Qualify for government subsidy: become a(n involuntary) unionized government employee

 Next up: doctors, section 8 housing owners, ????? Grocery stores, drug stores???

A year ago in December, Ms. Berry and more than 40,000 other home-based day care providers statewide were suddenly informed they were members of Child Care Providers Together Michigan—a union created in 2006 by the United Auto Workers and the American Federation of State, County and Municipal Employees. The union had won a certification election conducted by mail under the auspices of the Michigan Employment Relations Commission. In that election only 6,000 day-care providers voted. The pro-labor vote turned out.

Many of the state's other 34,000 day-care providers never even realized what was going on. Ms. Berry tells us she was "shocked" to find out she was suddenly in a union. The real dirty work, however, had been done when the state created an "employer" for the union to "organize" against.
Of course, Michigan's independent day-care providers don't work for anybody except the parents who were their customers. Nevertheless, because some of these parents qualified for public subsidies, the Child Care Providers "union" claimed the providers were "public employees."
Michigan's Department of Human Services then teamed with Flint-based Mott Community College to sign an "interlocal agreement" in 2006 establishing a separate government agency called the Michigan Home Based Child Care Council. This council was directed to recommend good child-care practices—and not coincidentally, to serve as a "public employer." Although the council had almost no staff, no control over the state subsidies and no supervision of the providers' daily activities, it became the shell corporation against which the union could organize.
Thus the state created an ersatz employer and an ersatz "bargaining unit" against which what was essentially an ersatz union could organize.
Today the Department of Human Services siphons about $3.7 million in annual dues to the union—from the child-care subsidies. The money should be going to home-based day-care providers—themselves not on the high end of the income scale. Ms. Berry now sees money once paid to her go to a union that does little for her. She says she is "self employed and wants nothing to do with the union."

Playing doctor with the White House

Who’s playing doctor with the White House: Another example of the lack of openness in the dealings of the Obama Administration

(Informed consent blurb: Organizing for America, etc., along with all the White House websites, are collecting data including email and other information from everyone who visits or contacts their sites. I got a couple of those emails from David Axelrod last month.

Don't worry - they already have my data. I used to email President Bill Clinton at least once a month and ask him to resign for the sake of our daughters – they are about the same age - because he'd set the women's movement back 50 years. He never answered. However, it occurs to me now that maybe that's why I was named to the Bush Administration's National Advisory Committee on Violence Against Women.)

On Thursday, September 17, 2009, I was web-surfing and searching Google news hits on the September 12th March on Washington and health care reform when I found information about a conference call between "Doctors for America," the White House "Office of Public Engagement" and doctors like me who somehow found out about the conference call.

I called in, but wasn't called on to ask my questions, so I re-wrote them as an essay (see below) and emailed it to info@drsforamerica.org I'm also sending the essay to the White House OPE.

When I started writing up my notes from the call, it finally occurred to me that – even though there was no attempt at disclosure - there might be a connection between "Drs for America," "Organizing for America" (whose website address is still "http://www.barackobama.com/ ," the same url once used by - and the remains of - “Obama for America,” the Barack Obama campaign machine.

I was slow to catch on, but I was right: The leadership at Doctors for America is made up of nearly the same roster of men and women who, in 2008, were the leadership of “Doctors for Obama” in 2008. Common names are Vivek Murthy, MD MBA, Mandy Krauthamer, MD MPH, Nikhil Wagle, MD, Alex Blum, MD, and Jay Bhatt, DO MPH

And, I was wrong: there’s a disclaimer at the bottom of the “Doctors for Obama” leadership page that says “Not affiliated with Obama for America.” (Yeah, right.)

In fact, former Obama Administration transition chief John Podesta's “Center for American Progress” funds the group :

May 04, 2009
'Doctors for America' launches

This may not wind up being decisive in the health care fight, but the organizing gap between the two sides continues to widen.
Sen. Max Baucus and the Center for American Progress Action Fund are announcing a new group on a conference call later this morning: Doctors for America, which is a reincarnation of Doctors for Obama, an arm of the Obama campaign that boasted more than 10,000 members.
The question of patients' relationships with their doctors is always a flashpoint in debating changes to the health care system, so doctors are often particularly credible messengers.
Today they'll "release new reports detailing the depth and breadth of America's health care crisis and announce a new effort to amplify physicians' voices in support of health care reform," according to the advisory.
By Ben Smith 11:07 AM

Here's the bio on the President and Co-founder, Vivek Murthy, MD MBA, at the Center for American Progress website:

Vivek Murthy is an internal medicine physician at Brigham and Women’s Hospital and an Instructor at Harvard Medical School. He received his undergraduate degree in Biochemical Sciences from Harvard University, his MD from the Yale School of Medicine, and his MBA from the Yale School of Management. He completed his residency training in Internal Medicine at Brigham and Women’s Hospital. Vivek is the co-founder of VISIONS and the Swasthya Project, international health non-profit organizations focused on HIV/AIDS education and women’s health, respectively. He is also the co-founder and chairman of Epernicus, LLC a web-based professional networking service for individual researchers and scientific institutions. Vivek’s past research has focused on the participation of women and minorities in cancer clinical trials; his current research interests include physician satisfaction and burnout. During the 2008 presidential campaign, Vivek served as a member of the Obama Health Policy Advisory Committee and the Obama New England Steering Committee.

