Not My Moral Values

by hilzoy

From the Denver Post, via Bitch, Ph.D.:

"The protocol of six Catholic hospitals run by Centura calls for rape victims to undergo an ovulation test.

If they have not ovulated, said Centura corporate spokeswoman Dana Berry, doctors tell the victims about emergency contraception and write prescriptions for it if the patient asks.

If, however, the urine test suggests that a rape victim has ovulated, Berry continued, doctors at Centura's Catholic hospitals are not to mention emergency contraception. That means the victim can end up pregnant by her rapist."

Or, in short: if a rape victim doesn't need emergency contraception, the hospitals' doctors will tell her about it; but if there's a significant chance that she might actually get pregnant as a result of her rape, and therefore does need it, they won't say a word.

I'm trying to figure out the thinking behind this. I realize that Catholics are opposed to contraception. But that doesn't necessarily mean that they must be opposed to mentioning contraception to a woman who might want it, especially when that woman has just been raped, and may not herself be Catholic. Apparently the people who write policy for these hospitals are not opposed to mentioning emergency contraception in general -- remember, it's part of the protocol to mention it to women who have not ovulated, and even to prescribe it if asked. It's only when the woman stands a significant chance of getting pregnant as a result of rape that their "consciences" kick in.

Moreover, quick access to emergency contraception can make the difference between using Plan B, which prevents conception, and either using RU486, which produces an abortion, or getting a surgical abortion. Plan B is most effective if taken within 72 hours of intercourse. If a rape victim is told about Plan B when she's being treated, then even if the hospital won't prescribe it, she stands some chance of being able to find a doctor who will before that window slams shut. If she is not told, however, she may not learn that it's possible to prevent conception until it's too late to do anything besides have the child or abort it. This is a choice that no woman should be forced to make when there is an alternative; and anyone who wants to minimize the number of abortions should think that enabling women to prevent conception after rape, rather than having to choose between abortion and carrying the child to term, is a very good idea.

The governor of Colorado has recently vetoed a bill that would have required all hospitals to inform rape victims about emergency contraception. The law would have provided a 'conscience clause' for doctors, but not for hospitals. According to Gov. Owens, that's wrong:

"It is one of the central tenets of a free society that individuals and institutions should not be coerced by government to engage in activities that violate their moral or religious beliefs," Owens wrote in his veto message. It is only his second veto of the year.

"While this bill did offer health-care professionals the right to decline to offer emergency contraception due to religious or moral beliefs, it did not offer those same protections to health-care institutions. This is wrong. And it is unconstitutional."

Wrong, Governor. To paraphrase the NRA, hospitals do not have beliefs; people do. If you protect the religious convictions of each and every person in a hospital, you have protected all the religious beliefs in that hospital, since the hospital itself does not have any religious beliefs. I am not a lawyer, but I would have thought that the reason that, say, a private religious club cannot be forced to do things that violate its members' religious beliefs, absent some compelling state interest, is not that it -- the organization -- has a first amendment right to the free exercise of religion, but rather that its members do, and that if it is a purely private organization, it is not subject to many of the laws that might otherwise constrain it (e.g., anti-discrimination statutes.)

In this case, however, both of those arguments fail. On the one hand, the consciences of individual medical professionals are protected under the statute in question. On the other, hospitals are not purely private organizations. They accept federal and state funds. They provide a public service, and do so under a variety of regulations and licensing requirements. I do not think it is too much to ask that they inform their patients, who may or may not be Catholic, about health care options those patients might want to pursue, especially in a case like this, where that option does not concern something frivolous, like removing some stray unwanted hair or mole, but whether or not to bear a child conceived in rape. Respecting individuals' religious beliefs and consciences requires giving them the information they need to make an informed decision about what to do with their bodies and their lives. In the case of women who oppose abortion, not providing this information could mean depriving her of the only way in which she could avoid bearing a child conceived in rape without violating her own moral or religious beliefs. To deprive her of this option because of the supposed need to respect the nonexistent religious beliefs of institutions is no part of any morality I recognize.

Comments

[blah]

Personally, I think the government should, in general, just stop treating institutions as individual actors.

[Katherine]

Emergency contraception is still useful if you've not ovulated, because IIRC sperm can swim around for a good five days. Wouldn't swear to this.

There's okay arguments for Constitutional rights for organizations and institutions. The classsic example of this is newspapers--if you bankrupt the publishing company the reporter's right to speak is threatened. And you would want various political organizations to have, e.g., the right to send their literature through the U.S. mail without fear of penalty. When you get into commercial speech rather than political ones it's trickier; I think you can exact special demands for the extremely useful limited liability arrangement.

The thing is, a hospital is not a private club. It gets licensed and accredited by the government, and I would strongly suspect it receives government funds. I am totally, totally cool with requiring some basic standards of behavior for this, and to me informed consent of the patient is a pretty fundamental issue of medical ethics. Not to offer a procedure or drug is one thing; to hide knowledge of its existence in an emergency is quite another.

[Jesurgislac]

There was a long thread about this at Alas, A Blog, a few days ago. A couple of guys were arguing that it would indeed violate their beliefs were they compelled to tell a woman who had been raped that she could use emergency contraception: because they didn't approve of EC, their argument appeared to run, it was their right not to inform anyone that it existed: it was up to the rape victim to find that out for herself.

[Katherine]

Oh, and as far as the thinking behind it:

Catholic doctrine holds that life begins at fertilization. Anything that prevents the implantation of a fertilized egg is regarded as abortofacient. (this includes the birth control pill & the IUD--the IUD works by preventing implantation & it's the pill's 3rd line of defense.) If a woman has ovulated there's a good chance that fertilization has already occurred, and the morning after pill would work by preventing implantation. If not, it will suppress ovulation.

I'm actually not sure that ovaluation-supressants or spermicides as contraception is actually verboten in the situation of rape, because the whole theory is that contraception is wrong because instead of giving yourself fully to your spouse, you're holding part of yourself back, and that is EEVVVILL. But in the case of rape--you are holding something back from the rapist that he has absolutely no right to and that compounds his sin. I don't know though. Obviously, I'm not a very good authority on Catholic doctrine.

I'm pretty sure about the fertilization/implantation thing though.

[Tacitus]

I realize that Catholics are opposed to contraception. But that doesn't necessarily mean that they must be opposed to mentioning contraception to a woman who might want it....

If you are opposed to a thing, presumably you are opposed to facilitating or propagating that thing. Catholic opposition to contraception (or abortifacients, depending) does "necessarily mean" what you say.

While I agree that this specific policy is internally inconsistent, that point above is not part of the inconsistency.

[blah]

"There's okay arguments for Constitutional rights for organizations and institutions."

I understand the arguments and I don't have a problem per se with the idea. My previous statement is based more on my perceptions, which I will have to admit are reactionary and possibly irrational. Those perceptions stem from fact that, whenever I encounter arguments/discussions/etc. about institutions (corporations, churches, PACs, charities, political parites, marriage, government agencies, hell, even governments), I'm frequently left with the impression that those institutions are viewed as unique entities distinct from their members as opposed to say a collective of people organized around a common interest(s) or goal(s).

[Jesurgislac]

Tacitus: If you are opposed to a thing, presumably you are opposed to facilitating or propagating that thing. Catholic opposition to contraception (or abortifacients, depending) does "necessarily mean" what you say.

Then evidently, this is a point where the state has to step in and tell religionists that they are not permitted to use their faith as an excuse to provide a substandard service. A Catholic who thinks that they shouldn't have to provide a rape victim with full information about emergency contraception, may be a good Catholic, but is not doing the job that the state pays them to do. Fire them and hire someone who will do the job.

[Tacitus]

Since we don't have an NHS, Jesurgislac -- and thank God for that -- it's not ipso facto "the state" that's paying employees at Catholic hospitals. They may well, as noted, receive varying levels of state funding, which one assumes may carry various restrictions upon which that funding is contingent -- but I doubt exercise of physician's conscience is among them.

Finally, your definition of "substandard service" may not be others'. That is fine: so long as the differences are differences of reasonable individuals (for example, we may reasonably disagree on abortion; disagreement on handwashing is not reasonable), it is not grounds for complaint.

"Religionists." That's interesting.

[Thomas]

Ordinarily, I don't comment here for a host of reasons, largely (but certainly not exclusively) because anything I say would be regarded (possibly correctly) as mere trolling. But one presumes that you would be in favor of forcing Jewish hospitals to allow Catholic Priests in for extreme unction? Secular hospitals to keep a Catholic woman on feeding tubes for the rest of her natural life, because the removal of those tubes would be, to her, murder?

That with which you appear to take issue is the Free Exercise Clause. Catholics regard, as Katherine somewhat inelegantly noted, the termination of a human being at whatever stage of life as murder. Catholic hospitals, in a somewhat surprising turn of events, therefore do not act in such a way as to cause that murder.

