Opinion: House Approves Bill that Defies Basic Standards of Medical Ethics

by Michael S. Dauber

On May 4th, 2017, the Republicans in the U.S. House of Representatives voted to pass the American Health Care Act, an Act that, if enacted into law, would repeal and replace many central elements of the Affordable Care Act, commonly known as Obamacare. The measure has received widespread criticism from many Democrats and from professional medical associations such as the American Medical Association and the American Cancer Society. Many people have questioned various parameters of the bill. This article questions it from an ethical perspective, and in particular, the potential consequences of abandoning health care protections designed under Obamacare to ensure that the most vulnerable people in society receive the care that they need.

The American Health Care Act would strip away protections that have facilitated access to care for pregnant women, patients with disabilities, patients that cannot otherwise afford health care, and patients with pre-existing conditions. While any attempt to discriminate against the sick and needy is unjustifiably wrong, the Act appears to directly target members of groups that are defined as most vulnerable and in most need of protection under most formulations of ethical practice.

For example, the Act would allow states to opt out of Obamacare requirements that prohibit insurers from charging patients with pre-existing conditions higher premiums for health insurance. It further classifies pregnant women, women who have had C-sections, and victims of domestic violence and sexual assault as patients with pre-existing conditions. It also targets elderly patients by allowing insurers to charge elderly patients up to five times as much as members of younger age brackets. Currently, under Obamacare, insurers cannot charge the elderly more than three times the amount they charge younger patients. The Act also includes plans to gradually eliminate $880 billion in Medicaid funding over the next ten years, funds that could have otherwise been utilized to extend coverage to low-income families.

In short, the Act specifically targets some of the most vulnerable members of society who might suffer immensely without health care and who may not be able to afford to pay the costs that many insurers may demand, or may be unable to pay for other essential expenses after paying their insurance premiums. Ahead of the vote in the House of Representatives, Senator Bernie Sanders called the Act “an abomination” and, in a CNN interview with Anderson Cooper, Sanders said, “thousands of Americans would die because they would no longer have access to health care.” Proponents of the Act argue that it is engineered to reduce the burdens of health care cost on the government and on insurers. Yet, the overall effect will be a higher cost for patients. Many patients will suffer and will lose their access to care because of circumstances beyond their control.

In this regard, the Act conflicts with basic principles of contemporary bioethics.  For instance, the Belmont Report (1979), as a blueprint for ethics in human subject research, stresses the importance of respect for the “dignity of persons” while ensuring protections in accordance with justice. The Belmont Report, though focused on ethics in human subject research, has become a defining document in the history of medical ethics, establishing a system in which patients must be respected and special protections must be given to members of vulnerable populations. If a patient falls into a protected class, health care providers have an ethical obligation to ensure that the patient receives the care he or she needs and that the patient is not denied care solely on the basis of disability, economic status, or prejudice against specific medical conditions.

There is an apparent conceptual link between commitment to protecting vulnerable populations in the clinical and research context and commitment to ensuring that vulnerable populations have access to care. The American Health Care Act has not yet become law. It must first obtain approval in the Senate and be signed by the President. Most recently, the Senate decided to modify the bill before voting on it and, as a result, the bill must be sent back to the House for a second vote. As the Senate prepares its own version of the bill, government officials should recognize that a policy that effectively precludes access to health care for members of vulnerable populations is unethical by virtually every principle of medical ethics.


Transgender Men Fighting Breast Cancer: The Difficulties in Accessing Care

In an article dated October 16, 2016, Eli Oberman, a transgender man discusses the social and medical difficulties he faced when diagnosed with breast cancer, including discrimination by health care providers. There are roughly 1.4 million transgender individuals in the United States and only recently has the federal government lifted the ban on Medicare coverage for transgender healthcare. New York State lifted a similar ban under its Medicaid program. However, there is still a lack of trust in health care providers among the transgender community, and a lack of knowledge of transgender health care needs among the medical community, that create barriers to accessing much needed health care.

From NYTimes.com, “Living as a Man, Fighting Breast Cancer: How Trans People Face Care Gaps”

Excerpt from article:

During one procedure, when Mr. Oberman had his shirt off, a male technician, seeing that he was transgender, exclaimed: “Why would you do this to yourself? It’s disgusting.”

Read Full Article

Long-Term Birth Control Becoming Popular Among North Carolina, Colorado Teens

An article dated October 6th, 2016 discusses the use of long-term, reversible contraception among young women in North Carolina and Colorado. Long-term contraception is endorsed by multiple medical organizations, and experts say that it is 99% effective. Despite this, young women in the United States are more reluctant to use this form of birth control than are their peers in other developed nations. In North Carolina and Colorado, however, long-term contraception is gaining traction among young women and teens. Healthcare providers in North Carolina clinics underwent training to learn about long-term contraceptives, and Colorado has been subsidizing the cost of them. Due to their success in lowering teen pregnancy and abortion, the Department of Health and Human Services suggests that this form of contraception should become more accessible to potential users.

From npr.org, “Long-Term, Reversible Contraception Gains Traction with Young Women”

Excerpt from article:

By using effective contraception to space out their children, teens and other young women can help reduce the risk of delivering a premature or low-birth-weight baby, research shows. And preventing unplanned pregnancies can be ‘essential to a woman’s long-term physical and emotional well-being,’ according to HHS.”

Read Full Article



A Potential Solution to the Emergency Room Data Problem Surrounding Violent Police Encounters

Recent studies have shown that while federal and national research groups keep scads of statistics, there is no reliable national data on how many people are shot by police officers each year. Recognizing the vital role the healthcare system plays in amassing data about violent injuries, criminologist Joseph Richardson recently proposed that emergency room staff should collect information about such injuries, not just fatalities, independent from police investigations. Richardson highlights the need for such data by pointing to a 2009 survey of academic emergency physicians, which revealed that although a majority of respondents had seen cases of excessive use of force by police, the group largely failed to report such findings. Without hospital reported information, data about violent police encounters relies heavily on police gathered information, which seems to be inadequate, especially with respect to survivors of police involved shootings

Doctors and nurses attribute physicians’ failure to report excessive use of force by police to concerns about logistics and consequences, specifically, difficulties associated with putting a standardized data collection approach into practice. Richardson’s findings from interviews at Prince George’s Hospital Center revealed two major barriers to gathering such information: the presence of police anytime a victim is under arrest and the need to provide testimony in court.

Although some hospital staff report feeling an ethical responsibility to document police-involved violence, others worry that such a requirement would compromise emergency care. For example, Dr. James Augustine, an American College of Emergency Physicians board member, worries that such a requirement would “muddle” hospitals’ missions, although he recognizes that the collection of such data is feasible since trauma centers nationwide already collect and submit information to the National Trauma Data Bank.

Despite early opposition, Richardson’s proposal recognizes police violence as a public health issue and highlights the vital role emergency room healthcare providers could play in addressing it. Only time will tell whether or not emergency departments will step in and capitalize on their unique access to compile an alternative data source.

Source: http://www.npr.org/sections/health-shots/2016/02/04/465568899/could-hospital-ers-provide-missing-data-on-police-shootings

Gitenstein Thought Leadership Conference




 A Spoonful of Sugar, Ethics and Practice:

Will It Help the Medicine Go Down?


Friday, October 24, 2014 | 8 a.m.-noon

David S. Mack Hofstra Student Center | Multipurpose Room East

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Questions? Contact Melissa Kessler at Melissa.J.Kessler@hosftra.edu.