Crisis of Conscience

January 31, 2018 • By

This month, the Trump Administration introduced a mechanism through HHS for healthcare providers to object to performing procedures they find morally distressing or objectionable based on their religion, or as reported:  to “ease the way for doctors, nurses or other medical professionals to opt out of providing services that violate their moral or religious beliefs” (See: https://www.washingtonpost.com/news/to-your-health/wp/2018/01/18/new-hhs-civil-rights-division-charged-with-protecting-health-workers-with-moral-objections/?utm_term=.81912e085354).

HHS will soon create the Conscience and Religious Freedom Division — an entire division devoted to conscientious objection.  The vast majority of bioethicists find this announcement to be cause for concern because it introduces further barriers to healthcare for many groups already disenfranchised or vulnerable, including women needing reproductive healthcare or transgender patients.  But it also violates what bioethicists see as clear duties of care inherent in the medical profession (See: https://www.reuters.com/article/us-usa-healthcare-religion/u-s-government-to-shield-health-workers-under-religious-freedom-idUSKBN1F7262).

I have mixed feelings about this new division, which may become a cautionary tale for the Trump Administration. Moral diversity and “moral objection” swings many directions, and by creating an official conscientious objection division, the Trump Administration must now allow for a wide range of moral protections for practitioners.  In some ways, this could provide unanticipated protections for the very groups the Administration seeks to inconvenience.

First, most hospitals already have these institutional policies in place. As a clinical ethicist, I invoke these policies frequently to protect and preserve the moral integrity of healthcare providers involved in care plans they find objectionable. I have rarely invoked these policies, however, for objections on religious grounds. I have mostly used them to relieve moral distress over medically inappropriate care plans in which limits to autonomy have not been properly asserted or championed by the institution, such as in situations where surrogates are demanding treatments that make no medical sense, and practitioners feel they are crossing ethical lines to appease surrogates. I have also invoked these policies to excuse practitioners from being forced to care for patients who have personally threatened them or their families, which sometimes includes situations where patients or surrogates are making personally racist statements, or when hateful misogynists make statements against their female doctors. In the Trump Era, healthcare providers newly exposed to racist comments are immigrants with accents from all parts of the world – many of whom are permanent residents or U.S. citizens.

In many of these cases, conscientious objection has worked well; in most institutional policies, there is a  mechanism for transfer of care or referral, and in extreme situations, transfer care to the Chief Medical Officer. Thanks to the Trump Administration, practitioners who experience racist patients, can now use the HHS’ new division to “object to care” on moral grounds. White supremacist patients, or patients who are anti-immigration, may be in for a shock when their practitioners “object” to caring for them because the patients’ personal views violate their moral integrity. Alternatively, practitioners who don’t believe women are equal based on their religion, for example, may decide that they don’t want to work with female colleagues in a secular environment and invoke “conscientious objection” to having to converse with another female colleague. The Trump Administration may become mired in all kinds of sticky cases arising from conscientious objection that has nothing to do with reproductive care. Could LGBT practitioners “object” to being forced to caring for patients who don’t support LGBT rights? Or, in a politically divisive country, perhaps Democrats can now morally object to caring for Republican patients, or vice versa. What might count as a legitimate claim of moral objection? Good luck with that.

A  2012 law review piece by Paul-Emile suggests that we should make every effort legally and ethically to  accommodate any patient’s request to see a different practitioner — even if the grounds are racist (See: https://www.uclalawreview.org/patients’-racial-preferences-and-the-medical-culture-of-accommodation/) as neither the practitioner nor patient is served when there is a breakdown in patient-practitioner trust.

Transfer of care or referral is an important caveat in any ethical conscientious objection policy, and the HHS’ new division will be no exception. In cases where the objector refuses to transfer care because of claims of “moral complicity”, this is where such policies become unworkable. I’ll be looking carefully for that “parachute clause” in the division’s language.

So, in response to the new HHS entity: conscientious objection swings both ways. Most of the care providers will object to care plans that probably have nothing to do with reproductive care. This new, controversial division may lead to a tsunami of moral assertions that block access to care for its most enthusiastic supporters because they may not realize that some of their own moral assertions may not be shared by the practitioners they will confront in the real world.


Reproductive Endocrinology

2017: Year of Women’s Reproductive Rage

December 30, 2017 • By

If you’re an endocrinologist with patients in their reproductive years, then here is a prescription for mandatory viewing: Hulu’s The Handmaid’s Tale, which is to reproductive justice what the 1997 film, Gattaca was to genetic sequencing. Part cautionary tale, and part “we’re practically there.” And soon, “Um…that actually happened last week.”

The premise of the series is that in the wake of decades of unregulated environmental toxins, most American women are now sterile; a small minority are able to conceive. Meanwhile, the political structure of the U.S. deteriorates into an authoritarian state ruled by Christian fundamentalists who assign roles to the females in the population: some are the “wives” of the ruling class in traditional marriages where women are subservient to males; some are forced “domestics” (the cooks and housekeepers); some are forced into reproductive service as “handmaids” to the infertile couples. Handmaids must submit to unconsensual intercourse with the male heads of households to which they’re assigned, with the goal of serving as surrogate birth mothers for the infertile ruling class. What about the lesbians? They are “gender traitors” who have forced clitoridectomies. (For more analysis of the series, see: https://www.newyorker.com/magazine/2017/05/22/a-cunning-adaptation-of-the-handmaids-tale).