Notes on the Conference Call

I couldn't catch all the names and I am not very good at telling who was speaking, but did try to take some notes from the opening statements. The quotations are the actual words of the speakers, the rest is my own interpretation and from memory.

The moderators talked about the "public option" as though it's a done deal and strongly pitched it as just a way to provide health care for people who have lost their insurance.

We were told that everyone will be required to have insurance, and that businesses will be asked to "chip in their part."

The White House has a plan to fix the SGR that has been pushed off over and over. In fact, there are plans for a “complete reform of the physician payment system.” without incentives for doing more procedures.

The President has given instructions to begin the medical liability demonstration projects to find a way to decrease defensive medicine while "mitigating risks to patients."

We were told that we are closer than we've ever been to health care reform this year.

The moderators were surprised by the second doctor who said he was from the former Soviet Union and that the public option would soon become the only option. They were adamant that the public option is not a pathway to single payer. (And besides, we all know that being paid by and regulated to the teeth by the government is not at all like working for the government.)

Later, one of the docs who called in asked specifically about the news stories that the public option was finished and the White House representative reminded us that the legislation is not written, yet. He was adamant that we shouldn't rule the public option out and that we should advocate with our patients and fellow doctors for that option.

One doctor asked about the effect on doctors with concierge or boutique practices and the other doctors who "opted out." The answer from one of the men was that these practices were just a reaction to cash pay patients who couldn't afford insurance.

There was a lot of excitement about one doctor's suggestion that doctors be required to give two years to a sort of National Healthcare Workforce. And huffy about the shortage of doctors that a Massachusetts doc reminded them that they'd have if all the uninsured were suddenly looking for primary care.

The woman naturopath was reassured that naturopathic primary care doctors would be evaluated by the same evidence based medicine that the traditional docs were judged by.

My letter to Doctors for America and the White House Office for Public Engagement

I’m Beverly B Nuckols, MD, the National chair of the Family Medicine Section of the Christian Medical Association as well as a member of the AMA, the Texas Medical Association and the American Academy of Family Physicians. I'm not officially representing the above, but I believe that my opinions are shared by a large number of doctors.

Many of my colleagues and I see the Patient Centered Medical Home plans, the protocols at Mayo and other medical centers that have been praised are attempts to model a bureaucratic form of practice for large practices so that they can do what the family doctor does every day.

My experience is that government bureaucracy is not only more restrictive and punitive than private insurers, the clout of the Federal government results in undesired UNINTENDED consequences all across the board. Doctors used to be the good guys, but now we feel as though we are assumed to be guilty of abuse of the system, largely due to Federal legislation and regulation.

These result in time and money spent on our futile attempt to keep up with Medicare regulations in order to avoid charges of fraud, abuse and waste. For instance: HIPPA, National Provider Identification numbers, bullet points and check boxes, E & M’s, procedure and diagnosis codes and qualifiers that change each year, and a whole alphabet soup of regulators.

In addition, government cost control attempts in the '90's actually limited the numbers of graduate medical slots, while encouraging sub specialty growth in relation to numbers of primary care doctors.

Making it all worse is the fact that under current Medicare payment schemes, Family Doctors who provide the same services as sub-specialists are paid less by Medicare.

Like the laws and regulations in the past, this year's “reform bills” and proposals are overly complicated and try to guarantee too much: school based clinics, nutrition data on menus and buffet lines, an overhaul of the federal income tax code, new lists of “enhanced penalties,” taxes, fines and the mixing of all of the above abuses with an overhaul of the Federal Income Tax.

Today’s announcement about the study of liability makes me worry that our Texas laws concerning tort reform will be over come by Federal inertia and interference.

1. Why not just look at Texas’ experience with tort reform rather than wasting time and money on new studies?

2. Is it possible to make the legislation smaller in scope so that it is focused on providing help for those patients and families who cannot afford or access medical care?

3. What plans are there to ensure training and sufficient payment for family physicians and other primary care doctors who are in the best position to coordinate care for our patients in the "Medical Home?"

Edit: added this 4th question that I believe I sent to Doctors for America:

4. Could the fines and mandates be replaced with tax incentives, removal of restrictions on Health Savings accounts, return of the major medical plans and the removal of the barriers preventing patients from owning their own health care insurance?

Page 425 (end of life counseling)

I received several emails over the last few days concerning page 425 of the House Bill on Health Reform, HR 3200, which outlines mandatory end of life "options" counseling.

