White Coat Underground

I’m one of those wacky idealists for whom January 20th was a great day. But with those high hopes, I have some fairly high expectations of our new president, one of the first of which is to repeal the Church Amendment, an HHS directive allowing health care providers to abandon proper ethics without consequence.

I’ve done quite a bit of blogviating about so-called conscience clauses, the rules that would allow health care providers to deny patients care not because it is outside the standard of care but because it bothers the personal beliefs of the provider. In case my previous writings have been unclear let me say right off the bat that conscience clauses are an ethical abomination.

Let’s look, though, at how these are being used in the real world. Providers who refuse care based on their own beliefs seem to make decisions that disproportionately affect women. I know, I know, this may seem obvious to some, but let’s look a little more closely.

The rules are quite broad and will allow providers to refuse to do nearly anything, including referring to a provider who will provide the treatment. For example:

[The statute] prohibits the Federal government and any State or local government that receives federal financial assistance from discriminating against any health care entity (including both individual and institutional providers) on the basis that the entity refuses to (1) receive training in abortion; (2) provide abortion training; (3) perform abortions; (4) provide referral for such abortions; and (5) provide referrals for abortion training.

Theoretically, the HHS rules should apply to any provider with any set of beliefs, but certain beliefs are mentioned explicitly in the draft rules.

Abortion

the Department proposes to define abortion as “any of the various procedures–including the prescription and administration of any drug or the performance of any procedure or any other action–that results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation.”

Contraception (female):

Despite the fact that several conscience statutes protecting health care entities from discrimination have been in existence for decades, recent events suggest the public and people in the health care industry are largely uninformed of the protections afforded to individuals and institutions under these provisions. This lack of knowledge in the health professions can be detrimental to conscience and other rights, particularly for individuals and entities with moral objections to abortion and other medical procedures.

The draft goes on to list state laws that require health plans to give equal coverage to female contraception and emergency contraception (“Plan B”). Condoms, the only “male” form of contraception, are nowhere mentioned.

Sterilization: Sterilization in mentioned no fewer than 28 times in the draft document, although in this case, there is no mention of female vs. male sterilization.

The statues allow for providers to refuse to dispense medications, refuse training programs from setting their own standards for their professions (e.g. it would forbid OB/GYN residencies from requiring abortion training in any way), allow unethical doctors to give false information about abortion and birth control (including that some birth control is equivalent to abortion (sic)), and allows them to refuse to give further information to help a patient find an alternate provider.

It is clear to all but the most muddled of thinkers that these rules are aimed at protecting providers with fringe religious beliefs when they violate the ethics of their professions. It should also be clear that these rules affect women disproportionately. If women cannot obtain birth control, Griswold is meaningless. It is inconceivable to me that in a modern democracy, the federal government can get away with passing laws that clearly discriminate against women. It is less inconceivable that there are doctors out there who would violate our most sacred duties toward our patients to fulfill our own religious needs.

Comments

#1 bob koepp
January 21, 2009

I won’t bore you with a defense of conscience clauses, nor try to explain to you the notion of freedom of conscience. But I’ll note that as a real world, practical matter, the president has no authority to repeal any legislation.
#2 PalMD
January 21, 2009

But…But he’s OBAMA!!!!

Actually, the statute has existed for a long time, but the bushies decided to push through a frame work to enforce it for the first time….perhaps he could work on that.
#3 The Ridger
January 21, 2009

Why exactly does your freedom of conscience allow you to take a job where it trumps mine?
#4 The Perky Skeptic
January 21, 2009

I keep telling these healthcare workers with “conscience” problems that Burger King is hiring…
#5 Phil
January 22, 2009

A buddhist goes to a hot dog stand and give the man five dollars and says “make me one with everything”. The vendor gives him his dog. The Buddhist says “where’s my change?” to which the hot dog vendor replies “change comes from within”.

I’m sorry, you may hit me now.
#6 Constance Reader
January 22, 2009

In re: Bob Koepp, I echo Ridger and Skeptic.

If your conscience prevents you from doing your job, you chose the wrong job. Get another one.

Healthcare providers have no more right to cherry-pick which of their job requirements they will perform and which they will not perform than the rest of us, without consequence. Should firefighters be permitted to decline to fight a fire at a location they find objectionable?