Based on the 1985 novel by Margaret Atwood, The Handmaid’s Tale asks a central question in the Trump era: Do women have autonomy or not? And, by extension, do women’s voices mean anything?

In 1985, Atwood was initially writing the novel in the context of the Reagan era, and the “moral majority” which was a movement that inspired her fictional and futuristic version of the United States in which the Constitution is dissolved by a far right, Christian militia, renaming the U.S. “Gilead”. Here is a 1981 New Yorker piece on the burgeoning “moral majority” entitled “A Disciplined Charging Army”: https://www.newyorker.com/magazine/1981/05/18/a-disciplined-charging-army

The 1980s “moral majority” was a feminist backlash movement that wanted to stop women’s social and reproductive progress, which it saw as a threat to the traditional family. But The Handmaid’s Tale was also written during the burgeoning era of artificial reproductive technologies (ART), such as IVF and surrogate motherhood. The “moral majority” eventually became the base of the Republican Party, which now operates all three branches of government. In 2017, to satisfy its base, we watched the Republican Party disband its Constitutional duties of oversight to cede control to the Executive Branch. We watched, too, as our democratic norms once “guaranteed” under the U.S. Constitution eroded. Now, we are living in a time in which the U.S. Congress is actively enabling an authoritarian, illiberal President of questionable decision-making capacity. Ultimately, the Trump era is one where anti-feminist, anti-civil rights, anti-science, and anti-evidence-based policies are fast becoming normalized. Legislators who are proponents of the Trump agenda pride themselves on restricting women’s reproductive rights and the civil rights of the LBGT community; the President is actively trying to ban transgender persons from military service (See: http://endocrineethicsblog.org/the-presidents-gender-bender/)

Of course, erosion of women’s reproductive rights did not happen overnight; state legislatures have been in Republican control for several years due to low voter turnouts in local and mid-term elections during the Obama era. A myriad of abortion restrictions and TRAP laws were introduced between 2011-2016 (See: http://endocrineethicsblog.org/2016/06/), but over 400 more abortion restrictions were introduced in 2017, with some states requiring completely unethical statements be made to the patients seeking the procedures, including (in Utah) a requirement that doctors attempt to medically rescue aborted fetuses when they are removed from the womb. (See: http://www.motherjones.com/politics/2017/04/guttmacher-report-abortion-restrictions-proactive-legislation-first-quarter-2017/#). In April, President Trump signed a new law to withhold public funds used for family planning (see: https://www.npr.org/sections/thetwo-way/2017/04/13/523795052/trump-signs-law-giving-states-option-to-deny-funding-for-planned-parenthood)

Earlier this month we learned that the Trump Administration has now banned the CDC and the Department of Health and Human Services from using certain words, such as “evidence-based”, “fetus” and “transgender”. (See: https://www.washingtonpost.com/national/health-science/cdc-gets-list-of-forbidden-words-fetus-transgender-diversity/2017/12/15/f503837a-e1cf-11e7-89e8-edec16379010_story.html?utm_term=.d1971c7307a8).

Ultimately, despite so many political distractions, 2017 was a very productive year for the erosion of women’s reproductive and civil rights.

On January 21, 2017, the year began with the Women’s Marches across the U.S., and in many other countries the day after the 45th President of the United States was elected despite his statements on video that he could “grab women by their pussies” whenever he wanted. The iconic symbol of the Women’s Marches became the pink “pussy hat”. But as the year progressed, policies targeting women have been a key part of the Trump agenda. Here is a summary of legislation on the menu in the first 100 days: https://www.americanprogress.org/issues/women/reports/2017/04/25/430969/100-days-100-ways-trump-administration-harming-women-families/).

Additionally, there were multiple attempts to repeal the Affordable Care Act and remove basic access to women’s health. (See: http://endocrineethicsblog.org/kill-bill-volume-1/)

But the most significant achievement in eroding women’s rights was the appointment of Neil Gorsuch to the “stolen” Supreme Court Seat. Gorsuch, a conservative judge, remains a threat to Roe v. Wade. The Trump Administration has also been very busy installing conservative judges on the federal courts (https://www.nytimes.com/2017/11/11/us/politics/trump-judiciary-appeals-courts-conservatives.html), who will surely help to rule in favor of laws that erode women’s reproductive rights and justice in the future. For now, the federal courts have held that women still have reproductive rights. But that could change quickly, particularly with the current Attorney General at the helm, who would feel right at home in “Gilead”. Alas, even if Trump gets impeached, the current Vice President is a character right out of “Gilead”, too. Under a potential Pence Administration, a Gileadian future is even more possible. We have already seen some foreboding signs this year. Undocumented pregnant women have been held against their will by the Justice Department, and prevented from accessing constitutionally protected abortions. In one case, even when the ACLU attorneys ultimately won the case for an undocumented teen to get an abortion, the Justice Department started suing the ACLU’s attorneys. See: https://www.washingtonpost.com/politics/courts_law/undocumented-immigrant-teen-has-abortion-ending-weeks-long-court-battle/2017/10/25/9805249a-b90b-11e7-9e58-e6288544af98_story.html?utm_term=.6930202c44b6