Technically, it appears on the surface to allow doctors (and other "providers") to charge for the counseling. But, yes, it's mandated counseling and in the wrong hands, it might encourage withholding of care more than some of us would like -- and certainly more that others might like.

Can you imagine a more personal and private subject? The subject should be broached by your family doctor. But it appears that every doctor who sees Medicare patients will be responsible. I can imagine the emotional undertones of different doctors as they recite the standardized language and present the forms to be signed! And then, the counseling will be reported to the Center for Medicare and Medicaid Services, with the appropriate modifying code.

I object to the mandated repeat counseling when someone gets sick, the inclusion in the "Medicare and Me" handbook with language to be formalized by the Secretary and forms for the counseling. I've mentioned before how "hot" an issue this could be, even with my limited exposure to the debate.

I hope that someone with sensitivity is in the Secretary's office, assisting with decisions on the literature and forms.

ABC explains the Obama Administration

ABC News Senior White House Correspondent Jake Tapper has written an article, "When Academic Words Become Political Ammunition," that gives an anonymous "White House official's" rebuttal to the many concerns expressed about President Obama's choices for advisers and "czars" who will affect the shape of health care policies. He attempts to debunk criticisms of the philosophies of Ezekial Emanuel, MD (a bioethicist who is heading the push for control of health care finance and delivery in order to provide universal insurance) and John Holdren, director of the White House's Office of Science and Technology Policy.

The problem is that with Medicare and Medicaid, about half of medical care in this country is already paid for using tax dollars, and we are currently considering expanding tax dollar payment for nearly all health care in the Nation. I disagree with Ezekial Emanuel's position, referenced in the Hastings journal article, "Where Civic Republicanism and Deliberative Democracy Meet," which is linked (in pdf) at Tapper's essay:

Americans fear that if society guarantees certain services as "basic," the range of services guaranteed will expand to include all - or almost all - available services (except for cosmetic surgery and therapies not yet proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services un- covered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services.

In fact, while we are concerned about the amount of taxes that will be imposed, the Tapper essay points out that we are very much afraid that government interference in health care will result in more limitations, so that none of us will be allowed, much less "guaranteed," to seek medical care that will prolong our lives and make us feel better, unless we are seen as members of a group that is more valuable than others. The examples that Dr. Emanuel gives and our observation of the government pre-paid medical care schemes around the world lead us to believe that, the more health care is financed by tax dollars, the more expensive and rationed it becomes.

Academic mind experiments that do not draw a line between what is acceptable and what is condemned by the authors understandably will be interpreted by others as at best, neutral, at worst, in support of condemnable acts.

Myth: doctors take out tonsils needlessly

Then, there's the charge that doctors will needlessly take tonsils out. First, it's unlikely that your Family Physician or Pediatrician does surgery. Second, I don't think the ENT's are getting paid for these anymore, unless they jump through hoops to prove that they're not over-doing it.

AP: In trying to rally support for health care overhaul, Obama described a patient who sees a physician for a sore throat, or a parent who brings in a child with a sore throat.

"Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. ... The doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out,'" Obama told a prime-time news conference.

The president added: "Now, that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change — maybe they have allergies. Maybe they have something else that would make a difference."

Video and here.

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.

Whose life is it, anyway?

Trait selection in babies "is a service," says Dr. Steinberg. "We intend to offer it soon."

Whoops, someone noticed that some of this reproductive technology stuff might not be ethical.

Talk about controlling parents!

Eugenics is a done deal. The cat's out of the bag. There's no going back. (Don't think about the 14th Amendment that overturned Dred Scot and took the slaves from their "owners.")


Of course, the "Progressives" and human-plus groups only commit *good* eugenics. All they want is control and more money.


The "Progressives" started raising the alarm a couple of years ago, when they were pushing for a change in the Bush embryonic stem cell policy. The logic was that the reason there is no regulation is that the government isn't paying for enough research.

At the same meetings, they were adamant that their group must have the power maintain control. (Alta Charo, Laurie Zoloth, Jonathan Moreno, Insoo Hyun and the rest of the "Ethicists for Hire" crowd.)

Funny, in all these links, I didn't find a single comment about the doctors who lost a discrimination suit in California for refusing to fulfill a patient's request for IVF -- even in the midst of the hulabaloo about the mother of octuplets.

HT to Vox Popoli

The (manufactured) Stem Cell Debate at Dartmouth

I don't believe I've ever seen a report on a presentation that allowed half the space for "debate," after the fact.

