Obama moves to overturn Conscience rules

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

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

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

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

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

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

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

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

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

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

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

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

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.

Washington Post Addresses Our "Birth Control Fears"

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

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

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

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

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

At issue is the American College of Obstetricians and Gynecologists' Ethics Statement "Opinion #385, Limits of Conscientious Refusal in Reproductive Medicine," which states that

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

It goes on to declare abortion “standard reproductive care” and demands that doctors who “deviate from standard practices” (object to abortion) “practice in proximity to individuals who do not share their views or ensure that referral processes are in place” (with a willing abortionist).

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

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

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

. . . and . . .

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

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

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

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

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

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

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

Wesley Smith on Toronto Conference on End of Life

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

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

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

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

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

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

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

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

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

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

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

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

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

Emotional Debate on "Physician Assisted Suicide"

On Tuesday night, November 26th, I drove to Houston to hear Wesley J. Smith, debate Physician Assisted Suicide (PAS) with Kathryn Tucker, the Director of Legal Services for Compassion & Choices, which was once the old Hemlock Society and then Compassion in Dying. Mr. Smith is the author of The Culture of Death and Forced Exit: Euthanasia, Assisted Suicide, and the New Duty to Die. The only biographical data I can find on Ms.Tucker is this pdf.

The Holocaust Museum Houston has teamed up with the University of Texas Health Science Center at Houston to present the Dr. Michael E. DeBakey Medical Ethics Lecture Series, called ""Medical Ethics and the Holocaust: How Healing Becomes Killing--Eugenics, Euthanasia and Extermination."

From the first, opening night, presentation featuring the-soon-to-be-unpopular James Watson and two other Nobel Laureates, it seems that we are being exposed to an ethics lab, rather than a history and theoretical series. The speakers the first night, including a doctor, Eric Kandel, M.D., 2000 Nobel Laureate, Medicine or Physiology, who was a child in Vienna on Krystallnacht before his family escaped to the US, told us not to worry about research on human embryos as long as the parents give "informed consent." Ironically, after descriptions of the build up to the Holocaust, Dr. Kandel reassured us that that we would gradually get accustomed to embryonic stem cell research.

I could tell that Mr. Smith and Ms. Tucker were irritated with each other during the program. In her introduction, Ms. Tucker referred to an earlier debate that had taken place that day when, as Wesley later told us, "it got angry." I got the idea that the moderator, Dr.Sheldon Rubenfeld, was slightly testy, although he did a good job moderating the questions, as always.

Ms. Tucker' s history of redefining, renaming, and litigating did not reassure me.

She was the lawyer in the case of a family suing a doctor for failing to give their loved one enough medicine to control pain at the end of his life and has fought laws against PAS for 10 years. Ms. Tucker misrepresented "terminal sedation," as though it is always intended to lead to death, rather than "deliberately inducing and maintaining deep sleep but not deliberately causing death in very specific circumstances." It was a surprise to hear Ms. Tucker warn against "back alley deaths" although it turns out that it wasn't the first time I'd heard the term. She frequently used the word, "choice," comparing the patient's choice at the end of life with a woman's right to "Reproductive Choice."

The silliest part of the evening - we were discussing death, after all - was when Ms. Tucker chided Mr. Smith for using the wrong terminology, "Physician Assisted Suicide." She showed us the recently revised policy statements of the American Medical Women's Association and the American Public Health Association. Because these two second tier (that's a word I learned from John Gearhart while attending the ASBH conference this year) organizations revised their own terminology to avoid the "emotionally charged" nature of certain words within the last year, Ms. Tucker shamed Mr. Smith for using the American Medical Association's terminology and legal term instead of calling the act "Aid in Dying."

Mr. Smith pointed more clearly to the problem of emotions when he remarked that it is often acknowledged in these debates that "existential pain," or the emotional component of pain, may be worse than physical pain.

