Religious Freedom Trumps Patient-Centeredness

On January 18th, 2018 the Department of Health and Human Services answered the President’s May 4th executive order “Promoting Free Speech and Religious Liberty” by creating the Conscience and Religious Freedom Division (“CRF Division”) in the Office for Civil Rights (“OCR”). The CRF Division seeks to enforce existing federal statutes that protect health care providers from discrimination if they refuse to provide or refer medical services that run contrary to their religious beliefs. HHS then followed up with a proposed rule requiring health care organizations to post notices of religious freedom protections on job applications and employee manuals. The proposed rule applies to health care facilities that receive federal funding. Collectively, these initiatives affect more than 745,000 health care facilities and are estimated to cost $312.3 million dollars in the first year. Supporters believe this is a monumental step in promoting long over-due religious freedom protection. However, opponents are concerned about how extensive these protections will be, and whether they will negatively impact patients’ access to critical health care.

The religious freedom statutes upon which HHS’s proposed rule is based, collectively referred to as “Federal health care conscience and associated anti-discrimination laws,” largely impact access to medical services for women. For example, the Weldon Act provides “protections for health care entities and individuals who object to furthering or participating in abortion” and the Coats-Snow Amendment provides “conscience protections related to abortion, sterilization and certain other health services.” HHS argues that while these laws and numerous others are in fact codified, they are not being enforced to the necessary extent. Therefore, the CFR Division is tasked with reviewing the growing number of complaints filed in the OCR. Since President Trump was elected, the OCR received thirty-four complaints of conscience violations while the Obama administration received ten. The complaints allege discriminatory employment practices ranging from compelling nurses to either provide abortion referrals or resign to not hiring an individual based on religious beliefs conflicting with hospital policies. Pursuant to the complaints, the CRF Division will conduct compliance reviews, investigations, and audits to ensure that health care providers are compliant with federal legislation.

How do these initiatives impact patients? While they focus on protecting health care providers, the Department of Health and Human Services’ proposed rule reveals how patients   can benefit from increasing religious freedom protections. These patient-centered benefits include having the ability to choose a healthcare provider who shares their “deepest convictions” and to “speak frankly about their own convictions that concern questions touching upon life and death.” However, critics argue that HHS’s initiatives are inherently not patient-centered because they go against the fundamental idea that health care providers are supposed to put their patients’ interests before their personal beliefs. For example, in a 2000 case, a New Jersey woman suffering from pregnancy complications was “standing in a pool of blood” and required an emergency C-section. After a nurse scrubbing in realized the C-section would terminate the pregnancy, she objected to continuing assistance on religious grounds and delayed the procedure. After refusing a reassignment offer to the newborn ICU from the hospital, the nurse was terminated. She sued the hospital and the court ruled in favor of the hospital. While the CRF Division was enacted to help protect nurses and other health care workers in situations like this moving forward, the fact still remains that patients risk receiving delayed care or no care at all.

The strong support behind protecting religious freedom also poses a concern when vulnerable populations like LGTB patients cannot access the care they need. OCR Director Roger Severino expressed during the CRF Division’s press conference that “a nation that respects conscience rights is a more diverse nation, it is a more free nation, and is a more just nation.” However, while HHS focuses its efforts on protecting religious freedom, it is risking promoting discrimination against vulnerable populations. For example, one Catholic hospital blocked a doctor from performing a hysterectomy on a transitioning transgender patient. It is unlikely that HHS will promote similar conscience protections for LGBT patients during the current administration. This is evidenced by a statement from Severino, who said “on the basis of religious teachings, moral reasoning, scientific evidence, and medical experience, many have strong grounds to hold that one’s sex is an immutable characteristic.” President Trump’s Justice Department also holds similar beliefs, stating said “sexual orientation is not a protected category” in regards to discrimination protections.

At this point, it is unclear the full impact these initiatives will have on access to health care for women and vulnerable populations like LGBT patients. However, one thing is clear: forcing doctors to refrain from care conflicts with their moral convictions the same way forcing doctors to provide it does. Therefore, a balancing test is necessary to ensure that while peoples’ religious convictions are being respected, patients’ access to care is not compromised as a result. The National Health Law Program argues that given the small percentage of people filing complaints with the OCR, the Trump Administration is creating solutions like the CRF Division to problems that do not really exist. However, if complaints continue to grow and cannot be solved by non-litigious means, the ultimate determination on whether religious freedom protections reach as far as HHS intends will come from adjudication in federal courts.

