Christian Medical Association
Memorandum to Office of Public Health and Science
Department of Health and Human Services
April 9, 2009
Commentary re: Regulation 45 CFR Part 88 (2008) [Rescinded]
U.S. Department of Health and Human Services
- Note: This commentary refers to a
in December, 2008 by the Bush Administration. It was eviscerated by the
Obama Administration and re-issued in February, 2011. [See
Christian Medical Association,
Vice President for Government Relations
Reproduced with permission
Re: Data and analysis of two national surveys on conscience rights
regulation and laws, as related to HHS requested information on rescission
The objective and scientific polling data reported in this document answers
the four specific questions posed by HHS:
1. "Information, including
specific examples where feasible, addressing the scope and nature of the
problems giving rise to the need for federal rulemaking and how the current
rule would resolve those problems;"
- Answer: Discrimination is rampant in health care, and those
experiencing the discrimination virtually unanimously support the
2. "Information, including specific examples where feasible, supporting or
refuting allegations that the December 19, 2008 final rule reduces access to
information and health care services, particularly by low-income women;"
- Answer: Rescinding the regulation--and thereby
diminishing the reality of the protections intended by the
laws the regulation implements--holds the potential to create a
crisis of healthcare access, particularly for the poor and medically
underserved populations served by faith-based healthcare
3. "Comment on whether the December 19, 2008 final rule provides sufficient
clarity to minimize the potential for harm resulting from any ambiguity and
confusion that may exist because of the rule;"
- Answer: To our knowledge, apart from anecdotal accusations by
opponents of the final rule, no credible data or scientific evidence
whatsoever has been presented to demonstrate that the conscience
protection rule has caused harm. Since the final rule went into
effect, none of the dramatic speculations of harm postulated by
opponents of the rule seem to have materialized.
To the contrary, this objective polling data clearly demonstrates
that the regulation is seen by those healthcare professionals who
have experienced actual harm as the best vehicle to reduce
the harm of discrimination caused by long-standing ambiguity and
confusion in the medical community regarding conscience-protecting
4. Comment on whether the objectives of the December 19, 2008 final rule
might also be accomplished through non-regulatory means, such as outreach
- Answer: This data clearly shows that healthcare professionals
who actually have been experiencing discrimination flatly and
overwhelmingly reject outreach and education as an alternative to
the regulation, which they virtually unanimously support.
The attached document provides scientific polling information that addresses
the four specific questions requested by HHS in evaluating the provider
- One poll was conducted online and sampled the opinions of
faith-based healthcare professionals-the group most likely to experience
the type of discrimination on the basis of religious beliefs prohibited
by the three federal laws that form the basis for the provider
- Another poll sampled opinions of the general public, was conducted
by the polling companyTM, inc./WomanTrend and fielded March 23-25, 2009
at a Computer-Assisted Telephone Interviewing (CATI) facility using live
Online survey of faith-based healthcare professionals
Rationale and methodology
Accurately gauging the impact of applicable civil rights laws and the
conscience protection regulation in addressing discrimination on the basis
of religious convictions requires a specific focus on the population most
likely affected by such discrimination: faith-based healthcare
On behalf of the Christian Medical Association, the polling companyâ„¢,
inc./ WomanTrend conducted an online survey of members of faith-based
healthcare organizations. The survey was fielded March 31, 2009 to April 3,
2009 and was completed by 2,298 members of the Christian Medical Association
(CMA), 400 members of the Catholic Medical Association (CMA), 69 members of
the Fellowship of Christian Physicians Assistants, 206 members of the
Christian Pharmacists Fellowship International, and 8 members of Nurses
Christian Fellowship. Respondents were allowed to select membership in
multiple organizations; the total number of participants was 2,865.
Each respondent was provided with a unique hyperlink to take the survey,
allowing no member to take the survey more than once and prohibiting
respondents from passing the link to another individual after completing the
survey. This survey is intended to demonstrate the views and opinions of
members surveyed. It is not intended to be representative of the entire
medical profession nor of the entire membership rosters of these
organizations. Respondents who participated in the survey were
In overwhelming numbers, faith-based healthcare professionals and
students will quit medicine before compromising religious convictions.
In the survey of 2,865 members of faith-based organizations, a full 91% of
respondents agreed with the question, "Please tell me whether you strongly
agree, somewhat agree, somewhat disagree, or strongly disagree with the
following statement: 'I would rather stop practicing medicine altogether
than be forced to violate my conscience.'"