No matter what we call it, death is always going to be an emotionally charged subject and is rarely dignified or controlled. For one thing, the body loses control of the bowels and bladder at death, as well as everything else. The questions from the audience were examples of people who approach the subject of end of life care from a strictly emotional viewpoint, rather than thinking it through to its logical consequences. The emotion is getting stronger as technology introduces more and more variables.

However, when we are discussing Medicine and the death of the body as well as of the mind and spirit, we should confine our conversations to the physical consequences. To be trite: When you're dead, you're dead.

There is no legal question as to whether "Assisting" or "Aiding" death is different from withdrawing care. We don't pinch the patient's nose or remove the oxygen from the room when we withhold or withdraw a ventilator. Physician Assisted Death, in contrast, is an irrevocable interventional act against the living processes of the body using State regulated medical knowledge and medicines, and should be treated as the violation of medical ethics that it is. The history of Western medicine, at least between Hippocrates and Roe, has always condemned intentional use of medicine to positively end the life of the body.

Mr. Smith and I have had several discussions about the ethics at the end of life, especially the Texas Advance Directive Act, which he refers to as the "Futile Care Act." We agree that doctors should never intend to cause death but that they may withhold or withdraw intervention at the request of the patient. We disagree, though, about whether a doctor may refuse to intervene because our best medical judgment is that the intervention will cause increasing damage to the body and prolong death.

I found myself, a Family Physician who cares for people at all stages of life, theoretically squeezed between two legal pressures, one law to force me to act with the purpose of killing a patient and another that would force me to act even though my medical judgment is that the intervention caused harm. Several people from the audience also advocated for legal consequences for doctors who failed to follow patients' end of life wishes by prolonging their lives.

To be honest, if I had to "choose" between the two, I would choose against Ms. Tucker's extreme, which would leave me with Mr. Smith's. I could live with that.

However, I hope that society will teach doctors to never take life while expecting the profession to assist one another in determining when medical intervention causes more bodily harm than healing, when a patient's bodily processes are breaking down faster than we can heal or maintain them.

(Edited 11/20/07 for grammar and order - BBN)

Wesley Smith reviews Physician Assisted "Suicide"

Bioethics.com, the blog of the Center for Bioethics and Human Dignity published Wesley Smith's excellent review of a British report on so-called "Physician Assisted Suicide."

PAS is not medicine in any sense of the word. Medicine, at the very least involves the intention of bringing health to the body and relief from unpleasant symptoms. It can never mean killing. We don't end suffering by ending the patient.

It's worth your time to read the excerpts.

"Back Alley Death" ("Physician Assisted Suicide" )

Oregon and Vermont - extremes on the map and extremes on medical ethics. But this is the first time that I've heard that doctors should give patients a deadly prescription to prevent a "back alley" death.

How many of us really want our Family Doctor to be proficient in killing? Or, in over-riding his or her conscience?

The Vermont Legislature is once again considering legalized, intentional death by medication and physician prescription.

From the Burlington Free Press:

Is it suicide? That's at heart of Statehouse debate

Published: Thursday, March 1, 2007
By Terri Hallenbeck
Free Press Staff Writer

MONTPELIER -- Dr. Robert Orr read the Webster's Dictionary definition of suicide: "The act or an instance of taking one's own life voluntarily and intentionally especially by a person of years of discretion and of sound mind."

How, he asked, is that different from proposed legislation that the House Human Services Committee is considering that would allow a terminally ill patient to hasten dying with a lethal dose of medication?

We're trying to change the dictionary definition we've been working with for years," he said.

Dick Walters, an ardent supporter of the legislation, sees the two -- suicide and physician-assisted dying -- as entirely different things. "Suicide is a desperate act," he said. "It's done in a back alley, a barn. It destroys families.

"What we're talking about in H. 44 is something totally different," he said. "They're doing this under care, with loved ones around them. They're saying goodbye in a way supportive of their own values."

(emphasis mine)


HT to Bioethicsnews.com