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“Moral Distress” Has Arrived On Health Care’s Stoop

By MIKE MAGEE

When Andrew Jameton, a Nursing Professor at the Department of Mental Health and Community Nursing at UCSF in 1984 published “Nursing Practice: The Ethical Issues”, the term “Moral Distress” was a novel term in clinical health care. It focused primarily on “care that they were expected to provide but ethically opposed.”

Over the past four decades, the definition has expanded and now encompasses the “inability to provide the care that one feels morally compelled to provide.” Beyond its’ impact on individual health professionals, it has growing health policy implications, explosively reverberating in the wake of the recent Dobbs decision.

There are approximately 1600 health care facilities nationwide that provide abortion care in the U.S. In the wake of the Dobbs decision overturning Roe v. Wade, 14 states have near complete bans on all abortions and this reproductive care is severely restricted in an additional 11 states “with few or no exceptions for maternal health or life endangerment.”

The impact of these rulings has created not only a moral dilemma for health professionals, but also intense legal jeopardy. As one Tennessee Obstetrician recently put it, “There are weeks when I commit multiple felonies.”

There now exists a validated psychometric tool to measure the mental health impact of the Supreme Court’s actions called the Moral Distress Thermometer(MDT). Experts recently surveyed 310 practicing clinicians involved in women’s reproductive health care, with a focus on comparing moral distress in those from restricted versus unrestricted states. What they reported in JAMA was that those in restricted vs. protected states had scores on the MDT that were more than double their comparators.

As one might expect, high scores on the MDT also correlate with higher rates of job burnout and attrition. This means lower rates of abortion care, but also a smaller maternal health workforce overall. This is in states that had already been lagging behind in access to obstetrical and reproductive health care in general. Clinical shortages are expected to rise in the months approaching an historic Presidential election.

Project 2025’s agenda for future women in America is much more expansive and aggressive than restriction of abortion alone. Trump’s denials aside, his selection of JD Vance as a running mate signals an intent to thoroughly engage in restriction of women’s reproductive rights in allegiance with a Supreme Court that appears equally committed.

With that in mind, the massive response to the Harris-Walz ticket appears to be offering a response that appears to be go well beyond simple “weird” labeling. Those words are a promise to each other, “We’re not going back.”

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

Vote, for Health Sake

By KIM BELLARD

If you had on your political bingo card that our former President Trump would survive an assassination attempt, or that President Biden would drop out of the race a few weeks before being renominated for 2024, then you’re playing a more advanced game than I was (on the other hand, the chances that Trump would get convicted of felonies or that Biden would have a bad debate almost seemed inevitable). If we thought 2020 was the most consequential election of our lifetimes, then fasten your seat belt, because 2024 is already proving to be a bumpier ride, with more shocks undoubtedly to come.

I don’t normally write about politics, but a recent report from the Commonwealth Fund serves as a reminder: it does matter who you vote for. It is literally a matter of life and death.

The report is the 2024 State Scorecard on Women’s Health and Reproductive Care. Long story short: “Women’s health is in a perilous place.” Lead author Sara Collins added: “Women’s health is in a very fragile place. Our health system is failing women of reproductive age, especially women of color and low-income women.”

The report’s findings are chilling:

Using the latest available data, the scorecard findings show significant disparities between states in reproductive care and women’s health, as well as deepening racial and ethnic gaps in health outcomes, with stark inequities in avoidable deaths and access to essential health services. The findings suggest these gaps could widen further, especially for women of color and those with low incomes in states with restricted access to comprehensive reproductive health care.

“We found a threefold difference across states with the highest rates of death concentrated in the southeastern states,” David Radley, Ph.D., MPH, the fund’s senior scientist of tracking health system performance, said in a news conference last week. “We also saw big differences across states in women’s ability to access care.”

Joseph R. Betancourt, M.D., Commonwealth Fund President, said: “Where you live matters to your health and healthcare. This is having a disproportionate effect on women of color and women with low incomes.” Dr. Jonas Swartz, assistant professor of obstetrics and gynecology at Duke Health in Durham, North Carolina agreed, telling NBC News: “Your zip code shouldn’t dictate your reproductive health destiny. But that is the reality.”

