Thoughts on Sebelius v. Hobby Lobby Stores, Inc., Pt. 2

**This is a modified version of an essay that I had published in the spring of this year. Essay material corresponds with PHI-130 Medical Ethics under Dr. Lance Stell. This post will detail my legal and medical reasoning for my predicted outcome in Sebelius v. Hobby Lobby Stores, Inc. While I realize that this post is longer, I feel that it is important to share some insight into how I view cases like these and how I approach them. My reasoning best matches that of the Brennan Center’s of NYU Law.

On March 23, 2010, Congress adopted the Patient Protection and Affordable Care Act (ACA), a broad legislative initiative to overhaul the nation’s health-care system and regulations. One feature of the act is that it requires a general provision that employer-sponsored group health care plans cover “preventive care and screenings,” including approved contraceptive methods, sterilization procedures, and patient education and counseling for women in relation to reproduction in accordance with recommendations from the Health Resources and Services Administration.

While some may contest that legislation like the ACA weaken individual liberties by disregarding business owners’ religious liberties, the ACA helps to promote individual liberties and does not infringe upon business owners. Contraceptive coverage should be mandatory for all health insurance policies, irrespective of business owner’s religious beliefs in accordance with the ACA. Businesses should accept the ACA mandate for contraceptive coverage because it does not infringe upon First Amendment Rights, does not violate the Religious Freedom Restoration Act of 1993, and promotes competent scientific practices. Because the ACA does not infringe upon constitutional rights and supports valid scientific practices, contraceptive coverage should be mandatory.

Since the nation’s founding, the Constitution has dutifully protected religious liberties as a personal right for citizens, yet businesses cannot take part in this constitutional tradition due to conflicts with the Free Exercise Clause within the First Amendment. Businesses lack reason, dignity, and conscience, distinctly separating them from fundamental human pursuits and the central pursuit of free exercise of religion.

In Citizens United, the Supreme Court held that government entities cannot suppress political speech for corporations in accordance with the Free Speech Clause, but in July of 2013, the US Court of Appeals for the Third Circuit determined that “for-profit, secular corporations cannot engage in religious exercise” in Conestoga Wood Specialties Corporation v. Sebelius.

As noted in Conestoga’s outcome reasoning, the purpose of the Free Exercise Clause is to secure religious liberty in individuals by prohibiting interventions from civil authorities. The court notes, “religious belief takes shape within the minds and hearts of individuals, and its protection is one of the more uniquely human rights provided.” The Tenth Circuit Court concluded in concurrence in 2013 regarding Hobby Lobby Stores, Inc. v. Sebelius that corporations simply do not exercise religion, for businesses are unable, apart from the actions of their owners and employees, to take religiously-motivated actions. Although business owners may hold personal religious convictions, Free Exercise protections do not extend to for-profit, secular corporations. “Artificial being(s), invisible, intangible, and existing only in contemplation of law” are distinctly different from United States citizens seeking to exercise human rights with a defined conscience (Dartmouth Coll., 17 U.S. 518).

Because the ACA does not require individuals who own businesses to personally provide health care coverage but rather only corporate entities, these businesses cannot be harmed by Free Exercise infringements or violate personal conscience.

Opponents of the ACA note that the steep fines and penalties associated with failure to comply with the provisions of the contraceptive mandate infringe upon provisions set forth by the Religious Freedom Restoration Act of 1993 (RFRA), but making contraception coverage mandatory is not in violation. RFRA is a federal law that seeks to prohibit laws that “substantially burden” a person’s free exercise of religion (RFRA, Sec. 3). The Government may not substantially burden this exercise unless the violation is in accordance with approved exceptions. These exceptions are broadly defined that the law “is in furtherance of a compelling governmental interest” and “is the least restrictive means of furthering that governmental interest.” Only beliefs rooted in religion are protected by the Free Exercise Clause; thus, even sincere secular beliefs would not be covered by the First Amendment in this context.