The Stem Cell Debate at Dartmouth

Sunday, November 16, 2008

Father Tadeusz Pacholczyk, Ph.D. was recently invited to give a lecture entitled “Stem Cells and Cloning: Understanding the Scientific Issues and the Moral Objections” at Aquinas House, in observance of the Feast of St. Luke, the patron saint of medical professionals. Pacholczyk, or Father Tad as he encourages his audience members to call him, is the Director of Education for the National Catholic Bioethics Center. He arrived at this position after receiving degrees in philosophy, biochemistry, molecular cell biology, and chemistry, a Ph.D. in Neuroscience from Yale University, and years of research in molecular biology, bioethics, and dogmatic theology. In a free public lecture lasting more than two hours, Pacholczyk outlined both the scientific and ethical considerations of human embryonic stem cell research and to a lesser extent cloning, giving justifications for the Catholic Church’s positions on these technologies.

After giving an in depth layman’s version of the science involved in stem cell research and a history of both scientific milestones and relevant policy decisions, Pacholczyk corrected what he believed were some of the most pervasive myths about stem cell research. He believes that individuals and organizations within the media and others who engage in expensive advertising campaigns have deliberately misled the American people in an effort to reframe the debate over the use of human embryos for research.

**************
The Dartmouth Review understands that this is an issue on which reasonable moral people can disagree, and so Michael S. Gazzaniga ‘61, Ph.D., Director of the Sage Center for the Study of Mind at the University of California, Santa Barbara was asked to explain some of the ethical justifications. He indicated that, “The handling of human tissue has always commanded the respect of the biomedical community and always will.” However, Gazzaniga does not consider an embryo to be in possession of the same moral status as an adult human, while acknowledging that the issue has “deep meaning to millions of people.”

The Review has raised several ethics questions regarding the virtual debate they created by interviewing Dr. Gazzaniga after Dr. Pacholczyk's talk.

Will they seek out opposing views in the future or is it only Catholic priests who require such answers? Will they now give Dr. Pacholczyk an opportunity to respond?

In addition, Dr. Gazzaniga finds the determination as to when a human being becomes a human being fairly simplistic:

Asked the basic question underlying this debate and that about abortion, when a human embryo becomes a human being, Gazzaniga called it a “social decision, not unlike the kind a society makes about when to call someone legally blind.”

Does Dr. Gazzaniga's emphasis on contrasting "adult" human beings with embryonic human beings indicate that he finds differing moral values in the lives of infants, children, and "adults," does he extend these differences to the state of function of the brain, and can he justify these variations at least as well as we can our culture's definition of "legally blind?"

More on the Obama Transition Team

Many of the coordinators of the Agency Review Teams and the Working group members have already been reviewed by Daily KOS-er "joehoevah," here. This is not my usual referral, and he doesn't look for the connection to Podesta, but I couldn't demonstrate the left-leaning nature of this team nearly as well. (Let me know if the page disappears, I've archived the information.)

I use the political terms because of the need for balance in the appointments to medical, scientific and bioethics jobs and advisory committees. When all of the OTT have worked for "progressives" and such pro-abortion men as Daschle, Gebhardt, Waxman, and/or are credited with claiming that Senator McCain cannot send an e-mail (Pfeiffer), their politics are more than relevant.


There are several famous (on Google) Lisa Browns, including a State Senator from Washington and an actress. This one is a former Clinton Staffer who's spent the last few years at the American Constitution Society for Law and Policy, teaching lawyers and law students to oppose "an activist conservative legal movement [which] has gained influence - eroding these enduring values and presenting the law as a series of sterile abstractions. This new orthodoxy, which threatens to dominate our courts and our laws, does a grave injustice to the American vision."


Here's Lisa Brown on a youtube video, introducing a briefing by the American Constitution Society on the 2nd Amendment.

And from the 2nd page of my "progressive" Google search:

"The American Constitution Society for Law and Policy is one of the nation's leading progressive legal organizations. Founded in 2001, ACS is composed of law students, lawyers, scholars, judges, policymakers, activists and other concerned individuals who are working to ensure that the fundamental principles of human dignity, individual rights and liberties, genuine equality and access to justice are in their rightful, central place in American law.

"This conference provides an extraordinary opportunity to engage and energize members of the moderate and progressive legal community as we begin a concerted effort to reclaim the Constitution and ensure that our laws and public policy reflect our nation's founding values," said ACS Executive Director Lisa Brown."

Science: "A call to serve"

Some of you may know that I served on the National Advisory Committee on Violence Against Women from 2002 through the end of 2005. Attorneys General Ashcroft and Gonzales and Secretaries of Health Thompson and Leavitt were co-chairmen during their terms. They and the Office on Violence Against Women were more interested in protecting the citizens of the US than in furthering strict Party discipline and appointed many members who were advocates for victims of abuse, but not necessarily "pro-life". Or even Republican.

This was the policy of the Bush Administration. I'll admit to a few rants about this policy, especially when the media and academia were claiming just the opposite. (If they're going to hate us anyway . . .)

However, for all of the criticism against it, the President's Council on Bioethics was not partisan or one sided. 7 of the original members favored expansion of funding for embryonic stem cell research and not all were pro-life. In contrast, Clinton's National Bioethics Advisory Commission did not have any members that I (or others)can identify as prolife.