The study evaluated a variety of health outcomes, including all-cause mortality, maternal and infant mortality, preterm birth rates, syphilis among women of reproductive age, infants born with congenital syphilis, self-reported health status, postpartum depression, breast and cervical cancer deaths, poor mental health, and intimate partner violence. To measure coverage, access, and affordability, it looked at insurance coverage, usual source of care, cost-related problems getting health care, and system capacity for reproductive health services.

There are, as you can imagine, charts galore.

The lowest performing states – and I doubt these will be a surprise to anyone — were Mississippi, Texas, Nevada, and Oklahoma. The highest rated states were Massachusetts, Vermont, and Rhode Island.

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Jake and Dana: Please Ask This Question.

By MIKE MAGEE

In case you were trying to forget, the first Presidential Debate is this week.

Question: Would Healthy Women Create a Healthy Democracy?

When he assumed the role as the AMA’s 178th president on June 13, 2023, Jesse M. Ehrenfeld, MD, MPH focused on inequities in health care as a top priority for his year in office. In a memorable opening that day in Chicago, the Wisconsin anesthesiologist shared a personal mission with 700 AMA delegates centered on his then 4 year old son. Ethan was born 10 weeks premature at 2 lbs 7 oz.

“Watching my son cling to life, I was struck by the painful reality that, even though I was a physician and now, a father, neither I, nor my husband, could donate blood simply because we are gay. Discriminatory policies—policies rooted in stigma, not science—barred us from doing the most humane of acts, donating our blood.”

Dr. Ehrenfeld used that story as a jumping off point to share his priorities as their new President. He pledged that day to seek justice and equity, highlighting:

“Black women are at least three times as likely as white women to die as a result of their pregnancy.

“Black men are 50% more likely to die following elective surgery.

“LGBTQ+ teens and young adults suffer higher rates of mental health challenges that often go undiagnosed.”

He also warned, in the shadow of the Dobbs decision on June 24, 2022, of  “… discouraging trends related to health outcomes—maternal mortality rates in the U.S. are more than double those of other well-resourced nations, for instance—and are becoming more prevalent.”

But when it came to the politics of reproductive health access, he chose his words carefully and took a quieter tone with the audience of politically savvy doctors from red and blue states.

“Certain aspects of the country’s political climate have become dangerously polarized. Politicians and judges are making decisions about health care formerly reserved for patients and physicians and patients…” he said.

This statement, coming one year after Dobbs, clearly did not mirror, in intensity, the words of his predecessor, Jack Resneck Jr.,MD, who wrote on the day of the decision, “The American Medical Association is deeply disturbed by the U.S. Supreme Court’s decision to overturn nearly a half century of precedent protecting patients’ right to critical reproductive health care…In alignment with our long-held position that the early termination of a pregnancy is a medical matter between the patient and physician, subject only to the physician’s clinical judgment and the patient’s informed consent, the AMA condemns the high court’s interpretation in this case.”

That sentiment was reinforced by the nation’s 25,000 OBGYNs, 60% of whom are women. Their association (ACOG) wrote, “Today’s decision is a direct blow to bodily autonomy, reproductive health, patient safety, and health equity in the United States. Reversing the constitutional protection for safe, legal abortion established by the Supreme Court nearly 50 years ago exposes pregnant people to arbitrary state-based restrictions, regulations, and bans that will leave many people unable to access needed medical care.”

Statements on behalf of the American Nurses Association, and the organizational arms for both physicians associates (PAs) and nurse practitioners (NPs) were equally forthright.

There are 4.2 million nurses, over 1 million doctors, and over 1/2 million PAs and NPs in the US. And as the latest US Census Report headlined, “Your health care is in women’s hands. Women hold 76% of all health care jobs.” This includes 90% of all nursing positions, 66% of PAs, and 55% of all current Medical School slots.

Not surprisingly, as women numbers have risen, traditional oaths for the caring professions have reflected changing priorities. For example, the women majority 2022 entering class of Penn State’s College of Medicine for the first time gave top billing in their professional oath to patients, not to the gods: “By all that I hold highest, I promise my patients competence, integrity, candor, personal commitment to their best interest, compassion, and absolute discretion, and confidentiality within the law.”

Seven years earlier, the American Nurses Association (ANA), created a formal Code of Ethics, which largely supplanted the 1893 Nightingale Pledge, with a four pillared Code which celebrated Autonomy (patient self-determination), Beneficence (kindness and charity), Justice,(fairness) and Nonmaleficence (do no harm), as anchors to Nursing’s 9 Provisions (or Pledges) that commit to: compassion and respect, patient-focus, advocacy, active decision making, self-health, ethical environment, scholarly pursuit, collaborative teamwork, professional integrity and social justice.

