Health Workers' Choice Debated
Proposals Back Right Not to Treat
By Rob Stein
Washington Post Staff Writer
Monday, January 30, 2006; Page A01
More than a dozen states are considering new laws to protect health workers
who do not want to provide care that conflicts with their personal beliefs,
a surge of legislation that reflects the intensifying tension between
asserting individual religious values and defending patients' rights.
About half of the proposals would shield pharmacists who refuse to fill
prescriptions for birth control and "morning-after" pills because they
believe the drugs cause abortions. But many are far broader measures that
would shelter a doctor, nurse, aide, technician or other employee who
objects to any therapy. That might include in-vitro fertilization,
physician-assisted suicide, embryonic stem cells and perhaps even providing
treatment to gays and lesbians.
Because many legislatures have just convened, advocates on both sides are
predicting that the number debating such proposals will increase. At least
18 states are already considering 36 bills.
"It's already a very hot issue," said Edward R. Martin Jr. of the Americans
United for Life, who is advising legislators around the country pushing such
bills. "I think it's going to get even hotter, for lots of reasons and in
lots of places."
The flurry of political activity is being welcomed by conservative groups
that consider it crucial to prevent health workers from being coerced into
participating in care they find morally repugnant -- protecting their "right
of conscience" or "right of refusal."
"This goes to the core of what it means to be an American," said David
Stevens, executive director of the Christian Medical & Dental Associations.
"Conscience is the most sacred of all property. Doctors, dentists, nurses
and other health care workers should not be forced to violate their
consciences."
The swell of propositions is raising alarm among advocates for abortion
rights, family planning, AIDS prevention, the right to die, gays and
lesbians, and others who see the push as the latest manifestation of the
growing political power of social conservatives.
"This is a very significant threat to patients' rights in the United
States," said Lois Uttley of the MergerWatch project, who is helping
organize a conference in New York to plot a counterstrategy. "We need to
protect the patient's right to use their own religious or ethical values to
make medical decisions."
Both sides agree that the struggle between personal beliefs and professional
medical responsibilities is likely to escalate as more states consider
approving physician-assisted suicide, as embryonic stem cell research speeds
forward and as other advances open more ethical fault lines.
"We are moving into a brave new world of cloning, cyborgs, sex selection,
genetic testing of embryos," Stevens said. "The list of difficult ethical
issues involving nurses, physicians, research scientists, pharmacists and
other health care workers is just continuing to increase."
Most states have long had laws to protect doctors and nurses who do not want
to perform abortions from being fired, disciplined or sued, or from facing
other legal action. Conflicts over other health care workers emerged after
the morning-after pill was approved and pharmacists began refusing to fill
prescriptions for it. As a result, some lost their jobs, were reprimanded or
were sanctioned by state licensing boards.
That prompted a number of states to consider laws last year that would
explicitly protect pharmacists or, alternately, require them to fill such
prescriptions.
The issue is gaining new prominence this year because of a confluence of
factors. They include the heightened attention to pharmacists amid a host of
controversial medical issues, such as the possible over-the-counter sale of
the Plan B morning-after pill, embryonic research and testing, and debates
over physician-assisted suicide and end-of-life care after the Terri Schiavo
right-to-die case.
"There's an awful lot of dry kindling in the room," Martin said.
At least seven states are considering laws that would specifically protect
pharmacists or pharmacies.
"Every other day, I hear from pharmacists who are being threatened or told
they have to sign somethingthat says they are willing to go along with
government mandates," said Francis J. Manion of the American Center for Law
& Justice, which is fighting an Illinois regulation implemented last year
requiring pharmacies to fill all prescriptions, which led to a number of
pharmacists being fired. "The right to not be required to do something that
violates your core beliefs is fundamental in our society."
Opponents say such laws endanger patients by denying them access to legal
drugs, particularly morning-after pills, which must be taken quickly. They
say women often must go from pharmacy to pharmacy to get those prescriptions
filled.
"Women all over the country are being turned away from obtaining valid and
legal prescriptions," said Jackie Payne of the Planned Parenthood Federation
of America. "These kinds of laws would only make the situation worse. It's
shameful." Planned Parenthood is supporting efforts in at least six states
to pass laws requiring pharmacists to fill all prescriptions.