In the real world, someone who refuses to do their job gets fired, and rightly so.
#7 N.B.
January 22, 2009

The whole “freedom of conscience” nonsense is a diversion. Imposing your personal, non-scientific, non-evidence-based beliefs on your patients as a physician, nurse, or pharmacist is an ethical tragedy.

I feel like this subject has been so thoroughly covered that there’s almost nothing I can say that hasn’t already been said better by somebody else. Nevertheless, I still find it astounding whenever anybody even considers defending the “conscience rights” of doctors over the autonomy of patients when there is no medical reason to deny a patient’s request for treatment.

Off-topic: Congrats on the transition to your own Sb, Pal! I meant to comment earlier, but the server needed to be properly blessed, or something, if the error message I was getting is any indication.
#8 bob koepp
January 22, 2009

While I defend freedom of conscience and thus the right to conscientiosly object to engaging in activities to which one has moral objections, I certainly do not defend violations of patient autonomy. Those who believe that a refusal to provide assistance is equivalent, either morally or legally, to a denial of the autonomy of the one seeking assistance understand neither the notion of conscientious objection nor the notion of autonomy. Remedial education is certainly in order, but I’m not the one to provide it.
#9 Jason A.
January 23, 2009

bob koepp:

Remedial education is certainly in order, but I’m not the one to provide it.

Ahh, the old ‘you’re too stupid to understand so I won’t explain it to you’ defense. Always popular with those who have no real defense of their ideas.

As someone else said, if you have a moral objection to performing your job, you need a different job.
#10 PalMD
January 23, 2009

bob, while a pretty good guy, has no concept of the ethical responsibilities we have toward our patients. Sad, really.
#11 WilliamtheCoroner
January 23, 2009

I am confused.

There have been times where people have used a conscience clause inappropriately, to cover lying (the woman who “accidentally” pulled out intra-uterine devices without the patient’s knowledge. That’s not acting as a matter of conscience, that’s lying to your patient and acting illegally (and paternallistically, too). A pharmacist refusing to dispense prescriptions is presuming an AWFUL lot, and doesn’t know exactly why the script is being given. That is overstepping bounds.

You can’t lie to people. You can’t tell them one thing and do another. You can’t interfere in a therapeutic relationship. You can’t abandon folks high and dry. But as a professional I am not a medical vending machine. I’m not a common carrier. I don’t take every case that comes over the transom. I have had people try to force me to opine when I refused a case. It was a very long deposition, because I kept refusing in various ways.

But, PerkySkeptic, are you really asking an OB like my colleague (who is also a Jesuit) that he is required to provide abortion services by the fact that he is an OB/GYN? I know he’s the only OB in Southern OH for quite a ways. I know he refers sterilizations to a colleague. I don’t know how he handles other situations. I know a group of Catholic OBs who hired a Jewish guy to do the tubals for their group–sort of a medical shabbat goy. I don’t know what Father F does.
#12 PalMD
January 23, 2009

It is generally considered ethical for an OB to refer expediently to a colleague for services they are unwilling to provide, provided they do not make the patient feel crappy about it.
#13 JustaTech
January 23, 2009

Why is it always reproductive choice? Really. It’s never “I won’t treat your diabetes because I think you’re just too damn fat and it’s your own fault.” Nope, it’s ” I don’t approve of what you do with your body, woman, so I shall arbitrarily make decisions that affect your life but not mine.”

WilliamtheCoroner (great name!), if Father F is upfront with his patients about his positions, *and* is willing to make prompt referrals that are also possible (“I want a tubal ligation, and I really need the doctor to be in my insurance network, will you work with me?” “Sure, here’s Suzie my insurance wrangler,and she’s ok setting this up,” would be how I imagine the conversation would go.) then he is an awesome doc. It would be better if he took on a partner who was willing to do these other services, but the world is hardly perfect.

But is it ever about anything other than reproduction? The cry is never: “No pacemaker for you!” Why is that? It is such a huge issue in American culture, this need to control what people do with each other and their genitals. For all that we’re about making your own choices, the pioneering spirit, there’s this simultaneous need to control others. Maybe if we could find the root we could find new and different ways to talk about it.
#14 WilliamtheCoroner
January 23, 2009

JustaTech

You’ve never heard doctors discuss fat people. The amount of abuse my diabetic grandmother got from her cardiologist, including “There was no diabetes in Auchwitz” and “I just hate taking care of gluttons”–both were said to her face.