During Dr. Ehrenfeld’s one-year tenure following the Dobbs decision women’s access to health care deteriorated in red state after red state, a point reflected in clear losses for Republicans on statewide initiatives supporting abortion access from Kansas to Kentucky, and Vermont to Michigan. But as the Kaiser Family Foundation reported this year, “As of April 2024, 14 states have implemented abortion bans, 11 states have placed gestational limits on abortion between 6 and 22 weeks…” Add to this that 1 in 5 current OB residents say they have decided to steer away from restrictive red states when they pursue practice opportunities on graduation.

And still, red states embracing MAGA’s marriage to White Nationalists seem to have doubled down on everything from restricting access to medication abortion and contraception, to book banning, to limiting  LBGTQ+ rights and promoting prayer in public schools in the hopes of achieving a Christian Nationalist society.

Which brings us to the fast approaching 2024 Presidential debate. Women’s reproductive autonomy will be well represented. It is arguably the premier equity and justice issue before us, central to both America’s patients and their caring health professionals. But let’s not forget it is also central to the health of our democracy.

John J. Patrick PhD, in his book Understanding Democracy, lists the ideals of democracy to include “civility, honesty, charity, compassion, courage, loyalty, patriotism, and self restraint.”

What other form of government is there that so closely aligns with the aspirational pledges and oaths of our doctors, nurses, and body politic?

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.

“What’s Up With The Alitos?”

By MIKE MAGEE

The 1st Presidential debate is just around the corner. What should be Jake and Dana’s 1st CNN question. Here’s a suggestion:

What’s up with the Alito’s these days?

Justice Sam weighed in with tipping the American scale (by virtue of his decisions) toward “godliness,” while a seemingly unhinged flag-flying Martha-Ann invited the world inside their marriage, declaring “He never controls me.” Good to know.

Making it clear that her visceral reaction to a neighbor’s PRIDE flag was faith-based, she revealed a short-fuse and a long memory. As she said, “I want a Sacred Heart of Jesus flag because I have to look across the lagoon at the pride flag for the next month. I said (to Sam), ‘When you are free of this nonsense, I’m putting it up.’”

Harvard sociologist, Robert Putnam, and his co-author, Notre-Dame political scientist David Campbell, made it clear in 2010 that something was up with gender, religion and politics in their publication, “American Grace: How Religion Divides and Unites Us.” In two sweeping surveys reported in the book, they revealed a change in attitudes that began to gain steam in 1970. To their surprise, “By 2006, majorities of every religious tradition except Mormons had come to favor women clergy. Nearly three-quarters of Americans said that women have too little influence in religion, a view that is widely shared across virtually all religious traditions and by both men and women.”

A recent AEI survey this year that catalogued religious affiliation of Boomers (1946-1964), Gen X (1965-1980), Millennials (1981-1996), and Gen Z (1997-2012) showed that women (in much greater numbers than men) apparently have had just about enough when it comes to religious subjugation. Only 14% of the baby boomer women were self-described religious “nones,” while 34% of Millennials and a whooping 39% of Gen Z’s were turning their backs on male-led religions.

The problem, experts say, tracks back to the concept of “complementarianism”, a belief that the Bible supports strictly different roles for men and women, and that “wives should submit to their husbands.”

Subjugation of women historically has taken many forms. The most recent has been the elimination of health care access with the Dobbs decision and reversal of Roe v. Wade. But placing a lid on women’s autonomy has a rich history in America. Take for example divorce.  It was outlawed in most states south of the Mason-Dixon line until the mid-19th century. As legal historian Lawrence Friedman explained, “Essentially husband and wife were one flesh; but the man was the owner of that flesh.”

In 1847, Wisconsin newspaperman and editor of the Racine Argus, Marshall Mason Strong, warned in an editorial that the “domestic sphere” was under attack with men being “degraded, the wife unsexed, and children uncared for.” Strong lamented the loss of women’s “finer sensibilities” with “every trait of loveliness blotted out.”