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Cozy Bedfellows – Journalism and the Pharmaceutical Industry

Announcing LeapsMag: a magazine created and funded by Bayer, the German pharmaceutical company that is covering Alzheimer’s diagnostics, gene therapy, and CRISPR. Bayer started the magazine with the goal of publishing a variety of stories and opinions – as long as the stories do not criticize Bayer initiatives, such as the Bayer-Monsanto merger. Both Bayer and their editor, Kira Peikoff, assert that the company does not have any editorial influence on the content of the magazine. Peikoff even published a statement of independence on the LeapsMag website. But before publishing the statement, she ran it by Bayer because she was “worried that it might ruffle some feathers.”

How do we ease the problem of pharmaceutical (or any commercial) sponsorship of news stories and publications? When I tweeted this article out, biotech reporter, Alaric DeArment asked, “Would journalists take these kinds of roles if the job market in news was better? My guess is that most company-sponsored publications would be staffed by PR and marketing people and not journalists if it was.”  I agree with him. As news consumers, we need to be more cognizant of the price we pay, when we don’t pay for our news or media.

This isn’t the first (or only) instance of cozy relationships between journalism and pharmaceutical companies. Last year, Pfizer sponsored a story in the Boston Globe on a woman’s struggles with Parkinson’s disease, as narrated by her daughter to a scientist working on Parkinson’s research. This story was part of the Boston Globe’s Brand Lab – a section of the Boston Globe enterprise with the specific aim of engaging consumers, encouraging brand loyalty, and communicating a brand’s ideals without using explicit messaging. What the sponsored page fails to mention is that Pfizer has a drug for Parkinson’s in Phase II clinical trials.

In a more scandalous story, STAT News (a subsidiary of the Boston Globe) published an op-ed piece by a physician praising how helpful drug reps are to his practice. When the piece was initially published, readers complained that the physician’s conflicts of interest weren’t disclosed (the physician had received $300,0000 from the drug industry, which is easily searchable on Dollars for Docs). When the physician was interviewed about his disclosures, he admitted to the reporter that he did not write the op-ed piece at all. Instead, the piece was written by a PR firm. The physician was approached by an industry-sponsored group, Alliance for Patient Access, if he wanted to “publish” this op-ed. The physician did say that he “agrees with the spirit of the article” or he “wouldn’t have put his name to it.” After this was revealed, STAT News did retract the article and update their policies on authorship and conflicts of interest in response to this incident.

These three stories are only examples of a pervasive problem of corporate influence in journalism. Health news readers need to be cognizant of the potential conflicts of interest that are present when journalists learn about health news from industry sponsored conferences or when news publications are partially sponsored by healthcare companies. Readers also need to work to support the media so that the news can financially be corporation-free. Although digital subscriptions have been increasing, big traditional news outlets, like the New York Times, have had declining revenue. As people stop paying to support media outlets, these industries become more dependent on ad revenue and commercial support. Another important thing to do is to support organizations that work to expose bias in journalism, like my favorite organization, HealthNewsReview, which reviews news articles and exposes marketing messages in healthcare reporting.

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Big Tech and Health: Implications for HIPAA?

This week, Apple announced that it will now allow users to download and view portions of their medical records on their Apple products. This function will become a part of Apple’s Health app, and now enables consumers to transfer clinical data from their health care providers to their iPhones. This tool will allow for “easier sharing across multiple providers,” meaning that users will be able to bring their medical records with them in the event of switching doctors or moving, rather than going through the process of getting their records faxed or sent by the office itself. However, the risk to consumers may be substantial. By having a considerable amount of protected health information (PHI) on a mobile device or wearable technology, it exposes the consumer to the potential risk of hacking and theft.

While this feature has just begun beta testing, with some high-profile medical institutions among the first to provide access to their patients, the introduction of this feature leaves open some important questions regarding the Health Insurance Portability and Accountability Act (HIPAA).