[hilzoy]

When I wrote that I was having trouble understanding the thinking behind the hospitals' policies, what made it hard was not that they forbade doctors to mention emergency contraception. That is easy. It's that mentioning it is part of the protocol at some times but not at others.

And I think that as long as these hospitals use public funds (not the nonexistent NHS, but Medicare and Medicaid, for starters), they can be required to mention emergency contraception. An alternative, of course, would be to require EMTs and police officers to ask rape victims whether they want to be transported to a hospital that provides emergency contraception, and act on the answer.

[Catsy]

Then evidently, this is a point where the state has to step in and tell religionists that they are not permitted to use their faith as an excuse to provide a substandard service.

Let's assume for a moment that you're a structural engineer. You believe, arguendo, in some wacky religion that worships the natural processes of physics, and forbids you to stop them. (Yeah, I know it sounds uselessly general and silly. But most of the 2,000-year-old absurdities of Christianity sound just as useless and silly to me)

You knew what kinds of jobs you'd be doing when you started down this career path. And suddenly someone contracts you to evaluate the soundness of a bridge that just went through an earthquake. You find it has a 30% chance of collapsing. Because of your religious beliefs, you decide not to tell your client about a procedure that could prevent the bridge from collapsing, or even describe your findings. Instead, you tell them that the level of risk isn't that high, and refuse to refer them to someone who would give it to them straight. Because after all, you have Revealed Moral Truth on your side.

It sounds absurd, yes--but this is exactly what religionists are doing every single day when they refuse to educate children about safer sex and contraception, dispense professionally prescribed medications, or provide the best medical advise possible about pre- or post-conception contraceptive options.

We wouldn't accept this kind of criminal negligence from an engineer. Why do we accept it from hospitals and medical "professionals"?

[Katherine]

"I realize that Catholics are opposed to contraception. But that doesn't necessarily mean that they must be opposed to mentioning contraception to a woman who might want it"

This is the whole scandal thing, I think. From the handy dandy Vatican website:

Respect for the souls of others: scandal

Scandal is an attitude or behavior which leads another to do evil. The person who gives scandal becomes his neighbor's tempter. He damages virtue and integrity; he may even draw his brother into spiritual death. Scandal is a grave offense if by deed or omission another is deliberately led into a grave offense.

Scandal takes on a particular gravity by reason of the authority of those who cause it or the weakness of those who are scandalized. It prompted our Lord to utter this curse: "Whoever causes one of these little ones who believe in me to sin, it would be better for him to have a great millstone fastened round his neck and to be drowned in the depth of the sea." Scandal is grave when given by those who by nature or office are obliged to teach and educate others. Jesus reproaches the scribes and Pharisees on this account: he likens them to wolves in sheep's clothing.

Scandal can be provoked by laws or institutions, by fashion or opinion.

Therefore, they are guilty of scandal who establish laws or social structures leading to the decline of morals and the corruption of religious practice, or to "social conditions that, intentionally or not, make Christian conduct and obedience to the Commandments difficult and practically impossible." This is also true of business leaders who make rules encouraging fraud, teachers who provoke their children to anger, or manipulators of public opinion who turn it away from moral values.

Anyone who uses the power at his disposal in such a way that it leads others to do wrong becomes guilty of scandal and responsible for the evil that he has directly or indirectly encouraged. "Temptations to sin are sure to come; but woe to him by whom they come!"

Makes a certain amount of sense, but in practice it's a force-multiplier that completely destroys individual autonomy. Note that it's especially bad when the state does it, and keeping morally sanctioned behavior legal is considered a form of scandal.

This is why it's considered evil for Catholic politicians to support rights for gay people, I believe. In general, this is why the Church seethes about Democratic politicans. (The policies that Republicans violate are considered "prudential judgment" which to conservative bishops mean "do whatever you want". The Church tends to be pretty understanding of the complexity of moral decisions when they're made by wealthy, powerful men and states at the expense of individuals, and relatively cautious in its condemnations. When it conmes to the decisions of less powerful individuals though, and especially decisions about the reproductive system, They Are The Law and there's no room for disagreement and no difficult choices and it's for your own good.)

The idea that teaching homosexuality is evil could lead people into mortal sin, is not really considered.

Again, I'm probably screwing this up. I'm half-educated about this at best so take all this with several grain of salt.

p.s. As much as you should take my explanations of Catholic doctrine with a grain of salt in favor of explanations by real Catholics, you should also do so with Thomas' explanation of First Amendment law. Specifically, he's full of it on the free exercise clause. I've gotta go, but see "Neutral laws of general applicability," Employment Division v. Smith. By Justice Scalia no less.

[Tacitus]

It's that mentioning it is part of the protocol at some times but not at others.

Yes, that is inconsistent, and evidence of the policy's formulators trying to have it both ways.

And I think that as long as these hospitals use public funds....they can be required to mention emergency contraception.

I'm not so sure about that. I can't think offhand of a principle positing that religious conviction is superseded by the demands of a governmental funding entity. Any such principle would have to be heavily qualified and invoked in extremis in cases where a meaningful danger to the public exists: for example, in making Muslim schools' receipt of public funds contingent upon non-use of Saudi textbooks on Islam. This scenario doesn't even begin to meet that test.

[hilzoy]

Thomas: I would of course think that patients in hospitals should allow any clergy, or other visitors, that their patients want. Feeding tubes: sure, although it's a separate question whether they should be forced to assume the responsibility to pay for care. (I can imagine cases in which I'd say they should not. For instance, imagine a religion which does not accept brain death as, well, death, and imagine that an adherent of that religion is brain-dead, but that his or her other organs might be kept functioning indefinitely. Must the hospital pay to keep that patient hooked up to what we'd normally call 'life support' indefinitely? Not clear.)

I do not take issue with the free exercise clause. As noted in the original post, health professionals' right to free exercise is protected. I do take issue with the idea that an organization like a hospital as opposed to its employees) has such a right.

[Catsy]

"Religionists." That's interesting.

I'd be surprised if you haven't heard the term before. O Of a kind with "Christanists" and "Islamists", it's a common term used to make a specific distinction between those who genuinely follow a given faith, and those who invoke their faith to justify their own wrongs.

Finally, your definition of "substandard service" may not be others'.

When a health care professional is deliberately withholding information about the medical options available to a patient, that is--at a /minimum/--substandard service by any ethical metric.

[Tacitus]

Catsy, the obvious answer is that your unverifiable and unquantifiable assumption of (at worst) indirectly-caused deaths -- which assumption, let us note, is very debatable -- is not the equivalent of the verifiable and quantifiable deaths caused by unsafe structual engineering. The parallel is so tenuous as to be irrelevant.

[CharleyCarp]

You know, it seems to me that a physician who does not mention a possible treatment is exposed to negligence liability.

Suppose I'm a lawyer, and I don't believe in preliminary injunctions. Some client comes to me, and I fail to mention that a preliminary injunction is available. None is sought, the client is irreparably harmed, and I'm looking at a malpractice suit.

The only thing that separates my hypothetical from the Catholic hospital is the triviality of my belief. OK, how about I don't believe in suing the Catholic Church, and a client comes to me with a multi-defendant claim, and, without talking about options, I only sue the other defendants. They turn out to be bankrupt, and again I'm facing a malpractice suit.

It seems to me that a fair condition of the state monopoly that doctors, lawyers, pharmacists enjoy is that they are upfront about their choices of conscience. "I don't approve of X (for non-medical reasons), and if you want to learn more about about X, you need to consult someone else."

[sidereal]

In principle, of course any hospital should be able to provide any service they want to and not any service they don't. The problem is that their customers have no way of being informed about their services. Currently, there is an assumption that all hospitals are functionally equivalent, and people (barring insurance scamming) are sent to whichever hospital is closest. If now we have an oligarchy of hospital treatments, people need to express a preference for treatment before they need a hospital, probably on their ID. This is incredibly onerous, but what else can you do. Then at some point when you're of sound mind, you're given the choice "Hospitals of class C do not provide the following services due to ethical belief. Do you want to be treated by a hospital of class C".

[Tacitus]

I'd be surprised if you haven't heard the term before.

I spend too little time with the anti-religious bigots crowd to pick up all the rhetoric, sorry.

When a health care professional is deliberately withholding information about the medical options available to a patient, that is--at a /minimum/--substandard service by any ethical metric.

Nonsense on two counts. First, there is no consensus on what constitutes a "medical option." Second, there are plenty of cases, particularly in public health, where you give out constricted information in order to reduce the incidence of risk inherent in other options.

[CharleyCarp]

I'm a slow typist, and apologize for duplicating catsy's point.

[Tacitus]

Sidereal's solution is probably the most reasonable here.

....the state monopoly that doctors, lawyers, pharmacists enjoy....

