Religious Coercion of Physicians: Whose Conscience Is It Anyway?

Comments open through February 6

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Leonard Fleck, PhD

Neil Mahoney is 64 years old and has a terminal cancer with a predicted life expectancy of 4-16 months. He lives in Colorado, a state that approved an aid-in-dying law in 2016. His physician is Dr. Barbara Morris, 65, a geriatrician whom he has asked to provide him with the drugs needed to end his life. She has agreed to do just that.

However, Dr. Morris works for the Centura Health Corporation, a Catholic-Adventist hospital system. Dr. Morris was fired from her position when it became public knowledge that she was willing to help Mr. Mahoney to end his life. We should note that she had no intention of doing this within the walls of the hospital or any of its facilities. She would accomplish this in the privacy of Mr. Mahoney’s home.

Moral-Dilemma-Ahead-road-sign

Image description: a yellow road sign reads “MORAL DILEMMA AHEAD” in bold black lettering. Image by Liz McDaniel.

In justifying its firing, the hospital CEO said Dr. Morris could be fired for “encouraging” the patient to pursue aid-in-dying, even if she never actually provided or assisted in any other way his accessing the drugs he requested. The CEO cited as a basis for this position the Ethical and Religious Directives for Catholic Health Care Services. The directives state that Catholic health care providers (which include everyone working in the institution, whatever their religious commitments or lack thereof) “may never condone or participate in euthanasia or assisted suicide in any way” (emphasis mine). Instead, “patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.” Alternatively, the care of that patient should be transferred to another provider, presumably one willing to respect the choice of someone like Mr. Mahoney.

It should be obvious that there is something ethically incongruous about this position. Imagine my walking into a Catholic gun shop in a horribly depressed state of mind and asking the owner to sell me a gun so that I could blow my brains out. He expresses compassion for my awful life circumstances, urges me to seek psychiatric care, then explains that as a Catholic he could not sell me that gun, knowing my intention. Having said all that, he informs me that a mile away is another gun store owned by an atheist who would have no qualms about selling me that gun. Given his religious commitments, would sharing such information be ethically justified?

Let’s translate the answer to that rhetorical question into Mr. Mahoney’s situation. He went to that hospital to get care for his cancer. He did not go there to receive aid-in-dying. However, imagine this situation. His cancer treatment at the hospital is failing miserably. At this point he does request aid-in-dying since he has no interest in redemptive suffering, either for himself or anyone else.

The hospital could transfer him to another hospital where his wish could be fulfilled. However, that sounds like the situation of our Catholic gun shop owner. Alternatively, they could explain to him that it would be contrary to their corporate conscience to effect that transfer. In addition, they believe several doses of redemptive suffering would be therapeutic for his spiritual well-being.

Mr. Mahoney could retain an attorney who would point out that Mr. Mahoney has the legal right to leave the hospital against both medical and spiritual advice. Other patients, however, who might be in much worse medical circumstances (unable to be transferred) would not be able to exercise that right or the right to access aid-in-dying. That brings us to the crux of this essay.

Whose conscience should prevail in this situation? If a physician or other health professional were asked to participate in some way in a request for aid-in-dying, and if such participation were contrary to their deeply held religious or ethical beliefs, we (political authorities in a liberal, pluralistic, tolerant, democratic society) would respect those beliefs and allow them to avoid participating. This is equal and reciprocal moral respect. What would that require if Mr. Mahoney were this latter hypothetical patient stuck in that hospital? Perhaps that would require allowing a physician who was not attached to the hospital to enter the hospital for purposes of providing aid-in-dying. It is hard to imagine Centura agreeing to that.

The alternative would be to allow a member of their medical staff who believed providing aid-in-dying to a patient in these circumstances was both ethically permissible and obligatory to do just that. However, Centura has made clear that no member of that institution would be allowed to do that, thereby imposing their conscientious beliefs on hundreds of staff who might not agree with that belief. This seems contrary to the notion of reciprocal moral respect.