Although HIPAA does not act as a general medical privacy law, HIPAA standardizes the privacy of health information in the United States by creating baseline protections for health information. The privacy rule, promulgated by the Department of Health and Human Services, focuses on HIPAA in its relation to “covered entities” and “business associates.” In doing so, the rule created a loophole that seems to be growing steadily as more and more of the population engages with websites, phone applications, and wearable technology that collects and stores health information, known as “non-HIPAA” health data.

As most of this health data falls outside of the scope of HIPAA’s protection, there is a serious question as to if, and how, this data should be regulated and protected. While Apple stated that it will not be able to view users’ medical data, which is encrypted, accessible only with the users’ password, and stored locally on the iPhone, users are also given the option to share such data with the company.

While the Apple was initially reluctant to consider the potentiality for HIPAA privacy and security issues, the tech giant has signaled, by seeking and retaining “Privacy Counsel” focused on HIPAA and health, that they are taking the issue of health privacy and security seriously. Recently, CEO Tim Cook stated that “the holy grail of the watch is being able to monitor more and more of what’s going on in the body.” As the Apple Watch itself has been held out to be and adopted as a “health monitoring device,” with 80 percent of its consumers utilizing the health and fitness tracking function, it becomes even more important for Apple to consider adopting a HIPAA-compliant system to protect the plethora of data collected by such devices.

As a recent report issued by the Obama White House demonstrated, “big data analytics” wield the potential to undermine established civil rights protections in how personal information is used in housing, credit, employment, health, education, and the marketplace. With implications such as these, one has to wonder what the next steps will be in addressing the proliferation of non-HIPAA data.

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Affects of Sexual Abuse by Physicians

As children we are all told to trust our doctors; they are the people who cure our ailments and keep us healthy. Therefore, we trust our doctors with our most private and intimate problems. A shared story among the Larry Nassar sexual abuse survivors is that they placed their trust in him as their doctor to heal them, and he violated that trust. Larry Nassar, the former USA Gymnastics doctor, was sentenced to 40 to 175 years in prison after he pled guilty to ten counts of sexual assault. Over 150 women gave impact statements at his sentencing hearing, and nearly all of them asked for a sentence that would set a precedent that manipulation of trust and sexual abuse by a doctor will not be tolerated.

Medical Obligations and Malpractice

“[You] used up every ounce of innocence not only abusing me but the oath you took when becoming a doctor to respect the privacy of your patients and not play God”

One survivor noted in her testimony that Nassar took an oath as a doctor to respect the privacy of his patients and he had violated the trust of all of his patients and their families when he committed sexual assault. Another survivor began her testimony began by stating that Nassar breached his duty of care to her and did not follow the medical regulations he was under.

Although the standards for medical care vary by state, in general, doctors have a duty of care to their patients. Medical malpractice is defined as a violation of the standard of care from that injures the patient. The American Medical Association’s “Principles of Medical Ethics” lay out the ethical obligations of physicians; these include, but are not limited to, respecting human dignity, patients’ rights, and standards of professional conduct. All doctors swear the Hippocratic oath before they become begin to practice medicine; the oath calls for doctors to protect the privacy of his patients, to do no harm, and to not play God.

Sexual abuse breaches a doctor’s duty to his patient, legally, ethically, and morally. If you want to see how your state manages doctor sexual abuse cases please see http://doctors.ajc.com/states/

Consequences of Sexual Abuse for Doctors

Talk is worthless to me… we need to demand real change and we need to be willing to be able to fight for it. It is clear now that if we leave this up to these organizations, history is likely to repeat itself”

While doctors are subject to the law, their oath, and medical board regulations, to not have sexual relations with a patient a study done by the Atlanta Journal –Constitution found that of the nation’s 2,400 doctors that were publicly disciplined for sexual misconduct with a patient, half still have their medical license today. Even more, when a medical board is composed chiefly of physicians, a doctor accused of sexual abuse is more likely to be allowed to continue practicing. Sexual abuse by doctors is often brushed off as rare; however, as Nassar’s case has shown us, rare does not mean unimportant, rare does not mean infrequent, and rare does not mean unpunishable.