Last I checked, there were many doctors, lawyers and pharmacists to choose from. A state licensing procedure does not constitute imposition of a monopoly.

[rilkefan]

Actually Catsy, I hadn't even heard the term "Islamists" before - I spend too little time with the anti-Islam bigots crowd to pick up all the rhetoric.

[Catsy]

Catsy, the obvious answer is that your unverifiable and unquantifiable assumption of (at worst) indirectly-caused deaths -- which assumption, let us note, is very debatable -- is not the equivalent of the verifiable and quantifiable deaths caused by unsafe structual engineering. The parallel is so tenuous as to be irrelevant.

Yours is a distinction without difference for the purposes of this argument. If a patient who does not desire pregnancy is raped, and a hospital refuses to disclose a medical procedure that could prevent contraception, it seems to me that the hospital's policy is not only medically unethical, but directly liable for her pregnancy.

Not that I'm surprised that you would try this flavor of deflection dressed up as an "obvious" truth, but the difference between the engineer and the doctor is one of scope, not kind. In both cases a professional is exposing their clients/patients to unnecessary risk because their religion forbids them from disclosing all best/available options.

One should not enter into a line of work if their religion could present an ethical conflict that regularly prevents them from doing their job right.

[Tacitus]

Oh, you've been around the term before, rilkefan. Forgive me if I say you're disingenuous -- to say nothing of ignorant of the meaning of the term. Unless, of course, you are prepared to argue that the Democratic Convention in Boston last year had "anti-Islam bigots" on stage.

Which, hey, you may.

[sidereal]

For the sake of thread sanity, let's draw a couple of distinctions. First, this isn't an emergency procedure. There is a very reasonable amount of time for the victim to get a test and learn her options elsewhere. Which leads to the second distinction. It's not clear from the source whether or not the hospital informs the woman that she has ovulated at all. I presume since she's given an ovulation test, they'd have to tell her the results, unless they disguised the nature of the test. The source says only that she's not told about contraception options. But I think in any real-world situation where a woman is told she ovulated during a rape, she should have at least some understanding of what the implications and options are and should be able to pursue more information elsewhere with little effort. On the other hand, if the hospital doesn't tell her, I think that's totally inappropriate. It would be another case of pro-life adherents treating pregnant women as the enemy.

[Tacitus]

Yours is a distinction without difference for the purposes of this argument.

Not at all. It's meaningful enough: if you are going to argue that a definable harm is being done, and provide a hypothetical illustrating such a harm, you can't cry foul when the applicability of the hypothetical is demolished. In this case, there is no definable harm occuring.

Okay, you may say the pregnancy is the definable harm -- or the "unnecessary risk," as you say. At the very least, you should have the honesty to acknowledge that this is a debatable point.

One should not enter into a line of work if their religion could present an ethical conflict that regularly prevents them from doing their job right.

Well, finish the sentence, here: "One should not enter into a line of work if their religion could present an ethical conflict that regularly prevents them from doing their job right by my definition.

And that -- the egregious failure of the Catholic Church to adhere to your standards -- is what you're really upset about here, isn't it?

[rilkefan]

Tacitus, forgive me if I say your reading skills when it comes to sarcasm directed at you haven't improved - well, or you're being "disingenuous".

As it happens, I think it's probably hard to find any moderately-sized group of Christians that doesn't contain some who are bigoted against Muslims - but then as a scientist I encounter remarkably few believers so perhaps I'm wrong.

[blah]

"One should not enter into a line of work if their religion could present an ethical conflict that regularly prevents them from doing their job right."

I don't have much of a problem with this statement, but the logic behind it could cause problems with say "conscientious objector" status for members of a voluntary military.

[Katherine]

As far as I know there is no conscientious objector status for members of a voluntary military. C.O. status only applies in cases where there's a draft.

Do people think hospitals have either a constitutional or moral right to decline emergency treatment for certain sorts of people?

[Catsy]

I'd be surprised if you haven't heard the term before.

Tac: I spend too little time with the anti-religious bigots crowd to pick up all the rhetoric, sorry.

So using the term "religionist" makes Jes and I anti-religious bigots?

Noted.

By your metric, then, I surmise that you're finally conceding being an anti-Islamic bigot.

First, there is no consensus on what constitutes a "medical option."

I invite you to try this argument on a real doctor. It should be good for a few laughs.

Second, there are plenty of cases, particularly in public health, where you give out constricted information in order to reduce the incidence of risk inherent in other options.

You make my point for me. Emergency contraception is orders of magnitude less risky than even the healthiest pregnancy and childbirth. By refusing to even inform women of the option, they are exposing them to the very risk you claim they're trying to avoid.

[Tacitus]

For the sake of argument, rilkefan, let's assume that I didn't understand you at all. False, but I'll play along. Which of the reasonable conclusions to be drawn from your statement are true?

1) You're lying.
2) You're ignorant.

A smart man in your shoes would walk away at this point. I therefore look to wrangling with you on this matter for hours to come.

[Jesurgislac]

Tacitus: Finally, your definition of "substandard service" may not be others'.

Let's say you have cancer. You go to a doctor. You don't know it, but the doctor is a Christian Scientist. He confirms you have cancer, and tells you that there is nothing that can be done except pray to God to cure you. In fact, the cancer is curable with a combination of surgery and chemotherapy: but your doctor feels his religious beliefs allow him to tell you about only what he considers to be the ethical option.

According to me, that's a substandard service.

According to you, that would be "giving out constricted information in order to reduce the incidence of risk inherent in other options". Right? After all, there is risk in chemotherapy and surgery.

A religionist, by the way, is one who expresses "excessive or affected religious zeal". A doctor or any other medical professional who imposes substandard treatment on a woman who has just been raped, in order to satisfy their own religious beliefs, is suffering from "excessive or affected religious zeal", no doubt about it.

[Tacitus]

So using the term "religionist" makes Jes and I anti-religious bigots?

I should let you parse this one out for a while, I think.

I invite you to try this argument on a real doctor.

Long since done, actually. Thanks for the invitation.

Emergency contraception is orders of magnitude less risky than even the healthiest pregnancy and childbirth.

Well. Not to the child, Catsy.

[sidereal]

"I invite you to try this argument on a real doctor. It should be good for a few laughs."

Are you sure? We do it all the time. Our original pediatrician didn't consider naturopathic treatments 'a medial option', didn't mention them, and certainly didn't prescribe them. So now we have a different pediatrician. Lest you think I'm confusing the issue, I understand that in our case we were seeking additional methods to achieve what we wanted, and in the Catholic hospital case doctors are intentionally avoiding what the patient would presumably want, but nevertheless it's clear there are differences of opinion on what constitutes a recommendable treatment.

[rilkefan]

Oh lord, Tac in fact doesn't understand sarcasm directed at him. I miss Timmy.

[Catsy]

Well, finish the sentence, here: "One should not enter into a line of work if their religion could present an ethical conflict that regularly prevents them from doing their job right by my definition.

No, thank you--I wrote what I meant. If you're prepared to argue that health care professionals do not have an ethical and professional obligation to make their patients aware of their treatment options, particularly those options which would reduce risks to their health, then be honest enough to make that argument. But don't presume to read my mind in order to concoct a straw man for you to knock down.

And that -- the egregious failure of the Catholic Church to adhere to your standards -- is what you're really upset about here, isn't it?

How nice that you're here with your magic Taci-yon Beams to penetrate deep into my mind and reveal my hidden motivations.

Or, not.

[Tacitus]

You don't know it, but the doctor is a Christian Scientist.

Um....can you think of something that might actually happen, here?

A doctor or any other medical professional who imposes substandard treatment....

Again, "substandard treatment" is not so simply because you declare it so.

[Catsy]

Oh lord, Tac in fact doesn't understand sarcasm directed at him. I miss Timmy.

He also deliberately avoided confronting the fact that his own metric for calling Jes and I anti-religious bigots--that we use the term "religionist"--makes him an admitted anti-Islamic bigot.

Which, executed in a far subler fashion, was the point of the sarcasm.

[Catsy]

Again, "substandard treatment" is not so simply because you declare it so.

And a sperm and ova that haven't even met yet are not "a child" simply because you declare it so, and yet you attempted to use that as an argument against emergency contraception above.

[Tacitus]

C'mon, rilkefan -- explain it in short words. So I understand. Really: I'm rapt.

If you're prepared to argue that health care professionals do not have an ethical and professional obligation to make their patients aware of their treatment options....

Well, I've already provided an example of health care professionals who do just that, yes? As has sidereal. What you're consistently failing to grasp is that what constitutes "treatment options" may vary among reasonable people.

How nice that you're here with your magic Taci-yon Beams to penetrate deep into my mind and reveal my hidden motivations.

Which you resolutely refuse to clarify, apparently. I stand by my interpretation of your rational premises.