As for Atwood’s dystopian premise of environmental toxins interfering with fertility, that story has been ongoing since the discovery of endocrine disruptors (see: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845732/) in the wake of weak regulations on organochlorines. Although the Obama Administration began to implement stricter regulations on environmental threats, in 2017 the EPA was effectively dismantled, and its scientists silenced, by the new anti-EPA director, Scott Pruitt. (See: https://www.pbs.org/wgbh/frontline/film/war-on-the-epa/). Between the destruction of the EPA, and the President’s exit from the Paris Climate Accord, it’s “deregulation gone wild” as polluters are granted the freedom to let loose. There is no telling how environmental deregulation will affect reproductive health; children’s health, and public health in general.

We are closer to The Handmaid’s Tale than you think, but there are signs that women are beginning to use their rage to prevent a future that is so tangible, we can taste it. The #MeToo Movement, which erupted in the Fall, closed the year, as women started to call out by name their sexual predators, sexual harassers and uninvited gropers, putting an end to several prominent males’ careers. It remains to be seen if there will be a male backlash. But we need to remember that right now, women’s civil and reproductive rights hang by a thread.

Atwood stated that The Handmaid’s Tale was an “antiprediction” because “if this future can be described in detail, maybe it won’t happen.” Indeed 2017 paved the way for women’s reproductive rage to translate into real legislative power. In Virginia, women were responsible for nearly flipping the state legislature by running for local office and voting out white males. In Alabama, African American women, in particular, were responsible for staving off a white male predator who meets the legal definition of a pedophile, and even stated he was pro-slavery.

The Handmaid’s Tale is too close for comfort; but 2018 may become the year women literally run for their lives (and reclaim their reproductive autonomy). One thing is certain: women will no longer accept “Lock Her Up” when they ask for power.












Price Fixing: Lessons in Moral Integrity

September 30, 2017 • By

This is an “I told you so” that ethicists have seen many times. When you find ethical integrity problems once with an individual – especially a physician — it is indicative of a larger pattern. To that end, Dr. Price’s ethical misconduct surrounding his extravagant travel tastes should come as no surprise to anyone — considering that he already was found to be self-dealing when he was a member of congress. He held stock in drug companies that he personally helped as a legislator. (See: http://www.wsj.com/articles/donald-trumps-pick-for-health-secretary-traded-medical-stocks-while-in-house-1482451061.) Typically, the laws of politics should have prevented his confirmation, but that didn’t happen. He was confirmed as Secretary of HHS by a Republican congress despite his glaring conflicts of interest, questions raised by the Office of Government Ethics (see: http://www.cnn.com/2017/01/18/politics/tom-price-conflicts-interest-oge-ethics-office/index.html), and concerns about his ethical integrity raised during his hearing (see: https://www.nytimes.com/2017/02/10/us/politics/tom-price-health-and-human-services.html). But he was not even unique. Just about everyone in this Administration’s cabinet has something to hide, and is either openly self-dealing or suspected of such. All political ethical norms have been shattered in this Administration, leaving those of us in the ethics business so morally upended, “moral distress” doesn’t seem like an apt definition anymore.

The only thing about Dr. Price’s resignation as Secretary of HHS that is unique is that the laws of political gravity seemed to work in this situation. Secretary Price, who, as it turns out, was not a particularly effective cabinet member, and did not mesh well with the President, was seen as disposable. He made the President look bad, which seems to be the reason he was asked to resign (See: https://www.theatlantic.com/politics/archive/2017/09/tom-price-resigned/541608/). Had the President liked him, and Dr. Price had been successful in helping to gut our healthcare system by leaving millions of Americans at the bottom of the sea, his tenure would have been considered a success, and his travel misdeeds would have surely been excused. I was genuinely concerned that Dr. Price would prove competent in his role, and do the damage he was hired to do (see: http://endocrineethicsblog.org/putting-a-price-on-healthcare/). Dr. Price’s own self-interest and hedonistic tendencies were his Achilles heel. Since he’s an orthopedic surgeon, maybe he can see an orthopedic colleague for that problem.

We will need to do a Price Comparison on his successor, and see if he or she can will end healthcare for millions, or actually heal it, as the Washington Post is hoping for (see: https://www.washingtonpost.com/opinions/the-opportunity-in-tom-prices-resignation/2017/09/30/f4c722f8-a5ee-11e7-b14f-f41773cd5a14_story.html?hpid=hp_no-name_opinion-card-c%3Ahomepage%2Fstory). I predict this Price Fix is only temporary.