Upon passing the ACA, debates regarding religious-employers received the most coverage, for while the law allows for churches and houses of worship to bypass the legislation, it does not leave room for conscientious objections. In order to understand the applicability of RFRA to corporations, religion itself must be defined. In a dissenting opinion in the US 7th Circuit, Justice Sykes writes:

“All of this reinforces what one would otherwise intuit about religion: that it is inextricably intertwined with characteristics that are uniquely human: conscience, belief, faith, and devotion. Religious beliefs have to do with such fundamental questions as the nature of mankind, where we came from, our place in the world, what happens when we die, and our relationships with and obligations to other people. Only the human mind can entertain such questions (Korte v. Sebelius, Nos. 12-3841 & 13-1077).”

Although Justice Sykes dissented from the majority opinion, the reasoning poses unique implications. In this reasoning, corporations are unable to generate autonomous decisions in that religious faith cannot be incorporated as legal construct. This ideological backing is similar to Planned Parenthood v. Casey where it was asserted that, “At the heart of liberty is the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life. Beliefs about these matters could not define the attributes of personhood were they formed under compulsion of the State.”

RFRA does not compel the individual owners to alter their own personal practices, but rather, it compels them to provide corporate health plans who in turn fund the insurance employees use to purchase contraception. As the American Civil Liberties Union notes in their amicus brief to the Supreme Court for Hobby Lobby Stores, Inc., v. Sebelius, the owners are only required to cover health insurance. Providing insurance plans does not place a “substantial burden” on the owners, and the decision to obtain contraception lies therein with the employee. RFRA does not protect individuals seeking to suppress the free-exercise powers of individuals who differ in religious or personal beliefs from the business owner.

Contestants of the ACA mandate claim that contraceptive coverage should not be supported as many forms of contraceptive are linked to abortive practices. In October 2013, Senator Ted Cruz of Texas told attendees of the 2013 Values Voter Summit that the ACA was “forcing… businesses like Hobby Lobby to provide ‘abortifacients’.” In 1976, Congress drafted and passed the Hyde Amendment in order to ensure that abortion is not covered through Medicaid health care services, a federal government program. Although the ACA does require employers to cover birth control and emergency contraception, businesses are not required to cover RU-486, the abortion-inducing medication that is often mistaken for emergency contraception. Many politicians contest that emergency contraception causes abortions by preventing implantation in the uterus, yet as Pam Belluck notes in The New York Times, “It turns out that the politically charged debate over morning-after pills and abortion, a divisive issue in this election year, is probably rooted in outdated or incorrect scientific guesses about how the pills work.”

Most drugs under the ACA delay ovulation, the release of eggs from ovaries that occurs before eggs are fertilized; thus, these drugs prevent the creation of fertilized eggs. In its brief on behalf of petitioners for Sebelius v. Hobby Lobby Stores, Inc., the Physicians of Reproductive Health et al. stated that, “Abortificient has a precise meaning in the medical and scientific community and it refers to the termination of a pregnancy. Contraceptives that prevent fertilization from occurring, or even prevent implantation, are simply not abortifacients (Sebelius v. Hobby Lobby Stores, Inc., No. 13-354).”

Although there was initial confusion regarding contraceptives, these products are now understood to prevent fertilization. Emergency contraception methods are not abortifacients, and abortifacients are not covered under the ACA.

Contraceptive coverage should be mandatory for all health insurance policies irrespective of business owners’ personal religious beliefs. The ACA does not infringe upon provisions set forth by the First Amendment or RFRA, as the businesses and corporations subject to the contraceptive mandate hold distinct behaviors and traits that distinguish them from acting as parties who can be placed under “substantial burdens” under law. Indeed, the ACA furthers adoption of evidenced-based medical practices to enhance the relationship between patients and physicians. Thus, it is within the interests of both business owners and their employees throughout the United States to support the contraceptive mandate within the ACA.

Expected outcome: This can really go either way. Expect a 5-4 ruling. Justice Kennedy will again be the swing vote.

This week is my Super Bowl.

