The ruling does cover emergencies and is only a clarification of the many laws in place at this time to protect the right not to act of health care professionals.

Was there any attempt to balance this opinion by contacting those in support of the ruling?

For more information on the Ruling and the (4 year or more) history behind it, see the many "conscience" articles at this blog and the information at Freedom2Care.

From the Texas Medical Association:

TMA Backs Rescinding 'Conscience' Rule

TMA, AMA, and state medical societies across the country support the Obama administration's plan to rescind a federal rule that prohibits recipients of federal funds from forcing physicians and other health care professionals to participate in actions they find religiously or morally objectionable.

In a letter to Acting Health and Human Services (HHS) Administrator Charles E. Johnson, the groups said the Conscience Rights of Health Care Providers regulation, adopted by the Bush administration in December, is unnecessary and could have far-reaching implications. They said it "could undermine patients' access to vital medical care and information, impede advances in biomedical research, and create confusion and uncertainty among physicians, other health care professionals, and health care institutions about their legal and ethical obligations to treat patients."

They wrote that they support "strong conscience protections" for physicians, residents, and medical students and other health professionals, especially when it comes to abortion. No physician, hospital, or hospital employee should be required to perform an act that violates good medical judgment or personally held moral principles. "However, while we support the legitimate conscience rights of individual health care professionals, the exercise of these rights must be balanced against the fundamental obligations of the medical profession and physicians' paramount responsibility and commitment to serving the needs of their patients. As advocates for our patients, we strongly support patients' access to comprehensive reproductive health care and freedom of communication between physicians and their patients, and oppose government interference in the practice of medicine or the use of health care funding mechanisms to deny established and accepted medical care to any segment of the population."

Other points in the letter include:

* Abortion education should be encouraged "so medical students receive a satisfactory knowledge of the medical, ethical, legal, and psychological principles associated with termination of pregnancy …" The letter adds that "the observation of, attendance at, or any direct or indirect participation in abortion should not be required." Resident training should include "specific educational standards for the knowledge and skills associated with pregnancy termination that allow an exclusion for individuals or residency programs with religious/moral objections or legal restrictions."
* Several provisions and definitions in the rule "are ambiguous, overly broad, and could lead to differing interpretations causing unnecessary confusion among health care institutions and professionals, thereby potentially impeding patients' access to needed health care services and information." The rule, for example, defines "health service program" as "any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded, in whole or in part" by HHS. "This definition inappropriately expands the scope of the conscience provisions beyond family planning and abortion services to include virtually any medical treatment or service, or biomedical and behavioral research," the letter says.
* The rule does not address how conscience rights of individuals and institutions apply in emergencies.

New England Journal of Medicine plays conscience politics ("Trust me, I will act against my conscience," cont'd)

The New England Journal of Medicine has published a "Commentary" by a lawyer who has worked for Planned Parenthood, concerning the practice of medicine and conscience.

I don't like to publish entire articles from subscription-only sources (especially one written by a lawyer), but this serious breach of ethics on the part of the NEJM should be documented.

The NEJM published this in advance of the dead-tree version because the last day for comments is the same day the paper Journal comes out.

This most definitely should have been in the "Free Content" form, and it is. We should thank the editors for this favor. Physicians and others who do not subscribe (to the tune of several hundred dollars a year) are able to read and answer this lawyer's viewpoint of the practice of medicine.

There is no opposing view offered. Yep, let's talk about "choice" and "consent." but only give their choice and their consent.

The essay contains more of the ridiculous examples that we should be used to by now: the author asks about a doctor who refuses to care for diabetics because his religion counts gluttony as a sin.

She calls abortion - all abortions, without making the distinction between elective abortion and those necessary to save the life of the mother - "standard of care."

More in a bit:


From the online version of the New England Journal of Medicine, published in advance of printing in the April 9, 2009 issue of the Journal:

The regulation, as explained in its text (see the Supplementary Appendix, available with the full text of this article at NEJM.org), aims to raise awareness of and ensure compliance with federal health care conscience protection statutes. Existing laws, which are tied to the receipt of federal funds, address moral or religious objections to sterilization and abortion. They protect physicians, other health care personnel, hospitals, and insurance plans from discrimination for failing to provide, offer training for, fund, participate in, or refer patients for abortions. Among other things, the laws ensure that these persons cannot be required to participate in sterilizations or abortions and that entities cannot be required to make facilities or personnel available for them. And they note that decisions on admissions and accreditation must be divorced from beliefs and behaviors related to abortion. On their face, these laws are quite broad.

But the Bush administration's rule is broader still. It restates existing laws and exploits ambiguities in them. For example, one statute says, "No individual shall be required to perform or assist in the performance of any part of a health service program or research activity funded" by DHHS if it "would be contrary to his religious beliefs or moral convictions."1 Here the rule sidesteps courts, which interpret statutory ambiguities and discern congressional intent, and offers sweeping definitions. It defines "individual" as physicians, other health care providers, hospitals, laboratories, and insurance companies, as well as "employees, volunteers, trainees, contractors, and other persons" who work for an entity that receives DHHS funds. It defines "assist in the performance" as "any activity with a reasonable connection" to a procedure or health service, including counseling and making "other arrangements" for the activity. Although the rule states that patients' ability to obtain health care services is unchanged, its expansive definitions suggest otherwise. Now everyone connected to health care may opt out of a wide range of activities, from discussions about birth control to referrals for vaccinations. As the rule explains, "an employee whose task it is to clean the instruments used in a particular procedure would also be considered to assist in the performance of the particular procedure" and would therefore be protected. Taken to its logical extreme, the rule could cause health care to grind to a halt.