Harvey, Disaster Ethics and Diabetes Care:

August 31, 2017 • By

On the 12th anniversary of Hurricane Katrina, another devastating hurricane and flooding situation is ongoing with Hurricane Harvey in the Houston area. But there are some new lessons learned from Katrina when it comes to the impact of hurricanes on people with diabetes: preventative ethics.

On the 10th anniversary of Katrina, I wrote this, which largely reminded us about the terrible health disparities in plain view among a largely African American population of hurricane victims: http://endocrineethicsblog.org/2015/08/

Since Katrina, the endocrine community has become much more aware of the impact of natural disasters when it comes to diabetes care. Here are some “real time” postings in anticipation of Hurricane Harvey, and the large diabetic population that is being affected.

Several diabetes organizations and drug companies are now offering targeted help to people with diabetes, on display here:




With more hurricanes to come in 2017, diabetes disaster planning, at least, has gotten a little better from the painful lessons of Katrina. But how many hurricanes will it take for there to be recognition that climate change is a public health menace, requiring major reform in carbon emissions policy? “The answer, my friend, is blowin’ in the wind…”

Transgender Medicine

The President’s Gender Bender

July 31, 2017 • By

It’s not unusual for the 45th President of the United States to go on a Twitter “bender” when he is unsupervised. But this month, one of his benders hit the endocrine community hard, when, on July 26, he tweeted:

“Please be advised that the United States Government will not accept or allow transgender individuals to serve in any capacity in the U.S. Military…Our military must be focused on decisive and overwhelming victory and cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail.”

The announcement effectively blindsided the military, which did not have plans to re-instate any such ban, and its response was swift: the military challenged the President to an intellectual exercise of drafting coherent policy that would (a) justify the ban; and (b) communicate a process. Until and unless that occurs, the military announced that transgender individuals should not be concerned about being kicked out of the military. According to the New York Times: “In a letter to the military service chiefs, Gen. Joseph F. Dunford Jr., the chairman of the Joint Chiefs of Staff, said that the policy on who is allowed to serve would not change until the White House sends the Defense Department new rules and the secretary of defense issues new guidelines. His letter stated that: “In the meantime, we will continue to treat all of our personnel with respect,” (https://www.nytimes.com/2017/07/27/us/politics/transgender-military-trump-ban.html)

Aside from the problem of dictating policy through Twitter, and the fact that it was announced on the anniversary of Harry Truman lifting the ban on African Americans serving in the military (see: https://www.vox.com/identities/2017/7/26/16034656/truman-integration-military-trump-trans), the proposed ban is not based on sound medical reasoning. According to the American Medical Association (see https://www.ama-assn.org/ama-statement-transgender-americans-military): “There is no medically valid reason to exclude transgender individuals from military service. Transgender individuals are serving their country with honor, and they should be allowed to continue doing so.”

According to a 2016 RAND Corporation study, as many as 15,000 active-duty troops may be transgender, and “have minimal impact on readiness and health care costs” for the Pentagon.

The response to the tweet was swift: the medical community issued a strong rebuke (See:

http://time.com/4875375/transgender-ban-military-doctors-react/). The public’s response – Republicans and Democrats alike — made clear that the ban was morally unacceptable, and several Republicans in Congress swiftly denounced the ban.

The main issue is the costs of gender-transition surgeries, which the Obama administration considered carefully, and decided to cover. The justification was that the costs of $2.4 million and $8.4 million annually for transition-related medical care was a drop in the bucket when compared to medical costs for the myriad of other conditions treated (see: https://www.nytimes.com/2015/06/09/opinion/what-doctors-say-about-transgender-troops.html). A study published in The New England Medical Journal (see: http://www.nejm.org/doi/full/10.1056/NEJMp1509230) concluded that “doctors agree that such care is medically necessary.”

Care for transgender patients represents a military health-care spending increase of 0.04 to 0.13 percent, which is one tenth of the annual budget of roughly $84 million the military spends on medication for erectile dysfunction. (See: https://www.theatlantic.com/health/archive/2017/07/things-that-cost-more-than-medical-care-for-transgender-soldiers/534945/)

Slate Magazine conducted an interview with Jesse Ehrenfeld, M.D., an expert in transgender health care and military service who stated: “There are some poorly done studies involving mental health that have been cited to suggest that trans individuals are at heightened risk of suicide or other mental health challenges solely because they are trans. That’s misinformation. There’s good emerging data demonstrating that when we provide a supportive environment and good high quality care to trans individuals, those issues seem to go away and people do well.” (See: http://www.slate.com/blogs/outward/2017/07/28/jesse_ehrenfeld_on_trump_s_transgender_troops_ban.html

Clearly, there are a myriad of ethical and constitutional problems with the President’s tweet; it echoed uncomfortable policies such as the ban on African Americans serving in the air force because of the risk of sickle cell (see: https://www.ncbi.nlm.nih.gov/pubmed/2197408)

Those who are oppose transgender troops raise concerns about psychological fitness, and whether mixing transgender troops into the traditional military population of troops is a social experiment. (See: https://www.nytimes.com/2017/07/26/us/politics/trump-transgender-military.html?_r=0)

If we’re going to use the “psychological fitness” argument, we need to consider the psychological fitness of a Commander –In-Chief who has poor impulse control on Twitter.