[sidereal]

"health care professionals do not have an ethical and professional obligation to make their patients aware of their treatment options"

Do you believe it's totally irrational to believe contraception is not a 'treatment option', given a different set of ethical assumptions than yours? What, specifically, is being treated?

[Jesurgislac]

can you think of something that might actually happen, here?

Okay. A Catholic doctor examines a woman who has just been raped. There's a good chance she may have conceived as a result of the rape. The doctor knows there is emergency contraception that would prevent conception. But he doesn't tell the woman about it, because his religious beliefs are such that he considers EC to be inethical, and he therefore fails to give her all available options.

Kind of like the doctor in my imaginary scenario who decided to let you die of cancer, rather than tell that a treatment existed that might well cure you.

Is that clearer?

[Tacitus]

....his own metric for calling Jes and I anti-religious bigots--that we use the term "religionist"....

Oh, Catsy. You need to re-read. You think that's my metric?

And a sperm and ova that haven't even met yet are not "a child" simply because you declare it so....

Indeed not. You merely need to acknowledge that the points here are debatable, and not the absolutes you keep wrongly positing.

[Jesurgislac]

sidereal: Do you believe it's totally irrational to believe contraception is not a 'treatment option', given a different set of ethical assumptions than yours?

Yes. Believing that EC is not a treatment option is an ethical decision that a person has to make for themselves. It is irrational to declare it is "not a treatment option" in the sense of pretending it doesn't exist and shan't be talked about.

It's the difference between believing it was wrong to send people to the Moon, and believing the Moon landings were faked. One is a rational belief: the other is an irrational assertion.

[Tacitus]

Jesurgislac, pregnancy is an "ill" to be "cured" only in a worldview substantively different from the Christian one. Your failure to acknowledge that differing worldview as being a valid participant in the public square is indicative of -- well, it's a word that's got Catsy quite excited.

[Katherine]

sidereal--there is a range of opinions and yet there are many, many things clearly inside it or outside of it. I mean, we've got this thing called the FDA...

Anyway, this is not a medical dispute, it's a metahysical one. The disputed issue is whether a fertilized ovum has a soul.

The institutional autonomy argument unravels in the emergency room, as far as I'm concerned. What's next, are we going to allow EMTs to follow their conscience and only take rape victims to Catholic hospitals so they will saved from being led into temptation to murder their babies? Can hospitals turn away gay patients?

[Tacitus]

Anyway, this is not a medical dispute, it's a metahysical one.

I'm not sure that the line between medicine and metaphysics is particularly sharp or bright.

The institutional autonomy argument unravels in the emergency room, as far as I'm concerned.

Only if you're prepared to argue that the caregivers, in the emergency room or elsewhere, do not have free will, conscience, or volition. Because if they have any of them, I assume it follows that they have a right to use them.

[Bernard Yomtov]

Since we don't have an NHS, Jesurgislac -- and thank God for that -- it's not ipso facto "the state" that's paying employees at Catholic hospitals. They may well, as noted, receive varying levels of state funding, which one assumes may carry various restrictions upon which that funding is contingent -- but I doubt exercise of physician's conscience is among them.

I think you are making the same error that hilzoy criticizes in Gov. Owens' statement. It's not the physician's conscience that is involved here. It's the hospital's policy. Non-Catholic physicians practice in Catholic hospitals. Now presumably the hospitals argue that all physicians practicing there are bound by hospital rules, even if the rules violate their conscience, e.g., even if the physician personally believes it is wrong to withhold the information.

But then what about a Catholic physician in a non-Catholic hospital? Can the Catholic physician be required by hospital rules to provide the contraception information?

Is the answer that physicians ought not work at hospitals that have rules requiring them to violate their consciences, or is it better that hospitals not make such rules? The latter seems wiser to me.

What seems even wiser is that the EMT's inform the victim about contraception, and even be allowed to provide a prescription. After all, it's an emergency situation, not the time when you want to have to think a lot about which hospital to go to, and it seems wrong to me that whether the rape victim is informed or not should depend on a random event such as what the nearest hospital happens to be, or which physician she sees when she gets there.

[Catsy]

Oh, Catsy. You need to re-read. You think that's my metric?

Oh please, now you're just being dishonest. It's not anything new from you, but it is rather annoying. I said I was surprised you hadn't heard the term "religionist" before. You repled that you "spend too little time with the anti-religious bigots crowd to pick up all the rhetoric". Clear implication: "religionist" is a term used by anti-religious bigots. Logical extension: "Islamist" is a term used by anti-Islamic bigots.

Hey, if the shoe fits, then by all means wear it. But don't presume to pick mine out for me, and don't try to wriggle out of what you said by lying about it.

[Jesurgislac]

Tacitus: Jesurgislac, pregnancy is an "ill" to be "cured" only in a worldview substantively different from the Christian one

Well, that's certainly a point of view. A woman who has just been raped and is terrified that she may have conceived may be condemned in your worldview for regarding her possible pregnancy as an ill to be cured. Or any of the other instances in which a woman may not wish to continue her pregnancy.

You have a right to your own religious beliefs. You do not have a right to impose them on others who do not share your religious beliefs, or do not interpret them in the same way.

A doctor in an emergency room is not there to make religious judgements: s/he's there to provide emergency treatment. That may or may not include prescribing emergency contraception, but it certainly includes telling a rape victim that this option exists.

[CaseyL]

Why would a rape victim go to a Catholic hospital for treatment? The Catholic view on contraception, including emergency contraception, is well known. A Catholic hospital strikes me as a bad choice for post-rape treatment.

If the victim is too young, or too traumatized, to know or remember that a Catholic hospital is a lousy place to go to for post-rape treatment, the police and/or EMTs have a responsibility to take her to a hospital that will treat her injuries, not make them worse.

The pro-religionists here offer arguments that make no logical sense. The purpose of a healthcare provider is to provide the best, most appropriate treatment based on approved standards of care, not proselytize religion. Proselytizing religion to a traumatized emergency patient is despicable, because the patient isn't in any condition to refuse or refute. Pro-religionists' arguments, taken to their logical conclusion, would have trauma patients taken to a Christian Scientist Healing Center, and preserve the 'right' of the Christian Scientists to do nothing but pray while the patient bled out.

If a hospital wants the right to refuse to offer certain treatments - or to refuse to treat certain individuals, illnesses, or injuries- based on its religious creed, it shouldn't be accredited as an acceptable healthcare provider, and EMTs shouldn't take patients there.

[Tacitus]

Bernard, I assume my argument stands if you substitute "hospital administrators" for "physicians" in that statement. For my part, it seems reasonable for me to allow hospitals to make such rules, and physicians may work where they feel morally at ease.

Catsy, your "clear implication" is of course correct. Where you fall flat is in your repeated assertion that use of the term is my metric for determining such bigots. (Heck, now that I know it's in the dictionary, I might use it too.) Suffice it to say that in your case, I'd arrived at that conclusion long ago.

[Jesurgislac]

CaseyL: Why would a rape victim go to a Catholic hospital for treatment?

Because it may be the only hospital available. Or the nearest.

If a hospital wants the right to refuse to offer certain treatments - or to refuse to treat certain individuals, illnesses, or injuries- based on its religious creed, it shouldn't be accredited as an acceptable healthcare provider, and EMTs shouldn't take patients there.

Indeed. Further, it should not receive any state funding. If it is operating as a place of religion first, and a hospital second, then it cannot expect to receive funding from the state to impose its religious beliefs.

[Jesurgislac]

Tacitus: For my part, it seems reasonable for me to allow hospitals to make such rules, and physicians may work where they feel morally at ease.

Can I assume, then, that you do not object to dying of cancer because the only hospital available has decided that the treatment which would cure you is inappropriate according to the religious beliefs of their administration, and therefore they won't even tell you it exists?

[Tacitus]

You have a right to your own religious beliefs. You do not have a right to impose them on others....

It is a pity indeed that you do not feel any similar compunction about imposing your areligious beliefs, eh?

As for your hypotheticals, again, please let's consider something that might actually happen. While I appreciate your concern for saving me from the Temple of the Blessed Carcinoma, it wasn't a danger I had particularly feared.

[jerseycityjoan]

This raises a lot of questions in my mind about Catholic hospitals.

Of course I knew that they didn't provide elective abortions, but other than that, I thought they were the same as other hospitals. Now I'm wondering what else they do differently and what other information their staffs are told to withhold.

[SomeCallMeTim]

People are arguing all across the map here. The underlying issue seems to regard Catholic hospitals providing information about abortion. That is, at this point, a policy question. It would be entirely reasonable to impose such requirements on a hospital, but, if I understand properly, that hasn't been done here.

So we're left with a situation in which, given freedom of action, the Catholic hospitals can so as they like. If you are pro-choice, you prefer that such a law be put in place. If not, not. Not terribly shocking. So what, exactly, do people think is newly at issue here?

