Medical conscience bill would allow discrimination and hurt quality of care

This month, the Register published a guest essay written by Dr. Lauris Kaldjian, medical ethics professor at University of Iowa’s Carver College of Medicine, supporting Senate File 2286, a bill to allow health care providers to refuse care on the basis of “religious beliefs and moral convictions."

Though the essay appears reasonable at first glance, it is written from a perspective of malicious intent. This bill is not about complex ethical issues such as brain death and organ transplant. This bill aims to protect health care providers and institutions who refuse care to gender-diverse and LGBTQ+ patients seeking gender-affirming care. It is akin to the 2018 Supreme Court case in which a bakery refused to serve same-sex couples. This bill, however, would protect discrimination on matters of life and death for patients seeking care in Iowa.

Senate File 2286, which has advanced to the Iowa Senate floor, would allow health care providers, along with insurance companies and administrative bodies, to refuse services to patients based on personally held or institutional beliefs without fear of retaliation. Providers could share misinformation that is not evidence-based clinical practice or deny procedures they deem violate their religious values, and insurance companies could deny claims post-service on this same basis. This creates an avenue for physicians to mistreat patients of already vulnerable populations with no examination of their personal biases. As stated in University of Iowa Hospitals and Clinics' vision, our institution strives to be one that provides an “equitable, inclusive, and innovative environment.”

Every day, physicians put aside their personal beliefs in order to give high-quality, evidenced-based care to all patients, despite disagreements in ideology or political philosophies. Kaldjian’s comments fail to recognize the pillars of justice — which ensure equitable access to quality health care for all patients — and autonomy, which seeks to protect the freedom for patients to choose the best treatment for themselves.

If every doctor practiced medicine according to their own moral compass, there would be no standardized system to ensure just and autonomous care for each and every patient. That is, no health care system would exist at all. There are many mentions of a morally pluralistic society to support the notion that the personhood and humanity of physicians is paramount to our practice; while this is true, physicians understand that their patients will not always hold the same values. Medical providers already have the power to choose not to provide services they disagree with, whether it be in which role they pursue, specialty choice, and choice of institutional employment. MercyOne, a Catholic health care system, does not offer tubal ligations at any of the hospitals it owns in the state.

There are laws in place to prevent medical providers from being grossly negligent and knowingly harming patients when doing so, which is what this proposed Senate bill is taking away. Iowa already has a conscientious objection exception for civil lawsuits when it comes to refusing abortion. The tort reform bill signed into law last year created a cap on noneconomic damages for pain and suffering that a jury can award in medical malpractice lawsuits, making it more difficult for injured patients to seek compensation.

Moreover, current Iowa Code already has language to protect providers: “An individual who may lawfully perform, assist, or participate in medical procedures which will result in an abortion shall not be required against that individual’s religious beliefs or moral convictions to perform, assist, or participate in such procedures.” Section 146.2 of the Iowa Code goes on to state these providers cannot be discriminated against in the workplace due to this refusal.

The Iowa Legislature is constantly chipping away at people's legal protections and rights to be compensated if the medical system harms them.

Furthermore, while the physician’s role in health care has historically been one of paternalism, contemporary models emphasize information sharing and shared-decision making without biased appraisement of our patients’ lives. Patients should be free to make decisions about their own care solely based on their goals and the objective medical advice given by their physician. It is not our job as current or future medical professionals to act as a moral authority on behalf of patients.

The dangers of this bill have severe consequences on the lives and safety of patients. What would happen if a patient who was suffering an ectopic pregnancy had the misfortune of encountering an emergency medicine physician whose religion did not support abortion? Denying the patient the treatment critical to their survival would result in treatment delays and subclasses in care in direct opposition of the Hippocratic Oath to do no harm. Should the same provider be allowed to refuse treatment to an LGBTQ+ patient seeking evidence based, gender-affirming care? Or if the physician refused to provide a life-saving blood transfusion on the basis of Leviticus 17:12? What if the provider witheld CPR from an elderly patient on the basis of the futility of that life-saving intervention? There is a recent frightening trend in our country’s courtrooms and legislatures to deny protections/services on the basis of religious bigotry masquerading as conscience.

The passage of this bill would allow Iowa’s medical providers, medical institutions, and insurance companies to discriminate against marginalized communities with impunity and would have catastrophic consequences on the standards of care by which physicians are expected to abide. Iowa is a rural state. Often, rural medical providers are the first and only health care provider to which a patient can turn to. The notion that it is appropriate and justified to refuse care and hand off a patient to another provider is an elitist one, as many do not have the time, money, or access to shop around for physicians who would be covered by their insurance. This does not even begin to address the physician shortage we have in rural areas in our country, as well as in our state — Iowa has the least number of OB/GYNs per capita. Only about one-quarter of psychiatric inpatient beds in the state since 2007 are still available. We are not in the position or line of business to deny patients care.

The statement that “different health care professionals have competing perspectives about what is good for patients, about what is harmful, and even about what health is” does not support the foundation on which health professionals practice — evidence-based medicine. Statistics show the harm of bills such as this one, particularly higher maternal morbidity and mortality and higher LGBTQ+ suicide rates. Abortion denial is associated with higher rates of eclampsia, postpartum hemorrhage, gestational hypertension, chronic pain, intimate partner violence, and death vs. patients who received abortions. Additionally, transgender youth disproportionately experience poor mental health outcomes, including depression and suicidal ideation and attempts. Gender-affirming interventions are associated with 60% lower odds of moderate to severe depressive symptoms and 73% lower odds of self-harm or suicidal thoughts during the first year of multidisciplinary gender care.

We can wax philosophical about "moral injury," but for patients this comes with the risk of serious harm. Iowa needs clinicians dedicated to improving patients’ health and well-being, not clinicians who look toward state-sanctioned discrimination to enforce their religious "beliefs."

Aastha Chandra is a second-year medical student at the Carver College of Medicine and University of Iowa graduate. Her views do not represent the University of Iowa.

Sophie Banega contributed. Over 100 Carver students have signed on to this essay.

This article originally appeared on Des Moines Register: Iowa medical conscience bill would allow discrimination, harm care