June 25 and 26, 2015 stand as Morality Markers for the United States. How does the ruling on the Affordable Care Act (King v. Burwell) http://www.nytimes.com/2015/06/26/us/obamacare-supreme-court.html and marriage equality (Obergefell v. Hodges) http://www.nytimes.com/2015/06/27/us/supreme-court-same-sex-marriage.html affect ethical issues in everyday endocrinology?
The ACA Ruling:
This ruling was about healthcare access for millions of American patients. The question was whether patients who purchased health insurance through the federal exchanges — in states refusing to set up their own exchanges—could keep their subsidies. Several states refused to set up their own exchanges due to partisan politics. But keeping federal subsidies is what made this care accessible for patients. After the ACA passed, endocrinologists were starting to see the impact on the uninsured. For the first time, they were seeing new patients with prolonged and severe endocrine diseases that had gone undiagnosed and untreated. Patients first presenting with severe diabetes and hypothyroidism were finally getting access to care; patients with aggressive thyroid cancers were able to get surgery and post-surgical treatment. Had the Supreme Court ruled in favor of the plaintiff, the payment structure that enabled truly affordable health insurance premiums, would have gone away, affecting care for untold thousands of endocrine patients in dramatic ways.
Now that major challenges to the ACA are over, we still need to work on improving the law: http://www.nbcnews.com/health/health-care/bioethicist-obamacare-here-stay-now-lets-fix-it-n382591.
Nor is the law immune from sabotage: http://www.nytimes.com/2015/06/28/opinion/sunday/the-fight-for-health-care-isnt-over.html?ref=opinion&_r=0
Surrogate decision-making is governed by state law, and many states follow the family hierarchy surrogacy laws, in which surrogate decisions are automatically designated to family members on a hierarchy unless otherwise stated in Advance Directives. The first family member on the hierarchy is typically the legal spouse. However, in states that had banned, or did not recognize same sex marriage, same sex spouses needed to specifically designate one another in Advance Directives, which was a burden heterosexual couples did not need to assume. While endocrinologists are not typically engaged in critical care, many endocrine patients require surrogate decision-makers, particularly when hospitalized. Here are some common examples:
- Poorly controlled diabetes patients
- Thyroid cancer patients requiring surgical management
- Impaired hypothyroid patients (See: http://www.ncbi.nlm.nih.gov/pubmed/18177258
Finally, gay patients who are married no longer have to worry that their spouses will be passed over as a surrogate decision-maker when they do not have full capacity.