Kindergarten lessons on health care

COMMENTARY

Excerpted from July 5, 2012 commentary published in The Washington Examiner

by CMA VP for Government Relations Jonathan Imbody:

Reforming health care is unquestionably challenging, but it's not brain surgery and works best when following basic principles most kindergartners learn. Help others up when they've fallen, keep your hands off other people's stuff and save your lunch money for when it's needed.

[For example]:

• Provide a targeted and sustainable safety net to assist the poor and patients with catastrophic health care costs.
• Preserve patient access to health care professionals through conscience rights and malpractice reform.
• Cut government bureaucracy and paper work and return decision making to patients and their physicians.
• Empower consumers with insurance competition between states and portability between jobs.
• Encourage health savings accounts that protect against unaffordable expenses and let consumers choose care and medicines through transparent pricing.

ARTICLE

CMA submits Congressional testimony on health care law

Excerpted from written testimony by the Christian Medical Association submitted to the United States House of Representatives, House Oversight and Government Reform Committee, Subcommittee on Health Care, District of Columbia, Census and the National Archives. The Subcommittee held a hearing July 10, 2012, "The Affordable Care Act (ACA): Impact on Doctors and Patients."
The ACA's weakening of conscience rights threatens to accelerate looming physician shortages and result in loss of access for millions of patients:

• Currently, 65 million people lack adequate access to primary care physicians.ⁱ
• Fifty medical studies have projected critical shortages of physicians.ⁱⁱ
• The American Association of Medical Colleges concludes, “If physician supply and use patterns stay the same, the United States will experience a shortage of 124,000 full-time physicians by 2025.” ⁱⁱⁱ
• Millions of patients, notably the poor and those in medically underserved regions, depend for care on religious health care institutions and professionals whose faith and conscience compel their service. Faith-based health care depends on protections against discrimination for upholding life-affirming ethical standards. Absent conscience protection, nine of ten faith-based physicians say they would be forced to leave medicine.^iv Yet the Obama administration eviscerated the only federal regulation that protected the exercise of conscience in health care, and partisans in the last Congress shot down amendments to protect conscience in the ACA.
• The HHS contraceptive mandate illustrates how an administration can use the ACA to weaken conscience rights and ignore First Amendment freedoms. Besides mandating a massive expenditure without a cost analysis, the mandate also tramples the conscience rights of virtually every patient, physician, employer and insurer who ethically objects to any of the contraceptives included in the mandate, including those which the FDA notes can end the life of a human embryo.
• Funding for abortion training is not excluded from the Teaching Health Graduate Medical Education (THCGME) program. Without strong conscience protections, such training can become essentially mandatory in practice and can effectively exclude life-affirming OB/Gyn residents from medicine.

REFERENCES:
ⁱ“Shortage Designation: HPSAs, MUAs & MUPs,” HRSA web site http://bhpr.hrsa.gov/shortage/
ⁱⁱ“Recent Studies and Reports on Physician Shortages in the U.S.,” Association of American Medical Colleges, April 2009. http://www.aamc.org/workforce/stateandspecialty/recentworkforcestudies.pdf
ⁱⁱⁱ“The Complexities of Physician Supply and Demand: Projections Through 2025,” AAMC report, October 2008.https://services.aamc.org/publications/index.cfm?fuseaction=Product.displayForm&prd_id=244
^ivhttp://www.freedom2care.org/docLib/200905011_Pollingsummaryhandout.pdf

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COMMENTARY

CMDA CEO David Stevens, MD, MA (Ethics):
"This past week I did a Christian Doctor's Digest STAT interview with Stewart Harris, who teaches constitutional law at a nearby law school. The interview will be released next month. He is Princeton-trained, articulate and media savvy, since he does a regular regional NPR program on constitutional law. Since the contraceptive mandate has generated more than 20 lawsuits that will likely end up at the Supreme Court, I asked him how he thought the Court might rule.