[Anders Widebrant]

What Tacitus seemingly fails to understand is that a doctor is paid to serve a customer, and that the customer is always right. Simple professionalism binds the doctor to make all options available that the patient can reasonably be interested in pursuing. The state should enforce that all who wants to use the state-supplied title of "doctor" measures up to such a simple standard of professionalism.

[sidereal]

"Believing that EC is not a treatment option is an ethical decision that a person has to make for themselves."

The medical industry makes ethical decisions for people all of the time. Hospitals can, for example, restrain suicidal patients as an ethical decision against the ethics of teh patient. Drug approval is slow, in large part due to the ethical constraints of the FDA approval process, even if it means patient death.

Second, you didn't answer my question. If EC is a treatment option, what is being treated? I hope you don't mind if I move the conversation along a bit by avoiding the back-and-forth and assume your answer is 'pregnancy'. There is a large contingent of people who in good faith and with perfectly clear consciences believe that pregnancy is not a condition to be treated away, and that therefore there can be no 'treatment' for it.

"Further, it should not receive any state funding."

I think that's reasonable. If the government wants to license a set of hospitals that follow a set list of procedures, then there's no reason they can't limit funding to licensed hospitals.

"The pro-religionists here"
woohoo!

"offer arguments that make no logical sense."
doh.

"The purpose of a healthcare provider is to provide the best, most appropriate treatment based on approved standards of care"

Which standards approved by whom? Do you think that anyone who doesn't meet a uniform set of standards should be precluded from caring for the ill or injured? Would this extend to private citizens?

"Proselytizing religion to a traumatized emergency patient is despicable, because the patient isn't in any condition to refuse or refute."

Let's be clear. There is no indication from any of the material we're discussing that the hospital is in any way trying to convert the rape victim to Catholicism, correct? They are dictating action because they perceive that action as a sin, first-order. Not because they're trying to win converts.

"would have trauma patients taken to a Christian Scientist Healing Center"

I wouldn't recommend that. In no way do I endorse anyone being forced to make use of a Catholic or Christian Science institution.

"and preserve the 'right' of the Christian Scientists to do nothing but pray while the patient bled out."

I think there are good samaritan laws against this, and certainly they'd be delicensed to practice medicine. Do you think being 1 day pregnant is, in medical terms, equivalent to bleeding to death?

[Tacitus]

....a doctor is paid to serve a customer, and that the customer is always right.

Possibly the most inane and wrongheaded description of the historical self-assessment of the medical profession ever.

Although I do note that those who endorse euthanasia and abortion certainly disagree.

[sidereal]

"the customer is always right"

That's simply untrue. If a hospital's 'customer' wanted to eat the patient in the bed next to him, they would be prevented from doing so.

"state-supplied title of "doctor" "

'doctor' predates 'state' by a large margin

[Anders Widebrant]

As for an example of what else this kind of unprofessional behaviour might lead to, the obvious case seems to be a doctor refraining from telling a mother that the life of her early born child could have been saved. The doctor may have felt that the chances were small and the most likely outcome would just be a short period of needless suffering followed by death, anyway, and made a moral judgement not to inform the mother of all her options.

Less dramatically, this is a question of how many questions we have to ask when we first meet a doctor. Is she catholic? Jewish? Muslim? What parts of her doctrine are relevant to health-care, and how does she interpret it? Life becomes significantly much easier if we can assume that a licensed doctor will first and foremost seek to maximise our ability to follow our own personal beliefs.

[hilzoy]

I have been asked by one of the other posters (whose present computer situation is such that he can read this blog but not comment) to note that Tac is out of line to call anyone here a bigot. To quote:

"I think if it's pointed out that Tacitus crossed the line with his bigot commentary (he really did, up until then it was a matter of opinion revolving around the word "religionist" which has not been used in any context that licensed him to jump to "bigot" so quickly, so he's to blame...hopefully he'll agree and back down."

One more bit from the email:

"I know the odds are great that Tac will wrongly accuse you of policing him when you don't police your own, so you can say I noted it if you choose."

For what it's worth, I was offline between my last comment and about five minutes ago.

[Katherine]

"There is a large contingent of people who in good faith and with perfectly clear consciences believe that pregnancy is not a condition to be treated away, and that therefore there can be no 'treatment' for it."

This is completely appalling and I can't believe I'm hearing this from you.

First of all, emergency contraception DOES NOT END PREGNANCY according to the medical definition of the term.

Second of all, sure it's a condition to be treated. You don't believe in prenatal care now? You don't believe in obstetrics? Somehow I doubt it.

You say, "it can be treated but not treated away"? Well, factually, it can be. Are you seriously claiming that, say, ending an ectopic pregnancy that will risk rupture of the fallopian tubes and death--that that's not a medical treatment?

For emergency contraception in the case of rape, as for abortion to end a dangerous ectopic pregnancy that will never come to term, the Catholic Church & some doctors regard the treatment as seriously unethical. Because they regard it as killing an innocent person. Because they believe that a human being acquires a soul at the moment of fertilization.

This isn't a question you learn the answer to in medical school; you learn the answer in Sunday school or in your metaphysics class.

Despite that, if it were a discretionary, non-emergency procedure like a vasectomy or a breast augmentation or laser eye surgery, I would completely support their choice not to perform it. But that's not the situation. Emergency rooms have special privileges and special legal obligations. And don't tell me this isn't an emergency because it's not directly life threatening--are you telling me emergency rooms can refuse treatment as long as it only causes you to lose your leg or suffer a debilitating illness instead of dying? Can emergency rooms refuse to provide a preventive course of AZT to rape victims because AIDS is no longer an automatic death sentence? Please. The consequences of being denied access to emergency contraception after a rape are just as serious and just as irrevocable.

[Anders Widebrant]

"Possibly the most inane and wrongheaded description of the historical self-assessment of the medical profession ever."

:(

"Although I do note that those who endorse euthanasia and abortion certainly disagree."

Then I am at least in the inane and wrongheaded company of the almost entire medical profession -- and nearly every justice system -- in the Western world.

-+-

"That's simply untrue. If a hospital's 'customer' wanted to eat the patient in the bed next to him, they would be prevented from doing so."

Providing human snacks is not a medical service. Providing options to deal with unwanted pregnancy is.

"'doctor' predates 'state' by a large margin"

Predates "christianity", too, but I am not sure where you are heading. Only the state can make a doctor.

[Bernard Yomtov]

I assume my argument stands if you substitute "hospital administrators" for "physicians" in that statement.

I don't think that's clear. There must be a difference between what is legitimate in our roles as individual actors and as rule-makers. This is, if I understand correctly, part of the point Katherine was making in her comment on the Catholic notion of "scandal."

[Jesurgislac]

Tacitus: It is a pity indeed that you do not feel any similar compunction about imposing your areligious beliefs, eh?

Hmm. Well, I certainly believe that a physician has the obligation to provide the best possible care available to all patients. This is an areligious belief, and you're right, I would feel no compunction about imposing it on others. Why do you feel this is a pity?

Sidereal: Do you think that anyone who doesn't meet a uniform set of standards should be precluded from caring for the ill or injured?

Yes, I do, and I think you'll find that hospitals also do.

They are dictating action because they perceive that action as a sin, first-order. Not because they're trying to win converts.

But unless they first convert their patients to their religion (and to their interpretation of their religion), they have no business refusing to provide treatment because they think it's a sin. (Neither, of course, would they have any right to enforce treatment that their patient felt was a sin.) In practical terms, by refusing treatment because they think that treatment is sinful according to the tenets of their religion, they are imposing the tenets of their religion on people who do not (necessarily) believe it.

No one has a right to impose their religious beliefs on other people.

[Phil]

The Catholic view on contraception, including emergency contraception, is well known.

Oh, I don't know -- up until today, I would never have guessed that that view includes, "Go ahead and prescribe it for patients who clearly don't need it." Which, in my mind, prescribing a non-placebo medication to a patient who clearly does not need it is far too close to malpractice for there to be any meaningful distinction.

[hilzoy]

And speaking for myself now: sidereal, you're wrong about this, I think:

"The medical industry makes ethical decisions for people all of the time. Hospitals can, for example, restrain suicidal patients as an ethical decision against the ethics of teh patient. Drug approval is slow, in large part due to the ethical constraints of the FDA approval process, even if it means patient death."

Suicidal patients are restrained because of doubts about their competence to make decisions, not because hospitals are empowered to make moral decisions about what competent patients can do with or to their bodies. In general, doctors are not allowed to make moral decisions about that at all. The FDA is a different matter, but in its case the grounds for approval or disapproval of a drug are supposed to be scientific (safety and efficacy), not moral.