Note: I think that media has largely missed the point of this case. “Obamacare” will continue to live, and women will still have access to contraception. This case primarily concerns provisions of corporate law assessing if corporations should have the same constitutional rights as individuals. I think that this HuffPo piece does a nice job of explaining these distinctions.

Let’s see if I’m right.

Two Young Fish

As many of you know, I like to retreat to my asylum of books and articles regularly. If you’ve had a conversation with me for more than ten minutes, you’ve probably heard one of my tangents on healthcare, child psychology, or my favorite books. Most of you know that my favorite authors are Hemingway, Oliver Sacks, and David Foster Wallace.

My favorite speech is David Foster Wallace’s 2005 commencement address to Kenyon College. It’s a common favorite, particularly among students who attend liberal arts colleges. It serves as a nice meditation on the truths and “Truth” we experience in life – a meditation on avoiding self-absorption and arrogance, a reminder to employ conscientiousness in daily living.

I’ve been thinking a lot about two fish.

Wallace opens his address:

“There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says ‘Morning, boys. How’s the water?’ And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes ‘What the hell is water?'”

Wallace asking "What the hell is water?" maybe. Unlikely. Steve Rhodes - Wikimedia Commons

David Foster Wallace
Steve Rhodes – Wikimedia Commons

I spend a lot of time thinking about death and dying. I don’t mean that in a morbid way, but rather, I am simply hyper-aware of the fact that my future career exists because of death and dying, specifically.

All of the students here are dealing with issues in bioethics, a topic that frequently presents emotional challenges. I think that all of us, to some degree, think about and are affected by these topics.

It’s tough listening to patients grappling with a surgical procedure, trying to measure the benefits of surgery with intense risks. It’s even harder when you don’t know if that patient has full mental faculties and has no family to contact to make an informed decision.

It’s difficult looking at photos of face transplant transitions. Many of these people have horrific stories – bear attacks, shrapnel from war, or chemical burns. They have been stripped of markers of personal identity. Hand and face transplants are new, emerging practices, and these forms of transplants are unheard of with children.

Biomedical ethics must shape the best policies, but the field is venturing into unknown territory. I’ve had the privilege of getting to know Adam and the other students more this summer, and while Adam may be insufferable to grocery shop with, I admire everyone’s ability in remaining conscientious in approaching these tough topics.

I’m not uncomfortable with my projects. I’m excited by them, really.

But one thing that I have thinking about is the fact that once these papers are published and my name is on them – once I have that new line to put on my résumé – some physicians may use this information to change their practice. I see this particularly with my systematic review on risk prediction on acute kidney injury and end-stage renal disease.

I’m not saying that as an undergrad that I have some huge, lofty power. I am, however, given a great deal of independence here to work and pursue my interests comfortably and on my own terms.

I am trying to convey the fact that my name will be on a paper that may cause physicians to change their care practices. The aim of this paper is to explore outcomes in mortality, quality of life, and economic aspects of dialysis treatment vs. no dialysis treatment.

I hope that I have had enough qualifiers and supporting statements before I lead into this next thought.

If those physicians do indeed change care practice, they may not recommend dialysis treatment for a patient. They may communicate with the family that they can’t expect good outcomes. This review may make clinicians pause before recommending dialysis.

The academic-looking-at-schools-after-Davidson-freaking-out-about-grade-deflation student in me is pleased that I will be contributing to a paper of this much depth and influence. I don’t even disagree with the end-goal of the paper; I support its larger ideological backing on an “uncomfortable” topic (that maybe we should consider how prolonging life can lead to severe decreases in quality of life). But the fact that my name will be on a paper that clinicians may use to recommend or not recommend life-sustaining treatment?

That’s heavy.

This is a new area for me. It’s not one I expected to be in at 20 years old.

I want to make it clear that I am fully committed to my projects and am willing to take on any associated challenges. Today, I read 800 titles of articles relating to absolute mortality for acute kidney injury, chronic kidney disease, and end-stage renal disease. I’m simply writing this tonight because I think that in order for me to go into this field, I need to be able to balance handling this information while still not being “too caught up” with it.