Two centuries later, the majority of women are having none of it, delivering political defeat after political defeat to religious conservatives after the Dobbs decision. That decision was the culmination of a carefully planned and executed conservative takeover of the Supreme Court with Justice Alito in the lead. His intent, according to Yale legal scholar Neil S. Siegel, was to protect “Americans who hold traditionalist conservative beliefs about speech, religion, guns, crime, race, gender, sexuality and the family. These Americans were previously majorities in the real or imagined past, but they increasingly find themselves in the minority.”

What do the Alito’s fear most? They fear that traditionalists like themselves will be “branded as bigots.” Justice Alito said as much in his dissent in Obergefell v. Hodges (same sex marriage). He wrote with some sense of drama “Those who cling to old beliefs will be able to whisper their thoughts in the recesses of their homes. If they repeat those views in public, they will risk being labeled as bigots and treated as such by governments, employers, and schools.”

His campaign to “protect majorities-turned-minorities” was also on full view five months before the 2016 Presidential election in his dissent after the Court declined to hear the case of a Washington State pharmacist who refused to fill prescribed contraceptives on religious grounds. Stormans, Inc. v. Wiesman, left standing according to Alito, was “likely to make a pharmacist unemployable if he or she objects on religious grounds to dispensing certain prescription medications…If this is a sign of how religious liberty claims will be treated in the years ahead, those who value religious freedom have cause for great concern.”

AEI has little encouragement to offer the Alito’s.

The survey’s conclusion is rather stark: “None of this is good news for America’s places of worship. Many of these young women are gone for good. Studies consistently show that people who leave religion rarely come back, even if they hold on to some of their formative beliefs and practices. The decline in religious participation and membership has provoked a good deal of concern and consternation, but these latest trends represent a four-alarm warning.”

And therein lies the problem. The recent actions of the Alito’s simply dig the hole deeper, as they await a reckoning with demographic fate. For the Alito’s, “the moment has revealed the man (and the woman).”

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical-Industrial Complex. (Grove/2020)

Are AI Clinical Protocols A Dobb-ist Trojan Horse?

By MIKE MAGEE

For most loyalist Americans at the turn of the 19th century, Justice John Marshall Harlan’s decision in Jacobson v. Massachusetts (1905). was a “slam dunk.” In it, he elected to force a reluctant Methodist minister in Massachusetts to undergo Smallpox vaccination during a regional epidemic or pay a fine.

Justice Harlan wrote at the time: “Real liberty for all could not exist under the operation of a principle which recognizes the right of each individual person to use his own, whether in respect of his person or his property, regardless of the injury that may be done to others.”

What could possibly go wrong here? Of course, citizens had not fully considered the “unintended consequences,” let alone the presence of President Wilson and others focused on “strengthening the American stock.”

This involved a two-prong attack on “the enemy without” and “the enemy within.”

The The Immigration Act of 1924, signed by President Calvin Coolidge, was the culmination of an attack on “the enemy without.” Quotas for immigration were set according to the 1890 Census which had the effect of advantaging the selective influx of Anglo-Saxons over Eastern Europeans and Italians. Asians (except Japanese and Filipinos) were banned.

As for “the enemy within,” rooters for the cause of weeding out “undesirable human traits” from the American populace had the firm support of premier academics from almost every elite university across the nation. This came in the form of new departments focused on advancing the “Eugenics Movement,” an excessively discriminatory, quasi-academic approach based on the work of Francis Galton, cousin of Charles Darwin.

Isolationists and Segregationists picked up the thread and ran with it focused on vulnerable members of the community labeled as paupers, mentally disabled, dwarfs, promiscuous or criminal.

In a strategy eerily reminiscent of that employed by Mississippi Pro-Life advocates in Dobbs v. Jackson Women’s Health Organization in 2021, Dr. Albert Priddy, activist director of the Virginia State Colony for Epileptics and Feebleminded, teamed up with radical Virginia state senator Aubrey Strode to hand pick and literally make a “federal case” out of a young institutionalized teen resident named Carrie Buck.

Their goal was to force the nation’s highest courts to sanction state sponsored mandated sterilization.

In a strange twist of fate, the Dobbs name was central to this case as well.

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We Freeze People, Don’t We?