Healthcare Access

Kill Bill, Volume 2

June 30, 2017 • By

Well, it’s time to bite our nails again over the Senate’s version of the “Kill Bill” called the Better Care Reconciliation Act of 2017. The name is deceiving because if passed, this bill will kill thousands of American citizens by denying them affordable access to healthcare, and dramatically altering Medicaid, which may leave many populations devastated. Drafted by only white, Republican males, this bill targets our vulnerable populations: the poor, the old – particularly those in nursing homes — the mentally ill, the disabled, pregnant women and their unborn children, and even NICU patients. (See: https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html?hp and https://www.nytimes.com/2017/06/23/opinion/senate-obamacare-repeal.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region).

The bill will allow states to opt out of covering vulnerable populations and essentially defunds Medicaid. It also eliminates caps on what insurance companies can charge people with complex health needs, and allows insurers to at least double what older people pay.

Here are the details of the bill: http://www.politifact.com/truth-o-meter/article/2017/jun/25/whats-senate-health-care-bill-here-are-five-key-pr/

Here is a nice summary by Atul Gawande: http://www.newyorker.com/news/news-desk/how-senates-health-care-bill-threatens-nations-health

Let’s be clear: this bill amounts to population control based on social Darwinism: the survival of the fittest. If you’re economically advantaged and can afford the ransom the insurance companies can now exact from this bill, you get to live. If you’re physically fit and free from chronic disease or disability, you get to live. The Republican Party argues this bill is “better” because you get to have “choices” the freedom to choose from a variety of unaffordable or inaccessible plans that will punish patients for their pre-existing conditions, and punish women for requiring prenatal and maternity care services. So if you like your healthcare, too bad – because you probably can’t keep it.

If you’re an endocrinologist burdened by too many diabetic patients, rest assured they’ll soon be gone from your practice if this bill becomes law. If you’re struggling with whether it’s more beneficent to observe “low risk” thyroid tumors (a still controversial practice), this healthcare law will remove your dilemma since many new thyroid cancer patients will not have access to treatment anyway.

When a healthcare reform bill drafted by the Republican party is so bad that only about 17% of voters approve of it, and even Republican senators are against it, it’s telling, but also perhaps a sign that reason will prevail with a bipartisan healthcare reform bill in the end. Indeed, if the “Better Care” bill passes, it will be America’s moral stain and shame. Even the American Medical Association states that this bill, as currently drafted, actually violates medical ethics. (See: https://www.forbes.com/sites/brucejapsen/2017/06/26/ama-says-mcconnells-trumpcare-bill-violates-do-no-harm-principle/#1674817b4040 )

Here is the AMA’s letter to Senators McConnell and Schumer, which states “Medicine has long operated under the precept of Primum non nocere, or “first, do no harm.” The draft legislation violates that standard on many levels.” For the full letter, see: https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2FBCRA-Letter.pdf

Not one single bioethics expert can endorse this “kill bill” – other than the endorsement of killing the bill itself. This bill is the health insurance equivalent of a travel ban – where insurance companies do “extreme vetting” of individuals with pre-existing conditions that will just cost too much to support.

Social Darwinism is not new; it was widely embraced throughout the early 20th century and was the principal framework used to justify gassing the disabled, and other “undesirables” in Third Reich-era Germany. To recall a poignant line from the 2007 film, Sicko, a film that outlined the pre-ACA U.S healthcare system: “May I take a moment to ask a simple question? Who Are We?”



Healthcare Access

Kill Bill, Volume 1

March 31, 2017 • By

The biggest bioethics story this month was, of course, the “death spiral” of the repeal and replacement of the Affordable Care Act (ACA), known as “Obamacare”.

The proposed replacement law, unveiled as the American Health Care Act (AHCA), was a “Kill Bill” in every way. Under the new law, it was estimated that 24 million Americans who currently have health insurance and access to healthcare, would have lost their coverage. As proposed, the AHCA would have removed the current requirement under the ACA of that mandated coverage for “essential health benefits” comprising 10 services: outpatient care, emergency room visits, hospitalization, maternity and newborn care, mental health and addiction treatment, prescription drugs, rehabilitative services, lab services, preventive care and pediatric services. Republicans argued that such coverage leads to higher insurance premiums.  (See: http://www.vox.com/2017/3/23/15031322/the-fight-over-essential-health-benefits-explained).

Basically, the AHCA, which was being dubbed “Trumpcare” would have removed the requirement to cover what most would define as “healthcare”. Some columnists referred to the proposed bill as “cruel” (See: http://www.gq.com/story/trumpcare-exposed-gop-cruelty). Ultimately, once coverage of pre-existing conditions is removed, people die. (See: http://www.npr.org/sections/health-shots/2017/03/23/521220359/gop-health-bill-changes-could-kill-protections-for-people-with-preexisting-condi?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20170323)

But there were many other problems with the bill that would have removed healthcare access, which included restructuring Medicaid, tax cuts, and eliminating the lubricant that allows the ACA to work in the first place: the individual mandate. (See: https://www.washingtonpost.com/blogs/post-partisan/wp/2017/03/24/your-guide-to-the-most-contentious-parts-of-the-gop-health-care-plan/?tid=a_inl&utm_term=.0d36a1dbe10f).