6292 articles on the wall..

At the end of the day, 800 titles on death and dying later, it can be hard to remember the end-goal. I have to remember that these study participants are real people in real hospitals with real pain. I can’t just sort these studies into “Include,” “Exclude,” or “Maybe” (group criteria for the review) without giving them proper thought and care.

And so this brings us to “the art of medicine”.

I talk a lot about evidenced-based medicine, yet I am more deeply concerned with the art of medicine. The practice of medicine, and the rest of the health care disciplines, is deeply rooted in the scientific method, in systems, and in theories. We now see an emergence of “checklists” (come on, we’ve all used WebMD before) in attempt to standardize medical care, despite the rapidly changing profiles and needs of patients.

If the goal of health care is to provide the best care (“the needs of the patient come first”), is it not, perhaps, odd that we have standardized patients and condensed backgrounds and experiences into a checklist?

We demand physicians to provide effective and efficient care. We demand for them to have answers, as if they are infallible. We want structure and competence.

But what about the individuality of each patient? What happens when you leave the lab and step into the waiting room?

I’m in the weird lobby, somewhere nestled between the two.

In a study published by Family Practicethe authors note that patients’ dissatisfaction with consultation lengths with their physicians can actually be managed by making consultations longer. You would think that patients simply want to be in and out of the office with a prescription slip, but patients value a doctor who listens and tries to understand them. In addition, patients are more likely to follow recommendations from an attentive doctor.

Patients want to be treated as an individual and not as an insurance billing opportunity. Patients can feel neglected in strive for a medical standardization.

People want others to care about their problems.

Dr. Brian Yeaman, CMIO, of Norman Regional Health System writes for Nuance:

“The art of medicine has always been just that: an art.  It’s about listening to your patients, bridging questions, answers and observations with clinical knowledge to form a diagnosis, and developing a treatment plan that is then documented in a progress note… For someone who has dedicated his or her life to practicing the art of medicine, being asked to distill a patient visit into a series of check boxes can seem reductive, administrative and, at times, irrelevant to the most important aspect of healthcare — the capture and sharing of the patient’s story across the care continuum.”

Healthcare change is looming and we, as a collective society, are about to be thrown into a massive overhaul. Perhaps, with those changes, we lose some of the artistry of medicine. In a pursuit of checklists, reimbursement forms, and standardization, we deviate from the heart of medicine itself. The patient-physician relationship is complicated.

We view the patient as a number with a checklist of symptoms.

As I’m swimming around in my cubicle asking myself, “What the hell is hypocalcemia and hyperphosphatemia with secondary hyper-parathyroidism?” understand that I’m still asking, “What the hell is water?”.

Tomorrow, I’ll try to read another 800 titles, and I hope that I am able to employ the necessary attention and professionalism when thinking about others. I hope that I’m able to find a balance between the artistry and science.

Thoughts on Sebelius v. Hobby Lobby Stores, Inc., Pt. 1

**This will be the first of two parts on my thinking regarding the Sebelius v. Hobby Lobby Stores, Inc. case currently in the Supreme Court. Part 1 will detail my personal interests in this case. Part 2 will detail my legal and medical reasoning for my predicted outcome. Please feel free to read only one or the other.

Growing up in a red state near a blue city, I am exposed frequently to people of different backgrounds. I have met people ranging from avid supporters and contributors of the Tea Party to Trotskyist International Socialist supporters within my hometown alone. Nashville, with its many diverse issues in Second Amendment rights, immigration, education, death penalty, and First Amendment rights, frequently provides evidence of the wildly political American South.

As you walk around the city, it’s easy to see that Nashville boasts an incredible amount of bars, gas stations, and churches for a city of its size (the common joke is that everyone is looking for a way out). But it’s difficult to ignore the sheer number of hospitals looming throughout the city. With Skyline, Centennial, Saint Thomas, and Baptist clustered together, the concentration of healthcare services is impressive. Of course, Vanderbilt Medical Center and its affiliates dominate the city.