- 14% Somewhat Agree
- 77% Strongly Agree
When Obstetricians and Gynecologists are segmented out of the overall survey
respondents, results show that nearly all say they will quit medicine if
pressured to compromise ethical standards. Over half of the faith-based
Ob-Gyn physician respondents serve the poor and medically underserved.
"Please tell me whether you strongly agree, somewhat agree, somewhat
disagree, or strongly disagree with the following statement: "I would rather
stop practicing medicine altogether than be forced to violate my
- 9% Somewhat Agree
- 88% Strongly Agree
"Are you currently involved in serving poor and medically-underserved
- 6%Yes, in a full-time capacity
- 13% Yes, in a part-time capacity
- 36% Yes, in an occasional capacity
- 54% Yes total
When the subgroup of students is segmented out from the survey respondents,
a similar response is found. An overwhelming 85% of students agreed with
this statement: "Please tell me whether you strongly agree, somewhat agree,
somewhat disagree, or strongly disagree with the following statement: "I
would rather stop practicing medicine altogether than be forced to violate
- 21% Somewhat Agree
- 64% Strongly Agree
Patient access-especially in medically underserved areas--will suffer
if faith-based healthcare professionals are forced to violate their moral
and ethical codes.
If these doctors follow through with their promises to limit their
practices, it could have wide-reaching implications in areas already lacking
in medical access:
- Eighty-nine percent of individuals who practice mostly in rural
areas, 82% who work mainly in urban areas, and 86% who provide services
in suburban areas said they would be "somewhat" or "very" likely to
reduce or end altogether their practice of medicine.
- Eighty-seven percent of respondents with a patient base that is
predominantly low-income (76% to 100% "low-income") said they could be
very or somewhat likely to limit the scope of their practice.
- Eighty-two percent who serve poor and medically-underserved
populations on a full-time basis said they would likely cut back or
cease practicing if coerced to perform abortions.
Physicians and other medical professionals voiced their concerns that
serious consequences could occur if doctors are forced to participate in or
perform practices to which they have moral or ethical objections:
- Nearly three-quarters (74%) believed that elimination of the
conscience protection could result in "fewer doctors practicing
- 66% predicted "decreased access to healthcare providers, services,
and/or facilities for patients in low-income areas,"
- 64% surmised "decreased access to healthcare providers, services,
and/or facilities for patients in rural areas,"
- 58% hypothesized "fewer hospitals providing services."
When asked how rescission of the conscience rule would affect them
personally, fully 82% said it was either "very" or "somewhat" likely that
they personally would limit the scope of their practice of medicine. This
was true of 81% of medical professionals who practice mainly in rural areas
and 86% who work full-time in serving poor and medically-underserved
Faith-based healthcare professionals nearly unanimously
support the conscience protection regulation and the principles behind it.
Fully 97% of the faith-based healthcare professionals who participated in
the survey supported the two-month-old conscience protection clause, and 96%
objected to rescission of the rule.In a question relating to current rules
and regulations, 97% of respondents offered their stamp of approval to the
rule that was described as follows: "just over two months ago, a federal
regulation known as "conscience protection" went into effect in the U.S.
after reports of discrimination against healthcare professionals who decline
to participate in abortions. It protects doctors and other healthcare
professionals who work at institutions that receive federal money from
participating in abortion and other procedures to which they object on moral
or religious grounds."
Among the more than 2,800 respondents who participated in the survey,
nearly all (98%) strongly or somewhat opposed any types of regulations that
"require medical professionals to perform or provide procedures to which
they have moral or ethical objections."
When asked to assess the importance of "[making] sure that healthcare
professionals in America are not forced to participate in procedures or
practices to which they have moral objections," 100% of respondents said it
was imperative (98% "very" and 2% "somewhat").
In a follow-up question, 92% of respondents said that the rule is
necessary (83% "very" and 9% "somewhat" necessary) based on their own
knowledge of discrimination in healthcare on the basis of conscience and
religious and moral values.
In a related question, respondents learned (or were reminded) that the U.S.
Department of Health and Human Services had more recently proposed
rescission of the rule. Specifically, respondents were told: "In early
March, a regulation change was proposed by the administration that would
effectively eliminate the two-month-old conscience protection regulation.
This could make it more likely that doctors and other healthcare
professionals could be coerced to participate in procedures to which they
object on moral or religious grounds." Reaction to this possible revocation
was intense, with fully 96% of these members of faith-based organizations
opposing any removal of the rule.
Faith-based healthcare professionals flatly reject outreach and
education as an alternative to regulation.
