Conscientious Objections, Professional Limitations, and Hard Realities for Hospitals
Laura Guidry-Grimes

Editor’s Note: This blog entry is part of our miniseries on conscientious objection including the Editor’s introduction and blog entries by Ruth Groenhout and Karey Harwood on this subject.

The newly formed Conscience and Religious Freedom Division of the Office for Civil Rights in HHS raises a host of questions that should be considered from multiple angles. I want to address this issue as a clinical ethics consultant who has been involved in conscientious objection (CO) policy discussions at multiple hospitals in different locations in the U.S. I have also served on Healthcare Equality Index initiatives and trained hundreds of staff on ethical care for LGBTQ+ patients. Because my experiences are in acute care hospitals, I will not comment directly on the ethically urgent issues that arise in other contexts, such as EMS and fertility clinics.

It is worth noting some important ambiguities and unknowns related to this Division’s role and powers. Based on the Division’s website and their recent press release, the Division will evidently force hospitals to give protections to healthcare professionals (HCPs) who claim CO, which could mean that HCPs cannot be fired for refusing to provide care to certain patients on the basis of conscience or religious conviction. It is unclear how much flexibility hospitals will have in training staff and promising protections for patients. For example, the Division welcomes complaints from HCPs who “feel pressured by employers to ‘perform, accommodate or assist with’ procedures that violate their beliefs.” Depending on what is meant by “pressuring,” hospitals could be tightly restricted in how they train staff on LGBTQ+ patient care, legal abortion care, or potentially other areas of cultural competence. Additionally, hospitals might not be permitted to ask staff to make reasonable referrals inside or outside the institution when they invoke CO, or even train staff on how to make such referrals, since doing so would presumably pressure them to accommodate patient requests.

A hospital should be a safe space for anyone to receive care, period. A hospital should actively take steps to ensure that they are not rendering patients vulnerable or compounding their vulnerability. Continue reading

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On the common good and medical conscience claims
Karey Harwood

Editor’s Note: This blog by Associate Professor of Religion Karey Harwood is the second in our miniseries reflecting on the Trump administrations’s support for expanded conscientious objection in medicine. For background readings, see the Editor’s introduction to the series. For another view, see philosopher Ruth Groenhout’s contribution to the miniseries.

The Trump administration’s new Division of Conscience and Religious Freedom in the Department of Health and Human Services aims to protect the rights of health care workers who refuse to do part or all of their jobs based on an alleged conscientious objection.  Such an objection could include anything from a pharmacist who refuses to fill a legal prescription for birth control based on his religious beliefs about artificial contraception to an ambulance driver who refuses to drive a transgender person to the hospital based on… Is anyone prepared to argue seriously that an ambulance driver’s distaste for transgender persons rises to the level of a “conscientious objection”?   Such individual acts of contrarian self-expression, whether they are based on church teachings or mere prejudice, are a breach of the social contract and do not deserve protection.

The Hastings Center puts the matter simply: “Conscientious objection in health care cannot be framed solely as an issue of individual rights or beliefs because it always affects someone else’s health or access to care.”

But in addition to disregarding the real harm conscientious objectors may do to others, framing conscientious objection in terms of individual rights and beliefs obscures the bigger picture: what is owed to the common good.

We see a valley and a river  through a small village at the base of a large dam, holding back the river. It has cracks in it. On the damn is written "THE COMMON GOOD."

Art by Frits Ahlefeldt

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The conflict in conscientious objection isn’t what we think it is: how religiously-based objections to providing medical care might undermine Christian faith
Ruth Groenhout

Editor’s Note: This is the first entry in our short series of blogs reflecting on the medical conscience policy of the current US President and his Administration. See the Editor’s introduction to this miniseries for more background on both this issue and bioethical considerations of conscience claims.

The Trump administration has just announced that it will form a new division within the Department of Health and Human Services, called the ‘Conscience and Religious Freedom Division”. The new department will be charged with reviewing complaints by medical professionals about institutional failure to protect their freedom to refuse to perform procedures that violate the professional’s conscience.

The formation of the new department does not change the law. Physicians have had the right to choose who they will accept as patients since the 1952 decision in Findlay, and courts have recognized the right of all medical professionals, from physicians to nurses to pharmacists, to refuse to participate in procedures they find morally unacceptable as well. This right is limited—emergency treatment cannot be refused on the basis of conscience, and if a care giver is the only professional available (as when a pharmacist in a rural area has no substitute) and providing treatment is within the normal professional expectations of the job (imagine our pharmacist being asked to dispense birth control), then the professional cannot make it impossible for the client to access the requested treatment, and may be required to dispense it in spite of personal beliefs. But there is already extensive legal protection for conscientious refusal in medicine.