Centura would expect that Catholic physicians in secular hospitals would be allowed to refrain from participating in any act of aid-in-dying. Why not allow non-Catholic physicians (or liberal Catholic physicians) in Catholic hospitals to act in accord with their sense of compassionate conscientiousness in Mr. Mahoney-like situations? There is a political and ethical contradiction here: the hospital is invoking our liberal pluralistic political heritage to secure protection for their conscientious beliefs, but denying that same protection to staff and patients within their walls who disagree with that religious commitment.

The hospital might portray itself as a “religious institution,” though this is misleading at best. It is not a church whose membership is comprised of individuals who freely choose to endorse a specific faith perspective. Hospitals, whether having any religious affiliation or not, are public institutions accepting public money (Medicare, Medicaid, etc.) to care for patients with or without any religious faith. People seek health care in those institutions, not spiritual guidance, and certainly not spiritual coercion.

Noteworthy in today’s health care environment is the acquisition of smaller hospitals by larger hospital chains, including Catholic hospitals absorbing secular hospitals and imposing a Catholic identity on them. Almost 20% of all hospital beds in the United States today are under Catholic auspices. Beyond that, these hospital chains are buying up all sorts of medical practices as a way of assuring a steady (and profitable) stream of patients and patient revenue. In effect, patients are being drafted (unbeknownst to themselves) into a religious environment, potentially to become soldiers in the cause of redemptive suffering.

More problematic, as noted earlier, was that Dr. Morris was going to provide aid-in-dying in the privacy of Mr. Mahoney’s home. Mr. Mahoney was likely not a saint. Still, it is unconscionable that he would have to undergo redemptive suffering for the sake of an institution to which he owed no allegiance to satisfy the conscience of that institution and its CEO.

Finally, a Canadian Catholic hospital was recently legally obligated to make available aid-in-dying to patients in accord with Canadian law. That service would be provided in a building adjacent to the hospital and owned by the hospital. Physicians employed by the hospital would be free to provide that service. This, I conclude, is a reasonable compromise that reflects mutual moral respect regarding an ethically complex situation rather than uncompromising redemptive religious righteousness. This also represents the equal political respect required for the peaceful functioning of a liberal pluralistic society and health care system.

Leonard Fleck photoLeonard M. Fleck, PhD, is Acting Director and Professor in the Center for Ethics and Humanities in the Life Sciences and Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, February 6, 2020. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Fleck: Health Care and Social Justice: Just Take Two Aspirin for Your Tumor If You Cannot Afford Your Cancer Care; Medicare For All: This Is Going to HurtGreed Is God: The Divine Right to Avaricious Drug PricingGene Editing: God’s Will or God’s Won’t

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Center faculty published in ‘Brain Sciences’ on deep brain stimulation patient study

Laura Cabrera photoKaren Kelly-Blake photoCenter for Ethics Assistant Professor Dr. Laura Cabrera and Associate Professor Dr. Karen Kelly-Blake, along with Dr. Christos Sidiropoulos of the Department of Neurology & Ophthalmology, are co-authors of a new article in Brain Sciences. Their article “Perspectives on Deep Brain Stimulation and Its Earlier Use for Parkinson’s Disease: A Qualitative Study of US Patients” appears in a special issue on “Brain Stimulation and Parkinson’s Disease.”

Abstract
Background: Deep brain stimulation (DBS) is being used earlier than was previously the case in the disease progression in people with Parkinson’s disease (PD). To explore preferences about the timing of DBS, we asked PD patients with DBS whether they would have preferred the implantation procedure to have occurred earlier after diagnosis. Methods: Twenty Michigan-based patients were interviewed about both their experiences with DBS as well as their attitudes regarding the possible earlier use of DBS. We used a structured interview, with both closed and open-ended questions. Interviews were transcribed verbatim and analyzed using a mixed-methods approach. Results: We found that the majority of our participants (72%) had high overall satisfaction with DBS in addressing motor symptoms (mean of 7.5/10) and quality of life (mean of 8.25/10). Participants were mixed about whether they would have undergone DBS earlier than they did, with five participants being unsure and the remaining nearly equally divided between yes and no. Conclusion: Patient attitudes on the early use of DBS were mixed. Our results suggest that while patients were grateful for improvements experienced with DBS, they would not necessarily have endorsed its implementation earlier in their disease progression. Larger studies are needed to further examine our findings.