Allegations of sexual abuse against Nassar began in the 1990s; however, the Michigan state disciplinary board did not revoke Nassar’s medical license until April of 2017, nearly nine months after The Indianapolis Star published an investigation of USA Gymnastics’ handling of sexual abuse and a formal complaint against Nassar had been filed with the MSU police; not to mention nearly twenty three years after dozens of sexual abuse allegations.

Effects of Sexual Abuse for Survivors

For me, it was a girl getting out her gun and laying it on the bed just to remind herself that she has control over her own life”

Sexual assault is undeniable married to mental health impacts. Among survivors of sexual abuse, anxiety, depression, and PTSD are common diagnoses. The women who testified several discussed the lasting mental health issues they now suffer from as a result of the abuse. Anxiety, depression, and eating disorders are only the tip of the iceberg of conditions that the survivors mentioned in their testimony. Several of the survivors mentioned that they currently seek counseling to cope with the effects of their abuse, others detailed suicidal thoughts, and one mother discussed how Nassar’s abuse contributed to her daughter’s depression and eventual suicide in 2009.

Nassar is the most recent and the most infamous example of a doctor abusing his privilege to treat patients with abuse and how our system can perpetuate the cycle of malpractice and abuse.

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New Year’s Resolution: Drug Abuse Prevention

The start of a New Year is often a time to reflect on the past and make resolutions to improve in the future. An ever going epidemic in the United States is drug abuse. Drug overdoses are currently the leading cause of death among Americans under the age of fifty. Research in 2017 has indicated that trends in drug abuse and overdose death rates are at an all-time high. With more than 64,000 drug overdose deaths estimated in 2016, the sharpest increase occurred among deaths related to synthetic opioids with over 20,000 overdose deaths.

Although there are delays in toxicology reports and inconsistencies in reported data, it is nevertheless clear that drug abuse and overdose are problems of exceptional and imminent importance.

The question, now, is what does this mean for 2018? Goals moving forward involve prevention, rehabilitation, and education for people across the county. These encompass both health and legal objectives, as they are very much intertwined, and addressing the drug epidemic will keep people safer, healthier, and also out of the criminal justice system.

Health objectives include medical advancements as well as treatment. There have been many medical advances in the war against opioid overdose, including the FDA approval of Naloxone, designed to rapidly reverse opioid overdose. While paramedics and specially trained responders typically administer Naloxone via injection, there are also nasal sprays and other forms of medicine that are more accessible to the general population. While the problem of drug abuse needs to be tackled starting with prevention, advances such as these are extremely important for rehabilitation purposes for people that struggle with substance abuse and addiction. It also can immediately save lives in grave situations.

Along with scientific medical advancements like Naloxone, research has shown that drug abuse treatment can help people with the many aspects and consequences of drug abuse. Drug abuse is very much tied to both legal and health problems. Treatment targeted towards individuals in the criminal justice system can help alter their outlooks and actions toward drug use, avoid relapse, and positively disconnect themselves from a life of substance use and crime. Treatment can be effective, whether voluntary or ordered by the court.

There are many places and organizations dedicated to drug abuse rehabilitation and prevention. Programs like Narconon International are devoted to education to prevent drug abuse and addiction, specifically targeting youth. They point to the fact that in today’s society, we are inundated with media and celebrities and influences constantly. Educating youths who are vulnerable to these messages and influences is vital to prevention. Reaching out to young people can help to combat the perpetual abuse cycles that we see in both the health world and the criminal justice world.

The 2018 National Rx Drug Abuse and Heroin Summit will take place this year in Atlanta, Georgia in April. The National Rx Drug Abuse and Heroin Summit is a congregation of experts from local, state, and federal agencies, businesses, academia, treatment providers, and allied communities impacted by prescription drug abuse and heroin use. This annual gathering offers an opportunity to discover what is effective in deterrence and healing.

It is very clear that drug abuse prevention is a top priority for our country as we ring in this New Year. For more resources and information about drugs, drug abuse, and prevention, please visit and share the 2017 version of the DEA Resource Guide, Easy-to-Read DrugFacts, and The Science of Drug Use – Discussion Points.

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