As to what's being treated: emergency contraception (e.g., Plan B) is used to avoid conception or implantation. Pregnancy is not an illness. But it is a condition with some real health risks, not to mention huge implications for the rest of the woman's life (I am not speaking of the child's here, since if conception has not yet occurred, there may not be any child yet), which people in this country have the right to decide to seek out or to avoid.

That being said, not all of medicine is about treating diseases. When a burn victim has plastic surgery, there need be no disease that's being treated or prevented. When a woman has a hysterectomy, she may be motivated by the desire to avoid the possible complications of pregnancy, especially if she has some condition that makes those complications likely, but she may also be motivated by the thought that eleven kids are as many as she can deal with. When a woman uses Plan B, she may also be trying to avoid pregnancy for medical reasons, or, again, she may think: I'd rather not have a child by my rapist, and I'd also rather not have an abortion. In any case, though, this is a choice she should make, and to deprive her of information is, I think, wrong.

I think that there are some professions in which a significant part of one's job is to acquaint people with the options available to them, and provide them with accurate information. This information need not include "all the options" -- there are often too many conceivable options to make that remotely feasible, even if one limits oneself to those likely to be effective. In general, professionals have to narrow the options based on their assessment of what will and won't work, for instance. But they should not exclude options based on their own religious views, I think.

The professional does not have to be ready to perform all of those options, according to me, as long as there are people nearby who are (where the meaning of 'nearby' depends in part on how urgent it is. In the case of a person in need of emergency surgery, I don't think a doctor who's a Jehovah's Witness can decline to offer a blood transfusion unless a doctor who is willing to perform one is very, very close by. In a case like Plan B, on the other hand, there is more of a time window.) But I think it would be a really bad idea to accept, as a general principle, the idea that members of professions part of whose function is to provide information can decline to provide that information on grounds of conscience.

When a doctor refuses to perform some procedure on grounds of conscience, s/he does not prevent the patient from finding someone else who will perform it. But when s/he does not inform the patient of the existence of that procedure, then that patient may never know to look for such a doctor. In that case, the patient's choice is really undermined.

One way around this, of course, would be for the doctor to announce up front that s/he will not provide certain kinds of information. But that, of course, could be ruled out on the same grounds: if the doctor thinks it's wrong to inform the patient of X, s/he would probably think it's equally wrong to tell the patient: there are treatments like X, but I won't tell you about them. Or, more specifically: if it turns out that you might be pregnant, I will not tell you about the existence of emergency contraception. Carry this line of thought a bit further, and any attempt to let patients know that you will not be informing them about the full range of options available to them will turn out to be wrong on the same grounds as telling them about their options: in both cases you are drawing their attention to the existence of an option you think it would be wrong for them to pursue, and so in both cases you might indirectly contribute to their pursuing it.

For this reason I think one can't accept the idea that people in professions that involve providing people with information on their various options can decide not to tell people about some options on the grounds that those options are forbidden by the professional's religious views. This goes for lawyers, as was noted earlier: if you fail to tell your client about a possible defense because your religion forbids it, you are open to malpractice. It goes for financial advisors: if you set up as a financial advisor, but never mention bonds because you disapprove of usury, as a fundamentalist should, you can be sued. And I think the same should hold here. We should try, when we can, to accommodate people's convictions by finding ways for them not to actually perform abortions (sell bonds, make loans, do blood transfusions.) But if you enter a field in which a significant part of your job is giving advice and letting people know what their options are, I don't think it's at all OK to just decide that you won't even inform them that those options exist. No one forces people to enter such professions. And my response to people who enter an advice-giving profession and discover that, oops, they can't actually tell people about some of the relevant options is like my response to people who discover that they are pacifists after they have enlisted in the army: namely, you should have thought of that sooner.

And all this doesn't get at one of the main points of the original post, namely: hospitals, in particular, have no business making these policies.

[Don Quijote]

Tac,
Well. Not to the child, Catsy.

Are you going to pay for the clothing, feeding & education of that Child!

If not, well you know what you cam do!

[John Thullen]

I agree that the "customer is always right" model may not be the most desirable when its comes to medical care. I don't think patients should be permitted to eat one another, unlike, for example, the patrons of shoe stores, where I believe eating one another is perfectly acceptable.

Further, I believe medicine is a different sort of commodity than shoes. I have no problem denying Guccis at taxpayer expense to those who can't afford them. I do have a problem denying health insurance and medical care to those who can't afford it, although it is nice that the most expensive option of the emergency room is still a viable option.

The exquisite delicacy and relevancy of all opinions expressed here is most appreciated.

[Bernard Yomtov]

One problem that occurs to me is that there is an issue of regress.

If it's OK for the physician not to provide information because it will be used for purposes he regards as immoral, is it OK for the medical school professor, who shares the physician's view, to refuse to teach students about emergency contraception? I suppose we can say that someone who objects to EC on moral grounds ought not teach courses where this would be relevant.

But then is it OK for a medical school at a Catholic university to bar the presentation of this material? That seems clearly wrong, yet the same argument applies as in the case of the hospital rules.

[von]

I think Charlie Carp made the only point that needs to have been made. Nonetheless, I'll hit it again:

A Catholic hospital has every right to refuse to provide certain treatments, according to its morality or preferences. (I use the term "treatment" broadly; there can be moral and immoral treatments.) This remains true even though treatment may be legal and even though some (and perhaps most) practioners in the field think that it would be immoral to withhold the treatment.

Indeed, I'll defend their right to make these kinds of choices at every turn.

The issue here, however, is not about treatment. It is about who holds the power and knowledge in the doctor-patient relationship. The doctor has superior knowledge, but he or she is but the agent of the patient. The patient holds the power as to what sort of treatments are appropriate; if there is a difference in the morality of the patient or doctor, the patient's morality should be pre-eminent.

This does not mean that the patient can force the Doctor to perform an act the Doctor finds repugnant. But I think that a Doctor does have a duty to advise the patient of his or her treatment options. The Doctor may counsel the patient against option X or Y -- indeed, I think it's part of their job to provide such counseling. The Doctor may refuse to provide it. But the Doctor cannot withhold knowledge regarding legal treatment options; he or she must always remember who has the final say.

By the way, Tacitus, lawyers absolutely do have a monopoly over the practice of law and doctors also absolutely do hold a monopoly over the practice of medicine. It has always been the rule that, by accepting such monopolies, doctors and lawyers cede to society the right to regulate their behavior.*

Also, since you're about (and In case you missed my past retraction): You were right about the growing crim law problems in Northern Mexico.

von

*There're a couple exceptions I'll not get into.

[von]

Apologies for the typos in the above; I'm being shouted at that we're late for our evening event(s). I hope it's clear.

[John Thullen]

It is clear that Von hits it right on the mark. What is not clear is why people would shout at him.

[von]

What is not clear is why people would shout at him.

Because we're supposed to be meeting friends for drinks about five minutes ago, and I'm still sitting here blogging.

[Jay Sundahl]

"hospitals, in particular, have no business making these policies" -Hilzoy.

I find this a thorny issue. I think the policy as described is a bad policy, but what are "these policies"? Should a hospital have the right to make a policy that required disclosure of certain medical options? I think it should have that right. Would you only restrict hospitals from limiting information about medical options? There are a number of options that might be considered inappropriate treatment by one group that is considered standard practice by another (chiropractors, acupuncture, herbal remedies, etc.*) Informing patients of these options might be viewed as an endorsement, or encourage them to seek treatments that your hospital board might think is a potential danger and waste of money. While I would lean toward giving more information to the patient, I can see a hospital board feeling the necessity to limit that information. Just because I wouldn't do it, doesn't mean the hospital has "no business" doing it.

Of course, I think it would be better to disclose and warn against practices you see as dangerous or worthless, but I can see a rational for not disclosing if you think it might actually harm patients in general. If hospitals have the right to make these kinds of policy decisions, some of them are going to make bad choices. In this case the choice appears to be for non-medical reasons. Maybe the motivation for the policy makes a difference, but I think it is wrong to say they have "no business" making this type of policy in a general sense. Public exposure and discussion may be a better way to fix these policies than legislation.

* I neither endorse or condemn some of the examples I chose.

[liberal japonicus]

Interesting issues. I did some googling of Centura and found a number of interesting facts that don't directly relate to the point at hand, but give some food for thought. Centura is (no surprise here) non-profit group, and has lowered the prices it charge to indigent patients out of fears of being being sued link. They also seem to have had some problems with overcharging for Medicaid/Medicare, though I suspect the set of hospitals not overcharging for this approaches zero.

Two Centura hospitals are listed in the 100 Top Solucient Hospitals. However, this ranking seems to based more on profitability, if I understood them correctly.

Going to the home pages of some of the institutions, there is this
which lists as the first value
Integrity: Honesty, directness and respect for commitments made.