Ultimately, between thousands of protesters voicing opposition to the replacement bill and polling that demonstrated only 17% of Americans were in favor of the proposed replacement bill, the GOP killed the bill, preserving (for now) the ACA. Here are two postmortems from the New York Times:

But the ACA is not “saved”; it remains at risk of being underfunded or sabotaged (See: https://www.washingtonpost.com/opinions/the-real-way-republicans-can-deal-with-obamacare-actually-fix-it/2017/03/24/cef5eba6-10c8-11e7-9b0d-d27c98455440_story.html?hpid=hp_no-name_opinion-card-d%3Ahomepage%2Fstory&utm_term=.eb1a99cec9f0) and http://www.politico.com/magazine/story/2017/03/will-obamacare-really-explode-214949 )

As we ended the month, there were rumblings that there may be another attempt at crafting a Republican healthcare bill, which could be “Kill Bill Volume 2.” (And that may make some heads spin).

Reproductive Endocrinology

Not OK (la-ho-ma): A shocking new abortion bill

February 28, 2017 • By

One of the most enduring and favorite American musicals is Oklahoma!, first performed in 1943 (See: https://en.wikipedia.org/wiki/Oklahoma!). It was turned into a wonderful 1955 film starring, among others, Shirley Jones, Gordon MacRae, and Rod Steiger (See: https://en.wikipedia.org/wiki/Oklahoma!#1955_film_adaptation). In 1943, a timeframe when women were being empowered in the war effort and went to work, the plot was rather shocking, as the main character, Laurey, is the victim of a predatory male who wishes to sexually assault her. In the nick of time, she is rescued from the sexual assault. The Rogers and Hammerstein score is superb, and anyone who has seen one of many stage productions or the film, knows the many popular songs, including how to spell Oklahoma: O-K-L-A-H-O-M-A! Let’s not forget “Oh What A Beautiful Morning” and “Surrey with a Fringe On Top”. Even people who hate musicals love this one: There is no bad number in the production. So there’s no doubt that there is a warm, fuzzy feeling when Americans think of the state of Oklahoma.

It’s important to note that the musical, Oklahoma! was particularly popular because it resonated with female audiences who were often targets of sexual predatory behaviors. The play and film delivered moral rescue from a desperate situation, which culminated in “Poor Jud is Dead” (officially spelled “Poor Jud is Daid” – to maximize the accent). Although the villain, Jud, got what was coming to him, there was also audience empathy for him. He was lonely; he had an unrequited, burning attraction to Laurey, and didn’t know how to curtail it.

Unfortunately all our warm, fuzzy feelings about the State of Oklahoma were ruined this month, as news of an ethically egregious proposed House Bill 1441 — a proposed abortion law with a “fringe on top” — was reported to have advanced in the Oklahoma State Legislature. This Bill upends the woman-friendly plot of the musical, Oklahoma!

House Bill 1441 will require a pregnant woman in Oklahoma to seek written consent and permission of the father to approve any abortion; she would need to name the father, and if the father contested, he could opt for a paternity test.

See: https://www.washingtonpost.com/news/post-nation/wp/2017/02/14/oklahoma-bill-would-require-father-of-fetus-to-approve-abortion/?utm_term=.f53b11099995



The requirement to name the father is, of course, fraught with psychosocial risks and harms – including to the father, who may be married to someone else. What if it’s a highly secretive (yet consensual) affair?

In many states, including mine (Kentucky), we don’t legally recognize the rights of “baby daddies” who are not legally married to the patient. We don’t recognize them as legal surrogates, nor do we allow them to be surrogates for neonatal patients. At many hospitals, paternity tests are not routinely offered, either. Thus, access to a paternity test could be a problem for a father who feels wrongly named; and finding access could be an additional undue burden.

Bill 1441 does provide an exemption in cases of rape, incest, or when the mother’s health is at stake. This is still problematic as there can be different interpretations of what constitutes “rape”; it’s unclear whose perception of rape would be accepted should this Bill ever become law, as perpetrators could argue it was all perfectly consensual and the woman was just a “girl who can’t say No”. What about cases of domestic violence rape? In such cases, “people will say they’re in love”. But in reality, violence may increase or be triggered by an unintended pregnancy.

This proposed law is unconstitutional, which even its author, Representative Justin Humphrey, concedes. It is also unethical, misogynistic, and logistically impossible. The Bill’s author also stated that prevention of pregnancy is the “responsibility of the woman”. That may be difficult in States where contraception is not taught or accessible. Oklahoma, in fact, has a terrible record with respect to teaching about contraception and making it accessible (see: https://sexetc.org/states/oklahoma_).