It also raises other concerns. In terms of employment law, Title VII of the Civil Rights Act, which applies to organizations with 15 or more employees, requires balancing reasonable accommodations for employees who have religious, ethical, or moral objections to certain aspects of their jobs with undue hardship for employers. But the new rule suggests that if an employee objects, for example, to being a scrub nurse during operative treatment for an ectopic pregnancy, subsequently reassigning that employee to a different department may constitute unlawful discrimination — a characterization that may be at odds with Title VII jurisprudence.2 As officials of the Equal Employment Opportunity Commission remarked when it was proposed, the rule could "throw this entire body of law into question."3

Furthermore, although the rule purports to address intolerance toward "individual objections to abortion or other individual religious beliefs or moral convictions," it cites no evidence of such intolerance — nor would it directly address such intolerance if it existed. Constitutional concerns about the rule, including violations of state autonomy and rights to contraception, also lurk. And the stated goals of the rule — to foster a "more inclusive, tolerant environment" and promote DHHS's "mission of expanding patient access to necessary health services" — conflict with the reality of extensive objection rights. Protection for the silence of providers who object to care is at odds with the rule's call for "open communication" between patients and physicians. Moreover, there is no emergency exception for patient care. In states that require health care workers to provide rape victims with information about emergency contraception, the rule may allow them to refuse to do so.

Recently, the DHHS, now answering to President Barack Obama, took steps to rescind the rule (see the Supplementary Appendix). March 10 marked the beginning of a 30-day period for public comment on the need for the rule and its potential effects. Analysis of the comments (www.regulations.gov) and subsequent action could take some months. If remnants of the rule remain, litigation will follow. Lawsuits have already been filed in federal court, and Connecticut Attorney General Richard Blumenthal, who led one of the cases, has vowed to continue the fight until the regulation is "finally and safely stopped."4

This state of flux presents an opportunity to reconsider the scope of conscience in health care. When broadly defined, conscience is a poor touchstone; it can result in a rule that knows no bounds. Indeed, it seems that our problem is not insufficient tolerance, but too much. We have created a state of "conscience creep" in which all behavior becomes acceptable — like that of judges who, despite having promised to uphold all laws, recuse themselves from cases in which minors seek a judicial bypass for an abortion in states requiring parental consent.5

The debate is not really about moral or religious freedom writ large. If it were, then the medical profession would allow a broad range of beliefs to hinder patient care. Would we tolerate a surgeon who holds moral objections to transfusions and refuses to order them? An internist who refuses to discuss treatment for diabetes in overweight patients because of moral opposition to gluttony? If the overriding consideration were individual conscience, then these objections should be valid. They are not (although they might well be permitted under the new rule). We allow the current conscience-based exceptions because abortion remains controversial in the United States. As is often the case with laws touching on reproductive freedom, the debate is polarized and shrill. But there comes a point at which tolerance breaches the standard of care.

Medicine needs to embrace a brand of professionalism that demands less self-interest, not more. Conscientious objection makes sense with conscription, but it is worrisome when professionals who freely chose their field parse care and withhold information that patients need. As the gatekeepers to medicine, physicians and other health care providers have an obligation to choose specialties that are not moral minefields for them. Qualms about abortion, sterilization, and birth control? Do not practice women's health. Believe that the human body should be buried intact? Do not become a transplant surgeon. Morally opposed to pain medication because your religious beliefs demand suffering at the end of life? Do not train to be an intensivist. Conscience is a burden that belongs to the individual professional; patients should not have to shoulder it.

Patients need information, referrals, and treatment. They need all legal choices presented to them in a way that is true to the evidence, not the randomness of individual morality. They need predictability. Conscientious objections may vary from person to person, place to place, and procedure to procedure. Patients need assurance that the standard of care is unwavering. They need to know that the decision to consent to care is theirs and that they will not be presented with half-truths and shades of gray when life and health are in the balance.

Patients rely on health care professionals for their expertise; they should be able expect those professionals to be neutral arbiters of medical care. Although some scholars advocate discussing conflicting values before problems arise, realistically, the power dynamics between patients and providers are so skewed, and the time pressure often so great, that there is little opportunity to negotiate. And there is little recourse when care is obstructed — patients have no notice, no process, and no advocate to whom they can turn.

Health care providers already enjoy broad rights — perhaps too broad — to follow their guiding moral or religious tenets when it comes to sterilization and abortion. An expansion of those rights is unwarranted. Instead, patients deserve a law that limits objections and puts their interests first. Physicians should support an ethic that allows for all legal options, even those they would not choose. Federal laws may make room for the rights of conscience, but health care providers — and all those whose jobs affect patient care — should cast off the cloak of conscience when patients' needs demand it. Because the Bush administration's rule moves us in the opposite direction, it should be rescinded.

Dr. Cantor reports representing an affiliate of Planned Parenthood in a legal matter unrelated to conscientious objection. No other potential conflict of interest relevant to this article was reported.


Source Information

Dr. Cantor is an adjunct professor at the UCLA School of Law, Los Angeles.

This article (10.1056/NEJMp0902019) was published at NEJM.org on March 25, 2009. It will appear in the April 9 issue of the Journal.

References

1. 42 U.S.C.A. § 300a-7(d).
2. Shelton v. Univ. of Medicine & Dentistry of New Jersey, 223 F.3d 220 (3d Cir. 2000).
3. Pear R. Protests over a rule to protect health providers. New York Times. November 17, 2008:A14.
4. Press release of the State of Connecticut Attorney General's Office, Hartford, February 27, 2009. (Accessed March 20, 2009, at http://www.ct.gov/ag/cwp/view.asp?A=3673&Q=434882.)
5. Liptak A. On moral grounds, some judges are opting out of abortion cases. New York Times. September 4, 2005.