At least nine states are considering "right of refusal" bills that are far
broader. Some would protect virtually any worker involved in health care;
others would extend protection to hospitals, clinics and other health care
facilities. Some would protect only workers who refuse to provide certain
health services, but many would be far more expansive.
At least five of the broad bills would allow insurance companies to opt out
of covering services they find objectionable for religious reasons. A sixth
state, Pennsylvania, is considering a bill designed for insurers.
"These represent a major expansion of this notion of right of refusal," said
Elizabeth Nash of the Guttmacher Institute, a nonprofit organization that
studies reproductive health issues and is tracking the legislation. "You're
seeing it broadening to many types of workers -- even into the world of
social workers -- and for any service for which you have a moral or
religious belief."
Supporters say the laws are necessary, given the rapidly changing nature of
medical research and care.
"We live in a culture where more and more people are on opposite sides of
these basic issues," said Manion, who has represented an ambulance driver
who was fired after she refused to take a patient to a hospital for an
abortion, a health department secretary who was not promoted after she
objected to providing abortion information, and a nurse who was transferred
after she refused to provide morning-after pills.
Opponents fear the laws are often so broad that they could be used to
withhold health services far beyond those related to abortion and embryos.
"The so-called right-to-life movement in the United States has expanded its
agenda way beyond the original focus on abortion," Uttley said. "Given the
political power of religious conservatives, the impact of a whole range of
patient services could be in danger."
Doctors opposed to fetal tissue research, for example, could refuse to
notify parents that their child was due for a chicken pox inoculation
because the vaccine was originally produced using fetal tissue cell
cultures, said R. Alto Charo, a bioethicist at the University of Wisconsin.
"That physician would be immunized from medical malpractice claims and state
disciplinary action," Charo said.
Advocates for end-of-life care are alarmed that the laws would allow health
care workers and institutions to disregard terminally ill patients'
decisions to refuse resuscitation, feeding tubes and other invasive
measures.
"Patients have a right to say no to CPR, to being put on a ventilator, to
getting feeding tubes," said Kathryn Tucker of Compassion and Choice, which
advocates better end-of-life care and physician-assisted suicide.
Others worry that health care workers could refuse to provide sex education
because they believe in abstinence instead, or deny care to gays and
lesbians.
"I already get calls all the time from people who have been turned away by
their doctors," said Jennifer C. Pizer of the Lambda Legal Defense and
Education Fund, who is representing a California lesbian whose doctor
refused her artificial insemination. "This is a very grave concern."
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For Americans, Getting Sick Has Its Price
Survey Says U.S. Patients Pay More, Get Less Than Those in Other Western Nations
By Rob Stein
Washington Post Staff Writer
Americans pay more when they get sick than people in other Western nations and get more confused, error-prone treatment, according to the largest survey to compare U.S. health care with other nations.
The survey of nearly 7,000 sick adults in the United States, Australia, Canada, New Zealand, Britain and Germany found Americans were the most likely to pay at least $1,000 in out-of-pocket expenses. More than half went without needed care because of cost and more than one-third endured mistakes and disorganized care when they did get treated.
Although patients in every nation sometimes run into obstacles to getting care and deficiencies when they do get treated, the United States stood out for having the highest error rates, most disorganized care and highest costs, the survey found.
"What's striking is that we are clearly a world leader in how much we spend on health care," said Cathy Schoen, senior vice president for the Commonwealth Fund, a private, nonpartisan, nonprofit foundation that commissioned the survey. "We should be expecting to be the best. Clearly, we should be doing better."
Other experts agreed, saying the results offer the most recent evidence that the quality of care in the United States is seriously eroding even as health care costs skyrocket.
"This provides confirming evidence for what more and more health policy thinkers have been saying, which is, 'The American health care system is quietly imploding, and it's about time we did something about it,' " said Lucian L. Leape of the Harvard School of Public Health.
The new survey, the eighth in an annual series of cross-national surveys conducted by Harris Interactive for the fund, is the largest to examine health care quality across several nations during the same period. The survey was aimed at evaluating care across varying types of health care systems, including the market-driven U.S. system and those that have more government controls and subsidies.
The survey, published in the journal Health Affairs, questioned 6,957 adults who had recently been hospitalized, had surgery or reported health problems between March and June of this year.
"These patients are the canary in the coal mine of any health care system," Schoen said.