Nor does there seem to be a desperate need for an entire new department to handle cases of this sort—the Washington Post reports that during the entirety of the Obama administration, only ten cases were filed, though there have been 34 already in the first year of Trump’s administration. These numbers hardly seem large enough to justify the formation of an entire new department; forming the department, instead, is seen by many as a gift to religious conservatives, particularly the white Evangelical voters who provide solid support for the Trump administration.

Critics of the new department note that without a corresponding emphasis on the right of patients to equal access to care as well as access to needed treatment under emergency conditions, the emphasis on the right of religious believers to refuse treatment poses a real danger. In a 2011 case, for example, nurses in New Jersey filed a case arguing that they had the right to refuse pre- and post-operative treatment for women undergoing abortions, even when the women required emergency care. Religious conservatives have also claimed a right to refuse care to lesbian couples, transgender individuals, and others who offend their sense of morality. Because there are often limited providers in any particular geographical region, and because it is the provider themselves who decides what offends their conscience in any given case, patients seeking medical care can face serious harms to their health and to their dignity by caregivers who invoke conscience clauses.

This image shows a a book lying on a flat surface. It's spine and cover bear the words "Holy Bible." The black leather cover is worn. On top of the book is a coiled stethoscope of the sort health care providers use to listen to patients' heart and lungs.

All of this raises a rather important question: ought Christians to see conscientious refusals of this sort as central to their faith and moral life? (This is a question for other religious believers as well, of course, but because the current controversy is almost exclusively focused on American evangelicals, and because I know the theological arguments in the Christian case, but am not well versed in other religions, I will focus on the Christian issue.) And although it seems to go without question in many conservative circles that of course Christians should loudly and publicly defend their right to refuse treatment to individuals of whom they disapprove, the issue is quite a bit more complicated.

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IJFAB Blog series: Responses to the Trump Administration’s policies on medical conscience claims
Editor

As you may have heard, the Trump Administration has announced an expanded policy on conscientious objection in medicine, with institutional support in the form of a Department of Health and Human Services office that will be responsible for protecting objectors. It will be called the Division of Conscience and Religious Freedom.

There are many possible responses to this, ethically speaking. Over the coming week, IJFAB Blog will be running several responses. While these will focus on the US context, this issue is by no means limited to the US. Women in Italy, for instance, have a remarkably difficult time accessing abortion even when it is allowed because providers have such a high rate of refusal, rising from 59% in 2005 to 70% in 2016.

Regardless of where you live or practice medicine or do bioethics, I encourage you to check in regularly to see the array of considerations.

Before we get started, some of you might want to learn a bit more about the current situation and about medical conscience claims AKA conscientious objection.

Here are some links if you want to learn more about the current situation:
And here are just a few links/cites to prior IJFAB, IJFAB Blog, and some useful bioethics work on conscientious objection. Many of these strive to balance respect for conscience claims against the interests or rights of patients. There is so much more out there. But these are a decent place to start.
In addition, Carolyn McLeod has a forthcoming book from Oxford University Press called The Power of Conscientious Objectors that you might want to seek out in the future.
I am excited about the posts we will have in this series. Stay tuned.
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Everything Old Is New Again: Patient Dumping in the United States
Editor

 

A recent, though smaller than deserved, furor erupted in the US over a video of a non-white female patient being dropped off via wheelchair at a bus stop by hospital personnel during freezing temperatures wearing only a hospital gown (you can read more here and here). It was recorded by a mental health professional whose office in Baltimore, Maryland, was across the street and was stunned to see the disoriented woman left alone to fend for herself.

This is part of an old practice known as “patient dumping.” This term dates back at least to a New York Times article from the 1870’s (yes, 1870’s, not 1970’s) which described a practice of hospitals transporting patients by horse-drawn ambulance to Bellevue Hospital, the city’s primary public hospital at the time. These were patients who could not pay for private hospitals or were unprofitably sick (for more on this practice, see Emily Abel’s 2010 article covering patient dumping in New York City from 1877-1917). Such practices have long been a problem in Los Angeles, for a complex array of reasons, and have been documented in other states including Alabama and Nevada.

Do other nations also experience patient dumping? What factors contribute to patient dumping?  Is patient dumping ever ethically acceptable? If not, how does the system need to change to make it easy to provide care? What can you contribute to the discussion?