The "Rescission of the Regulation Entitled 'Ensuring That Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices in Violation of Federal Law'” was posted on the Federal Register on March 10th, with the announcement of a 30 day period in which to comment. The full announcement can be read here. (PDF Acrobat document) Comments must be made by April 9th.

Please consider taking a look at the website Freedom2Care to learn more about the problem of restricting conscience. You can use one of their forms online to let the Administration and Health and Human Services Secretary Sebelius know how you feel or to tell your story.

To send a comment directly to the HHS, go to the website, http://www.Regulations.gov and fill in the form there or send an email to proposedrescission@hhs.gov.

This is your future on Government Medicine

Imagine that it is 2016, and you are a 65 year old boomer. You have been admitted to your local community hospital with malaise, fatigue, vomiting and cloudy mental status. You have had blood pressure problems and diabetes for a few years, and have just been diagnosed with renal failure. As you drift in and out of consciousness, you are vaguely aware your old family practice physician, who had taken care of you for 20 years, is not around. A religious man, he quietly retired from medical practice in 2014, after the full force of the Obama administration‘s removal of conscience protection for physicians in February, 2009, came into effect.

Read the whole article for a chilling look at the future and a concise review of how we got to this point.

Bravo, Dr. Davenport!

Goodbye Medicare, hello County Clinic

Where is the outrage over the destruction of (what is left of) Medicare and the debt we owe to veterans? I'm afraid that we're not talking about "Medicare for all," or even "Medicaid for all." We're talking about County Clinic for all.

For a look at the proposed cuts in cost for Medicare, take a look a this table.

Consider that "reduce costs for re-admissions" and the "bundling" of hospital and outpatient costs after a hospitalization.

That means that Medicare will only pay a flat fee to the hospital for any hospitalization and follow up care after the hospitalization and will not pay if the patient has to be readmitted for complications or a new illness within a certain period of time. Patients would not be able to return to their family doctor for follow up care, unless the doctor works for the hospital. And there would be a lot of pressure to keep patients out of the hospital.

People who "cost" Medicare the most money would be encouraged to forgo care. I predict a huge push for hospice care for anyone with complicated, chronic diseases. (Or, possibly, a back-alley, underground medical care system for cash and barter. Wonder how long that will be legal?)

The AMANews reports that coordination of care doesn't lower costs to Medicare, only 2 out of 15 of the model centers cut patients' days in the hospital, and that the coordination is burdensome for small and solo practices. For every 100 patients, we interact with 99 other doctors in other practices. (I knew it was a lot.) (I don't think any of these links require subscription, let me know if there's a problem.)

This is my favorite part from that article:

"It doesn't matter if you back up a truck to their offices and drop off bundles of money," Dr. Norman said. "They don't have the time, resources or expertise right now to put this all in place."

Speaking of "bundles of money," the stimulus has a chunk to support Community Health Centers, as reported by Reuters' Maggie Fox. Will these centers really be open longer hours, as advertised, and will they continue to mandate the hiring of mid-levels (Nurse Practitioners or Physician Assistants), rather than allowing the hiring of physicians with the grants, as currently the case for other Federally funded clinics?

The budget includes plans to pay for the 667 Billion dollar health care for all by cutting payments to “providers” (including doctors and hospitals, pharmacists and wheel chair companies), according to the Wall Street Journal. We're already scheduled to have that automatic “Sustainable Growth Rate” 20% cut in Medicare payments to doctors, next year. Want to bet that the cut won't go through and/or won't be considered part of the "savings"? (And mesh with the President’s plans to cut the deficit.)

That WSJ and the LATimes articles also mention a “public” health care plan, and possible new taxes (on the employer’s portion of insurance payments or a new income tax).

Speaking of which, the Massachusetts mandatory health insurance trial isn’t working - even to make sure that people have insurance or are able to see their doctor in a timely manner - according to the Boston Globe The solution? That old United States National Health Insurance Act, paid for by "a modest progressive tax."

Obama moves to overturn Conscience rules

For a couple of years, LifeEthics has covered the conscience of physicians and what it would mean if a doctor, nurse or hospital were to be forced to go against their consciences. My review is here.

From the LA Times, we learn that President Obama plans to rescind the ruling clarifying conscience laws in force in the US today:

Conscience' rule on abortions may be overturned
The Obama administration wants to clarify a Bush policy that lets healthcare workers deny services because of moral beliefs.
By Noam N. Levey
February 27, 2009
Reporting from Washington -- Taking another step into the abortion debate, the Obama administration today will move to rescind a controversial rule that allows healthcare workers to deny abortion counseling or other family planning services if doing so would violate their moral beliefs, according to administration officials.

The rollback of the so-called conscience rule comes just two months after the Bush administration announced it late last year in one of its final policy initiatives.

Inevitably, no matter what they say, the outcome will be to further politicize abortion and to force doctors to perform abortions and assisted suicide, force Catholic hospitals to allow abortions and sterilizations and - inevitably - physician assisted suicide.

Last month without official ceremony, Obama overturned a controversial ban on U.S. funding for international aid groups that provide abortion services.

The move by the Department of Health and Human Services to throw out the conscience rule is being made equally quietly as most of Washington focuses on the president's blockbuster budget plan.

On Thursday officials stressed that before the administration finalizes the rollback, a standard 30-day comment period seeks input from people across the ideological spectrum.