Nearly a third of U.S. patients reported spending more than $1,000 in out-of-pocket expenses for their care, far outpacing all other nations. Canadians and Australians came next, with 14 percent of patients spending that much. The proportion reporting similarly high costs was far lower in the other countries.
Americans had the easiest access to specialists, but they experienced the most problems getting care after hours, and Americans and Canadians were the most likely to report problems seeing a doctor the same day they sought one.
Americans were also much more likely to report forgoing needed treatment because of cost, with about half saying they had decided not to fill a prescription, to see a doctor when they were sick or opted against getting recommended follow-up tests. About 38 percent of patients in New Zealand reported going without care; the numbers were 34 percent in Australia, 28 percent in Germany, 26 percent in Canada and 13 percent in Britain.
"If that's not a reason for moral outrage, I don't know what is," Leape said.
About one-third of U.S. patients reported problems with the coordination of their care, such as test results not being available when they arrived at a doctor's appointment or doctors ordering duplicate tests. In the other countries, 19 to 26 percent of patients reported similar problems.
Americans also reported the greatest number of medical errors. Thirty-four percent reported getting the wrong medication or dose, incorrect test results, a mistake in their treatment or care, or being notified late about abnormal test results. Only 30 percent of Canadian patients, 27 percent of Australian patients, 25 percent of New Zealanders, 23 percent of Germans and 22 percent of Britons reported errors.
"The findings show that we have a lot to learn from our colleagues" in other countries, said Carolyn Clancy of the federal Agency for Healthcare Research and Quality during a briefing at which the results were released. She said the federal government has launched a number of initiatives to find ways to improve care, particularly for the increasing number of Americans with chronic illness.
"The findings here reinforce how difficult it is coordinating care. . . . That's the next frontier," Clancy said.
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Some pharmacists say no to filling birth-control prescriptions
By Rob Stein
The Washington Post
An increasing number of pharmacists around the country are refusing to fill prescriptions for birth-control and morning-after pills, saying that dispensing the medications violates their personal moral or religious beliefs.
The trend has opened a new front in the nation's battle over reproductive rights, sparking an intense debate over a pharmacist's right to refuse to participate in something he or she considers repugnant, versus a woman's right to get medications her doctor has prescribed.
It has triggered pitched political battles in state legislatures across the nation as politicians seek to pass laws either to protect pharmacists from being penalized or to force them to carry out their professional duties.
"This is a very big issue that's just beginning to surface," said Steven Aden of the Christian Legal Society's Center for Law and Religious Freedom in Annandale, Va., which defends pharmacists.
"More and more pharmacists are becoming aware of their right to conscientiously refuse to pass objectionable medications across the counter. We are on the very front edge of a wave that's going to break not too far down the line."
An increasing number of clashes are occurring. Pharmacists often risk dismissal or other disciplinary action to stand up for their beliefs, while shaken teenage girls and women desperately call their doctors, frequently late at night, after being turned away by sometimes-lecturing men and women in white coats.
"There are pharmacists who will only give birth-control pills to a woman if she's married. There are pharmacists who mistakenly believe contraception is a form of abortion and refuse to [dispense] it to anyone," said Adam Sonfield of the Alan Guttmacher Institute in New York, which tracks reproductive issues. "There are even cases of pharmacists holding prescriptions hostage, where they won't even transfer it to another pharmacy when time is of the essence."
That's what happened to Kathleen Pulz and her husband, who panicked when the condom they were using broke. Their fear spiked when the Walgreens pharmacy near their home in Milwaukee refused to fill an emergency prescription for the morning-after pill.
"I couldn't believe it," said Pulz, 43, who with her husband had long ago decided they could not afford a fifth child. "How can they make that decision for us? I was outraged."
Supporters of pharmacists' rights see the trend as a welcome expression of personal belief. Women's groups see it as a major threat to reproductive rights and one of the latest manifestations of the religious right's growing political reach.
"This is another indication of the current political atmosphere and climate," said Rachel Laser of the National Women's Law Center in Washington. "It's outrageous. It's sex discrimination. It prevents access to a basic form of health care for women. We're going back in time."
The issue could intensify further if the Food and Drug Administration approves the sale of the Plan B morning-after pill without a prescription — a step that would likely make pharmacists the primary gatekeepers.