"He thought since the contraceptive mandate is "generally applicable" in that it applies to everyone except churches that this will likely be the argument made by the government, and it could succeed.
"I commented that the religious exemption clause in the contraceptive mandate is the narrowest one ever written into federal law. If it is not overturned, this could have a profound effect on religious freedom, essentially narrowing our right of freedom of religion to simply a freedom of worship. In other words, we could worship whatever and however we desired but would no longer have the right to exercise our religious beliefs in the public square.

"I then stated as an example, 'So if the government required all doctors in OB/Gyn or family practice to have abortion training or to provide abortions in their practice and thus the law was generally applicable to all physicians in those specialties, that would be constitutional?' He responded, 'I hadn’t thought of it in that way, but the answer could be, 'Yes.'

I’m not a constitutional lawyer, but I know there are other factors to consider. CMDA partners with a number of legal organizations that are involved in these suits. These attorneys will also argue that the government does not have a compelling interest to force religious groups to effectively subsidize, against their convictions, all contraceptives. They will also argue that the mandate is not the least religiously restrictive way to pursue its goals. There are also laws on the books prohibiting requiring abortion training or other participation in abortion.

"Stewart went on to comment that the interpretation of the Constitution is unfortunately often based on the 'rule of five' – whatever you can get five Justices of the court to agree on is considered constitutional. He then commented that this is why it is so important to elect people to office who represent your views on important issues. Not only will they pass laws that don’t abuse religious liberty; they are also some of the ones who will decide who the next Supreme Court Justices will be--and whether those justices will follow the original intent of the Constitution or bend it to suit their own preferences. He expects three Justices to be replaced in the next four years.

"It may seem obvious to us that the First Amendment free exercise of religion clause makes the contraceptive mandate unconstitutional, but others see it in a totally different light. We dare not let ourselves think we are too busy to be involved in this crucial time in the history of our country. This fall we must vote and urge as many others as possible to register to do the same."

Assisted suicide advocates: Bypass physicians for lethal prescriptions

ARTICLE:
Excerpted from "Redefining Physicians' Role in Assisted Dying," by Julian J.Z. Prokopetz, B.A. and Lisa Soleymani Lehmann, M.D., Ph.D. New England Journal of Medicine: N Engl J Med 2012; 367:97-99, July 12, 2012) - Under the Death with Dignity Act (DWDA), the patient's physician prescribes lethal medication after confirming the prognosis and elucidating the alternatives for treatment and palliative care. In theory, however, the prescription need not come from the physician. Prognosis and treatment options are part of standard clinical discussions, so if a physician certifies that information in writing, patients could conceivably go to an independent authority to obtain the prescription. We envision the development of a central state or federal mechanism to confirm the authenticity and eligibility of patients' requests, dispense medication, and monitor demand and use. This process would have to be transparent, with strict oversight. Such a mechanism would not only obviate physician involvement beyond usual care but would also reduce gaps in care coordination: in Oregon and Washington, patients whose doctors don't wish to participate in assisted dying must find another provider to acquire a prescription. Physicians who strongly object to the practice could potentially refuse to provide certification or could even alter their prognosis, but these possibilities yield the same outcome as permitting conscientious objection. Patients could also provide an independent authority with their medical record as proof of their prognosis.

Such a mechanism would make it essential for physicians to offer high-quality palliative care. The availability of assisted suicide in Oregon seems to have galvanized efforts to ensure that it is truly a last resort, and the same should hold true regardless of who writes the prescription. Usual care for terminally ill patients should include a discussion of life-preserving and palliative options so that all patients receive care consistent with their own vision of a good death.

Momentum is building for assisted dying. With an independent dispensation mechanism, terminally ill patients who wished to exercise their autonomy in the dying process would have that option, and physicians would not be required to take actions that aren't already part of their commitment to providing high-quality care.