"We believe that this is a complex issue that requires a thoughtful process where all voices can be heard," said one official, who was not authorized to speak on the record about the policy change.

The officials said the administration would consider drafting a new rule to clarify what healthcare workers could reasonably refuse to do for their patients.

For more than 30 years, federal law has allowed doctors and nurses to decline to provide abortion services as a matter of conscience, a protection that is not subject to rule making.

In promulgating the rule last year, then-Health and Human Services Secretary Mike Leavitt said it was necessary to address discrimination in the medical field.

Conscience: more than abortion

Last month, a judge in Montana ruled that patients have the right to a doctor's assistance in their intentional death by suicide. Baroness Warnock argues that doctors who will not kill their patients on demand are "wicked." The States of Washington and Oregon already have legalized "Aide in Dying." Is it now my duty to inform my patients on Hospice that they have a "right" to "safe(?) and legal" death by prescription?

Here is part of a poignant Letter to the Editor from an Internal Medicine doc in Oregon:

I was caring for a 76-year-old man who came in with a sore on his arm.

The sore was ultimately diagnosed as a malignant melanoma, and I referred him to two cancer specialists for evaluation and therapy.

I had known this patient and his wife for more than a decade. He was an avid hiker, a popular hobby here in Oregon. As he went through his therapy, he became less able to do this activity, becoming depressed, which was documented in his chart.

During this time, my patient expressed a wish for doctor-assisted suicide to one of the cancer specialists.

Rather than taking the time and effort to address the question of depression, or ask me to talk with him as his primary care physician and as someone who knew him, the specialist called me and asked me to be the "second opinion" for his suicide.

She told me that barbiturate overdoses "work very well" for patients like this, and that she had done this many times before.

I told her that assisted suicide was not appropriate for this patient and that I did NOT concur.

I was very concerned about my patient's mental state, and I told her that addressing his underlying issues would be better than simply giving him a lethal prescription.

Unfortunately, my concerns were ignored, and approximately two weeks later my patient was dead from an overdose prescribed by this doctor.

His death certificate, filled out by this doctor, listed the cause of death as melanoma.

The public record is not accurate.

My patient did not die from his cancer, but at the hands of a once-trusted colleague.

This experience has affected me, my practice, and my understanding of what it means to be a physician.

ACOG: Abort or refer

The American College of Obstetricians and Gynecologists (ACOG) have finalized and published their Ethics Statement # 385. It looks like they ignored the ruling from the Department of Human Services on Conscience -- or believe it will soon be overturned.

The ACOG pdf is set so that it is not possible to copy and paste - I have typed in the first bit, myself. Click here for the full document.

ABSTRACT: Health care providers occasionally may find that providing indicated, even standare, care would present for them a personal moral problem – a conflict of conscience – particularly in the field of reproductive medicine. Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients, negatively affect a patient’s health, are based on scientific misinformation, or create or reinforce racial or socioeconomic inequalities. Conscientious refusals that conflict with patient well-being should be accommodated only if the primary duty to the patient can be fulfilled. All health care providers must provide accurate and unbiased information so that patients can make informed decisions. Where conscience implores physicians to deviate from standard practices, they must provide potential patients with accurate and prior notice of their personal moral commitments. Physicians and other health care providers have the duty to refer patients in atimely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request. In resource-poor areas, access to safe and legal reproductive services should be maintained. Providers with moral or religious objections should either practice in proximity to individuals who do not share their views 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.

____________________________________________________________

Physicians and other providers may not always agree with the decisions patients make about their own health and health care. Such differences are expected – and, indeed, underlie the American model of informed consent and respect for patient autonomy. Occasionally, however, providers anticipate that providing indicated, even standard, care would present for them a personal moral problem – a conflict of conscience. In such cases, some providers claim a right to refuse to provide certain services, refuse to refer patients to another provider for these services, or even decline to inform patients of their existing options.

Conscientious refusals have been particularly widespread in the arena of reproductive medicine, in which there are deep divisions regarding the moral acceptability of pregnancy termination and contraception.

For more on the controversy, here are my posts on Conscience, and here is a history of the ACOG and DHHS statements.

Baroness Warnock: doctors who won't kill are wicked.

Baroness Warnock took part in a debate in Belfast, Ireland on January 5, 2008.

According to a Belfast news report, the Baroness said that doctors who will not kill their patients are "genuinely wicked."

Baroness Warnock, who last year caused worldwide controversy when she said that some dementia patients had a "duty" to seek death, said last night: "I think that people should be able to beseech their doctors, nurses to end their life when it is no longer worth living (in the patient's eyes]."

Speaking of terminally ill patients who, while in good health, have made a written request to be killed when they reach a certain point in their illness, she said: "There are doctors, we know, who don't pay any attention (to those wishes to die].

"But that seems to me a genuinely wicked thing to do – to disregard what somebody had quite explicitly said, that he wants to die – not to be resuscitated in certain circumstances and in certain circumstances to be helped to commit suicide.

"I believe that if someone is diagnosed as having the beginnings of Alzheimer's or dementia, at that stage it is a positive duty that doctors should talk to them about what will happen when the moment comes where they reach steep decline."

Speaking of the impact that medicine-prolonged life has had, she said: "The consequence (of living longer] is financial, but much more importantly, I think of the number of people who end their life demented, unable to recognise family, unable do anything for themselves.

"They can be kept alive and are kept alive, but the question has to be: What is the point of the life at the last stages of Alzheimer's or dementia?"

The point of any life is one of those big questions, isn't it?