By KIM BELLARD

Perhaps you’ve heard about the controversial Alabama Supreme Court ruling about in-vitro fertilization (IVF), in which the court declared that frozen embryos were people. The court stated that it has long held that “unborn children are ‘children,’” with Chief Justice Tom Parker – more on him later – opining in a concurring opinion:

Human life cannot be wrongfully destroyed without incurring the wrath of a holy God, who views the destruction of His image as an affront to Himself. Even before birth, all human beings bear the image of God, and their lives cannot be destroyed without effacing his glory.

Seriously.

Many people have already weighed in on this decision and its implications, but I couldn’t resist taking some pleasure in seeing “pro-life” advocates tying themselves in knots trying to explain why, when they legislated that life begins at conception, they didn’t mean this kind of conception and that kind of life.

John Oliver was typically on point, noting that the Alabama ruling was “wrong for a whole bunch of reasons. Mainly, if you freeze an embryo it’s fine. If you freeze a person, you have some explaining to do.”

The case in question wasn’t specifically about IVF, nor did the ruling explicitly outlaw it. It was a case about a patient who removed stored embryos and accidentally dropped them, and the couples whose embryos were destroyed wanted to hold that patient liable under the Wrongful Death of a Minor Act. The court said they could. Note, though, that neither the patient nor the clinic was being charged with murder or manslaughter…yet.

Although the Alabama Attorney General has already indicated he won’t prosecute IVF patients or clinicians, the ruling has had a chilling effect on fertility clinics in the states, with The University of Alabama at Birmingham health system and others indicating they were putting a pause on IVF treatments.

Justice Parker has long been known as something of a theocrat; as The New York Times wrote:

Since he was first elected to the nine-member court in 2004, and in his legal career before it, he has shown no reticence about expressing how his Christian beliefs have profoundly shaped his understanding of the law and his approach to it as a lawyer and judge.

His concurring opinion claimed: the state constitution had adopted a “theologically-based view of the sanctity of life.” Alabama is not alone. Kelly Baden, the vice president for public policy at the Guttmacher Institute, told BBC: “We do see that many elected officials and judges alike are often coming at this debate from a highly religious lens.”

Speaker Johnson has said:

The separation of church and state is a misnomer. People misunderstand it. Of course, it comes from a phrase that was in a letter that Jefferson wrote. It’s not in the Constitution. And what he was explaining is they did not want the government to encroach upon the church — not that they didn’t want principles of faith to have influence on our public life. It’s exactly the opposite.

And here we are.

Many Republicans are backtracking on the ruling.

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The Voice of Democracy is Young and Female

By MIKE MAGEE

“Don’t call me a saint,” said founder of the early 1930’s Catholic Workers Movement, Dorothy Day. “I don’t want to be dismissed that easily.” Oddly enough, says Jesuit writer, James Martin, “That quote is probably the biggest obstacle to her canonization…Given that quote, would Dorothy really want to be canonized?”

This week’s election results were a sliver of bright light in what has been a rather dark period. But it is at times like this that quiet heroes emerge. If courage has a face, this morning, as results across the land show a sweeping victory for Democrats, and specifically those advancing the cause of women’s autonomy in managing their own health decisions with their doctors, it belongs to a young woman from Kentucky named Hadley.

In the final weeks of the Kentucky governor’s race, as Politico reported, Andy Beshear gave voice to the woman who directly addressed his opponent on camera.  “Anyone who believes there should be no exceptions for rape and incest could never understand what it’s like to stand in my shoes. This is to you, Daniel Cameron. To tell a 12-year-old girl she must have the baby of her stepfather who raped her is unthinkable.”

Absorbing the results of the elections with the rest of us are Governor Chris Christie, Governor Ron DeSantis, Ambassador Nikki Haley, Vivek Ramaswamy, and Senator Tim Scott who took the stage last Wednesday evening in Miami at the 3rd Republican Primary Debate. No doubt they are surrounded by consultants trying to figure out how best to spin this issue. As Dobbs has played out in states like Kansas, Ohio, Kentucky, Wisconsin and beyond, political scientists are likely reminding that in politics, “Sometimes when you win, you lose.”

Court packing on a federal level, and even more importantly by Republican leaders on the state level, has tipped the power of our nation toward minority rule, allowing repugnant leaders to seize control of our legal system. That power has been used over the past decade to allow passage of laws that attack existing rights such as women’s power and autonomy over their own bodies, or construct barriers that obstruct the popular will of the people.  Examples include promoting  extreme gerrymandering and voter suppression, dead ending the Dream Act, or allowing citizen access to weapons of war and a permitless gun-carry law in Florida.