The Department of Health and Human Services has asked whether the objectives
of the conscience protection regulation can be achieved "through
non-regulatory means, such as outreach and education." Nearly nine-in-ten
(87%) members surveyed - those who are on the ground, in hospitals and
clinics across the country - felt "outreach and education" alone were
insufficient to accomplish the goal.
Ninety-two percent declared the
codification of conscience protection to be necessary (83% "very" and 9%
"somewhat") based on their knowledge of "discrimination in healthcare on the
basis of conscience, religious, and moral values."
High percentages of faith-based professionals report experiencing
discrimination in professional practice.
When asked to evaluate the prevalence of discrimination in the medical
system against doctors, nurses, and other healthcare providers for"declining
to participate in or provide medical procedures to which they have moral or
religious objections," nearly three-in-five (59%) said it was "very"
(25%) or "somewhat" (34%) common. Women were more likely than men (62% vs.
58%) to say this occurred with some frequency. Respondents in the following
specialties were above the average in citing such discrimination as a common
occurrence: anesthesia (69%), emergency medicine (69%), family medicine
(67%), general medicine (76%), internal medicine (69%), and obstetrics and
gynecology (66%). When asked to assess their own professional experiences:
- 32% have "been pressured to refer a patient for a procedure to which
[they] had moral, ethical, or religious objections
- 26% have "been pressured to write a prescription for a medication to
which [they] had moral, ethical, or religious objections
- 17% have "been pressured to participate in training for a procedure
to which [they] had moral, ethical, or religious objections."
- 12% have "been pressured to perform a procedure to which you had
moral, ethical, or religious objections."
Respondents have witnessed growing hostility toward medical
professionals with strong moral and religious beliefs.
Nearly two-thirds (66%) of respondents felt that "the number of doctors
being asked to compromise their moral, ethical, or religious beliefs in the
capacity of their work" increased during the course of their professional
experience; just 7% thought it has stayed the same while a paltry 1%
believed it has decreased.
Though respondents with 20+ years of experience were especially likely to
believe that the number of instances has grown, even those who are
relatively "new" to the profession have witnessed an upward trend in this
type of discrimination:
Separately, more than three-quarters (78%) reflected on their careers and
considered the federal government to have become less tolerant of "doctors'
moral, ethical, or religious beliefs." In contrast, 6% believed the
tolerance level has not changed while only 2% saw improvement.
High percentages of faith-based professionals report experiencing
discrimination in education.
Many respondents held this opinion due in
part to their own personal experience. When asked to assess their
- 39% have "experience pressure from or discrimination by faculty or
administrators based on [their] moral, ethical, or religious beliefs"
- 33% have "considered not pursuing a career in a particular medical
specialty because of attitudes prevalent in that specialty that is not
considered tolerant of [their] moral, ethical or religious beliefs."
- 23% have "experienced discrimination during the medical school or
residency application and interview process because of [their] moral,
ethical or religious beliefs."
Significant numbers are eschewing careers in obstetrics because of
discrimination and coercion.
Among the 608 respondents who said they have "considered not pursuing a
career in a particular medical specialty because of attitudes prevalent in
that specialty that is not considered tolerant of [their] moral, ethical or
religious beliefs," 81% said they specifically avoided obstetrics and
gynecology when presented with a list of 38 medical specialties and asked to
identify the areas they passed up.
An alarming number of faith-based
students are deciding not to pursue careers in Ob-Gyn as a result of
perceived discrimination and coercion in the field related to their
convictions. The following responses were entered in response to, "Which of
the following best describes you:"
- 6% I am currently pursuing a career in Obstetrics or Gynecology
- 20% I am not pursuing a career in Obstetrics or Gynecology mainly
because I do not want to be forced to compromise my moral, ethical, or
religious beliefs by being required to perform or participate in certain
procedures or provide certain medications.
Nationwide survey of American adults
The polling companyTM, inc./WomanTrend on April 6 presented to the
Christian Medical Association the findings of a recent nationwide survey of
800 American Adults (18+). All substantive questions were closed-ended in
Following is an analysis of the specific questions in that survey that
address the four questions solicited by HHS in evaluating the provider
conscience regulation. Also included is an analysis of some questions that
address public opinion in general related to the regulation and the laws
that undergird the regulation.
The survey was fielded March 23-25, 2009 at a Computer-Assisted Telephone
Interviewing (CATI) facility using live callers. The sample was drawn
utilizing Random Digit Dial, a computer dialing technique that ensures that
every household in the nation with a landline telephone has an equal chance
of being called. Each respondent was screened to ensure he or she was 18
years of age.