Renewed fuss over conscience in medicine

For some reason, the media has decided to focus on the proposed rule from the Health and Human Services Department on the right of conscience, even for doctors, and even for abortion. I guess they felt it was the right thing to do.

LifeEthics has been following the conscience issue as it unfolded over the last year and I wrote a review of the history of the rule in November. Here is the actual notice of the proposed rule, in pdf.

Kaisernet.org, the Kaiser Family Foundation's daily on line newsletter article recalls the report by the New York Times last month that 3 of 5 members of the Equal Employment Opportunity Commission (two Democrats and one man, the legal council appointed by President Bush) released a statement that the new regulation would "overturn" years of protection. In my opinion, that is ridiculous in light of the recent debate about the American College of Obstetricians and Gynecologist's Ethics Statement #385 requiring member physicians to provide abortion, practice in close proximity to an abortionist, and/or make prior arrangements with an abortionist. In practice, all physicians who provide health care to women, including Family Physicians, Internists and Pediatricians, are held to the ACOG standards.

For those physicians and other medical professionals who are employed, the regulation will merely underscore and clarify protections. For those of us who are self-employed but subject to Boards and ethics statements like that of ACOG, the new regulation will provide protection from new pressures to act against our consciences.

For the worst report that is not on a blatantly pro-abortion website, see the AHN ("AllheadlineNews") editor's incredibly biased contribution. Practice your skills at unravelling biased non-news statements on this excerpt:

The Equal Employment Opportunity Commission has advised the president that the rule would overturn four decades of civil rights laws in the nation. They also say that current law protects people who have religious objections from performing duties that conflict with their religion.

Many groups support the regulation, although about as many oppose it.

******

The new rules probably wouldn't stop people with money or those living in large cities, or metropolitan areas, from finding the care they needed.

However, critics worry that poor people, or those living in small towns, might not be able to afford to travel outside their area to find a medical facility or health care workers that would provide them with the medical care they needed.

Thus the new regulation would create a two-tier health care system for some in America, while being funded from taxpayer money.

Overthrow protections by protecting? And, "Many . . . about as many?"

Remember that ACOG would requirements doctors who do not perform abortions to only practice "in close proximity" to those who do.

I still say that the ethical solution would be to make sure that pro-abortion OB/Gyns spread out to cover any shortage areas, rather than force the rest of us to clump together or make some areas - and all the men, women, and children that will never need an abortion - do without a local doctor so that no one ever has to be exposed to a conscience.

Why we need legal protection for the conscience

The pro-abortion forces are objecting to the regulations that Secretary Leavitt has been working on, claiming that the Bush Administration is trying some "last minute" manipulations.

However, LifeEthics reported way back in September 2005 about a move to make referral for abortion mandatory for doctors -- in a sneaky way, too:

The American College of Obstetricians and Gynecologists (ACOG) is sponsoring a bill that would require that all doctors refer patients to abortionists. ACOG is asking that Senators tuck this provision into the the FY06 Labor, Health and Human Services, and Education Appropriations bill. According to an internet alert from the American Association of Pro-Life Obstetricians and Gynecologists, if the provision is not voted down by our Senators, every doctor would be required to help arrange abortions at the patient's request.

The American Journal of Bioethics devoted one of its debates to conscience in 2007. LifeEthics reviewed the subject, here.

ACOG stirred the pot again, about a year ago, as reported in these posts:

Governments threaten physicians for anti-abortion policy

Tuesday, December 11, 2007: CMDA to ACOG: Stop Attack on Conscience

Tuesday, December 11, 2007: Text of Letter from CMA to ACOG on Conscience

Wednesday, December 12, 2007: Doctors, Abortion and Conscience

In response, the conversation about these specific clarifications of the regulations has been covered on LifeEthics and at the Christian Medical and Dental Association since March, 2008:

Saturday, March 15, 2008: Secretary of Health Supports Conscience

Thursday, April 03, 2008: Gynecology and Obstetrics Policy makers respond to doctors on conscience

Saturday, August 02, 2008: Forcing Pro-life Doctors Out of Baby Business?

Another end of life dispute (Motl Brody)

Doctors at a hospital in the District of Columbia have determined that a 12 year old boy, Motl Brody, has no upper or lower brain activity. He was declared dead by legal criteria November 4. Here's the Washington Post article on the case.

By legal and medical criteria, the boy died last week.

The dilemma is that he was placed on a ventilator and receiving drugs to stimulate his heart beat before the determination that he met the criteria for legal death in the District. His parents are Hasidic, Orthodox Jews and have legally objected to turning off the ventilator or stopping the medications, saying that their religion does not recognize anything other than cessation of breathing as "death." The case is now in court.

Perhaps the parents would consider discontinuing the addition of new doses of medications when the current ones run out? In this way, there is no intentional act of stopping the heart, and there would be no intervention if the heart continued to beat.

One way to look at the case is that it's never ethical to force doctors to act against their medical judgment as to what is in the patient's best interest. However, this patient is now dead. What do we owe the parents of a dead child?

The child's doctors have said, '"Ethically, there is no appropriate treatment except removal of the ventilator and of the drugs."'

However, it is considered ethical to continue cardiopulmonary support in order to preserve organs for harvest and transport. So, the organ support itself is not unethical. Is support for the body ethical in order to meet the religious requirements of the deceased patient's family?

Finally, who is responsible for carrying out acts that the doctor believes is not in the medical best interest of the patient? And for how long?