Understandably, citizens have wondered, “Will our Democracy die.” Hadley’s courageous decision reflects a stubborn and determined stance, by she and many others throughout this land, to assure the answer is, “No. Not on my watch!”

Her image and words will be lasting for three major reasons. They prove that:

  1. A healthy democracy requires participation and engagement of citizens.
  2. Freedom and autonomy, including access to health professionals, is sacred and personal.
  3. Women will not accept second class citizenship.

Trump no doubt remains unaware that he has lost everything. Many of his most ardent supporters, including Leonard Leo, the mastermind behind the court packing scheme that brought us the Dobbs decision, remain firmly in a state of denial. But even they must admit this morning, as they stare into Hadley’s eyes, and listen to her steady voice, they have met their match. And she is a young woman who’s message is clear, “Enough is enough!”

Likely channeling another woman’s spirit from a century ago, Hadley’s courage (listen here) was more human than super-human. As Dorothy Day quietly proclaimed, “Don’t call me a saint. I don’t want to be dismissed that easily.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.

Republican Misbehavior Promoted Health Professional Activism

By MIKE MAGEE

If you wanted to create a motto for the summer of 2023 – one that would stand the test of time from the medical exam room of Ohio to the gilded bathroom of Mar-a-lago – it would have to be Jack Smith’s “Facts matter!” If that is true on a national scale, it is equally true in states across the nation where doctors increasingly are coming out from behind a self-imposed clinical curtain and going public.

As reported in ProPublica last week, “Doctors who previously never mixed work with politics are jumping into the abortion debate by lobbying state lawmakers, campaigning, forming political action committees and trying to get reproductive rights protected by state law.”

A few examples:

1. One thousand Ohio doctors signed a full-page ad titled “A Message to our Patients on the loss of Reproductive Rights” in the Columbus Dispatch in response to actions of a state legislature highjacked by radicalized Republicans enacting a 6-week abortion ban post the Dobbs decision. This was after their coalition delivered a protest letter with 700,000 signatures earlier to the State House.

2. Dr. Damla Karsan, a Houston obstetrician, faced off Texas legislators  on July 20th, lending truth to power when she said , ““I feel like I’m being handicapped. I’m looking for clarity, a promise that I will not be persecuted for providing care with informed consent from patients that someone interprets is not worthy of the medical exception.”

3. In Nebraska, the doctor-led “Campaign for a Healthy Nebraska” raised $400,000 to hire political consultants to launch a women’s health rights campaign which helped the Nebraska Medical Society “find its inner voice” and openly oppose abortion restrictions in that state. State Senator Danielle Conrad was impressed. She said, “It’s really just incredible from my vantage point to see how these doctors have been able to not be hobbled by those decades of political baggage, to step forward with this fresh, clear medical perspective and be able to engage more people.”

4. A month earlier, Dr’s Katie McHugh, Gabriel Bosslet, Caroline Rouse and Tracey Wilkinson penned an Op-Ed in STAT in support of their colleague, Dr. Caitland Bernard, who had come to the rescue of a 10 year old Ohio rape victim who had fled to Indiana to gain access to an abortion. Caitlin was shamefully fined $3,000 by the Indiana State Licensing Board. Her colleagues wrote, “While a relatively minor punishment, this finding should send a chill through the medical community and beyond. But that chill shouldn’t be silencing.”

5. In Michigan, a doctor-led group, the Committee to Protect Health Care, teamed up with the ACLU, and successfully passed “Proposal 3”,  a “constitutional amendment to enshrine reproductive rights into the state constitution.” Dr. Rob Davidson declared, “This is a historic victory for reproductive rights in Michigan, and the Committee to Protect Health Care was proud to help get Proposal 3 across the finish line.”

Yesterday’s indictment of  Donald Trump, the citizen, squarely places him and his legislative enablers in Washington and Republican led state houses across our nation, on the wrong side of the truth. As reported, he is accused of “three conspiracies: one to defraud the United States; a second to obstruct an official government proceeding, the certification of the Electoral College vote; and a third to deprive people of a civil right, the right to have their votes counted.”