The full text is available online via MDPI.

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Listen: Considering Consciousness in Neuroscience Research

No Easy Answers in Bioethics logoNo Easy Answers in Bioethics Episode 19

What can neuroscience tell us about human consciousness, the developing brains of babies, or lab-grown brain-like tissue? How do we define “consciousness” when it is a complex, much-debated topic? In this episode, Michigan State University researchers Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences, and Dr. Mark Reimers, Associate Professor in the Neuroscience Program, discuss the many layers of consciousness. Examining recent research on lab-grown brain organoids, they discuss moral and ethical considerations of such research, including how future technologies could challenge our definitions of consciousness and moral agency. They distinguish consciousness from intelligence, also discussing artificial intelligence.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

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Bioethics for Breakfast: Our Sick Health Care System: What’s the Differential Diagnosis?

Bioethics for Breakfast Seminars in Medicine, Law and SocietyLaura Appel and Marti Lolli presented at the December 5th Bioethics for Breakfast event, offering perspectives and insight on the topic “Our Sick Health Care System: What’s the Differential Diagnosis?”

This year’s Bioethics for Breakfast series centers on the theme “Is There a Cure for Our Sick Health Care System?” The series is generously sponsored by Hall, Render, Killian, Heath & Lyman.

Our health care system is exhibiting multiple symptoms of serious illness. Treating symptoms is rarely a good idea. What we need is a differential diagnosis. What are the root causes for skyrocketing costs, increasing access barriers, physician burnout, patient non-adherence and dis-satisfaction, failed therapies, and so on? Too many greedy profit-takers? Too many stingy insurers? Too much administrative bureaucracy? Too much competition? Too little competition? Too much unhealthy behavior by patients? Too little time for patients? Too much technology? Large empathy deficits? Too little prevention? Too many medical specialists? Too few primary care physicians? Not enough evidence-based medicine? Too much waste and inefficiency? Too many hospital mergers? Too fragmented a financing system? Patients demanding too much care? Unregulated drug prices? Too many special interests shaping health care policy?

Addressing these questions, Priority Health’s Marti Lolli first emphasized that these challenges are complex and cannot be simplified. She posited that there is enough money in the system—collectively we must get creative. In “diagnosing” our health care system, she put forward three items: 1) radically overhaul the fee-for-service system, 2) move away from the “one size fits all” health care model, and 3) accept data, technology, and transparency.

Michigan Health & Hospital Association’s Laura Appel then shared her perspective. Her three-item “diagnosis” began with the first point that there is a focus on health care when the underlying problem is health. One example she gave was that kidney disease in Michigan cost Medicaid $1 billion, stating, “We cannot change the output if we don’t change the input.” Her second item was that we don’t really have a “system,” also discussing the need for more behavioral health resources. Her third item focused on evidence, and that overall, to have a “system,” the system needs to respond to the evidence, recognizing what needs to change.

 
Attendee questions and comments addressed a variety of topics, including caregiver education, advance care planning, evidence-based medicine in practice, and social and structural determinants of health. Finally, one overarching point that those in attendance seemed to agree on: change is hard.

Marti Lolli Laura Appel and Leonard Fleck speaking to audience

Image description: pictured left to right are Marti Lolli, Laura Appel, and Leonard Fleck during the question and answers portion of Bioethics for Breakfast on December 5. Image source: Liz McDaniel/Center for Ethics.

About the Speakers

Laura Appel
Laura Appel is senior vice president and chief innovation officer at the Michigan Health & Hospital Association. She focuses on healthcare policy, hospital finance, legislation and governance. At the federal level, she represents the interests of Michigan hospitals and health systems in both the legislative and regulatory arenas on key issues, including federal healthcare reform and Medicare. She is an expert in auto insurance and legislative policy and has a proven ability to influence legislation and healthcare policy through her understanding of the issues, educating influencers and policymakers, and introducing fresh ideas.