On Conscience: Philosophical, not Scientific or Medical Debate

Some of you may have already seen this transcript from the September '08 President's Bioethics Council meeting. Three physicians gave testimony on September 12th, including Dr. Farr Curlin, Dr. Howard Brody, and (from the American College of Obstetrics and Gynecology, although she says she's not there as an ACOG representative) Dr. Anne Drapkin Lyerly.

Council member Robert P. George has this to say about the debate (speaking specifically on conscience and the American College of Obstetrics and Gynecology's Ethics Statement on conscience and physicians, "The Limits of Conscientious Refusal in Reproductive Medicine," )

The first thing to notice about the ACOG Committee report is that it is an exercise in moral philosophy. It proposes a definition of conscience, something that cannot be supplied by science or medicine. It then proposes to instruct its readers on, "...the limits of conscientious refusals describing how claims of conscience should be weighed in the context of other values critical to the ethical provision of health care."

Again, knowledge of these limits and values, as well as knowledge of what should count as the ethical provision of health care, are not and cannot possibly be the product of scientific inquiry for medicine as such. The proposed instruction offered here by those responsible for the ACOG Committee report represents a philosophical and ethical opinion — their philosophical and ethical opinion.

The report goes on to, "outline options for public policy," and propose, "recommendations that maximize accommodation of the individual's religious and moral beliefs while avoiding imposition of these beliefs on others or interfering with the safe, timely, and financially feasible access to reproductive health care that all women deserve."

Yet again notice that every concept in play here — the punitive balancing, the judgment as to what constitutes an imposition of personal beliefs on others, the view of what constitutes health care or reproductive health care, the judgment about what is deserved is philosophical, not scientific or, strictly speaking, medical.

To the extent that they are medical judgments even loosely speaking they reflect a concept of medicine informed and structured, shaped by philosophical and ethical judgments. Those responsible for the report purport to be speaking as physicians and medical professionals.

The special authority the report is supposed to have derives from their standing and expertise as physicians and medical professionals, yet at every point that matters, the judgments offered reflect their philosophical, ethical, and political judgments, not any expertise they have by virtue of their training and experience in science and medicine.

At every key point in the report their judgments are contestable and contested. Indeed they are contested by the very people on who consciences they seek to impose, the people whom they would, if their report were adopted and made binding, force into line with their philosophical and ethical judgments or drive out of their fields of medical practice. And they are contested, of course, by many others. And in each of these contests a resolution one way or the other cannot be determined by scientific methods, rather the debate is philosophical, ethical, or political.

Lay aside for the moment the question of whose philosophical judgments are right and whose are wrong. My point so far has only been that the report is laced and dependent upon at every turn philosophical judgments. I've not offered a critique of those judgments, although anyone who cares to can find plenty of criticisms in my work of those judgments. But lay that aside for now.

The key thing to see is that the issues in dispute are philosophical and can only be resolved by philosophical reflection and debate. They cannot be resolved by science or methods of scientific inquiry. The committee report reflects and promotes a particular moral view and vision and understandings of health and medicine shaped in every contested dimension and in every dimension relevant to the report's subject matter, namely the limits of conscientious refusal, by that moral view and vision.

The report, in other words, in its driving assumptions, reasoning, and conclusions is not morally neutral. Its analysis and recommendations for action do not proceed from a basis of moral neutrality. It represents a partisan position among the family of possible positions debated or adopted by people of reason and goodwill in the medical profession and beyond. Indeed, for me, the partisanship of the report is its most striking feature.

Its greatest irony is the report's concern for physicians' allegedly imposing their beliefs on patients by, for example, declining to perform or refer for abortions — or at least declining to perform abortions or provide other services in emergency situations and certainly to refer for these procedures. The assumption here, of course, is the philosophical one that deliberate feticide is morally acceptable and even a woman's right.

But lay that aside for now. Of course, the physician or the pharmacist who declines to dispense coerces no one, though I think that Prof. Brody and I would have a debate about that.

Interesting that both Dr. Lyerly and Dr. Brody refuse to discuss the ACOG statement.

A compelling look at the problem of contrasting world views is posed by Dr. Gilbert Meilander:

. . . the fascinating question you raised under your slide on professional integrity about a professional elevating the — in this case the patient's needs above his own interests, and then you said does one's own interest include one's personal integrity. But then you confused — and I think that's — it's like, you know, "Should I be prepared to go to hell in order to help somebody," a question which theologians have actually discussed.

But you gave the, to me, puzzling example of physicians who should be willing to risk their own lives in an epidemic, for instance, to do it, and then you said, you know, if you'd risk your life, why wouldn't you risk your integrity.

But I thought the reason for a physician being willing to risk his life in an epidemic was precisely that he didn't think staying alive was the most important thing, that there was something else that was morally more compelling and obligatory even than preserving his existence. And that would have something to do with the personal integrity that you seem willing to think may be — one should be willing to set aside in embracing what one thinks is evil.

How can anyone live well without integrity? Or, from the Christian philosopher, Paul, "What shall it profit a man if he gains the whole world, but loses his soul?"

(Edited to add italics on that long quote.)

Discussion on Abortion in Australia

A med student's blog, "Degranulated" posts his thoughts about the presence of anti-abortion protesters outside and inside his medical school. It seems that the Australian medical community is in the midst of a debate like ours on conscience rights, with new laws that impose a duty to refer and /or perform abortions on physicians.

Public policy and medical ethics should be taught in medical schools. With every bit of the objectivity, pluralism, and inclusiveness that the most radical pro-abort demands from the rest of us.