We must demand that *our* new President and his Administration maintain balanced citizen representation. And we must, as this opinion piece notes, answer the call to service.

Every pro-life man and woman should volunteer for a position in their State or on one of the National advisory committees. We should demand representation of our views through the coming years. Here is the current page for application to Executive Branch nominations. However, the best thing would be to start with a letter to your Congressional Representative's office or one of your Senators and others to any sort of association or organization that you work with, outlining your interests.

If we don't, who will?

From this week's Science Magazine:

Once Barack Obama becomes the 44th president of the United States in January 2009, he will, sooner or later, appoint individuals to science and technology policy positions within the executive branch of government. It seems as though every science- and engineering-related think tank either has published, or shortly will, a report calling on the new administration to appoint these people quickly and give them the authority and tools to do their job.

But it is not just an administration choice; qualified scientists and engineers need to be willing to take those jobs. The quality of the decisions and actions of an administration directly depends on the quality of those appointees and others who serve. Our premise is that every engineer and every scientist ought to include service to their country in their career plan.

Too often we have heard "I am too busy," or "my research is my service to the country," or various disparaging remarks about government bureaucrats and not wanting to be associated with them. There are several reasons why technically literate people should serve. First, they are needed. The world is more technologically sophisticated than it has ever been, and today most public policy issues have technical dimensions. Without sound technical input, some bad public policy will result. Without unrelenting oversight by individuals with technical expertise to ensure sound implementation, foolish actions will be taken.

The U.S. population broadly supports the nation's research and, frankly, in return the research community owes it to society to ensure that the best possible policy decisions are made. And there is a self-interest factor. This community believes that increased support for research would benefit the nation in the long term, but that case needs to be made from within the government as well as from the outside. The same argument is valid for other nations as well. Lastly, government service can be intellectually interesting. Executive agencies have resources to deal with problems. The challenge is to address them creatively and effectively.

Scientists and engineers think about problems differently. For example, lawyers, who disproportionately populate government positions, are trained to marshal an argument to support a predetermined conclusion (e.g., the client is innocent). In contrast, scientists and engineers are taught to analyze and design so that the outcome is not predetermined but is derived from the constraints of the problem. They collect relevant information, and only solutions that fit the data are acceptable. Scientists and engineers also think in terms of the total problem—for today and for tomorrow. An engineer will design a bridge to be taken down cost-effectively at the end of its life. This culture of thought and analytic tools and decision-making methods needs to have a stronger influence in decisions made about issues that at their root involve science or technology.

So how might one try out such service? One approach is to volunteer to advise some element of the government. Once a person is seen to contribute, they are increasingly called on to advise at higher levels. This can lead to appointment to more senior advisory bodies. Alternatively, an individual can apply to be a program officer in a federal or state government agency. Universities routinely grant leaves of absence for such service. Although one does not begin as the head of an agency, these program officer positions wield considerable resources and can materially address important challenges.

We believe that the scientists and engineers of all countries need to step up. Every one has a contribution to make. Shouting from the sidelines does not work. And if the technical community does not engage, we will get what we deserve.

10.1126/science.1167218

Washington State passes assisted suicide law

Washington has joined Oregon in legalizing "physician assisted death." From the Wall Street Journal blog post on the initiative:

A state measure known as Initiative 1000 passed by a margin of 59% to 41%, making it legal for doctors to prescribe a lethal dose of medication for patients with less than six months to live.

As we reported last week, the law is packed with provisions intended to limit the practice. Patients must make two separate requests, orally and in writing, more than two weeks apart; must be of sound mind and not suffering from depression; and must have their request approved by two separate doctors. Doctors are not allowed to administer the lethal dose.

Backers of the bill, including national right-to-die organizations and a former Democratic governor who has Parkinson’s, raised $4.9 million to support it. Opponents, including several Catholic organizations, raised $1.6 million to fund their fight, the Seattle Times reports.

In Oregon, the only other state with a similar law, some 341 patients have committed physician-assisted suicide in the 11 years the law has been in effect, the New York Times reported last week.

American Society of Bioethics and Humanities Convention

I'm on my way to Cleveland, Ohio for "Future Tense," the Annual meeting of the American Society for Bioethics and Humanities.

Tonight, there's a pre-conference symposium focusing on the novel, House of God. The book written by Dr. Stephen Bergman was a rite of passage when I was pre-med. It's now 35 years old, and (although I didn't read it until the mid-'80's) I'm a bit older, myself. I'm about half-way through the re-reading, now.