Yes, there is a significant desire to control women’s reproduction. That bothers me. I would rather have people not NEED abortions–which is a whole other ball of wax. There’s a tremendous desire for power and control on both sides of the political spectrum. For some it’s reproduction. For others it is drugs, nicotine, and ethanol.
#15 Roger Knight
January 24, 2009

I thought the ob-gyn people were the ones who perform abortions, or under the conscience clause, don’t.
Should heart surgeons be required to perform abortions and to receive training to perform abortions?
Used to be health care providers subscribed to the Hippocratic Oath, first do no harm.
An abortion harms the child.
It is not a fringe religious belief to not want to participate in such and to oppose making participating in such a requirement for membership in the health care profession. And certainly when an abortion is contemplated for a child with an extra chromosome, it is not a fringe religious belief to not want to engage in such practice of eugenics.
It is simply to agree with Governor Sarah Palin.
And to disagree with the Nazi Party.
#16 Jon H
January 24, 2009

I’m surprised PETA hasn’t tried a strategy of dominating steakhouse employment over the country, and then refusing to serve meat en mass.
#17 bob koepp
January 24, 2009

I’m still not going to try to explain how conscience based objections relate to the practice of autonomy — and it’s not because I think people here are incapable of understanding. Rather, because of my rather acerbic style, I’m simply not the person to try to foster that understanding. There is a large body of easily accessed literature that would do a much better job.

But Pal, do you really think I’m unaware of the ethical obligations of health care professionals to their patients? If so, that’s sad. I’ll tweak your memory again, and note that you are on record acknowledging that, speaking generally, physicians do not have a professional ethical obligation to provide elective services. Now, given that contraception and abortion are usually not medically indicated, how do you get to the conclusion that those who decline to provide such services are violating professional ethical norms?
#18 PalMD
January 24, 2009

But Pal, do you really think I’m unaware of the ethical obligations of health care professionals to their patients?

Yes.
#19 bob koepp
January 24, 2009

Good! A direct answer. Let’s go for two. Again…

Now, given that contraception and abortion are usually not medically indicated, how do you get to the conclusion that those who decline to provide such services are violating professional ethical norms?
#20 PalMD
January 24, 2009

Your premise is false. Contraception and abortion are almost always medically indicated. And it’s certainly not up to a pharmacist to decide. In fact, if the pharmacist isn’t the patient, if the medication is legally and properly prescribed, and if the rx follows the standard of care (ie there are no fatal interactions etc that make rx’ing it against any rational professional’s judgment) then really the pharmacist’s opinion is irrelevant.

Seriously, are you going to say next, “well, the patient’s ldl cholesterol might be at goal, so i’m not going to dispense the higher dose of simvastatin because in my opinion as some random pharmacist, it’s not medically indicated./”

That is the height of arrogance.
#21 bob koepp
January 25, 2009

Contraception and abortion are almost always medically indicated? That’s a pretty far out there claim, which I don’t think you can back up. In other words, I think you’re making stuff up as you go. But show me wrong — cite a reputable medical reference describing the medical indications for abortion or contraception according to which they’re almost always medically indicated. And then explain why MDs who don’t routinely recommend them aren’t being cited for negligence.
#22 PalMD
January 25, 2009

Bob, i don’t think “medically indicated” means what you think it means.

i also suspect you are so narcissistically devoted to your own needs that you can’t yet conceive of what everyone’s proper roles in the health cares system are.
#23 bob koepp
January 25, 2009

Pal – I haven’t said what I think “medically indicated” means, and you haven’t said what you think I think it means. Not a direct answer. And you haven’t cited any medical source for your claim that contraception and abortion are almost always medically indicated. Or was I right to think you just made that up?

What’s this got to do with my own needs? If you mean that I’m ignoring the needs of women who wish to exercise their right to control their own reproduction, you’re simply wrong. In fact, I think the ability of women to exercise such control (i.e., to engage in the practice of autonomy) would be greatly enhanced if access to the means of control were demedicalized. To my way of thinking, that would be a good thing. And it wouldn’t require trampling on the principle of freedom of conscience — another good thing, if you embrace liberal values. Do you?
#24 susannac
January 27, 2009

I thought freedom of choice was a core liberal belief. Why does it not extend to the physician?