Marti Lolli, MBA
Marti Lolli is chief marketing officer and senior vice president of consumer and government markets at Priority Health, a nationally recognized health plan. She oversees the individual market, Medicare advantage and Medicaid markets, and market intelligence. She also oversees all marketing, digital strategy, communications and customer experience at Priority Health. Her areas of expertise include consumerism in health care, market trends in health care, competitive and consumer analytics, health care reform, health care innovation and strategic planning.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.
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Listen: Social Determinants of Health in Medical Education

No Easy Answers in Bioethics logoNo Easy Answers in Bioethics Episode 18

How can social determinants of health be integrated effectively into medical education and clinical practice?

This episode focuses on the topic of social determinants of health, or the social and environmental factors that influence our health and access to resources. Center for Ethics Assistant Director Libby Bogdan-Lovis and Associate Professor Dr. Karen Kelly-Blake speak with College of Human Medicine student Brittany Ajegba, who emphasizes the need for standardization when training physicians on social determinants of health. From medical education to clinical encounters, they provide a variety of perspectives on this increasingly important work.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

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Article from Dr. Laura Cabrera in November ‘Bioethics’ issue

Laura Cabrera photoAn article by Center Assistant Professor Dr. Laura Cabrera has been published in the November 2019 issue of Bioethics. The article, “A human rights approach to low data reporting in clinical trials of psychiatric deep brain stimulation,” advocates for “the importance of reporting clinical trial data of invasive procedures in highly vulnerable populations, such as psychiatric DBS trials.”

Abstract: The reporting of clinical trial data is necessary not only for doctors to determine treatment efficacy, but also to explore new questions without unnecessarily repeating trials, and to protect patients and the public from dangers when data are withheld. This issue is particularly salient in those trials involving invasive neurosurgical interventions, such as deep brain stimulation (DBS), for ‘treatment refractory’ psychiatric disorders. Using the federal database ClinicalTrials.gov, it was discovered that out of the completed or unknown‐status trials related to psychiatric DBS up to November 2018, only two had submitted results to ClinicalTrials.gov. These results suggest that, despite federal requirements to report clinical trial data, reporting on psychiatric DBS trials is problematically minimal. It is argued that a human rights approach to this problem establishes a legal and ethical foundation for the need to report clinical trial results in this area.

The full text is available online via Wiley Online Library (MSU Library or other institutional access may be required to view this article).

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We Need Healthier Schools, and Student Activists Are Stepping Up

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Sean A. Valles, PhD

California just passed two laws that advance health in schools in ways that might not seem intuitive: pushing middle school and high school start times to after 8am, and banning school districts from “lunch shaming” that treats students differently based on whether they have unpaid school lunch debt. These laws are part of a collection of diverse efforts to make U.S. schools healthier places. The fact that some of these efforts have been led by students themselves is especially heartening.

Bioethics of school policies
The two new laws in California are worthy of attention in a bioethics blog because U.S. schools are, for many students and in many ways, unhealthy places. Not simply because they are crowded spaces infamous for spreading coughs and colds (and stress). For many students, they are also places of food insecurity, social stigma, or even fear of violence. Those problems also shed light on larger problems in society. Even as a child in Los Angeles, I grasped that the local high school having a metal detector at the door signified that something much bigger had gone horribly wrong in my community. Most student problems have their roots outside the school walls, but we can at least do our best to design schools to contend with the difficult realities of young people’s lives.

There is now compelling evidence that later start times for schools are better for adolescent health than early morning ones. As pointed out in one review of the research, adolescents’ bedtimes seem to be more or less independent of when school starts in the morning, partly due to biological clock rhythms changing during puberty. Students forced to begin school early in the morning suffer all of the resulting harms of insufficient sleep (most readers are surely aware that insufficient sleep is bad for physical and mental well-being). This change is surprising in part because the American Academy of Pediatrics has, with limited success until now, been pushing for later school start times, insisting that school start times should facilitate the 8.5-9.5 hours of sleep appropriate for adolescent biology. It will be a difficult schedule transition for some California schools and families/guardians to adjust to, but the health rationale remains powerful.