The rest of the week, I'll be attending - and possible blogging on - "Welcome and Plenary Session How to Stay Human in Medicine: The House of God, Mount Misery, and the Spirit of the Place," "Building Better Humans," " Advancing the Debate on Futility to a New
Level: Ethical, Legal, and Clinical Implications," "Future Directions for Public Health Emergency Planning: Broader Moral Perspectives," and last, but not least, "Limiting Rights for the Public Good: Balancing Public Safety and Civil Liberty in Response toTerrorism, Epidemics, and National Security," with "Organizer," Paul Root Wolpe, PhD and Jonathan Moreno, PhD. The former has served as the ethicist for both NASA and Planned Parenthood, and the last is on staff at the Progressive bioethics arm of the "Center for American Progress."

For some reason, there always seem to be several very interesting sessions going on at the same time. For instance, Saturday morning, I have to choose between "Professionalism in Bioethics and Medicine" or "Role of Government in Public Health."

Wish me luck. The weather here in South Texas is in the 80's in the daytime, while in Cleveland, the highs will be in the 40's and the 50's. Before I knew Cleveland would have the heat wave, I bought gloves and dug out the scarves. Since I don't own a real coat - I'm claustrophobic more than I'm "cold-natured" and who needs a heavy coat in San Antonio, anyway? - I'll be the extra-bulky one in layers of red and black.

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.

"The motivation is abortion"

“The motivation is abortion,” says R. Alta Charo, a professor of law and bioethics at the University of Wisconsin at Madison. “If the Supreme Court allows states to declare embryos as personhood, you would be in a position to say immediately that all abortions have to stop.”

LifeEthics covered this story a few days ago, but this quote deserves a second look - and repeating for the record.

The comment by (Robin) Alta Charo in the LA Times explains the opposition of "Resolve," the National Infertility Association, to Colorado's proposed State Constitutional Amendment 48. That Amendment reads,

“The term ‘person’ or ‘persons’ shall include any human from the time of fertilization.”

Here's an article on a rally in Colorado opposing the Amendment, led by Resolve.

The "foes" of the amendment are claiming that it would criminalize "several forms of contraception" and in vitro fertilization. However, I believe that IVF could be carried out in a manner that respects each individual begun that way, if each is treated as a human being deserving of life.

In vitro fertilization and the beginning of life

The Los Angeles Times (a one time free registration may be required) finally notices that couples who initiate in vitro fertilization are "finding themselves ensnared in a debate about when life begins."

The proposed Colorado amendment states, "The term 'person' or 'persons' shall include any human from the time of fertilization." If it is passed, the courts would have to interpret the meaning of those words, says Kristi Burton, sponsor of the initiative and founder of Colorado for Equal Rights, which focuses on the rights of unborn children. The goal of the amendment, says Burton, a college student, "is to respect and protect all life."

Fertility advocates are skeptical that "personhood laws" wouldn't limit their choices for reproductive healthcare. In August, Resolve released a statement opposing the Colorado amendment.

"The motivation is abortion," says R. Alta Charo, a professor of law and bioethics at the University of Wisconsin at Madison. "If the Supreme Court allows states to declare embryos as personhood, you would be in a position to say immediately that all abortions have to stop."

The reproductive rights of infertile women may not be the target, says Dr. William Schlaff, director of reproductive endocrinology at the University of Colorado Health Sciences Center, "but the implications are massive depending on how this law would be used if adopted."

For instance, what happens to embryos determined to be afflicted with serious genetic diseases? "What do you do with that embryo then?" Schlaff asks.

Says Burton of the initiative's possible ramifications: "All those things would have to be dealt with later on. . . . We don't see it as preventing infertility treatment."

As for the Rathans, over the course of several weeks, the couple ruled out discarding the embryos. They discussed donating them to research but heard that option was a logistical nightmare. They pondered giving the embryos to another infertile couple.

"Before I became pregnant, I thought the decision would be easier for me," Gina Rathan says. "But when it actually happened, I realized these are three potential lives."

Finally, the couple paid for three more years of cryopreservation.

"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?

Human-pig embryo approved in UK

The "cybrid" or hybrid human-animal embryos are created in the laboratory by Somatic Cell Nuclear Transplantation, using emptied eggs from animals and the nuclear and cellular DNA from humans.. We know that there are currently experiments on-going with the human embryos made using emptied cow eggs (more on the "ease" of making these embryos, here), and now the British have authorized the development of pig-human embryos.

The experimenters admit that the problem will be achieving embryos and embryonic stem cells that do not contain DNA left from the egg. Proving the purity and "human-ness" of the stem cells will be a complication that I do not believe they will be able to overcome, at least for transplantation into humans, except possibly in the case of severe, last-hope disease and trauma.

The ethical debates about xeno-transplants and treatments using living organs, cells and tissues from animals carry the risks of transmitting animal diseases that humans have no immunity for and the development of new strains of disease that cross species lines. Ethicists have predicted that at least the early patients will have to live their lives in isolation at the worst, and have life-long surveillance at the best. (more on the debate, here and here.)

However, the researchers will probably be able to develop other uses, such as the early warning chemical weapon detection systems that are being developed by our own military, using human embryonic stem cells.