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Keisha Ray makes an important analysis of black women’s maternal health disparities in the US
Editor

This image accompanied Keisha Ray’s original blog entry at bioethics.net

Over at bioethics.net, bioethicist Keisha Ray addresses the maternal health disparities experienced by black women, in particular. In her blog, “BLACK WOMEN ARE DYING IN DISPROPORTIONATE NUMBERS DURING AND AFTER GIVING BIRTH AND NOT EVEN CELEBRITY SERENA WILLIAMS IS SAFE” Ray gives an overview of a few other health disparities black folks experience in the US including sleeplessness and pain management, and then moves on to maternal health. Ray says,

In my research on racial disparities in health care I have found a troubling trend among bioethicists and that is a reliance on a connection between poverty and lack of education that black people experience to explain their poor health and racial disparities in health care. As the typical argument goes, black people tend to be poorer and have less education than white people and since wealth and level of education are some of the social determinants of health, it is expected that they would experience adverse health issues such as high death rates during pregnancy and child birth.

This attempt to explain poor black health by focusing on social factors is problematic for many reasons, including it misleadingly contributes to the narrative that all black people are poor and it ignores an increase in black wealth. But more importantly this argument ­relies on assumptions that are not backed by data. For instance, according to a 2016 study that analyzed 5 years worth of data on pregnant women in New York, “college-educated black mothers who gave birth in local hospitals were more likely to suffer complications of pregnancy or childbirth than their white counterparts who never graduated from high school.” This study disproves the traditional narrative in bioethics that education can be equated to better health and better health care. This may be true from some people, but as a general rule it is not true for black people, specifically black women giving birth. Just as more education does not always equal better health and better health care from practitioners for black women giving birth, neither does income. 

Ray goes on to note the widely publicized story of how tennis star Serena Williams, herself, had to be her own health advocate in the face of serious maternal health issues and nearly did not receive the treatment she needed.  As Ray says, “If Williams had a hard time convincing her doctors that she knew her body and knew something was wrong, we can image just how hard it would be for another black woman who does not have the accolades or wealth of Williams to convince a suspicious nurse or doctor.”  But we don’t have to imagine, for Ray goes on to detail several examples. I recommend you click through to the blog article for more.

What narratives drive our ethical reflections on health disparities? When is the narrative of poverty and lack of access to health  care the whole story, and when is it only part of the story? How do narratives shape our responses to ethical issues and, perhaps, lead us astray?

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What does it mean that caring for the environment is seen as unmasculine?
Editor

As we know, the state of our environment has significant health effects and disruptions to climate are especially likely to harm the most vulnerable among us. This would seem to make it important for people to get behind conservation efforts. It’s worthwhile to look at why this kind of thinking doesn’t have the appeal it might seem that it ought to have.

Scientific American recently gave Aaron Brough and James Wilke a space to discuss their research on masculinity and “green” behaviors.

…men may shun eco-friendly behavior because of what it conveys about their masculinity. It’s not that men don’t care about the environment. But they also tend to want to feel macho, and they worry that eco-friendly behaviors might brand them as feminine.

The research, conducted with three other colleagues, consisted of seven experiments involving more than 2,000 American and Chinese participants. We showed that there is a psychological link between eco-friendliness and perceptions of femininity. Due to this “green-feminine stereotype,” both men and women judged eco-friendly products, behaviors, and consumers as more feminine than their non-green counterparts.  In one experiment, participants of both sexes described an individual who brought a reusable canvas bag to the grocery store as more feminine than someone who used a plastic bag—regardless of whether the shopper was a male or female.  In another experiment, participants perceived themselves to be more feminine after recalling a time when they did something good versus bad for the environment.

How much of this is due to marketing and advertising, which sell gas guzzling supercharged vehicles to men as avatars of their masculinity as in this Dodge Charger ad–“Man’s Last Stand”– which aired during the super bowl some years ago?

And how much of it is due to the way that modern hegemonic masculinity is structured: individualistic, not giving into peer pressure, not “PC” (politically correct), aggressive, uncompromising, commanding and, well, dominant? After all, it is humanity’s unrelenting dominance over nature that is questioned by green thinking.

Perhaps we need an alternative conception, one which appeals to the provider/caretaker aspects of modern masculinity, in which we are stewards of the environment. Could this work? What conceptions of masculinity would be consonant with environmental conservation? Is hegemonic masculinity necessarily against environmental preservation? What do you think?

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New Year’s Resolutions
Alison Reiheld

My New Year’s Resolutions about obligations to self and others in no particular order, and about balancing work and life and activism as a woman, a mother, and a feminist bioethicist.