Stigmatizing and manipulating students are problems, not solutions
It is also encouraging to see California legislate against lunch shaming. Unless prohibited, U.S. schools have the freedom to intentionally or incidentally shame students for being unable to afford their lunch meals. They have done so by giving indebted students inferior meals, marking the students with wristbands or stamps, etc. This is a serious health matter because imposing a stigmatized status upon a child, or even just amplifying an existing one, is a harmful act. Research is quite clear that stigma (“the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised”) is a powerful and pervasive cause of health injustices. Stigma stresses bodies, socially controls people, and excludes them from social opportunities and resources available to others. Being a child without enough money to pay for lunch is quite hard enough, without one’s school officials metaphorically painting a target on one’s back.

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Image description: Young person at the March for Our Lives protest, holding a placard painted with the words “AM I NEXT?” in red. Image source: Roger Jones/Public Domain.

The desirability of the California law gets clearer when one looks at a policy that goes in the opposite direction. In a widely-criticized lurch backwards, a newly-created policy in a New Jersey school district gives discretion to principals to ban students with lunch debt from participating in extracurricular activities. Which students? Under which circumstances? What goals are achieved by such exclusions? Certainly banning students from soccer practice or chess club doesn’t make money magically appear in their parents’ pockets. The policy is a setback, but I am encouraged by the backlash that gives a new sense of clarity to how remarkably regressive this policy is in light of the opposite trend.

Student advocacy should be welcomed
Most encouraging to me is the fact that students are advocating for themselves and the health of their schools. I am glad that the American Academy of Pediatrics and some California state legislators are advocating for healthier schools, but I have argued at length elsewhere that it is preferable to empower people advocate for themselves. And so students are. For instance, they have been at the forefront of a series of lobbying efforts (successful in Oregon and Utah) to get mental sick days recognized as legitimate reasons for missing school.

It is no coincidence that this push to create space for “mental health days” comes in the middle of a period of worsening mental health of young people in the U.S. Deaths from suicides just replaced deaths from homicides as the second leading cause of death among 15-19-year-olds (deaths from traffic accidents are down, but still exceed both). And homicides are also a target of student activism; after the Parkland school shooting, young people became the unexpected leaders of a new wave of gun control activism.

The late 2010s have been a time of disorienting rapid change, but I suspect that future historians will highlight one global social phenomenon: young people demanding a better world. The most prominent example is the rise of young climate change activists around the world—Greta Thunberg being the most famous—demanding action with a new sense of clarity and resolve. As I write this, Teen Vogue’s website teases an article with a link saying “Why Homeless Advocates Aren’t Happy With the 2020 Presidential Candidates” and an op-ed on radical labor organizing among nail salon workers.

Better health through better spaces
Even though lunch shaming, poor mental health, exhaustion and all sorts of other health problems still tragically afflict young people in schools, I am optimistic because it really does feel that the winds have shifted—thanks in large part to student activists, unhealthy schools are finally getting reforms they have long needed. As I argue at length in the book Philosophy of Population Health, health depends not just on whether we have good medical care, but also on whether the places where we live our everyday lives have been thoughtfully designed to support good health.

Sean Valles photo

Sean A. Valles, PhD, is an Associate Professor with an appointment in Lyman Briggs College and the Department of Philosophy at Michigan State University. His research spans a range of topics in the philosophy of population health, from the use of evidence in medical genetics to the roles played by race concepts in epidemiology. He is author of the 2018 book, Philosophy of Population Health: Philosophy for a New Public Health Era. He is also Director of the MSU Science and Society @ State Program, supporting interdisciplinary faculty collaborations that join the humanities, arts, and sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 28, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Valles: Recognizing Menstrual Supplies as Basic Health Necessities: The Bioethics of #FreePeriodsTrump’s Attempt to Reignite the Coal Industry Is Another Health Policy BlunderPolitics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence; Climate Change and Medical Risk

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