The question of health-care workers refusing to provide certain services first emerged over abortions. The trend began to spread to pharmacists with the approval of the morning-after pill and physician-assisted suicide in Oregon, with support from such organizations as the U.S. Conference of Catholic Bishops and the Pharmacists for Life International, which claims 1,600 members on six continents, primarily the United States, Canada and Britain.
"Our group was founded with the idea of returning pharmacy to a healing-only profession. What's been going on is the use of medication to stop human life. That violates the ideal of the Hippocratic Oath that medical practitioners should do no harm," said Karen Brauer, the Pharmacists for Life president, who was fired from a Kmart pharmacy in Delhi, Ohio, for refusing to fill birth-control prescriptions.
No one knows exactly how often that is happening, but cases have been reported across the country, including in Washington, California, Georgia, Illinois, Louisiana, Massachusetts, Texas, New Hampshire, Ohio and North Carolina. Advocates on both sides say the refusals appear to be spreading, often surfacing only in the rare instances when women file complaints.
Pharmacists are regulated by state laws and can face disciplinary action from licensing boards. But the only case that has gotten that far involves Neil Noesen, who in 2002 refused to fill a University of Wisconsin student's prescription for birth-control pills at a Kmart in Menomonie, Wis., or transfer the prescription elsewhere.
An administrative judge last month recommended Noesen be required to take ethics classes, alert future employers to his beliefs and pay what could be as much as $20,000 to cover the costs of the legal proceedings. The state pharmacy board will decide whether to impose that penalty next month.
Wisconsin is one of at least 11 states considering "conscience-clause" laws that would protect pharmacists like Noesen. Four states have laws that specifically allow pharmacists to refuse to fill prescriptions that violate their beliefs. At the same time, at least four states are considering laws that would explicitly require pharmacists to fill all prescriptions.
The American Pharmacists Association recently reaffirmed its policy that pharmacists can refuse to fill prescriptions as long as they make sure customers can get their medications some other way.
The alternative system can include making sure another pharmacist is on duty who can take over or making sure another pharmacy nearby is willing to fill the prescription, said Susan Winckler, the association's vice president for policy and communications.
"The key is that it should be seamless and avoids a conflict between the pharmacist's right to step away and the patient's right to obtain their medication," she said.
Large pharmacy chains, including Walgreens, Wal-Mart and CVS, have instituted similar policies that try to balance pharmacists' and customers' rights.
Women's advocates say such policies are impractical, especially late at night in emergency situations involving the morning-after pill, which must be taken within 72 hours.
Even in nonurgent cases, poor women have a hard time getting enough time off work to go from one pharmacy to another. Young women, who are often already frightened and unsure of themselves, may simply give up when confronted by a judgmental pharmacist.
"What is a women supposed to do in rural America, in places where there may only be one pharmacy?" asked Nancy Keenan, president of NARAL Pro-Choice America, which is launching a campaign today to counter the trend. "It's a slap in the face to women."
But Brauer defends the right of pharmacists not only to decline to fill prescriptions themselves but also to refuse to refer customers elsewhere or transfer prescriptions.
"That's like saying, 'I don't kill people myself, but let me tell you about the guy down the street who does.' "
Pulz, of Milwaukee, eventually obtained her prescription directly from her doctor.
"I was lucky," Pulz said. "I can sympathize with someone who feels strongly and doesn't want to be involved. But they should just step out of the way and not interfere with someone else's decision."
U.S. activist Cindy Sheehan waves to the crowd as she arrives at the meetingof World Social Forum Organizations with Venezuelan President Hugo Chavez in Caracas, Venezuela January 27, 2006. The sixth world forum, an event that began in Port Alegre in Brazil, has registered more than 67,000 participants and starts with a march against imperialism and war that will likely focus on U.S. President George W. Bush and the conflict in Iraq. REUTERS/Howard Yanes
U.S. peace activist Cindy Sheehan (L) stands next to Venezuelan President Hugo Chavez during a meeting with World Social Forum Organizations in Caracas, Venezuela January 27, 2006. The sixth world forum, an event that began in Port Alegre in Brazil, has registered more than 67,000 participants and starts with a march against imperialism and war that will likely focus on U.S. President George W. Bush and the conflict in Iraq. REUTERS/Howard Yanes
The annual ideological antidote to the World Economic Forum was winding up in Caracas on Friday under the shadow of host President Hugo Chávez. 