Sampling controls were used to ensure that a proportional and representative
number of people were interviewed from such demographic groups as age, race
and ethnicity, and region according to the most recent figures available
from the U.S. Census Bureau and voter registration and turnout figures.
After data collection, weighting was used to ensure that the sample
reflected the current population. This is a common and industry-accepted
practice. Age, race, and gender were allowed four points of flexibility in
pre-set quotas while three points of flexibility was permitted on region.
The overall margin of error for the survey is Â± 3.5% at a 95% confidence
interval, meaning that in 19 out of 20 cases, the data obtained would not
differ by any more than 3.5 percentage points in either direction if the
survey were repeated multiple times employing this methodology and sampling
method. Margins of error for subgroups are higher.
It should be noted that some of the subgroups in this study are quite small,
accounting for less than 50 total respondents, e.g., Asian-Americans (n=32),
self-identified Agnostics/Atheists (n=3 1), and self-identified moderate
Republicans (n=36). It is not advisable to draw scientific conclusions about
these cohorts within this study.
Americans of All Demographic Characteristics and Political Stripes
Seek a Shared a Set of Values with their Healthcare Providers.
Fully 88% of American adults surveyed said it is either "very" or "somewhat"
important to them that they enjoy a similar set of morals as their doctors,
nurses, and other healthcare providers. Intensity was strong, as 63%
described this as "very" important while at the other end of the spectrum,
just 6% said it is "not at all important," a ratio of more than 10-to-1.
Healthcare Providers' Conscience Protections Viewed as an Inalienable
A sizable 87% of American adults surveyed believed it is important to "make
sure that healthcare professionals in America are not forced to participate
in procedures and practices to which they have moral objections." Support
for this protection garnered considerable intensity as well, with 65% of
respondents considering it very essential. Majorities of men, women, and
adults of all ages, races, regions, and political affiliations considered it
critical to defend the rights of healthcare providers to refuse to perform
certain procedures on moral grounds.
Americans Oppose The Principle of Forcing Healthcare Providers to Act
Against Their Consciences...
A majority (57%) of Americans opposed regulations "that require medical
professionals to perform or provide procedures to which they have moral or
ethical objections." In contrast, 38% favored such rules. The potency of
opposition was twice that of the supporters: 40% strongly objected to the
laws while just 19% strongly backed them.
...support laws that protect them from doing so...
Without any names or political parties being mentioned, respondents were
provided with a short description of the new conscience protection law and
its recent inception: "Just two months ago, a federal law known as
'conscience protection' went into effect after reports of doctors being
discriminated against for declining to perform abortions. It protects
doctors and other medical professionals who work at institutions that
receive federal money from performing medical procedures to which they
object on moral or religious grounds."After hearing this short description,
support for this new law outpaced opposition by a margin of more than 2-to-1
(63% vs. 28%). Intensity favored the law, with 42% strongly backing it and
19% strongly rejecting it. Endorsements for the rule spanned demographic and
political spectra, with majorities in all cohorts offering their support.
Even 56% of adults who said they voted for President Obama last fall and 60%
of respondents who self-identified as "pro-choice" said they favor this
two-month old conscience protection rule.
... and oppose any efforts to remove such laws.
Next, respondents were asked to react to the proposed rescission of the
conscience protection law: "Earlier this month, officials from the U.S.
Department of Health and Human Services introduced a rule change that would
effectively eliminate the two-monthÂold conscience protection. This could
mean that doctors and other medical professionals could be coerced to
participate in medical procedures to which they object on moral or religious
grounds."Opposition to revocation of the conscience protection law outpaced
support by a margin of more than 2-to-1 (62% vs. 30%). As was the case in
the previous question, intensity favored retention of the law (44% strongly
opposing rescission versus 17% strongly supporting it). Again, there was
consistent demographic alignment, as a majority of men, women, and adults of
all ages, races, incomes, regions, and geographic types stood together to
reject removal of the law. And, there was cohesiveness across political
lines, as 52% of self-identified Democrats, 67% of self-identified
Independents, and 73% of self-identified Republicans, as well as 50% of
liberals, 65% of moderates, and 69% of conservatives also opposed
Americans pursue healthcare providers who share a similar set of
A full 88% of American adults considered it important for their doctors,
nurses, and other healthcare providers to possess a common code of morals
and values to their own. In fact, 63% said this criterion is "very
important," more than 10 times the number who said it was "not at all
Majorities of men, women, and adults in all age and
income groups and of all races, regions, political identifications, and
ideologies considered it not only important, but very important, that they
share values with their healthcare providers. Even majorities of
conservative Republicans (89%), moderate Republicans (95%), liberal and
moderate Democrats (80%), and conservative Democrats (96%) aligned on this
question, deeming it meaningful to find healthcare providers with analogous
values as them.