I also think it is ironic that the hospital also subscribes to a Centura Health Patient Bill of Rights. I realize that there are hard decisions, but essentially witholding information (which to me is a form of lying) seems to contradict this.

This is an interesting article about Catholic hospitals in general and Centura in particular(free reg req'd)

The nation's second-largest Catholic health system is based in Denver, but you won't see the name Catholic Health Initiatives atop local hospitals.

That's because the two hospitals it owns in the Denver area are managed by Centura Health and they are generally branded with that name. Catholic Health Initiatives, or CHI, owns 63 hospitals and 44 long-term care, assisted living and residential facilities in 19 states.

Last year, the company's revenues hit $5.7 billion.

The organization is also vying for some governmental support via referendum.

The main Centura hospital is moving from the city to the suburbs and some suggest that the move is motivated by profits rather than service.

More disturbing is the reprocessing of surgical instruments. It would be interesting to know if the discount is passed on to the patients.

On the plus side of the balance, there is this

[hilzoy]

Jay: I think that the non-medical reasons do make a difference. Clearly (as I said about doctors, but it applies here too) one cannot inform patients of all their options. I mean, one way to treat athlete's foot is to shoot your foot off, but that doesn't mean a hospital (or anyone else) has to mention it. Likewise for lawyers: one way to avoid being sued is to kill yourself, but that doesn't make it an option a lawyer has to mention.

I think (as I said above) that wen you are in one of the information-providing professions, you have an obligation to provide information on those options that are available and that work. If a hospital believes that some treatment is inappropriate because it doesn't work, they might disclose it and warn against it if they think the patient might be tempted by it otherwise, or they might fail to mention it if not. (If you think of the sheer number of "treatments" that don't cure any given disease, the idea that you should have to disclose all of them is crazy. I mean, are you supposed to say: eating sugar cookies is an option, but it won't cure your cancer. Playing checkers is also an option, but it won't cure your cancer either. -- and so on through the infinitely many possibilities? Clearly not. If you believe that taking some herb is no more likely to work than playing checkers, no reason to bring it up.) But if they think it's inappropriate for some other reason -- e.g., if they have reason to think it's an effective treatment for what the patient has, but for some reason it's not the sort of thing they want to talk about at that hospital -- then I think they have an obligation to disclose.

[hilzoy]

Oops, I cut out something inadvertently (and misspelled 'when', as well.) Options that are available and work: here, 'work' was supposed to be qualified, so that it meant something like: treats the disease (or whatever) with reasonable side effects (excluding e.g. shooting off your foot to cure athlete's foot.) (What's reasonable of course varies with what the treatment accomplishes: almost any side effect is tolerable in chemo that cures an otherwise lethal cancer; a lot less would just rule out a cure for acne.)

[Jay Sundahl]

Hilzoy,
I agree that the policy is bad, and generally disclosing is better than not disclosing. If it was made for non-medical reasons, that's worse. But you said it had no business making the policy, and here I think you haven't made the case. Are you saying the hospital shouldn't be able to make policy about disclosure? I don't think so, but it isn't clear in what sense you mean that they had no business making the policy. Maybe I'm pick a nit here, but that's the issue I was addressing.

[Opus]

What's next, are we going to allow EMTs to follow their conscience and only take rape victims to Catholic hospitals so they will saved from being led into temptation to murder their babies?

I think that's a reasonable interpretation of the "scandal" principle quoted way upthread. I'd be interested to hear Tacitus' take on it.

In any debate that involves abortion, and those who believe that life begins at fertilization, the only way (that works for me) to imagine that POV is to picture Siamese twins, one smaller and more vulnerable -- then to ascribe to the smaller twin the larger claim to life. After 6-9 months, a procedure can be done to separate the twins -- in most cases, it can be done safely, with no risk to either person.

This twin does not start out smaller and get bigger. It appears, fully-formed, in an instant. One minute a woman is walking around; the next, she's walking around with another person attached to her.

Now you can guess at the decisions the anti-abortion person would come to, and -- aside from the whole "siamese twin" image -- they make sense.

In Florida, with the 13-year-old? She's standing in court, with this other person attached to her. The rape victim? She's in the emergency room with this other person attached to her. The developmentally disabled incest victim? She has a fully-formed person attached to her and must keep that person there until the "separation surgery." None of these women can be allowed to say, "I don't want this person attached to me -- kill him/her."

Now, this is not how I see pregnancy and life.

But it is how Tacitus, and others, do. There is *no* point in arguing. This is what's at stake for them.

[Jay Sundahl]

That was "picking a nit" at 9:56.

Here's a link to the text of the bill in Colorado.

[hilzoy]

Sorry: by 'such a policy' I meant: the sort of policy described in the original post, namely one whereby the hospital bars its health care professionals from informing rape victims about emergency contraception. I didn't mean: policies about care generally. (Actually, the original sentence was just a throwaway line meaning: and I haven't even gotten into the physician vs. hospital distinction...)

I think that the reasons why doctors should not refrain from discussing options that are safe and effective apply to hospitals as well. Namely: patients come to them not just for treatment, but for information on what treatment to have, and hospitals should not adopt policies that prevent their employees from fulfilling this function.

[SKI]

As an attorney, I am appalled by the policy. It violates the most basic concept of professional ethics.

A professional is obligated to look out for his/her client's (patient's) interests by providing them with all relevant information but cannot ever presume to make decisions for the client. We can offer advice but should not, can not, must not 'play G-d'and take over the role of decision-maker for our clients.

[Jay Sundahl]

From Title 25 Article 6 25-6-102 of Colorado statutes, it seems that this policy is already in violation of state law.

(4) No hospital, clinic, medical center, or pharmacy licensed in this state, nor any agency or institution of this state, nor any unit of local government shall have any policy which interferes with either the physician-patient relationship or any physician or patient desiring to use any medically acceptable contraceptive procedures, supplies, or information.

[Jay Sundahl]

Of course, to muddy the waters, the same section 26-6-102 contains this language:
(9) No private institution or physician, nor any agent or employee of such institution or physician, shall be prohibited from refusing to provide contraceptive procedures, supplies, and information when such refusal is based upon religious or conscientious objection, and no such institution, employee, agent, or physician shall be held liable for such refusal.

[Jay Sundahl]

Sorry,
"The same section 25-6-102"
Thats:

Title 25 Health
Article 6 Family Planning
25-6-102. Policy, authority, and prohibitions against restrictions.

[McDuff]

I'm not looking up the exact dates right now, but I think it's very interesting that "life begins at conception" is a form of religious pseudoscience that emerged at approximately the same time as eugenics -- sometime in the mid 1800s.

Until less than two centuries ago, neither the Catholic or Protestant churches held anything like a belief that life began at conception. Instead, there was a belief in a point of time called "quickening", at which a baby's soul entered it's body -- coincidentally the first time a mother would feel a baby's movement. A miscarriage before this time was not regarded as the death of a person.

Interestingly, the ancient and well-established point of "quickening" seems to approximately line up with the modern understanding of when brain activity begins, which is as close to the secular view of what the human "soul" constitutes as I can find.

From this, I think it is fairly reasonable to conclude that religious folks were a lot more sensible and clued-in two-hundred years ago than they are now, and that the corrupting influence of hearing half a scientific idea and mixing it with religious superstition has rendered most mainstream Christians almost insensible with madness, causing them to leech hold of damaging and nonsensical ideas which, despite their origins in the intellectual fervour of the 19th century's scientific discoveries, now require anti-intellectualism by the wheelbarrowload to maintain.

Still, I remain optimistic that, just as the pseudoscience of eugenics has finally been laid to rest, so too can religion's demon grasp on this foolish notion that a human without brain activity at one end of the spectrum of life is somehow equipped with a soul, where one at the other end of life is merely a corpse, be removed to the unfashionable sectors of society and shunned from mainstream political debate as being far too silly for words.

In the meantime, of course, we have to put up with ridiculousness like this.

The crux of the matter regarding the OP, incidentally, is really rather simple. As long as you take a stand and say "this is morally wrong," the practical implications of such a stand, even if these include harm or suffering in another human being, are immaterial. In the above case, the most common course of action I imagine being taken is that the woman in question, should she fall pregnant, will seek out a later-term abortion from a doctor sympathetic to her situation. The Catholics have taken a moral stand but I cannot imagine for a second that they prevent a statistically significant quantity of abortions, but rather than a termination of a conceptus with no brain nor nervous system in a manner that is of minimum danger to the woman involved, they are instead ensuring that higher risk and later term procedures are used. This doesn't matter, however, because they have established that they are standing on the moral high ground, no matter the practical results.

And at the end of the day, all that matters is that everyone knows you're more moral than everyone else.

[McDuff]

Incidentally, please forgive the egregious abuse of grammar above. It is late where I am.

[sidereal]

Sorry if I left anything dangling. . had a birthday barbecue to attend.