(after the same old "men don't have the right to object to abortion")

Secondly, the opponents argue that the bill does not adequately deal with doctors whom object to abortion on moral grounds. In medical school, we are taught that the patient has a right to be made aware of all their options, and if a doctor is unwilling to refer a patient for a ToP, they should refer the patient to a doctor who is willing to explain all possible options. In this way, the patient's autonomy can be fully exercised. The opponents of this Bill appear to not currently do this. So, do they believe paternalism or patient autonomy, or even womens' rights? Hmph. Isn't it good to see how times have changed.

If times have changed, Dame Warnocke's call for the rest of us to kill ourselves and others in the face of dementia is the sign of those times.

Here's what I wrote in my comment:

I'm maternalistic, matronizing occasionally. And you sound/read as though you haven't had many conversations about the subject of abortion.

You should inform yourself, as the same rules apply to euthanasia, "assisted death," the death penalty, and our upcoming debates on genetic manipulation of future generations.

I'm sure that you understand the difference between the embryo or fetus and a body part or end stage cell line. There's no doubt that what we are discussing is a human being.

The nature of this individual human being is underscored by in vitro fertilization. Just as a neonate may be cared for by other people, that embryo in the lab can be nurtured by others and even adopted for implantation into a woman other than his or her biological oocyte- mother. What we do to that embryo affects the later toddler and adult, and even his or her own children.

Once the individual human being is acknowledged, we have to discuss whether or not to afford him or her the protection from intentional killing by others - what some call "personhood." This is the dangerous point of our conversation. How do we justify intentional, interventional and elective killing of that embryo or fetus in such a way that does not put other human beings that we acknowledge are "persons" at risk?

Autonomy should not be your first consideration in this deliberation. Instead non-maleficence, then beneficence and justice should be weighed with autonomy. Your own note about the decision to act or not act according to rules and laws by you future colleagues points out that these other values come into play when you are discussing the interaction of the mother, the unborn child, and the doctor and nurse, and the law.

Is conscience solely a religious matter?

I've commented on the surprising accusation that protection of the consciences of physicians is anti-gay as well as anti-abortion by the pro-abortion faction. Now, the atheists are chiming in, claiming over and over that it's just the Christians who might refuse to perform abortions and object to calling abortion standard reproductive care.

"Pharyngula," is the blog of PZ Myers, who teaches biology at the Morris campus of the University of Michigan. Dr. Myers is one of the sources of the mocking of the Catholic communion and a "Red Letter," evangelical, atheist. He's also notorius for being banned from the local free showing of "Expelled, the Movie."

His blog post, "I don't want to be healed by Jesus, I want real medicine," advocates the view that "the religious" are the only people who would advocate for regulations protecting the jobs and licensure for people who conscientiously do not perform or refer for abortion.

"Trained" (medical professionals) should shut up and perform

"Trained" medical professionals should just shut up and perform, according to the President of the National Family planning and Reproductive Health Association.

As mentioned in the last few posts, the right not to be forced to act against the conscience has been under attack by the American College of Obstetricians and Gynecologists. The Washington Post article mentioned in my last post linked to the blog of Health and Human Services Secretary, Mike Leavitt.

Today, the Secretary wrote that he's not used to having nearly a thousand comments and many more "hits" on his blog. Take a deep breath and read the comments on each page.

Take a look, also, at this quote, in today's post:

One thing I did find helpful was the clear explanation of the ideological basis of opposition to physician conscience. Mary Jane Gallagher, President of the National Family planning and Reproductive Health Association, was quoted in Congressional Quarterly’s HealthBeat saying,

“Family planning providers work to provide family planning services. So it’s really not acceptable to the people I represent that this administration is considering allowing doctors and nurses and pharmacists that have received their education to provide services to now be able to not provide those services if they don’t want to.”

“Who’s going to provide access to contraceptives services if the administration provides this large loophole to deny services?"

CQ reported Ms. Gallagher continued: “Providers are ‘given an oath—now they get to pick and choose what they want to do' if a regulation is issued, she said.”

The Secretary answers Ms. Gallagher better than I could. However, don't you wonder that the conversation has moved from "choice" and patients' rights ("If you don't believe in abortion, don't have/do one.") to threats that we who oppose abortion should give up our practices, to the declaration that we trained and obtained a license only to be forced to do what someone elsed demands of us?

Washington Post Addresses Our "Birth Control Fears"

As well as our fear of death and homophobia, in today's article, "Birth Control fears addressed."

Health and Human Services Secretary Mike Leavitt has denied that a controversial draft regulation would redefine common birth control methods as abortion and protect the rights of doctors and other health-care workers who refuse to provide them.

In a statement posted on his blog on Thursday, Leavitt appeared to try to allay fears that the proposed regulation would create sweeping new obstacles to women seeking a variety of commonly used contraceptives, such as birth control pills and the Plan B emergency contraceptive.

"An early draft of the regulation found its way into public circulation before it had reached my review," Leavitt said. "It contained words that lead some to conclude my intent is to deal with the subject of contraceptives, somehow defining them as abortion. Not true."

Leavitt's statement, however, failed to alleviate concerns among members of Congress, family planning advocates, women's health activists and others.

At issue is the American College of Obstetricians and Gynecologists' Ethics Statement "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."

It goes on to declare abortion “standard reproductive care” 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).

After publication of the Opinion, the President of ACOG then wrote letters asking Congress to pass laws to force these limits on our consciences: to force doctors who object to abortion to either change their practice so that they don't take care of women and girls of reproductive ages, or move close to a willing abortionist.

Somehow, the pro-abortion crowd has turned this into an "physician assisted suicide" and "gay, lesbian, bisexual, transgendered, transexual" issue as well as one of hyper-support for abortion and one more opportunity to bash the Bush administration.