Americans place high value on doctors' rights to decline to
participate in procedures they find morally wrong
A similar number to those who placed a premium on having healthcare
providers who share their moral beliefs, 87%, said in a separate inquiry
that it is important that "healthcare professionals in America are not
forced to participate in procedures or practices to which they have moral
objections." Intensity was potent, with 65% saying that such a protection is
"very important." In contrast, just 11% dismissed its significance (5% "not
too important" and 6% "not at all important").Again, there was demographic
alignment across the board, as majorities of men, women, and adults of all
ages, races, regions, and political stripes emphasized the need to protect
medical professionals from being forced to violate their consciences.
Adults with opposing views on abortion forged similar opinions on this
matter as well.
Three in five back two-month-old conscience protection rule; three in
five oppose its rescission
In the next two questions, respondents were asked to express their views on
the current conscience protection rule signed into law in January 2009
toward the end of the Bush administration and again on the proposed
rescission of the rule suggested by officials at the U.S. Department of
Health and Human Services. As indicated in the verbatim recitation of the
questions (see textboxes), neither President Bush's nor President Obama's
names were mentioned in the language of the questions; this was an
intentional omission so as not to overly personalize or politicize
respondents' answers.In the first question, respondents learned about the
conscience protection rule, its origin, and its implications. Overall,
support outpaced opposition by a margin of more than 2-to-1 (63% vs. 28%);
and intensity favored the rule (42% strongly supporting vs. 19% strongly
opposing). Even 59% of people who earlier in the survey generally supported
regulations that required medical professionals to perform or provide
procedures to which they have moral or ethical objections supported this
Again, majorities of adults across gender, age, regional, party,
ideological, and income lines, as well as among all three major geographic
types (urban, rural, suburban), endorsed the twoÂ-month-old conscience
protection law designed to protect doctors from obligatory participation in
procedures to which they object.
In the second question, respondents were informed that officials at the U.S.
Department of Health and Human Services had introduced a rule change that
would effectively eliminate the conscience protection rule with a young age
of two years. Like the previous question, a 2-to-1 margin emerged. In this
case, however, opposition outweighed support (62% vs. 30%). Intensity
favored retention of the rule (44% strongly oppose elimination vs. 17%
strongly support elimination).
A majority of men and women, as well as
more than one-half of adults in all age groups and of all races, regions,
political parties, ideologies, income levels, and geographic types opposed
rescission of the rule.
Hyde-Weldon backed by a majority of adults
After provided a short definition of the Hyde-Weldon amendment (see adjacent
textbox), 57% of American adults affirmed their support for the law that
states that tax dollars cannot be used by programs (government or non-
government) to discriminate against hospitals, health insurance plans, and
healthcare professionals who refuse to perform abortions. Though 31% overall
opposed the rule (13% "somewhat" and 18% "strongly"), an even greater
proportion of respondents - 34% - strongly backed the amendment. In every
major demographic category - age, gender, region, race, and income - as well
as in all political categories - party, ideology, and presidential vote -
more than one-half of respondents offered their support for the Hyde-Weldon
The objective evidence is clearly on the side of the conscience
protection regulation. Faith-based healthcare professionals report rampant
discrimination in healthcare based on conscience. They overwhelmingly
support the regulation and the laws that undergird it.
The support of the American public mirrors the support of these healthcare
professionals for the regulation and civil rights protections in healthcare.
Removing conscience protections-as embodied in the regulation-is an affront
to most American patients, who prize the ability to choose healthcare
professionals who share their moral values.
Virtually all faith-based
healthcare professionals, if forced to violate their conscience and
convictions, report that they will leave medicine. This loss could
create a monumental healthcare access crisis, with poor patients and
medically underserved populations hit hardest.
The conscience protection rule well serves its purpose--which is to
implement the conscience protection laws and principles that have been
neglected and violated for so long in the medical community. If left
unchanged, will significantly reduce the discrimination in healthcare that
has targeted life-affirming healthcare professionals with increasing
ferocity and which threatens the conscientious care of millions of patients.