As for women being primarily affected…it’s abortion. Men don’t have wombs. They don’t have any equivalent body functions. So issues about bearing children can’t be about men. It is a logical fallacy to say that every time someone takes a position against abortion they are necessarily taking a position against women just because only women can have abortions. You can’t conclude that I hate all men just because I believe murder is wrong and men commit by far the majority of murders. You can’t conclude I hate all men just because I hate domestic violence and men commit by far the most damaging and frequent domestic violence. I am not “oppressing” men by not condoning murder and domestic violence. I am not “oppressing” a woman by telling her I won’t perform an abortion for her, especially when that service is readily available elsewhere.

As for condoms not figuring into any laws – they aren’t restricted. You can buy 100 of them on any day in any town in America. There’s no reason to include them.

The abortion issue has become little more than a cultural stick wrapped in medical and legal jargon used to beat back people who believe differently than the current liberal mainstream. I’m not in favor of women having back-alley or hanger abortions, nor in favor of women being forced to bear more children than they want because contraception is being withheld. But there are a lot of options between no abortions and forcing all doctors to perform abortions on demand. And contraception is available at Wal-Mart. Quite frankly, what you are proposing is religious oppression of the type our ancestors fought to end. You fail your own liberal values when you seek to force someone to do something they do not believe is right. You are becoming the oppressor you claim to despise.
#25 PalMD
January 27, 2009

I thought freedom of choice was a core liberal belief. Why does it not extend to the physician?

Because a doctor serves the needs of the patient above their own.

As for women being primarily affected…it’s abortion. Men don’t have wombs. They don’t have any equivalent body functions. So issues about bearing children can’t be about men. It is a logical fallacy to say that every time someone takes a position against abortion they are necessarily taking a position against women just because only women can have abortions. You can’t conclude that I hate all men just because I believe murder is wrong and men commit by far the majority of murders. You can’t conclude I hate all men just because I hate domestic violence and men commit by far the most damaging and frequent domestic violence. I am not “oppressing” men by not condoning murder and domestic violence. I am not “oppressing” a woman by telling her I won’t perform an abortion for her, especially when that service is readily available elsewhere.

If a decision disproportionately affects one sex in a negative way, it’s fair to say it’s sexist. If, for instance, insurance plans in the south decided to stop covering skin cancer treatments, it might be fair to say that the decision is discriminatory against fair skinned people.

As for condoms not figuring into any laws – they aren’t restricted. You can buy 100 of them on any day in any town in America. There’s no reason to include them.

Sorry, i don’t get it.

The abortion issue has become little more than a cultural stick wrapped in medical and legal jargon used to beat back people who believe differently than the current liberal mainstream. I’m not in favor of women having back-alley or hanger abortions, nor in favor of women being forced to bear more children than they want because contraception is being withheld. But there are a lot of options between no abortions and forcing all doctors to perform abortions on demand. And contraception is available at Wal-Mart. Quite frankly, what you are proposing is religious oppression of the type our ancestors fought to end. You fail your own liberal values when you seek to force someone to do something they do not believe is right. You are becoming the oppressor you claim to despise.

That’s a parody, right? If you freely choose to enter a profession whose activities and standards are pretty damned clear, and then you decide you just don’t want to follow them, well, you’re either an idiot or an unethical bigot.
#26 md logic
January 28, 2009

i work at an evil catholic hospital and i have dome a lot of my med school and residency in catholic hospitals. I have never seen the life of a mother placed at risk. the safity of the mother is first. it is a myth that the well being of a women is not taken into account. I have participated in many HEELP and pre-eclampsia cases some of which resulted in the delivery of a very premature baby with no argument from anyone. The treatment of any ob emergency is delivery wheather the baby is alive or not is not an issue. Can someone tell me what condition requieres the delivery of a dead baby for the well being of the mother? Elective procedures a re elective go get them done at an elective place. Emergency care meaning real are taken care by all staff in every hospital catholic or other.
#27 susannac
January 28, 2009