Quickly,
Katherine - I'm sure you appreciate the difference between treating the complications of pregnancy and treating pregnancy itself. And ectopic pregnancies get into health-of-the-mother territory which is important, but not relevant to moral questions about otherwise unwanted pregnancies.

Phil - on not needing it. My understanding is that EC is contraceptive if there has been no fertilization yet. The rapist's sperm will still be active and can fertilize for up to something like 3(?) days. If fertilization has already occured, it acts as an abortive. This is, I assume, the basis behind the distinction. The odd thing is that under Catholic doctrine contraception is itself sinful, so unless I'm mistaken, I don't understand why they allow it in that case.

To all, is the correct solution simply to preclude observant Catholics from practicing medicine? I think that would be an unfortunate outcome, given that 99.99% of medical practice is unaffected by this issue, and we could certainly use more doctors.

[Jesurgislac]

Tacitus: As for your hypotheticals, again, please let's consider something that might actually happen.

You don't seem to wish to discuss what will inevitably happen as a result of these policies: a raped woman who may be pregnant who needs to know that she can take emergency contraception.

You argued that not telling this woman that the option of EC is available to her is not a sub-standard service. I disagree, and offered you a clear analogy: a doctor who decides to let you die rather than tell you about a treatment that might cure you, because his religion disapproves of that treatment. That seems to me to be a clear analogy: I'm not sure why you have trouble with it.

Opus: None of these women can be allowed to say, "I don't want this person attached to me -- kill him/her."

And yet, we do not permit people to attach themselves to other people with that expectation in any other role. If a rapist discovered that the woman he had just raped had precisely the right tissue-type to be a kidney donor for him, we would not assume that his act of rape gave him the right to insist the woman donate a kidney to him.

The fertilized egg is not a person. Nor is this really about being "pro-life": many so-called "pro-lifers" are also pro-death penalty and pro-war: nor are they particularly interested in preserving the life or health of a child after it is born - let alone the life and health of the woman who gave birth to it.

If this were truly a pro-life issue, you would see pro-lifers out there arguing for a free health-care system that would take care of all pregnant women and all children to the age of 18. (We have this pro-life system in the UK, of course: it's called the NHS, and Tacitus's opinion of such a system was given earlier: "Since we don't have an NHS, Jesurgislac -- and thank God for that") A "pro-lifer" who is not interested in preserving and supporting life, who is only interested in preventing woman from deciding whether or not they want to be pregnant, is not "pro-life".

The issue is fundamentally: are woman to be allowed to control their own bodies? And to these so-called "pro-lifers", the answer is No.

[liberal japonicus]

sidereal
There is also a very interesting (to my mind) paradox on Catholic theology and medicine, and that is that transplantation is considered to be worthy because it is literally giving of oneself, and is specifically contrasted with the 'selfishness' of abortion. Unfortunately, the Catholic church has to conduct a 'stealth' campaign because the notion that life begins at conception is not a concept that is supported by the majority. If it were, I believe that IVF would be looked at much more critically.

We've had a number of tong and hammer conversations about Roe v Wade here, but I've always felt that the notion of viability seemed to be a commonsensical approach (as is McDuff's citing of the traditional notio of 'quickening'), but was undercut by the rapidity of medical science advances.

[JKC]

I'm willing to cut Centura some slack, even if the notion that contraception = abortion is based on large quantities of ignorance about human biology.

But following that path does lead to a logical conundrum: if giving emergency contraceptives to a rape victim is equivalent to providing an abortion, and therefore immoral, then what of the physician who treats a woman with methotrexate for a tubal pregnancy? Isn't he or she commiting murder, too?

[hilzoy]

lj -- the trouble with viability is that it makes things dependent on the state of technology. If it became possible, at some point, to make a sort of artificial womb, so that a fertilized egg could be brought to term without needing to be implanted in a woman, any fertilized egg would be 'viable'.

In my view, the best line to draw is: when the nervous system has developed to a point at which the fetus has some sort of experience of its own. Since it is not entirely clear when this is, one could err on the safe side. But it could not possibly be before the end of the first trimester, and probably not before around the end of the second.

Before that happens, the fetus/embryo/whatever stage it's at cannot feel, let alone think. If brain death is what happens when your brain has existed but then dies, this is the analog before it gets going.

[CaseyL]

JKC - The Catholic Church has a doctrine that 'allows' pregnancies to be ended if, and only if, the action that ends the pregnancy is primarily to save the mother's life and the end of the pregnancy is a consequence, not an intent.

That means pregnant women can have medically necessary surgery that entails removal of the uterus, even if there's a fetus in there. They can also have chemo, radiation treatment, and other highly toxic medical treatments that would probably cause a miscarriage - but, if there isn't a miscarriage, they still can't have an abortion, even if they know the fetus will be deformed, fatally ill, or not live long after birth as a result of the highly-toxic treatments.

It also means the Church has no problems with ending ectopic pregnancies. Ectopic pregnancies are not only invariably fatal to the mother, they're invariably fatal to the fetus: since a live birth is simply not possible in that circumstance, the surgical or chemical removal (abortion) of the fetus is allowed.

This is part of the "double effect" doctrine. Other denominations, esp. the fundamentalist sects, do NOT subscribe to it. Presumably they would let the ectopic pregnancy (or the cancer, or other medical condition that would be fatal if not treated) continue, and kill the mother or child or both, on the basis that "God could miraculously prevent the deaths if He wanted to, and we must abide by His Will."

[Opus]

Jesurgislac, just to reiterate: that's not my thinking -- but it that of some of my friends who are virulently anti-abortion. I will not play Karnak on Tacitus or others; it may be about controlling women, and it may be a sincere belief. In a debate on abortion, I'm goign to default to the latter, and assume the most immovable position, since that's what most anti-abortion folks declare. I'll take them at their word, and debate from there.

For example, hilzoy has articulated my position pretty well -- but she's going to get exactly nowhere in trying to convince anyone like tacitus. We've got some give in our thinking about legislation on this subject; the anti-abortion movement has none.

That's why they have to take it to the judiciary -- and all the wailing about activist judges is such nonsense. If it comes down to legislation, this country as a whole will never ban all abortions, which is what any true "pro-lifer" wants. The only way for them to get their way is a loaded Supreme Court.

Meanwhile, yes -- there are plenty of people (perhaps the majority of the movement?) who are using anti-abortion as a political tool. It's the reason that legislation like the "partial birth" ban is written so that it must be struck down by the courts. Short term political capital, no long-term political risk (supposedly). I guess I'm not in the mood to let them get away with that -- so I'll treat all people who align themselves with the true believers as true believers, and insist they hold those views proudly and vocally.

[Jesurgislac]

Opus: I will not play Karnak on Tacitus or others; it may be about controlling women, and it may be a sincere belief.

"Karnak" is not required. I'm not going to pick on Tacitus in especial, that's unfair: for all I know he does actively campaign for free healthcare for all pregnant women and children under 18, and his sneers at the NHS are merely because he wants the US to adopt the (rather better, I have to say) French system, rather than the UK system, which is merely superior to the US - as which healthcare system in the developed world is not?
-
But for so-called "pro-lifers" in general, mind-reading is not required: they are as a group not interested in preserving life or ensuring fewer abortions. They do not campaign on these issues. They campaign, not for better sex education, an end to abstinence-education, free access to contraception, free daycare, free health care - but exclusively to make abortions either illegal, or far more difficult to obtain.

Further, not only are they as a group uninterested in the welfare of children once they are born, they are often (for all their pro-life talk) pro-war and pro-death penalty: it's evidently okay to kill children, even unborn children, providing it's done at a distance with advanced weaponry.

Therefore, when judging "pro-lifers", I conclude by their actions that they are not pro-life: they want to control women.

[Bernard Yomtov]

Other denominations, esp. the fundamentalist sects, do NOT subscribe to it. Presumably they would let the ectopic pregnancy (or the cancer, or other medical condition that would be fatal if not treated) continue, and kill the mother or child or both, on the basis that "God could miraculously prevent the deaths if He wanted to, and we must abide by His Will."

Can that possibly be true? It is beyond my comprehension how someone could believe that.

[Dianne]

It is standard of care in medical practice in the early 21st century to offer emergancy contraception to a woman who has been sexually assaulted if she presents for treatment within 72 hours of the assault. What the hospitals mentioned in the post are doing is malpractice. If anyone has been so treated, I suggest you get a lawyer with a bad attitude who works on commission and sue for the maximum. I don't like malpractice lawsuits in general--it seems unfair to sue someone for making a mistake, as though the person suing had never done so--but malpractice law was made for situations like this one in which the doctor or hospital involved willfully and deliberately delivers less than the best care. (I apologize if this issue has already been discussed into the ground: I haven't read all 99 previous posts.)