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Monroe Carell Jr. Children’s Hospital at Vanderbilt at night

Unfortunately, I had to spend some time in high school within these buildings. When I was fifteen, I began having sharp pains in the right side of my abdomen. I started visiting several specialists with my mother, and my physicians remained puzzled. Nothing was showing up on scans, X-rays, etc., but it was obvious that I was having pains. The doctors prescribed a “wait and see” approach with levonorgestral and ethinyl estradiol. The pains would come in cycles – some weeks were better than others, so really, there wasn’t too much that they could do.

My condition worsened my junior year. One morning, I woke up in the worst pain that I have experienced in my life. Being the normal, Type-A student, I tried to go about getting ready: brushing my hair, putting on some make up, and getting into the kilt (well, maybe that part isn’t so normal). I remember my mom calling up to me on the second floor and asking how I was doing that morning, and I responded that I was “a bit nauseous” but fine. She left to go to work, and I was alone.

A few minutes later, I was sweating on my bathroom floor. I reached up to grab my phone on the counter, and my vision kept “going white.” I stayed on the floor for a few minutes, and I was then able to call my mom. She told me to wait it out a bit and see how I felt. I was usually able to wait out waves of pain, so this was normal. However, my conditioned worsened. I called my grandmother, who worked as an anesthesiologist at one of the Nashville hospitals, as I began to become violently ill. Fortunately, my family was able to take me to my pediatrician who completed an exam in my less-than-perfect state. She recommended that I immediately go to Vanderbilt to have them check my possibly ruptured appendix.

A few hours and morphine naps later, the physicians still had not found a diagnosis. My appendix was not showing anything abnormal. The next morning, I was feeling better, and the doctors discharged me. Levonorgestral and ethinyl estradiol, levonorgestral and ethinyl estradiol, and repeat.

During my senior year, I grew tired of “waiting and seeing.” I wanted a laproscopic procedure (where a surgeon will make a small incision in the abdomen to insert a small camera to check out what’s going on inside). Before I went under the anesthesia, a surgeon told me that if I woke up with two incisions, then they had probably found the problem. If I woke up with only one, then that would likely mean that they would continue testing.

I woke up with two incisions. Almost three years later, I had a diagnosis.

I have a condition called endometriosis (see the hyperlink for Mayo’s description of this condition). In short, endometriosis causes the tissue that normally lines the inside of a uterus to grow on the outside. This causes the tissue to become trapped and irritated, possibly forming adhesions. Abnormal tissue then can bind organs together or cause cysts to form. It’s treated with levonorgestral and ethinyl estradiol, and if I have significant pain, I can just go in for a quick laproscopic surgery. My case was unique because the pain was so intense due to my young age and time to diagnose (usually, this condition affects women over 30, but no one is too young to face symptoms). On a typical day, I am pain-free and can go about my usual activities with ease.

Maybe you noticed throughout that I used the term “levonorgestral and ethinyl estradiol.” I’m sure that many of my female readers recognize this phrase. These are the progesterone and estrogen combinations of the common birth control pill. I treat my condition primarily with birth control.

I will not be working explicitly on issues of reproductive rights or accessibility to contraception this summer, but I am closely following the Sebelius v. Hobby Lobby Stores, Inc. case. The issue of this case primarily surrounds questions regarding the 1993 Religious Freedom Restoration Act (RFRA). RFRA asserts that the government “shall not substantially burden a person’s exercise of religion” unless that burden is the least restrictive means to further a “compelling” government interest. Thus, the question remains: can a for-profit, nonreligious corporation, such as Hobby Lobby, deny its employees the health coverage of contraceptives if the owners have religious objections?

When I read about issues in contraceptive coverage, I can’t help but to feel a bit anxious. Throughout high school, I was confident that my physicians would be able to take care of me, but there was always a small bit of lingering doubt and frustration. To me, this isn’t some thought piece on Sandra Fluke. This isn’t the Senate debating President Obama’s policies.