Rather than humanitarian and medical hope, I believe that time will show us that the research is the result of pure greed, with each lab hoping to come up with a product that can be patented and sold. I'm disappointed that the courts and "ethics" bodies in the US and UK have allowed these patents of human organisms. The drive to "create" new human cells and artifacts using human DNA is the logical outcome.

FDA goes after fraudulent cancer cures

We were just talking about this.

The Washington Post reports

Neil Baker, a retired maker of truck canopies in Helena, Mont., fills about two orders a month for E-Mune through his company, Herbal Remission. It is made from bloodroot, a plant that contains sanguinarine, which has been studied for possible anti-tumor activity. He says one customer's melanoma was cured.

"I really don't know a whole lot about it. All I know is it works," said Baker, 63. "As far as I'm concerned, humanity should have it. But if the FDA doesn't like it, that's okay with me, too."

The FDA's list of "fake cancer cures" is at http://www.fda.gov/bbs/topics/factsheets/fakecancercures.html.

New Bioedge edition available

The weekly newsletter, Bioedge, from the land down under is one of the better bioethics/biotechnology on-line newsletters.

Readers who consider the pro-life movement mainly as a US political matter, may be surprised by the existence of Bioedge, since it is pro-life. The publishers' aim is to:

* to promote evidence-based ethics in medicine
* to promote compassion in medical care
* to highlight the fact that medical excellence is not possible without ethical principles
* to provide high-quality up-to-date information and commentary on bioethics
* to facilitate the participation of health professionals in policy debates on bioethics

This week's headlines include

"Stem cell scientists seek to shed snake oil image"

"California euthanasia lobby scores victory"

"Nature attacks ‘human dignity’"

"Surprise on operating table"

"US Catholic bishops reject embryonic stem cell research"

Everyone else does it

The American Medical Association and the American Medical Student Association are both up in arms about contact between drug companies and other vendors and doctors and medical students. And yet, no one complains when a New York Times story about the fuss contains advertising. (Free registration required -- is "free" anything undue influence?)

I've said it before, perhaps I can be bought, but not for a pen, some samples or lunch.

Nature nurtures debate on namesake

Josh Carter, over at the Bioethics.com blog, comments on the editorial in the April 10th issue of Nature, (subscription only. Joe quoted some but let me know if you need the full text) which uses news of a transgendered (but not transexual) pregnant and bearded woman to ask the age-old question, what is "natural" and whether "natural" is better than "un-natural."

What do you want to bet that the author prefers "natural" fibers for his clothes and "organic," when it comes to groceries? We know that the editorial board has opinions on the good and bad, since the cover of the April 3 issue in front of me has the headline, "Carbon emissions: it's worse than you thought."

Even though the question couldn't have been asked quite this way in the past, Nature asks one of the oldest philosophical questions. Unfortunately, they ask in a juvenile manner. In fact, they beg the question by stating that the approved purpose is to "enhance the human condition."

(As I commented on the Bioethics.com blog) The “natural” uses of medicine and science seek to discover and use our discoveries to encourage, enhance, and/or return to optimal what Aristotle called the “telos,” the “what it is meant to be.” For instance, a splint reduces pain and holds the limb in physiological position as it heals. Hip replacements, glasses and hearing aids aren't normally intended to give you the ability to jump higher or stronger, see with the sight of an eagle or hear a pin drop in the next county -- they are used in an attempt to return your functioning to "normal."

The most active debates in science today are actually discussions about the “nature” of the thing we are studying or manipulating. Is global climate change causing the Earth to heat up more than is “natural,” is it man-made (due to those carbon emissions), or cyclical, etc. Should there be regulation on abortions to for sex-selection or to choose for deafness? Who gets the resources to be the Six MillionTrillion Dollar Woman and why not allow men and women to demand that their limbs be cut off or that their faces be botoxed and surgeried into a human caricature that scares children?

Again, we see the problem with setting up the ethics hierarchy so that "autonomy" trumps "non-maleficence." "I want" ethics over "First, do no harm."

Is there good in the telos, or is there any standard for dividing funding and power in science and medicine? If there aren’t good and bad uses of science and medicine, then “Anything goes,” if you can get the financing, the power, or the ability to do it.

Designated Donations (Saving black girls from punishment)

There's no way to avoid the politics if I'm going to comment on these two stories.

First, here's a link to the audio recordings of Planned Parenthood employees, agree will be earmarked to decrease the number of "African Americans" or a "black baby." The employees include the Vice President of Development of the New Mexico PP, Sue Riggs, agreeing to accept money that the caller has specifically said should go to the abortion of an African American. Another call includes the statement that the man does not want his children to face a lot of competition in college due to affirmative action.