COMMENTARY:

CMDA Member Mark McQuain, MD: responded to this NEJM article: "Returning to Pre-Hippocratic Medicine - Margaret Mead has been quoted as saying (regarding the Hippocratic Oath), 'For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure, including specially the undoing of his own killing activities. He who had the power to cure would necessarily also be able to kill...With the Greeks the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age or intellect - the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child...'
"Amongst other things, Margaret Mead was talking about trust between the patient and her physician. Society should not want physicians and other health care providers to be placed in any position where this trust becomes questionable, particularly as other entities insert themselves into the decision-making process. This is particularly the case as physician's conscience protections are being challenged and arguably eroded via federal regulations."

COMMENTARY:

CMDA Senior VP Gene Rudd, MD: "This is 'reasonable' progression of the assisted suicide initiatives. 'Reasonable' in the sense that once you cross the moral boundary of facilitating death, you need only improve the efficiency of the process by removing impediments.

"Some see state laws as the greatest impediments to expanding assisted suicide. Actually, our experience in opposing expansion has shown resistance of the medical community as the most effective impediment. The opposition from individual doctors and state medical societies has been key to thwarting the agenda of death. So proponents of assisted suicide now want to bypass that impediment.

"The article states that the Oregon experience proves there is no slippery slope. However, the author’s proposal for government involvement in order to expand assisted suicide is evidence to the contrary. Since the great majority of physicians refuse to participate or even endorse assisted suicide, the author concludes we simply need the government to step in with a system to assist in dying. That’s all we need, another costly federal program and more bureaucratic control of our health care – or in this case, control of our dying. I used to think it inappropriate to make this comparison, but as I have seen events unfolding, I am compelled by the slogan in the wake of the Holocaust, 'Never again!' We must stop this descent into cultural insanity or the next proposal will be that we establish federal centers where people will be 'referred' for death."

CMDA joins USAID pledge

Excerpted from "Study: Newborns are 40 percent of preventable child deaths," USA Today, by Aamer Madhani. June 11, 2012--Newborns now account for 40 percent of preventable child deaths worldwide, but only a tiny fraction of international aid targets newborns, according to a report to be published in the medical journal Health Policy and Planning Tuesday.

The study, which was spearheaded by the advocacy group Save the Children and funded by the Bill & Melinda Gates Foundation, comes as the Obama administration, India and Ethiopia prepare to host a summit in Washington that will focus on bolstering efforts to reduce the number of children younger than 5 who die from preventable ailments. The world is far off track in achieving one of the Millennium Development Goals set in 2000 - of reducing preventable child deaths by 66 percent by 2015 - but U.S. Agency for International Development (USAID) Administrator Raj Shah told USA TODAY he hasn't given up hope of reaching the target.

"This meeting is about that acceleration," Shah said. "It's about looking at the evidence, making the tough calls and doing things much differently and engaging a much broader set of partners so that we can accelerate progress."

UNICEF said in a report last week that pneumonia and diarrhea are two of the leading killers - accounting for 29 percent of deaths among children under age 5 worldwide - and said the global community should increase its focus on those diseases.

"Deaths due to these diseases are largely preventable through optimal breast-feeding practices and adequate nutrition, vaccinations, hand-washing with soap, safe drinking water and basic sanitation, among other measures," the report said.

Shah said the global community needs to do more on all fronts to reduce the yawning death toll. Ethiopia, India, Nigeria, Pakistan and the Democratic Republic of Congo - five countries that account for nearly half of all preventable deaths of children under 5 - are expected to announce a series of initiatives and new policies at this week's meeting in Washington. Performance needs to improve dramatically among these countries in order to get back on track, Shah said. Full story can be found here.

CMDA Senior Vice President Gene Rudd, MD: "It takes a wide range of interventions to decrease the death rate in under age five mortality including good prenatal and pregnancy care, childhood immunizations, clean water, breastfeeding education, good nutrition, adequate sanitation, malaria prevention and more. Mission and church health programs have had a huge impact already in this area and are the most trusted source of information in many countries. More needs to be done. That is why CMDA was a signatory to the Interfaith Child Survival Pledge and has been working with USAID in its Saving Lives at Birth program.