Pal, just because “activities and standards are pretty damned clear” doesn’t mean those activities and standards are proper or desirable. When abortion was illegal in the US, do you believe it was moral and ethical for a doctor to refuse to perform one for a woman who clearly medically needed it? Do you believe that performing abortions only became moral and ethical when the law changed? Or do you believe that there are absolute standards of right and wrong that exist outside the culturally-derived boundaries that laws (and professional standards) reflect? Your post and comments would indicate the latter. So how can you say that someone with beliefs just as strong but on the opposite side is wrong for holding those beliefs? For acting on them, especially if (s)he is not seeking to impose his/her approach on other practitioners? You think their conclusion is wrong, but to condemn them for holding and acting on their convictions condemns every doctor who has ever held and acted on your same convictions when the cultural boundaries rejected them. You can’t have it both ways. You can’t argue that the boundaries are inviolable now without also agreeing they were pre-legal abortion as well. Would you, in the 1950s, have argued this agressively against doctors who performed abortions?

You are also ignoring the needs and preferences of the patients. There are many women who prefer an ob/gyn who will not perform abortions, because they believe it is wrong and they think a doctor who shares that belief will care for them and their unborn children with greater respect for the child’s life. They think a doctor who believes that little mass of cells is a person will take more care than a doctor who believes that mass of cells is roughly equivalent to a cyst or wart until some amorphous magical moment when it becomes a person. I’m not saying that those patients are always or even usually correct in their thinking. But it’s a legitimate concern, and not uncommon.

As for your skin cancer example, it is not germane. Only a few issues carry the same concerns as abortion – euthanasia being another. It is a moral question of life. And it is a moral question about ending a life. Women’s bodies have been a political and cultural battleground for millenia. I agree that we must be careful not to make laws that give some preferential treatment to men over women. However, abortion laws don’t give preferential treatment to men. They apply only to women *because it’s physically impossible to apply them to men*, not because men are getting some edge on women. To oppose abortion on moral grounds is not sexist. To claim that I or anyone opposes abortion because we’re sexist is bigoted on your part. Are you an anti-religion bigot?
#28 Calli Arcale
February 2, 2009

Can someone tell me what condition requieres the delivery of a dead baby for the well being of the mother?

I know of a woman who got eclampsia in the first trimester. Extremely rare, but it happens. Only cure is ending the pregnancy, whether through abortion, miscarriage, or early delivery. No first trimester baby is gonna live. Any condition where the mother must deliver in order to live, which occurs before the child is viable, basically meets the criteria for your question, and yes, those do happen. Car accidents where the placenta separates, leading to massive bleeding. Diagnosis of a disease where the treatment will kill the baby; there’s really no point maintaining the pregnancy then. Ectopic pregnancies. Certain chronic diseases are incompatible with a successful pregnancy. High-risk pregnancies which start to go south for one reason or another. Getting into gray areas, there’s the question of which is more ethical — an abortion or a high risk pregnancy. A healthy woman has little to fear from a normal pregnancy, besides parenthood (and of course adoption is an option for that problem). But an unhealthy woman may have a great deal to fear, and if it increases her death risk, is it fair to ask her to shoulder the risk? How much risk is she obliged to accept? One must also consider what sort of life the child will have; imagine, for instance, a woman in a high-risk pregnancy discovering on ultrasound that the child is severely deformed and will have a low quality of life. Is it worth risking her own life to bring that child into the world? That’s not a simple question to answer, and is probably going to depend on the specific situation.

That’s why I disagree with the usual pro-life stance, and with “conscience clauses”. In medicine, things are seldom simple enough to just make a blanket pronouncement to cover all cases. “Abortion is never acceptable,” for instance. A responsible medical professional needs to be guided by ethics and the unique details of the situation.
#29 David Manly
September 10, 2009

You don’t like religious people. Period. That’s your choice but it doesn’t justify being irrational. Before Roe vs. Wade in 1973, there was no conscience clause. Why? Because American medics had a basic agreement about what was ethically permissible and what wasn’t. That consensus has gone, haven’t you noticed? That’s why we have the Church amendment in 1973.
Secondly, is there any medical procedure that you think a doc should refuse to perform? Female circumcision, for instance? Non-therapeutic mutilation?