To me, this is my daily life. This is me reaching for a pill every night before I go to bed. To me, this is an eighteen year old girl taking off her make up, washing her face, and hoping that tomorrow morning she doesn’t wake up in the worst pain of her life.

Perhaps some will think that I am misguided in writing this. Maybe politicians really are just springing to provide me the care that I need.

Yet, when people tell me that my contraception “serves no medical purpose,” they aren’t looking to just start a debate. They are jeopardizing medication I need to go about living with the best quality of life. They are looking to restrict access to an evidenced-based-medical practice that helps me get the best education, have the best relationships, and get the most benefit from my daily life.

I’ve grown up in a city with bustling healthcare, many diverse political beliefs, and several cultural values. I think that a lot of this debate centers around the nature of preventing pregnancy (which is a whole different political blog entirely), and politicians will cut the medical research out of the debate.

By refusing to acknowledge the medical benefits of contraceptives, we ignore the millions of women who may face polycystic ovary syndrome (PCOS), endometriosis, amenorrhea resulting from radiation or chemotherapy, or anemia. Contraception, in addition, helps lower the risk of getting endometrial and ovarian cancer alike.

There is an important political debate that must surround reproductive rights for women. However, we must remember that accessibility to medical care should not be compromised.

We must not forget the millions of women who face these difficult medical conditions daily.

Starbucks and End-Stage Renal Disease

I had my first meeting with my primary mentor – Dr. Bjorg Thorsteinsdottir!

I want to take a moment to extend a quick thank you to Ashley Parker, a previous Vann Fellow. Ashley introduced me to this fellowship and helped review my cover letter and résumé during the application process. To my professors Dr. Lauren Stutts and Dr. Lance Stell – I also appreciate you taking the time to write my letters of recommendation. Without your help and confidence, I would not be writing from Rochester today.

View from the Skyway

View from the Skyway

As I stood outside of Dr. Thorsteinsdottir’s office in anticipation, I couldn’t help but to think of all of her impressive credentials. A double major in physics and mathematics, she received her MD from the University of Iceland. She completed her residency in Categorical Internal Medicine at the Mayo Graduate School of Medicine. In her words, “life happened” while conversing with a colleague over dinner one night, and she then became a fellow of Clinical Ethics at Harvard Medical School.

I really hope “life happens” for me over a dinner conversation and I become a fellow of Harvard.

You can find a full profile of her education and research interests here.

Yet, her Mayo profile cannot describe her kindness and ability to articulate complex issues. Immediately upon entering into her office, she greeted me with a warm hello and then pulled me out of it, asking if I liked coffee. We walked down Plummer hallway, and she lead me to the Starbucks around the corner. We continued to talk about our interests outside of medicine and healthcare policy – talking about Denmark, Southern cities, and her daughter starting kindergarten this year. Among all of the medical and ethical challenges she has on a day-to-day basis, she describes her greatest challenge every day as organizing her three kids to get ready for school with “chaos.” Because her husband is from Denmark (where I am traveling in the fall), she recommended various cities and offered to put me in contact with another individual here with connections near Copenhagen. She’s also trilingual in English, Icelandic, and Danish, of course.

I’m from Nashville – I’ve met celebrities. I’ve met politicians from previous experiences or jobs. Yesterday was really my first time being “star-struck.”

Dr. Thorsteinsdottir is hoping to recruit my help on writing a systematic review of risk-prediction in acute kidney injury and end-stage renal disease. The following information comes from the National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC).

End-stage renal disease (ESRD): total and permanent kidney failure. When the kidneys fail, the body retains fluid. Harmful wastes build up. A person with ESRD needs treatment to replace the work of the failed kidneys.

Acute kidney injury (AKI): sudden, temporary, and sometimes fatal loss of kidney function

Essentially, this means two things: 1) how can the United States healthcare system properly allocate resources for treating patients with ESRD? and 2) how can patients and families approach the issue in deciding whether or not to treat? This issue is particularly complex when considering implementation of dialysis treatment. Dialysis helps patients to retain function and can extend their lives. Immediately, this seems like it should be the go-to treatment option. However, we must make two considerations for treatment: 1) what is the cost to the families or larger healthcare system? and 2) what does the quality of life look like with dialysis treatment?