These calls should be enough to make any thinking person condemn at least the lack of sensitivity and training at the offices of Planned Parenthood. Unless you realize that they probably think they're rescuing a black woman or girl from the punishment of having a black baby -- as stated so clearly by Barack Obama last Sunday, March 30, while campaigning in Philadelphia:

"I've got two daughters -- 9 years old and 6 years old," Obama said. "I am going to teach them first of all about values and morals. But if they make a mistake, I don't want them punished with a baby. ... So it doesn't make sense to not give them information."

The mindset that calls pregnancy a "punishment" is one that we who value human life often encounter. In a classic case of projection - seeing your own opinion, wants, flaws or tendencies in the other person - the abortion advocate will claim that we see sex as bad, and that women and girls should be punished.

No, we see women and girls as us. We see their babies as the children of the future - as our fellow human beings and citizens. The information that we give our children is that there are consequences to our actions. Each of us has a responsibility to work toward good consequences by choosing our actions. Taking responsibility, expressing compassion and empathy, and even parenthood are not "punishment."

In fact, you could call the opportunity and ability to do so a "blessing."

Edited 4/2/08 at 10:00 PM for typos.

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.

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."

Warnock Answers

Dame Mary Warnock has written an essay which was published in the November 29, 2007 issue of Nature, which appears to be an apologetic for her part in the establishment of the ethics of embryonic research in the United Kingdom. The bloggers at Women's Bioethics Project speculate that she wrote in anticipation of Parliament's review of the Human Fertilization and Embryo Authority.
The full essay is for subscribers only - but there's a 2006 article that describes the wider function of the committee, here.

What Warnock explains (but doesn't acknowledge) is that her committee did exactly what they accused the Catholics of doing: "answering in advance the very question we were asking."

The task was to justify embryo experimentation, posed to the Committee after it was proven that the embryonic Louise Brown was the born Louise Brown. They did the job they believed that they were assigned, and then projected their own act of "answering in advance" upon anyone who drew a connection between the moral worth of the embryonic Louise Brown and the born Louise Brown.

Ironically, Dame Warnock admits to no expertise in morality yet feels justified in rejecting the moral expertise of the Catholic Church simply because it is the Church. All the while complaining about the difficulty of pleading the case that the issue is one of morals.

I wonder whether we could get murder and rape prohibited by this committee.
From the Nature essay (emphasis is mine):

When in 1978 the first baby was born by in vitro fertilization (IVF) it was inevitable that there would be calls for the procedure to be prohibited. That science develops too fast for morality had become the cliché of the twentieth century. Wisely, the UK government decided to set up a committee from which to seek advice before legislating on such a complex and emotive issue.

The Committee of Enquiry into Human Fertilisation and Embryology was founded to examine the social and ethical implications of the new techniques. Therefore the committee could not be made up entirely of physicians and scientists. With some difficulty, 16 people — including me as the chair — were gathered to look at the problem from all angles. Our areas of expertise included social work, law and theology.

We were not a group of 'moral experts', with particular moral authority derived from our expertise. Rather, our entitlement to propose legislation derived from the fact that we had been set up by government and that we had been given the time and resources to do so. The only other requirement was that we should all be capable of formulating and listening to arguments.

The central and most controversial issue before us was whether or not research using live embryos should be permitted. There was little possibility of a moral consensus. If research were prohibited, IVF could not continue. It would have been too risky for patients.

When legislation seemed imminent in Britain, the Catholic Church published an instruction condemning IVF and research using human embryos. The Church stated that its instruction was based on "the criteria of moral judgement as regards the application of scientific research and technology, especially in relation to human life and its beginnings".

The Church claimed a right to regulate science in this area, because of its superior knowledge of morality. In sharp contrast, the committee's entitlement to issue moral advice to ministers derived from its having been set up to do so, and from its having a wide and non-partisan membership.

Prohibition of IVF did not seem to the majority of the committee to be a serious option, given its widespread welcome as an innovative remedy for infertility. We all regarded infertility as a serious malfunction, causing much distress. Instead, we proposed a strict system of licensing, backed up by the criminal law. Regulation was not a mere sop to science-phobia. There was a real danger that women, desperate to conceive, might be exploited, taken in by unrealistic promises and charged extortionate fees for futile or dangerous treatment.
Establishing what limits should be placed on embryonic research entailed a decision by the committee as to the moral and legal status of the live human embryo in vitro. Those who opposed the use of embryos in research could seek to demonstrate that it was morally wrong only by answering in advance the very question we were asking. They deemed that the embryo had the same moral status as any human being.

One of the most difficult tasks the committee faced was to get parliament to understand that the status of the embryo in vitro was a matter not of science but of moral decision. The novelty of the embryo in vitro meant that there could be no appeal to precedent or existing moral convention or to religious laws.

30 years later, the evolution of the HFEA regulations - through one mutation followed by another due to pressure to expand the limits of research - allow preimplantation genetic diagnosis, selection for "savior siblings" and against low risk genes, cloning and (most recently) licensing the use of non-human oocytes and human DNA for cloning experimentation.