It is self-evident that a woman has the right to make decisions about her body; she is not simply a “host” for the fetus, as the Bill’s sponsor states. She is an American citizen with civil rights; as a legal person, her rights “trump” an unborn, potential person with no legal status. A 1992 Pennsylvania law with similar overtones was struck down by the Supreme Court for these reasons. A pregnant patient and her fetus are a single biological entity pre-viability in which the practitioner’s ethical obligations are owed to the mother unless she presents her fetus as a patient. There is virtually no court that would hold that a capacitated pregnant woman does not have the constitutional right to make medical decisions for herself. From a bioethics perspective this proposed law completely violates the Principle of Autonomy and Respect for Persons.

As another song from Oklahoma! goes: “It’s a Scandal and an Outrage!”


Endocrine Research

The Endocrine Society Weighs in on Trump’s Travel Ban

January 31, 2017 • By

January, 2017 has been arguably one of the most chaotic months in the democratic history of the United States, with many Americans wondering if the country has devolved into an autocracy or dictatorship. Anyone trying to keep up with the news has probably become exhausted. There are many issues that have begun to dominate the science news, including a Scientists’ March on Washington. But that’s the not the subject for this month’s blog. Instead, it is the Executive Order issued January 27th, which is the travel ban on 7 Muslim-majority countries (the word “ban” is the President’s words), which affected even permanent residents of the U.S. (something that is currently being potentially corrected or evaluated on a “case by case” basis), as well as people who have dual citizenship in one of the banned countries as well as another country, such as Canada. The ban has had immediate and dire ramifications for the scientific and medical communities. Several universities have issued statements, and in a rare instance, The Endocrine Society has now weighed in. Here is the official Press Release:


In individual letters sent to members, it made these statements (bold added for emphasis):

“We are currently working with the broader research and medical communities on supporting legal efforts to overturn the order… [And] we have already heard concerns from colleagues in targeted countries about missing ENDO this spring. We also recognize that as a result of this order there are physicians and scientists training in the US who are now unsure of their status and patients from targeted countries blocked from participating in studies.

There are clearly research and clinical ethical consequences to such orders from President Trump that were likely not considered, which may violate basic bioethics principles.

But the travel ban has had an unprecedented detrimental global impact on the U.S.’ relationships with other countries. Notwithstanding harsh criticism from various European countries, Britain, as well as Iran and Iraq, the President of the European Union made the statement today that the U.S. is now being considered a global threat to Europe on par with Russia. See: http://www.cnn.com/2017/01/31/politics/european-union-trump/

When the Acting Attorney General of the United States, Sally Yates, declared that she could not defend this travel ban in court because she was not convinced it was lawful, she was demonstrating moral courage. (See: https://www.nytimes.com/interactive/2017/01/30/us/document-Letter-From-Sally-Yates.html?_r=0). As is sometimes the case when speaking out against something that compromises professional and moral integrity, she was fired and called a “betrayer” by the White House. (See: https://www.nytimes.com/2017/01/30/us/politics/trump-immigration-ban-memo.html). Such an action recalled the “Saturday Night Massacre” of the Watergate era when former President Nixon fired then Attorney General, Elliot Richardson and his Deputy Attorney General for refusing to fire Archibald Cox, the Independent Prosecutor investigating the President.

All Endocrine Society Members should applaud the Endocrine Society’s moral courage in speaking out on this ethically and legally problematic ban. Future Society meetings may be best held in Canada, which has spoken out against the ban and can offer a safe travel situation for all Endocrine Society Members. (See: http://www.theglobeandmail.com/news/world/us-politics/trumps-travel-ban-on-citizens-from-muslim-majority-countries-causes-anger-chaos-in-us-andabroad/article33818462/).

The history of science and medicine is filled with refugee scientists’ accomplishments. What would have happened had we banned Albert Einstein from entering the U.S. in 1933, prior to the infamous and unfortunate banning of Jewish refugees who tried to flee later (See: https://www.theatlantic.com/politics/archive/2017/01/jewish-refugees-in-the-us/514742/)? Who knows what scientific discovery was on the ship we turned away, and how much science was lost to the ashes of the Holocaust? It is all the more ironic that this new Executive Order was signed on Holocaust Memorial Day. It’s worth noting that the influx of Jewish refugees who did get into the United States led to a 31% increase in patents. (See: http://news.stanford.edu/news/2014/august/german-jewish-inventors-081114.html)

Academics around the country have initiated petitions about this travel ban, such as this one: https://notoimmigrationban.com . We do not yet know the complete toll this ban has had on the academic medical community or patients. Stay tuned.




Putting a Price on Healthcare

December 31, 2016 • By

As we begin to reflect on the chaos of 2016, there is only one major bioethics story for healthcare providers: the fate of American healthcare access. Again. As December began, the picture for 2017 was beginning to fill in – particularly with the Cabinet pick of Dr. Tom Price as HHS secretary. Here are some alarming facts in a compelling piece published in the New England Journal of Medicine: (See: http://www.nejm.org/doi/full/10.1056/NEJMp1615714)

The authors, who both formerly served as Assistant Secretaries at the Department of HHS, make these points:

  • “…Price’s record demonstrates less concern for the sick, the poor, and the health of the public and much greater concern for the economic well-being of their physician caregivers.”
  • Price supports changing the Medicare and Medicaid systems so substantially that it would “shift financial risk from the federal government to vulnerable populations.”
  • “Price has also been a vociferous opponent of the Affordable Care Act (ACA) and a leader of the repeal-and-replace movement.” Essentially, Price endorses a dismantling of the American healthcare system with a “regressive” plan that “offers much greater subsidies relative to income for purchasers with high incomes and much more meager subsidies for those with low incomes.”