1) Move in ways that feel good, as much as feels good
2) Be grateful for clean water, and take advantage of it
3) My feminism will be intersectional or it will be bullshit
4) Enjoy my children while they enjoy me; especially, more cuddles
5) Wake up ready to fight fascism
6) Take more risks in my bioethics and philosophy work now that I have tenure (that’s what it’s for, n’est-ce pas?)
7) Notice and explicitly appreciate my Mom’s awesomeness more often
8) Use my privilege to good effect
9) Go on more dates with my spouse

For more on numbers 3 and 5, see Flavia Dzodan’s famous essay and Woody Guthrie’s new year’s resolutions, respectively.

What are your resolutions? Pitch in with a comment!

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New assisted reproduction regulations require feminist voices

Editor’s Note: Today we have a special co-authored blog entry by four feminist reproductive justice advocates working on what is known in bioethics as ARTs (Assisted Reproductive Technologies) and other related tech. 

Francine Coeytaux, MPH    Co-Director, Pro-Choice Alliance for Responsible Research

  Marcy Darnovsky, PhD    Executive Director, Center for Genetics and Society

    Susan Berke Fogel, JD    Co-Director, Pro-Choice Alliance for Responsible Research

       Emily Galpern, MPH    Consultant, Center for Genetics and Society

For more than a decade, Canadian regulation has explicitly countered commercialization of reproduction, prohibiting payment for surrogacy, sperm, or eggs as part of the Assisted Human Reproduction (AHR) Act of 2004. These policies are grounded in the view that preventing a market trading in reproduction as “goods and services” is fundamental to safeguarding the health, safety, and rights of gamete donors and surrogates.

This screen cap from the Center for Genetics and Society shows the beginning of a brief Introduction to the law. Click on the image for higher resolution.

Currently, Health Canada is in the process of developing additional regulations that were required but never created under the AHR Act. The department has published a consultation document to solicit input to the process. A number of Canadian women’s health scholars and advocates have submitted responses based on decades of involvement with assisted reproduction policy, women’s health research, and bioethics deliberations.

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IJFAB’s Pronoun Policy: Singular ‘they’ or gender-neutral forms such as ‘ze’ or ‘zir’… just be consistent within your paper
Jackie Leach Scully

Editor’s Note: In the past year, IJFAB Blog has featured several blog entries on shifting pronoun usage not only in the English language but in the International Journal of Feminist Approaches to Bioethics itself.  IJFAB Editor Jackie Leach Scully brings us this reflection on IJFAB’s revised pronoun policy. Several authors have battled with IJFAB copy editors over pronoun usage in their articles. This policy should put an end to such conflict and provide a shared reference for authors, editors, and copy editors.

From Volume 12, issue 1 onwards the style guide of IJFAB includes the following section:

Since “he” or “she” is no longer adequate to describe the genders of all individuals, IJFAB supports the use of the singular “they” as long as the usage is consistent throughout the article or review. Other options including recasting the sentence to obviate the need for pronouns, dropping pronouns or replacing them with nouns, using plural nouns and plural pronouns, or using gender-neutral forms such as “ze” or “zir.”

This addition to the style guide was agreed upon by the Editorial Team in June 2016, in response to current shifts in language use that, in turn, reflect changes in the way some people wish to identify themselves and live out their lives.

All language use changes over time, as a result of complex social and political developments. Sometimes, these shifts just seem to happen for reasons of fashion or economy of effort (here in England, at some point back in the mid-twentieth century we got tired of saying “motor car” and started using the more succinct “car” instead). Other developments, however, come about through conscious decisions and involve a lot of deliberate, strategic work. For example, those of us concerned about gender equality, and who believe that language profoundly affects cognitive frameworks – that it’s not just about words conveying information – have struggled to gain acceptance for the use of “Ms” alongside “Miss” and “Mrs.” We’ve also highlighted the problematic claim that the pronoun “he” can be understood to include both genders without also importing assumptions about the types of human we consider normative.

Many people today are challenging conventional gender binaries, and some are actively trying to live outside them.

This screenshot from the University of Wisconsin – Milwaukee LGBT Resource Center shows some of the reasons people want to move beyond the use of “he” and “she” as singular pronouns in the English language

The Editorial Team of IJFAB (and much of the readership, as we know from feedback) wants to acknowledge and explicitly endorse the moral position staked out by doing so. In practice, this has been IJFAB’s position for some time, but we decided last year to include an explicit statement in our style guide – because we wanted to make it clear that we support the social and ethical work being done by those involved in this endeavor. We’re making this announcement here because recent exchanges on social media show some people still assume that IJFAB’s policy is to refuse submissions with a more inclusive pronoun usage. This isn’t the case.