Understanding how to allocate resources and maintain communication between patients and physicians with ESRD is essential. Between 1980 and 2009, the prevalence rate for ESRD increased nearly 600% alone. ESRD is both prevalent and increasing within medical settings. Dialysis can prolong life, yet life expectancy, according to the Medical College of Wisconsin’s End of Life / Palliative Care Education Resource Center, “remains only a third to a sixth as long as similar patients not on dialysis” [this means that patients on dialysis will only live a third to a sixth greater than patients who do not use dialysis – dialysis can extend a patient’s life, but not by much when the kidney is already in complete failure].

Increases in ESRD cases - NKUDIC

Increases in ESRD cases – NKUDIC

Patients with ESRD or other associated kidney problems experience threats to quality of life, particularly if they utilize dialysis treatments. Dialysis changes patients’ eating, ability to work, medication use, sleep habits, and ability to participate in the community. Furthermore, patients may feel that they are a burden to their families or caretakers, furthering reports of depression and anxiety. Dialysis can be frustrating and can restrict day-to-day functioning.

American medicine is a complex topic. We are the leading innovator in medicine and medical technologies, but the American system, unfortunately, sometimes brings families to ruin. It’s no secret that medical expenses are the leading cause of bankruptcies in America. Consequently, we must consider the financial investment that is dialysis.

According to one Harvard study, 62.1% of all bankruptcies in 2007 resulted from medical expenses, and 92% of those debtors had debts over $5000. Within the highly politicized debate of healthcare reform, we sometimes get an “image” of what someone in bankruptcy looks like. Yet, most people in medical debt are well-educated, in the middle-class, and own homes. Over 75% have health insurance. I think that it’s important to remember these facts as I review this information.

These issues don’t affect some random stranger across the country. They affect your friends, family members, and neighbors. They affect someone in your workplace.

I’m happy that I am able to approach end-of-life care in the context of health policy with its associated ethical issues – patient/physician relationships, quality of life, cost-benefit analyses, communicating with families, and physician authority. I feel that my mentor’s expertise will certainly aid patients and their families in approaching the sensitive issue of whether or not to begin dialysis treatment. I am excited about the opportunity to work with her!

Disclaimer

This is the point in my blog where I will begin describing my research, legal, ethical, medical, and political interests in bioethics.  I met with my first mentor yesterday, and I will be describing my meeting in a follow-up post.

*Disclaimer

Because I am working primarily in end-of-life care issues and healthcare reform, some of these posts may be emotionally and politically charged for readers. I understand that everyone has a different opinion on these issues and comes from different backgrounds, upbringings, and experiences. I hope that I am able to provide you all with new information on these topics and maybe explain why I hold a particular viewpoint. If you feel that you may be particularly affected by a topic, please feel free to check the tags beforehand. I will do my best to maintain accuracy in my tags. Views reflected in this blog are mine alone.

American media frequently tries to condense charged topics such as end-of-life care and treatment options (think dialysis, euthanasia, ventilators, etc.), reproductive rights, and healthcare insurance to “black-and-white issues.” Maybe some of you hold strongly convicted opinions on these issues and are indeed unmovable forces, but in my experiences in talking with others from Tennessee, New York, North Carolina, California, Washington, Maryland, Iowa, Iceland, Germany, England, France, and beyond, most people realize the gray nature of these issues. It’s hard to hold “black-and-white” views in medicine, as every case is unique, and additional factors can further complicate an individual’s case. I, myself, hold many strong principles in approaching these issues, but I also realize that nearly every case in medical ethics forces me to consider my own principles. Sometimes, my final decision in how I would approach a case differs from the immediate principle. I realize that there are few absolutes within my system of values.

