Freedom of conscience in health care: “an interesting moral swamp”?

Responding to Caplan AL. Whose rights come first: Doctors or patients? Medscape, 5 November, 2019

Sean Murphy*

“Whose rights come first?” asks Professor Arthur Caplan in a recent Medscape column. “Doctors’ or patients?”

“You can’t have physicians, pharmacists, nurses, and social workers saying they are not going to do legally allowed medicine or standard-of-care treatment because it violates their rights,” says Professor Caplan. He does suggest that refusal can be allowed if the objector can find a substitute “and it doesn’t disrupt the ER or the organization of healthcare delivery.” . . . Full text

Nova Scotia hospital forced to provide euthanasia, assisted suicide

Services to be provided in attached building

Arrangement said to preserve Catholic identity

Sean Murphy*

Hospital

St. Martha’s Regional Hospital in Antigonish, Nova Scotia, will begin providing euthanasia and assisted suicide (EAS). The hospital had refused to provide the services because they were considered to be contrary to the Catholic identity of the hospital. The change of policy appears to have been forced by the threat of a lawsuit by EAS advocates. A campaign to force the hospital to permit EAS services had been ongoing for some time [See 958 days without medical assistance in dying policy, Ban on assisted dying at St. Martha’s hospital should end, says law prof].

St. Martha’s was established by a Catholic religious order, the Sisters of St. Martha. However, in 1996 the order transferred ownership of the hospital to the state. The terms of the transfer were set out in a “Mission Assurance Agreement” that required the state to ensure that “the philosophy, mission and values of St. Martha’s Regional Hospital would remain the same and the hospital would keep its faith-based identity.”1

Notwithstanding the terms of the agreement, from 1996 the hospital was not legally a private or Catholic institution, even though it is popularly known as “Nova Scotia’s only Catholic hospital .”2 EAS advocates argued that state ownership of the hospital made it a state actor obliged to provide euthanasia and assisted suicide.1 Logically, this would also apply to abortion, surgical sterilizations, and other procedures contrary to Catholic teaching.

The Nova Scotia Health Authority states that the change of policy is consistent with “the spirit of the Mission Assurance Agreement,”3 which seems to imply that a way has been found for the hospital to “keep its [Catholic] faith-based identify” while providing euthanasia and assisted suicide.

According to NSHA’s Vice President of Health Services and Chief Nursing Executive Tim Guest, euthanasia and assisted suicide will be provided in the Antigonish Health and Wellness Centre, formerly the Martha Center.4

Built in 1961, the Antigonish Health and Wellness Center is attached to St. Martha’s Regional Hospital. In 2009, still known as the Martha Center, it was described as “primarily a professional building” of 92,000 square feet that had undergone major renovations between 2006 and 2009.5

The Sisters of St. Martha have issued a statement:

The Sisters of St Martha were informed that the Nova Scotia Health Authority continues to uphold our Mission Assurance Agreement, while providing access in Antigonish for individuals who request Medical Assistance in Dying (MAID).

The Nova Scotia Health Authority has assured us that Medical Assistance in Dying (MAID) will not take place in St. Martha’s Regional Hospital. We do not own St. Martha’s Regional Hospital, or the building called the Antigonish Health and Wellness Center. . . 6

It is not clear from the statements if assessments and preliminaries for euthanasia/assisted suicide will occur in the hospital building, with actual administration of lethal medication taking place in the Health and Wellness Center.

1. Downie J, GilbertD. Nova Scotia now a leader in medical assistance in dying [Internet]. The Chronicle Herald. 2019 Sep 19.

2. Willick F. Ban on assisted dying at St. Martha’s hospital should end, says law prof [Internet]. CBC News. 2018 Dec 28.

3. Lord R, Quon A. NSHA quietly changes medically assisted dying policy at Catholic hospital [Internet]. Global News. 2019 Sep 18.

4. 989XFM. Nova Scotia Health Authority allows Medically Assisted Death at St. Martha’s Regional Hospital [Internet]. 2019 Sep 19.

5. Guysborough Antigonish Strait Health Authority. Request for Proposal: Radio Frequency (RF) Wireless Site Survey [Internet]. 2009 Apr 17.