"CMDA’s Center for Medical Missions is in communication with more than 1,000 missionary doctors around the world to motivate, train, support and equip them for ministry. The e-Pistle publication inspires, teaches, shares ideas and puts missionaries in touch with resources each month. The Continuing Medical & Dental Education Commission organizes a 10-day, four-stream certified education event for doctors working in mission facilities in either Thailand or Kenya each year. Up to 550 attend this event for networking, fellowship, spiritual renewal and superb education.

"But more than just good ideas and new programs, the greatest need is more personnel. Through the Global Missions Health Conference in Louisville, Kentucky, student rotation scholarships, resource development, publications and speaking opportunities, CMDA is a prime mover in a medical mission renaissance on campuses. The Center for Medical Missions is now mentoring more than 1,300 students and residents who want to serve overseas long-term. Each September, we bring missionary organization executives together for a “Mission Summit” to exchange ideas, analyze research and strategizing.

“Motivated by the love Christ, we can be proud of CMDA and its many members who sacrifice to meet the needs of the less fortunate of the world, especially these young children.”

Global Health Outreach
Global Health Relief
Medical Education International
Pan-African Academy of Christian Surgeons

CMDA assists with two pro-life victories

Excerpt from "Maryland pregnancy centers in the clear," Onenewsnow.com by Charlie Butts. June 29, 2012--ADF is proud of the Fourth U.S. Circuit Court of Appeals for ruling against two unconstitutional ordinances that regulated pro-life pregnancy centers in Maryland.

The Baltimore and Montgomery County laws required pro-life facilities to post signs saying they do not provide birth-control or abortions. Abortion clinics, however, were not required to advertise the services they do not offer. So, Alliance Defense Fund (ADF) filed a friend-of-the-court brief arguing that pro-life centers should not be required to post material that discourages women from working with them.

"Pregnancy centers offer real hope and help to women. They should be free to share that message and not be forced to provide the government's preferred message," attorney Matt Bowman contends. "Pregnancy centers offer emotional support and practical resources to women, giving them more choices. They should not be made to speak negatively about the services they provide, and the Fourth Circuit was right to rule against that in both of these cases."

The Fourth Circuit decision upholds federal district court ruling last year that declared the ordinances infringed on the pro-life facilities' free speech rights (see earlier story). Similar ordinances in San Francisco and Austin, Texas are also facing court challenges. Full story can be found here.

CEO David Stevens, MD, MA (Ethics): "CMDA has been involved in a number of these cases on behalf of our members. This favorable ruling is likely to affect similar court cases in Austin, Texas and perhaps even San Francisco. There was no deceptive advertising here. These crisis pregnancy centers were simply hurting the business income of abortion clinics. Some women who would have paid for an abortion instead decided not to abort after entering a pro-life clinic. These abortion companies lobbied to get these laws pushed through.

"The government cannot compel speech except in limited circumstances. For example, they can compel drug advertisers to state the side effects and potential complications so patients can make informed healthcare decisions. In these situations, the groups that withhold true informed consent information are usually abortion clinics. A good example of this is Planned Parenthood whose own data in their 2010 annual report reveals they performed 329,445 abortions but only referred 841 women for adoptions. I suspect that one in 400 referral number represents women who had already made up their mind to put their child up for adoption before they walked in the door and couldn't be talked out of it.

"This ruling is important for pro-life professionals because abortion zealots are advocating that they also must post information that they don't do abortions, provide certain types of contraception or other information. The 4th Circuit ruling provides powerful ammunition to stymie those efforts.

AAPLOG et al Amici Brief for the city of Baltimore
Great Baltimore Center v. City of Baltimore 4th Circuit Court of Appeal
Centro 4th Circuit Ruling