In perusing the onslaught of daily emails, one stood out to me as particularly disturbing.
From the New England Journal of Medicine online material was a “perspective” dated July 31, 2019, entitled “Toppling the Ethical Balance — Healthcare Refusal and the Trump Administration.” It was by Elizabeth Sepper, J.D., from the University of Texas at Austin School of Law.
It refers to a new “rule” published in May 2019 by the Department of Health and Human Services entitled “Protecting Statutory Conscience Rights in Health Care.”
Supposed to take effect July 22, implementation has been delayed until Nov. 22 because of the very real ethical controversy it produces for any and all health care providers.
Sepper points out that the rule goes far beyond enforcing current statutes.
“For nearly 50 years, U.S. federal law has permitted professionals and religious institutions to refuse, for religious or moral reasons, to provide abortions and sterilizations,” she said. “More recently, similar safeguards have been developed for medical professionals who do not wish to comply with patients’ advanced directives or deliver physician aid in dying.” Hospitals and clinics receiving federal funding cannot force them to provide such care.
But she said health care providers “still bear legal and ethical duties to patients. They must provide information about treatment options. They may not abandon a patient without reasonable notice while the patient needs continuing medical attention. Providers also generally must comply with laws that prohibit discrimination on the basis of sex, sexual orientation, religion or gender identity. In emergency situations, physicians and emergency departments must deliver even contested care.” The ethical guidelines of both the American Medical Association and American College of Gynecology and Obstetrics reflect this compromise between conscience and care.
The proposed rule “creates a wide-ranging right to refuse to provide health care services.”
Any entity getting money from the HHS is barred from requiring anyone to ‘assist in the performance of any health-care service or activity’ that is contrary to that person’s religious beliefs or moral conditions.”
Refusals beyond abortions can include ectopic pregnancies, cancer care that produces infertility and denying care based on sexual orientation or gender of patients.
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The author writes that the majority of physicians in a nationwide survey accept the ethical compromise of agreeing to refer and counsel patients.
“The new rule, by contrast, invites the substantial minority who would prefer to withhold counseling and referral to do so, as well as enter fields where they cannot meet the standard of care,” she said.
It could mean so many services not delivered, such as a pediatrician who won’t administer vaccines or a nurse in an ICU who won’t follow advanced directive care. Patients with emergencies would be especially vulnerable to the rigidity of this “rule.” If allowed to go into effect, “patient welfare, public health and trust in the medical profession hang in the balance.”
“As the county executive of Santa Clara, California, which is challenging the rule, explained, ‘If the rule goes through as it’s written, patients will die.’”
An internist with whom I worked said, “You can’t impose your personal beliefs on a patient.” If you are the doctor or other provider, you have assumed a centuries-old philosophy of taking care of a person until it is no longer possible or your expertise is exhausted. At that point, you find other help for the person. That is what I have believed, practiced and taught to residents my entire professional life.
I have a few personal stories about patients who were doozies and supreme challenges to care for, but you just do it.
All docs with experience have those. The approach allowed by the new “rule” forsakes patients perhaps in their worst hour and circumstances.
If your personal beliefs are strong enough, you need to find a job that accommodates them and it might be best not to choose medical care.
That’s my perspective.