6. Boisvert B. Sisters of St. Martha Media Statement [Internet]. 2019 Sep 19.

Pope Francis on conscientious objection by health care practitioners

La Croix misrepresents papal statement

Sean Murphy*

Pope FrancisAn article in La Croix International, “Pope reminds health workers to put patients first” includes a subtitle, “Conscientious objectors told that human dignity demands exceptions sometimes be made.” (La Croix International, 20 May, 2019)

The subtitle reflects speculation by critics unidentified by the article’s anonymous author(s) that the Pope’s comments were aimed at “pro-lifers who may object to performing an abortion, even though the mother may, for various reasons, risk serious and even life-threatening physical or psychological trauma should she try to conceive.”

La Croix appears to be alone among news agencies in putting this “spin” upon the Pope’s address (Compare reports by Crux, Vatican News, ANSA, and the Catholic Herald, for example).

“[T]o put patients first” accurately conveys one of Pope Francis’ messages to the Italian Catholic Association of Health Care Workers.

“Conscientious objectors told that human dignity demands exceptions sometimes be made” does not.

Nothing in the text of the of the Pope’s address remotely suggests that human dignity sometimes requires health care workers to set aside their conscientious convictions and their objections and do what they believe to be wrong.

Pope Francis said nothing of the kind.  But that is precisely the kind of demand made by activists and even state authorities in a number of countries, even (as in Canada) to the extent of forcing unwilling practitioners to be parties to killing their patients or helping them commit suicide.

The misrepresentation exemplified in the La Croix article supports such attacks on freedom of conscience (and religion) and exacerbates the problems faced by healthcare practitioners attempting to resist them.

What Pope Francis actually had to say warrants attention by anyone who wants to understand the exercise of freedom of conscience by health care practitioners.

He noted that “any medical practice or intervention on the human being must first be carefully assessed if it actually respects human life and dignity (“di ogni pratica medica o intervento sull’essere umano si deve prima valutare con attenzione se rispetti effettivamente la vita e la dignità umana.”) .

When health care practitioners refuse to provide procedures or services, it is typically because they have made that assessment,and consider the interventions contrary to the good of the human person and subversive of the integrity and dignity of human life: in brief, harmful to the patient.

Conscientious objection in such circumstances, the Pope said, does not just reflect the need to preserve one’s personal integrity, but “also represents a sign for the healthcare environment in which we find ourselves, as well as for the patients themselves and their families” ( “ma rappresenta anche un segno per l’ambiente sanitario nel quale ci si trova, oltre che nei confronti dei pazienti stessi e delle loro famiglie. “)

In many situations, this “sign” may well be a sign of contradiction to the dominant ethos, likely to trigger violent emotional reactions and repression by state or professional authorities. Hence, for purely pragmatic reasons, it behooves objecting practitioners to be careful in expressing themselves. Beyond this, Pope Francis offers advice that reflects the actual practice of practitioners who responsibly exercise freedom of conscience:

La scelta dell’obiezione, tuttavia, quando necessaria, va compiuta con rispetto, perché non diventi motivo di disprezzo o di orgoglio ciò che deve essere fatto con umiltà, per non generare in chi vi osserva un uguale disprezzo, che impedirebbe di comprendere le vere motivazioni che ci spingono. È bene invece cercare sempre il dialogo, soprattutto con coloro che hanno posizioni diverse, mettendosi in ascolto del loro punto di vista e cercando di trasmettere il vostro, non come chi sale in cattedra, ma come chi cerca il vero bene delle persone. Farsi compagni di viaggio di chi ci sta accanto, in particolare degli ultimi, dei più dimenticati, degli esclusi: questo è il miglior modo per comprendere a fondo e con verità le diverse situazioni e il bene morale che vi è implicato.

The choice of the objection, however, when necessary, must be made with respect, so that what must be done with humility, so as not to generate an equal contempt, which would prevent the understanding of the true motivations that drive us. Instead, it is good to always seek dialogue, especially with those who have different positions, listening to their point of view and trying to transmit yours, not as someone who goes up in the chair, but as someone who seeks the true good of people. Be the traveling companions of those around us, especially the last, the most forgotten, the excluded: this is the best way to fully understand the different situations and the moral good that is involved.