But what he and his Republican supporters in Washington and state houses across the nation are primarily guilty of, is not simply lying and deceit, but attempting to destroy our democracy and disenfranchise our voters. That is why prosecution under Civil Rights statutes employed in the past to address the savagery of the KKK, are totally appropriate here. Jack Smith’s “stand tall” leadership is a model for us all, and that includes our doctors and nurses.

As I have repeatedly argued, the health of our democracy is inseparably interwoven with the health of our system of caring for each other. At the helm of this system, our health professionals have survived the hurricane force winds of a pandemic, an inequitable and inefficient health delivery system, and a medical-industrial complex that is more focused on seizing patents than serving patients.

And yet, today we take heart. Our physicians, in growing numbers, are rediscovering their strength and their voices. Like Jack Smith, they are speaking up, in opposition to a small group of bitter and evil leaders, who have earned our active condemnation, and now must face the weight of the law.

Mike Magee MD is a Medical Historian, regular THCB contributor, and the author of CODE BLUE: Inside the Medical-Industrial Complex.

Burden of Pain

BY JAY JOSHI

We’re seeing a trend of late, where matters in healthcare once deemed to be civil in nature are turning criminal. We see it for nearly every polarizing health issue, from abortion to opioids. And it’s affecting vulnerable patients the most.

We have two separate systems in place, civil and criminal, because we have different standards of behavior. Civil laws determine whether undue harm was caused by one party to another. Criminal laws determine whether someone committed a crime. The threshold is distinctly different. If someone is caught driving ten miles over the designated speed limit, that person committed a civil infraction of traffic laws. But if someone is caught speeding well in excess, say thirty or forty miles over the speed limit, while driving recklessly, that person committed a crime. The extent of the violation determines the applicable law. That’s why traffic laws have distinct civil and criminal laws.

The same logic applies to healthcare. We have civil penalties for undue harm or malpractice and we have criminal penalties for crimes that transpire in the clinical context. The difference between the two, for something to go from civil to criminal, is mens rea, or a requirement of criminal intent.

Criminal intent implies certain violations were committed deliberately – literally as an act of crime. Normal civil violations, such as malpractice claims, offer physicians protection against liability. That protection doesn’t apply for criminal violations. And that’s the point. It explains why the sudden push by regulators, prosecutor offices, and federal agents to investigate otherwise civil matters as criminal is so pernicious.

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Matthew’s health care tidbits: Texas is the present future of abortion care

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

In this edition’s tidbits, I have to return to the stunning impact of the Dobbs ruling. We know will happen because it is already happening in Texas where the 6 week law was already being enforced in contravention of Roe v Wade.

Taxpayer money is going to “pregnancy crisis centers” that flat out lie to vulnerable patients about the impact of abortions on their health. Doctors are questioning women who have miscarried–at a moment that is already terrible for them, and women who have miscarried are being denied basic D&Cs–which can kill them.

Don’t get me started on the absolute nonsense being talked–and passed into law –about ectopic pregnancies, of which there are over 130,000 each year in the US, being carried to term. How unlikely is it that an ectopic pregnancy makes it to term with no ill effects? Let me tell you a story. My dad was an OBGYN. He and his anesthetist saved the life of a woman and her baby who somehow had made it to term while being ectopic. During the surgery she needed 12 pints of blood (a normal woman has 7-8 pints in her body) and he considered it the greatest piece of surgery he did in his entire career. He thought that he and the patients were very lucky. So I demand that crazy legislation saying ectopic pregnancies have to be carried to term also mandates that my dad is around to do every single C-Section. Unlikely, as he’s dead, but no crazier than the legislation in Indiana.

Then there’s the impact on telehealth. Most abortions are done using drugs but more and more of the pandemic-era exemptions to prescribing drugs and seeing patients over telehealth across state lines are being withdrawn. Clearly the state-based licensing of doctors is itself ridiculous in an age of online commerce, but despite the DOJ statements the legality of prescribing abortifacients across state lines is very unclear and, as Deven McGraw explained in this harrowing piece on THCB Gang, HIPAA doesn’t protect patient privacy from local law enforcement. So what happens to someone in a state where abortion is banned if they have to go to hospital because of a complication from taking an abortifacient? Trump thinks they should go to jail.

What is clear is that bans on abortion don’t stop abortions. But they do endanger women. And if the pregnancy crisis center stops a woman from getting an abortion, do they help afterwards? Why yes, if you mean by “helping”, they have a celebratory dinner and light a fricking candle.