In essence, Price opposes any cost-sharing subsidies, which could “doom millions”. See: https://www.washingtonpost.com/national/health-science/trump-could-quickly-doom-aca-cost-sharing-subsidies-for-millions-of-americans/2016/12/21/05349066-c2fc-11e6-9a51-cd56ea1c2bb7_story.html?hpid=hp_hp-top-table-main_costsharing-10pm%3Ahomepage%2Fstory

Price is a polarizing figure for American doctors. Although the American Medical Association endorsed Dr. Price as a pick, many of its members were dismayed. Over 5,000 doctors have signed a petition opposing him, while many AMA members have spoken out, or not renewed their memberships. (See:


Price also is a member of the Association of American Physicians and Surgeons (AAPS), which has been coined a “crank medical society” by Scienceblogs.com. The AAPS is noted for its anti-vaccine stance. (See: http://nymag.com/scienceofus/2016/12/tom-price-belongs-to-a-really-scary-medical-organization.html)

Advocates of women’s health are concerned that even the most basic contraception for women would become a challenge because “the extremity of Mr. Price’s views on women’s health.” For example, he was a co-sponsor of legislation that defines life at conception, arguing that “common forms of birth control constitute a murder weapon.” (See: http://www.nytimes.com/2016/12/28/opinion/how-donald-trumps-health-secretary-tom-price-endangers-women.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-right-region&region=opinion-c-col-right-region&WT.nav=opinion-c-col-right-region&_r=0

It gets worse. Price has alarming conflicts of interest according to a Wall Street Journal Report. He has all kinds of ties to the pharmaceutical industry, having traded over $300,000 in big pharma stock while in Congress. See: http://www.wsj.com/articles/donald-trumps-pick-for-health-secretary-traded-medical-stocks-while-in-house-1482451061



Of course, the HHS Secretary cannot, alone, repeal the ACA. That is an act of Congress, which has made clear that it’s the first thing on its agenda in 2017. That is sending “red flags” (no – not the Russia hacking thing) across the healthcare spectrum. For example, as the New York Times reported:

“In a letter to Mr. Trump and congressional leaders this month, the two biggest hospital trade groups warned of ‘an unprecedented public health crisis’ and said hospitals stood to lose $165 billion through 2026 if more than 20 million people lose the insurance they gained under the law. They predicted widespread layoffs, cuts in outpatient care and services for the mentally ill, and even hospital closings.” See:


It’s clear to any bioethicist that the new GOP-led Congress is about to step into the mire of what scholars call a “wicked problem”. Anyone who looks closely at the muckiness of the U.S. healthcare system will see that there are two options: a market-based system, which basically looks like the ACA, or some form of a single-payer universal healthcare system, which is what every other democracy has. So for the GOP, it’s a wicked problem of BernieCare of ObamaCare, because voters will not like any of the voucher-based plans they have been discussing for years, which do not resolve distributive justice problems.

The GOP Congress, in recognition of this “wicked problem” has come up with a “neither fish nor fowl” solution, called Repeal and Delay. But that has problems, too, according to the Urban Institute, which estimates that “repeal and delay” would “increase the number of uninsured by 4.3 million people near immediately”. (See: https://www.brookings.edu/research/why-repealing-the-aca-before-replacing-it-wont-work-and-what-might/)

As for the Trump voters, they don’t want to see the ACA repealed, either, which makes their vote for Trump perplexing. In two of the poorest states (one of them, mine), the uninsured rate has fallen from 25 percent in 2013 to 10 percent today. One reporter decided to investigate the paradox of the Trump voter and ACA-lover, and took a deep dive into my own state of Kentucky (See: http://www.vox.com/science-and-health/2016/12/13/13848794/kentucky-obamacare-trump.) Voters who understood that their Kentucky healthcare of “Kynnect” was “Obamacare” simply didn’t take Trump seriously about taking it away. They thought he was kidding, proving the adage of “taking him seriously but not literally”. Other voters who love their healthcare in Kentucky, didn’t understand that what they love, is in fact, Obamacare, proving there is a wide gap in understanding the law. (See: https://www.washingtonpost.com/opinions/trump-voters-didnt-take-him-literally-on-obamacare-oops/2016/12/20/46ef3cae-c6f3-11e6-bf4b-2c064d32a4bf_story.html?hpid=hp_no-name_opinion-card-c%3Ahomepage%2Fstory&utm_term=.0decc010c34c )

Patients who voted for change are going to get it in 2017. It just may not be the change they want. And many bioethicists fear some may have unwittingly voted for their own executioner if their healthcare goes away.