Source: Libreria Editrice Vaticana, Discorso del Santo Padre Francesco all’ Assocziazone Cattolica Operatori Sanitari (ACOS).  Sala Clementina, Venerdì, 17 maggio 2019.

Photo by Nacho Arteaga on Unsplash

Maine, assisted suicide, and freedom of conscience

Accommodation of objecting physicians convoluted and unsatisfactory

Sean Murphy*

Introduction

Maine’s Death with Dignity Act1 was signed by the state governor on 12 June, 2019,2 to take effect on 18 September.  By the last week in August, physicians in the state were deeply divided and significant institutional health care providers were expected to opt out.3

In reviewing the Act, the Project focus is on sections relevant to the protection of those who refuse to provide or facilitate suicide for reasons of conscience.  These are convoluted and unsatisfactory.  In brief, the Act

  • imposes obligations on physicians that may be unacceptable to those who unwilling to facilitate assisted suicide,
  •  provides insufficient protection for objecting physicians not employed or by or under contract with an objecting institution,
  •  limits the ability of objecting health care facilities to maintain institutional integrity. . . [Full text]

New Jersey assisted suicide law and freedom of conscience

Lack of clarity on referral  is unsatisfactory

Sean Murphy*

Overview

New Jersey’s Medical Aid in Dying for the Terminally Ill Act1 came into effect on 1 August, 2019.2

The Act permits physician assisted suicide for any resident of New Jersey who is 18 years of age or over, who can make and communicate informed health care decisions, who has been diagnosed with a terminal illness and who is likely to die within six months. Physicians assist by providing a prescription for lethal medication.  The patient must make two oral requests for the medication 15 days apart, and a written request.  Two physicians must agree that the patient is decisionally competent and meets the medical criteria.  Additional consultation is required if there is concern about psychological or psychiatric conditions that may impair a patient’s judgement.  . .[Full text]

Assisted-death lawsuit adjourned, government evidence widens eligibility: lawyer

More Canadians eligible for assisted death: lawyer

The Chronicle Journal

Laura Kane

VANCOUVER – The British Columbia Civil Liberties Association and a woman with a degenerative illness have adjourned their lawsuit challenging the federal assisted-dying law after they say government evidence expanded eligibility for the procedure.

The law says that only people who have a “reasonably foreseeable” natural death qualify, but a government expert has filed a report that states some doctors are now interpreting this category to include people who refuse care that would prolong their lives. . . . [Full text]

Court reinstates lawsuit against Catholic hospital for refusing transgender patient’s surgery

Los Angeles Times

Michael Hiltzik

Stating that California’s interest in fighting discrimination against LGBTQ residents outweighs the right to impose religious standards on healthcare, an appeals court has reinstated a lawsuit against the Catholic Dignity Health hospital chain for barring a hysterectomy for a transgender patient.

The lawsuit was brought by Evan Minton, whose hysterectomy was abruptly canceled by Dignity’s Mercy San Juan Medical Center of Carmichael, Calif., in 2016 when hospital officials learned he was transgender. The hospital took the action to comply with the church’s Ethical and Religious Directives for Catholic Health Care Services, which prohibit sterilization procedures except in very narrow circumstances. . . [Full text]

The RH Act (2012) in brief

Appendix “B” of Philippines RH Act: Rx for controversy

Sean Murphy*

An outline of principal sections of the Responsible Parenthood and Reproductive Health Act of 2012 relevant to freedom of conscience.