Kathryn Tucker, director of legal affairs for Compassion & Choices, which advocates for physician-assisted suicide, said she remains concerned that the regulation could apply to health-care workers who refuse to participate in a variety of end-of-life care, including the withdrawal of unwanted feeding tubes and ventilators.

. . . and . . .

"Until the regulation removes the re-definition of abortion and it clearly states that it deals solely with abortion (and not with any other procedure, nor with any refusals based on the nature of the patient, such as single or gay), I would not be satisfied," R. Alta Charo, a lawyer and bioethicist at the University of Wisconsin wrote in an e-mail. "There is no reason to extend any benefit of the doubt to this administration when it comes to reproductive rights or the civil rights of gay people."

You want to talk about "alarmed"? If an ethicist like Charo can't distinguish between negative rights and positive rights, then the state of "ethics" is worse than I thought. (See "Ethicist for hire")

Remedial ethics 101: you have the right to expect someone not to act, but only in very rare cases can you force them to act when they don't want to. You have the right to liberty, meaning society will protect you from someone who wants to turn you into a slave. But you can't make others to do your will, either. You have the right to swing your arm if you want, but your right to swing your fist ends at the other guy's nose.

In case you're wondering, the Post took their only prolife quote from the Secretary's blog.didn't quote a single pro-life advocate. How hard would it have been to get a quote from the Christian Medical and Dental Association?

I would have never guessed that the attack on physician's conscience rights would somehow become a gay/lesbian/bisexual/transgendered/transexual/pea-green-with-lavender-stripes issue, although I predicted the involvement of "Compassionate Choices" and other pushers of intentional physician killing.

In Oregon, I have the right to a prescription of barbiturates if I want to die. The State limits that right and tells me when my right kicks in, of course. According to lawyers Charo and Tucker, I can go up to any MD or DO and demand that he or she write the prescription.

I ask again: "How far do you trust doctors who will violate our consciences?? How much practice will it take until we do what the State tells us to, rather than what our patients ask - without regard to silly notions of "right" and "wrong?""

Forcing Pro-life Doctors Out of Baby Business?

Two writers from the Heritage Foundation have published an editorial on the Fox News Site that discusses the risks of the new ethics statement of the American College of Obstetricians and Gynecologists (ACOG). Daniel Patrick Moloney and Peter Reed appreciate that limiting obstetrics and gynecology only to those doctors who will do abortions or arrange in advance to refer patients to doctors who will abort, limits women who themselves believe that their children's lives begin at conception and who do not want anything to do with abortionists.

Should pro-life doctors and pharmacists be free to practice their profession according to the dictates of their consciences? Should a woman have the freedom to choose an obstetrician or gynecologist she trusts to provide care consistent with her beliefs?

Current federal law says yes. But many women may have that choice greatly restricted, and their doctors driven out of business, if a medical association is able to require that all doctors either perform abortions or make referrals for abortions.

In November 2007, the American College of Obstetrics and Gynecology (ACOG) announced that the ethical standards of the profession had changed. Its ethics committee stated that an ob/gyn who is unwilling to perform an abortion has an ethical duty to refer the patient to someone who will perform it. If the physician is unable to refer the patient in a timely manner, he would be required to perform the abortion himself.

This decision threatens the livelihood of pro-life doctors. Every ob/gyn who works in a hospital or clinic needs not only a license, but also certification that his skills are up to date and that he is aware of recent developments in the field. To be certified, he must follow the ethical standards of the profession, so under the new ethics policy a pro-life doctor risks losing his certification if his pro-life convictions don't allow him to perform or cooperate in an abortion. And if he loses his certification, a hospital or clinic won't let him deliver babies there.

The American Association of Pro-Life Obstetricians and Gynecologists has labeled the decision “a raw power play to cripple, and ultimately eliminate from practice, those doctors who hold a conscience conviction on the sanctity of human life.” Besides forcing current ob/gyns out of the profession, the policy would make any bright young pro-life student think twice about going to medical school for obstetrics or gynecology.

(More here.)

Besides limiting a woman's choice to have a doctor who shares her pro-life views, restricting all prolife doctors from obstetrics will adversely affect her access to health care in general. Few doctors are doing OB, now. The number can only decrease if the traditional, conservative, prolife man or woman is threatened by ACOG's insistence that conscience is merely a personal feeling and that we doctors can only practice if we promise to go out of our way to violate that conscience.

These ethical statements affect all doctors who care for women and girls through their reproductive ages. In fact, Family Physicians who deliver babies are also held to the same ACOG standards that the OB/Gyns must meet. (If anything, we had better be more careful, since any breech of protocol or "standard of care" may be thought of as due to our training.)

In many rural and underserved areas, the only docs around are the Family Physicians, who care for babies, kids, the elderly, and expectant mothers. In fact, I was the first FP in my small town ( just 20 miles from San Antonio but considered "medically underserved" as it had a large number of Medicaid, Medicare and indigent patients) who did not do "surgical OB," or do Cesarean sections and sterilizations. (I'm a wimp, not a cutter. Although I love to sew up and put back together, I even refuse to make the traditional, courtesy, "first cut" at appendectomies and other non-OB surgeries when the surgeon offers. I finally quit doing circumcisions on new born boys because it made me physically ill to cut perfectly healthy tissue.)

Okay, how far will you trust someone who trains herself to forget that she believes the Creator of the universe - the One who knows every thought and can send her to hell - hates what she's doing? Or even without a religious underpinning, a doc who believes he is killing a person at abortion, but does it anyway?

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."