From the point of view of this journal, the important thing is that authors reflect on pronoun use and make their own choices. You’re free to use whatever form(s) you want, as long as it doesn’t obscure or confuse your meaning, and as long as it’s not discriminatory or offensive. Whatever and however you write, IJFAB welcomes your submissions!

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Who Should Be Responsible for Environment, Health, and Politics: Detroit and 1,300 other “hotspots” have higher lead poisoning rates than Flint and someone needs to do something
Alison Reiheld

The long-time reader of IJFAB Blog, and alert bioethicist who follows the news, will remember the Flint water crisis.  As numerous investigative news articles–and even at least one news comedy show–have pointed out, Flint is by no means alone in the US in having water that is not actually safe to drink. But water isn’t the only source of lead poisoning.  According to a Reuters review of news and research, nearly 4,000 communities in the U.S. have lead poisoning rates in children that exceed acceptable levels. 1,300 have blood levels that are at least four times the rate in Flint at the height of the crisis. Baltimore, Maryland and Cleveland, Ohio and Buffalo, New York and Philadelphia, Pennsylvania are among them.

Lead Levels in the US. The darker the shade, the higher the percentage of children affected by lead poisoning.

So is the city of Detroit which, like Flint, is one of Michigan’s major population  centers. According to The Detroit News, a study done by the Detroit Health Department in 2016 found a correlation between lead poisoning and housing demolitions in the city; 93% of homes were built before 1978 and the risk was highest for kids who lived within 200 feet of demolitions that occurred between May and September when kids are liable to be playing outside. It is this old housing stock that public health experts primarily blame for lead poisoning in Detroit. Old housing stock not only has lead-based paint still in the walls, but also often lead service lines connecting them to the city’s main lines. Replacing these, much like demolishing houses in a way that would contain dust and debris, is costly.

We often see the headlines about specific cities. But just as we can miss  the forest by focusing on the trees, focusing on individual cities can cause us to miss the big patterns. America’s public health problems are based in a number of factors. Pediatric lead exposure in particular has many possible causes, from communal resources and whether they are sufficient to replace aging infrastructure to whether politicians care about all stakeholders equally when distributing resources to where people live and whether they can afford to move.  It thus bridges concerns about health disparities and health care justice, political justice, and environmental justice.

Individual communities might be able to resolve some of these problems, but this is a systemic problem that a far-reaching agent of justice may be needed to resolve. Indeed, it may be that only a far-reaching agent of justice can intervene successfully to require local communities to do what is right and to give them the resources needed to do so. And as Onora O’Neill has argued, the capability of an agent of justice to remedy injustice gives rise to obligations to do so. How much moreso when there are very few agents that have such a capability?

It’s time for the federal government to do more about infrastructure, more about environmental contaminants which impact some people more than others based on where they live, more about the public health issue of childhood exposure to lead. The feds have acted before: legal requirements for unleaded gasoline made enormous nationwide improvements in pediatric exposure to lead.

What can be done now? What should be done? The answer cannot be “nothing” or “the same thing that’s been happening.” Neither of those will, or has, worked. By whom? That one, at least, is clear: those who can, whether they be local, state, or federal agencies.

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Disparities in Maternal Mortality: Some American women have a higher risk of the highest cost of being pregnant
Editor

Maternal mortality is a basic public health measure. It is also one of the many health outcomes on which the United States ranks much lower than other comparably developed nations. As per Ann Simmons’ superb article on the subject of maternal mortality in the US and specifically in the state of Texas:

A woman in the U.S., where the maternal death rate more than doubled between 1987 and 2013, is more likely to die from pregnancy-related causes than in any country but Mexico among the 31 industrialized countries of the Organization for Economic Cooperation and Development that reported data.

As Simmons goes on to note, the state of Texas, of all of the US’s 50 states, has one of the worst maternal mortality rates. But most distressingly, Texas’s statistics–like the entire nation’s–show health disparities on this measure. Some Americans have substantially worse maternal mortality rates than other Americans. Those Americans are African-American women.

The maternal death rate in Texas after 2010 reached “levels not seen in other U.S. states,” according to a report compiled for the American College of Obstetricians and Gynecologists, based on figures from the U.S. Centers for Disease Control and Prevention.

Black women in Texas are dying at the highest rates of all. A 2016 joint report by the Texas Department of State Health Services’ Maternal Mortality and Morbidity Task Force found that black mothers accounted for 11.4% of Texas births in 2011 and 2012, but 28.8% of pregnancy-related deaths.

Simmons goes on to adeptly break down the results of several investigations into health disparities in maternal mortality. I strongly recommend the article to anyone following global public health, maternal mortality, pregnancy and childbirth, and health disparities.

 

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