SEC. 1. Title
  • [Not reproduced here]
SEC. 2. Declaration of Policy

The State recognizes and guarantees the human rights of all persons,1 including their right to equality and nondiscrimination of these rights, the right to sustainable human development, the right to health which includes reproductive health,2 the right to education and information, and the right to choose and make decisions3 for themselves in accordance with their religious convictions, ethics, cultural beliefs and the demands of responsible parenthood.4 . . . [Full text]

Philippines population control and management policies

Appendix “A” of Philippines RH Act: Rx for controversy

Sean Murphy*

Establishment of POPCOM

In 1967, President Ferdinand Marcos joined other world leaders in adding his signature to a Declaration on Population that had been made the previous year by representatives of 12 countries (often incorrectly cited in Philippines government documents as “the UN Declaration on Population”).1 Two years later, Executive Order 171 established the Commission on Population (POPCOM), and in 1970 Executive Order 233 empowered POPCOM to direct a national population programme.2

The Population Act

The Population Act [RA 6365] passed in 1971 made family planning part of a strategy for national development. Subsequent Presidential Decrees required increased participation of public and private sectors, private organizations and individuals in the population programme.3

Under President Corazon Aquino (1986 to 1992) the family planning element of the programme was transferred to the Department of Health, where it became part of a five year health plan for improvements in health, nutrition and family planning. According to the Philippines National Statistics Office, the strong influence of the Catholic Church undermined political and financial support for family planning, so that the focus of the health policy was on maternal and child health, not on fertility reduction.4

The Population Management Program

The Ramos administration launched the Philippine Population Management Program (PPMP) in 1993. This was modified in 1999, incorporating “responsible parenthood” as a central theme.3 During the Philippines 12th Congress (2001-2004) policymakers and politicians began to focus on “reproductive health.”5

Responsible Parenthood and Family Planning Program

In 2006 the President ordered the Department of Health, POPCOM and local governments to direct and implement the Responsible Parenthood and Family Planning Program.

The Responsible Parenthood and Natural Family Planning Program’s primary policy objective is to promote natural family planning, birth spacing (three years birth spacing) and breastfeeding which are good for the health of the mother, child, family, and community. While LGUs can promote artificial family planning because of local autonomy, the national government advocates natural family planning.3

Population policy effectiveness and outcomes

The population of the Philippines grew steadily from about 27million in 1960 to over 100 million in 2018. Starting from similar populations in 1960, Thailand, Myanmar and South Korea now have much lower populations (Figure 1) . . . [Full text]

Philippines RH Act: Rx for Controversy

Diatribe by Philippines’ President turns back the clock

Sean Murphy*

Abstract

Turning back the clock

In June, 2019, Philippines President Rodrigo Duterte blamed the Catholic Church for obstructing government plans to reduce the country’s birth rate and  population.  “They think that spewing out human beings by the millions is a gift from God,” he claimed, adding that health care workers should resign if they are unwilling to follow government policy on population control for reasons of conscience.

Duterte’s authoritarian diatribe clashes with a ruling of the Supreme Court of the Philippines and turns the clock back to times of harsh and extreme rhetoric when the current law (commonly called the RH Act) was being developed.  The RH Act was the product of over fourteen years of public controversy and political wrangling. It was of concern when it was enacted because it threatened some conscientious objectors with imprisonment and fines. 

In January, 2013, the Project reviewed the Act in detail.  Project criticisms about the law’s suppression of freedom of conscience were validated in April, 2014, when the Supreme Court of the Philippines struck down sections of the law as unconstitutional.

Given the long history of attempts at legislative coercion in the Philippines and President Duterte’s obvious hostility to freedom of conscience and religion in health care, the Project’s 2013 review of the RH Act is here updated and republished.

Assuming that the Philippines government’s concern about population growth in the country is justified, it does not follow that it is best addressed by the kind of state bullying exemplified by President Duterte’s ill-tempered and ill-considered eruption.  Aside from the government’s enormous practical advantage in its control of health care facilities, it has at its disposal all of the legitimate means available to democratic states to accomplish its policy goals.  Not the least of these is persuasive rational argument, an approach fully consistent with the best traditions of liberal democracy, and far less dangerous than state suppression of fundamental freedoms of conscience and religion.

TABLE OF CONTENTS

Turning back the clock

A history of coercive legislative measures

Background

The “RH Act” of 2012: General comments

The “RH Act” of 2012: Specific provisions

Freedom of conscience and religion

The Supreme Court weighs in

The way forward

Appendix “A”:  Philippines population control and management policies

Appendix “B”: The “RH Act” (2012)  in brief

Project Comments