Research in bioethics requires both several commas and disclaimers. I don’t have a checklist to work with. I’m working within a system that is subject to patient, familial, government, physician, institutional, procedural, and legal forces.

With that, I hope that you understand the intent of this blog. I’m not looking to shake your ethical or moral foundations, yet I do think that reexamining our beliefs is certainly healthy. I’m just looking to share information with you as I come across and think about these issues.

Blisters

Before I flew to Rochester, I had a quick, minor procedure for my toe in my hometown. The podiatrist told me that I have small Achilles tendons and that I should wear open-toed shoes to help with the recovery. After spending two full days in heels from 7:00-4:00 and 9:00-7:00, I really want to call my podiatrist, ask her some questions about W-4 forms, and sob a little.

Last week, Adam and I didn’t do much. I can’t speak to his perspective, but this week, I’ve been thrown into adulthood. I’ve complained about rent, huddled around a television with six girls to scream at Andi (The Bachelorette), and discovered how to make coffee without a Keurig machine. I went two nights without a blanket and pillow in my bedroom with no lights, and I’m in sync with the 6:00 A.M. ambulances.

Yet, I love it here. I think that this is the “biggest small town” I have ever been in. I haven’t been to New York myself, but I can’t help but to think that this place is New York City scaled down into a few blocks. On one hand, you’ll find massive tour groups walking around with cameras, but in any one of the five bars surrounding our apartment, you’ll hear frequent locals laughing and shrieking to Katy Perry as the bar plays “Dark Horse” for surely the tenth time in one night. Mayo eclipses the city with its powerful skyscrapers, but there is definitely a positive relationship between employees and locals.

The history of the clinic itself is impressive to me. During the Civil War, William Mayo traveled to Rochester, MN to aid President Abraham Lincoln in examining soldiers for the draft. Serving in several philanthropic roles, Mayo soon opened his medical practice. His sons, William and Charles, continued the family practice. When a tornado struck the city in 1883, at least 30 townspeople died and several hundred remained injured; therefore, the brothers worked to provide relief efforts, transforming local hotels into temporary hospitals.

I could tell you more about the 76 buildings or how Mayo has ranked as a Fortune 100 company for over ten consecutive years. I could mention the one fire extinguisher I got to play with yesterday (they told us to use it!). Overall, I am still overwhelmed with the building that I work in. This summer, I will be working within the Plummer building.

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Plummer Building Jonathunder / WikiMedia Commons

Plummer, constructed during the Great Depression, served as the office for the Mayo brothers and partners. I will be working on the 3rd floor within the Program for Professionalism and Ethics.

This means that the entry to my office is almost directly across from the original Mayo brothers’ offices. Of course, I was honored to receive this fellowship in January, but seeing the offices really helped me understand the weight of this experience. As I looked around at the main room with every wall covered from floor to ceiling in honorary degrees, a Noble Peace prize, and awards, I couldn’t help but to be amazed at the brothers’ prestige.

Today, in one hour, I spoke with someone who handles $5 million donations, an ethicist trying to find a translator for the Dinkan (?) language to help a patient, and a Franciscan sister hoping to help the patients among the 800+ beds in St. Mary’s Hospital. I have looked in on offices of physicians that I have read about in national news – today, I gazed up at one of the main research buildings where a physician helped cure a patient’s cancer with the help of measles.

I’ve entered into something bigger than just some summer fellowship. I’m working for a leading provider in both care and research endowed with approximately $500 million in donations every year. I’m not throwing that number out to show off some figures for a company. As a not-for-profit organization, Mayo Clinic relies on its benefactors and patients alike for donations.

Over 80% of patients give to Mayo Clinic. Over 1,000,000 people visit Mayo per year in search for clinical care.

People give to Mayo because they have the confidence in what the organization does. They have entrusted Mayo to lead research in regenerative medicine, advance cancer care, and reform health care administration. They have entrusted the staff who work tirelessly to provide the best care.

They have faith in Mayo Clinic’s ability to transform medicine, to follow the tradition set forth by the Mayo family.