by Craig Klugman, Ph.D.
Medical School Interviewer: “If you could, please tell me why you decided to apply to medical school and pursue a career in medicine?”
Applicant: “So that I could refuse to treat the godless heathens.”
Interviewer: “Under U.S. rules, that is your right. Welcome to Med School.”
Under a new rule, the Trump Administration has strengthened a religious liberty clause that protects health care workers who refuse to perform procedures or treat patientsthat violate their religious beliefs. The rule allegedly attempts to protect these health care providers from having to perform abortions, sterilizations, assisted suicide, global health, hearing screening, vaccination, mental health treatment, and even to follow an advance directiveif that legal and safe procedure violates their moral conscience, even if inaction would result in the death of the patient. The protections extend not only to the health care providers actions but allows them to refuse to refer a patient to another provider. Doctors can now be judge, jury, and executioner in their own religious courts of health care.
Besides a blow to women, the elderly, and people with terminal illnesses, the new rules also pose an [intended] threat to the health of people who identify as LGBQT, especially the T. The administration seems threatened by people who transition and are setting up roadblocks to their fair and equal treatment in society (e.g. exclusion from the military). If a health care provider believes that HIV is a punishment from a deity for being LGB, then that practitioner can refuse to provide treatment. Believe that people who overdose deserve it as a punishment for the “sin” of addiction? You can withhold naloxone. For people at the end of life, the new rules restrict their options both legal and illegal such as assisted suicide, euthanasia, mercy killing, and advanced[sic] directives. Also effected is anyone needing certain health screenings for hearing.
These rules follow on the laws of 46 states that permit conscience objection for performing abortions. The Texas legislature is looking at a bill that allows any state licensed professional to refuse to serve based on religious ground. A hairdresser could refuse to style a person of a particular ethnicity. A therapist could refuse to help a suicidal, gay teen. And a real estate agent could refuse to sell a house to a family because they aren’t wanted in this neighborhood. The “bigot bill” as opponents have called it seeks to entrench discrimination into the law under the guise of religion. But let’s call this what it is, this is a move to privilege a group of people (mostly White, mostly middle and upper socioeconomic class, mostly male, mostly straight, mostly cis-gendered, mostly Christian) over everyone else. This is an attempt to legalize bigotry and to return us to the era of Jim Crow, restricting Jews in clubs, keeping women at home, and keeping LGBQT people in the closet. This is an effort to create a theocracy our of a democracy.
Although there has been a lot of news reporting on these rules, none of them have discussed that these regulations give a health care provider the right to ignore an advance directive if it conflicts with the practitioner’s religious belief. If a patient has an advance directive, a POLST, even a medical power of attorney all agreeing to withdraw or withhold treatment, the health care provider can refuse to follow them if their religion does not permit doing anything less than everything. These rules are a direct attack on patient autonomy. Of course autonomy does not mean you get what you want when you want it, but not a provider has cover if they wish to ignore patient-provider-family decision-making. Imagine a Jehovah’s Witness doctor refusing to give a patient blood because their religion suggests that might be a moral problem. With a rising rate of preventable infectious diseases due to vaccine refusal, several states have removed exemptions based on philosophical, personal, or religious belief to save lives, but the new rules allow a health care provider to refuse to give vaccines. Thus, even if a state requires vaccination, a health care provider can refuse to give them.
Beyond the deadly health implications of this new rule, they may also lead to stigmatizing people, groups of people, and certain health care conditions. Being refused a treatment because of a disease or identifying as a member of a group can be harmful to a person’s psychological and social sense of health and well-being. A person being told no, they cannot get their sex transition surgery may feel further stigmatized. A person being told they cannot have their HIV medication, may be forced back into the closet, become sicker, and potentially spread the virus to others. A person refused an abortion that threatens her health, may find herself pursuing back alley methods or dying. I expect to see rates of morbidity and mortality to increase.
Not every health care provider will push their beliefs on their patients. The rules do not do that. But, the rules protect those who do make that choice. The rules privilege the health care provider’s religious beliefs above all else.
If you are a health care provider who cheers these new regulations, you might want to reconsider your chosen profession. A health care provider is someone who must put their professional ethical obligations over their personal morality. They are someone who has joined a profession dedicated to altruism—the healing of others in need no matter who that person is. Thus, if your religion or personal beliefs require to refuse to do some safe, legal procedures or to refuse to treat some populations, now is the time to find a new profession. Health professional, nursing, and medical training programs should admissions adopt questions to screen out candidates who would have trouble treating some patients or using some procedures. If you cannot act to serve your patient’s needs and to put your professional duties and obligations above your own, then you should find work elsewhere. If your need to judge people and condemn them based on your own notions of right and wrong, then you should seek careers in places where people’s lives and well-being do not rest in your hands. At the very least, do not go into a discipline or specialty where you might encounter procedures or patient populations that offend your religious sensibilities. No, the new regulations mean you cannot be fired for acting on your bigotry, but just because something is legally covered does not make it ethically correct. A license to practice means to apply the best scientific evidence toward healing, not religious belief. Have no doubt, these rules are ethically wrong.
San Francisco has filed a lawsuitagainst these rules in claiming it will harm people by reducing access to care. They have asked a US District Court judge to stay the rule for now. I hope that many more cities, states, and professional organizations join in.