The community of Sasquatch, Connecticut, is an increasingly diverse population, and as such, has a diverse set of needs. Though the town has a predominantly Irish population, Sasquatch has notable Jewish communities, mixed white and black communities, as well as influxes of Lebanese Shia and Japanese immigrants. Due to large distance between the town and a major hospital, major decisions must be made on a number of controversial topics. I am an outsider to the community of Sasquatch, and study in Atlanta. My experiences are not those of these community members’, and I have used a central doctrine of mutual respect, respect for the established law, and maximal freedoms for the most people. My ethical judgements will largely be made on the legal and normative lines, with an attempt to respect and please people from various backgrounds, to provide a set of ethics suggestions.
Before we begin, one must ask the question: what is the nature of the Catholic-affiliated hospital’s shift to become non-denominational? The background information of whether this move was motivated by diversity or as a nominal tactic is imperative to understand what effects this report’s suggestions may have. I will, however, proceed under the assumption that the shift was more than a titular change. The American hospital system exists largely in the private sector with various government regulatory agencies and legislatures who oversee the creation and maintenance of rules and protocols. It is under that umbrella that many of the implicit suggestions made in the prompt of this paper raise legal eyebrows—is it within the law for hospitals to refuse to provide particular treatments or procedures? Due to conscience clauses in Connecticut, only individuals would be able refuse particular care, but it institutionally cannot refuse emergency situations in cases of uninsured people (“Refusing to Provide Health Services” 2017). Therefore, life-threatening abortions that are provided to insured patients ought to be granted to uninsured ones as well.
A second presumption that must be made is that both scenarios of each question are legal. I believe that once the argument becomes pointedly about the law, this becomes a conversation for lawyers and jurists, not for bioethicists. The nearby hospital subsidizes care for under-insured patients, an assistance that can be seen in many hospitals across the United States. There is a growing issue of growing medical costs that result from the assistance of the under-insured—a burden that falls to a great extent on the deductibles of the lower middle class. The assistance given by the hospital close to Sasquatch has also been implicitly called into question. A third presumption is that these fragmented populations will behave or believe similarly to those we have read about in our course. It is entirely conjectural and reductionist to pigeonhole a group of people as similar to their macrocosmic religion, an identity which they may or may not hold as very salient. With these initial conditions, the principal debate is that of assisted reproductive technologies (ARTs) and prenatal testing, a controversial topic that varies by culture, which must be taken into account given the heterogeneous population of Sasquatch. First, let’s take into account the faith and tradition of the Irish Catholic population. According to the Congregation for the Doctrine of Faith’s Donum Vitae and Dignitas Personae, we know that in vitro fertilization (IVF) and prenatal testing which would lead to termination of the fetus are not permissible. We must also recognize that this is the religious view of the Catholic Church, the majority religion of the Sasquatchian community and the religion of the hospital’s donors. Therefore, the power of this situation likely falls into the hands of the Catholics, akin to the axiom “money talks.”
It would be important to know how fundamentalist this Irish population is—the advocacy and maintenance of their religion may be an importantly held value to them, which would highly influence their interactions with the rest of the town. In the United States, the availability of choice is very important. Few things are mandatory and few things are banned, many fall in between and are available if one would like, which can be seen in the American controversy of autism-causing immunizations whereby parents sometimes forego vaccines only later to be hit by a crippling (and preventable) disease. What keeps this process continuing is the American adherence to ‘choice’ and ‘rights.’
I would like to define a tenet of American culture that I have observed, ‘refusable availability.’ One often retains the right of choice and is infrequently obligated to anything. For example, a parent can choose not to vaccinate their child. Conversely, the thought of a political obligation for a woman to carry a child to term is being met with mainstream animosity (Rothman 1991). In-line with this thinking, medical services in general ought to be available but refusable.
To support this claim, I’d like to provide a few more analogies to substantiate the notion of ‘refusable availability,’ but first I’d like to highlight its weakness. It is not absolute, and both federal and state governments occasionally extend their reach past the bounds of ‘refusable availability.’ This is a natural process, as any governing body alters its own capacity of control and is met with either complicity or opposition. During a tuberculosis outbreak, denizens are mandated to be tested and re-tested through state laws, whether or not one wants to. Additionally, the US military conscription has proven not to comply as readily with religious exemptions as most other parts of the American government. Many Black Muslims of The Nation of Islam were jailed for objecting to the draft of World War II, as well as 6,000 other conscientious objectors being imprisoned (Chambers 1987). These exceptions seem to occur only when there is a tremendous desideratum, such as public health or war.
Two US Supreme Court cases that strongly elucidate the theory of American ‘refusable availability’ are Burwell v. Hobby Lobby and Gonzales v. O Centro Espirita Beneficente Uniao do Vegetal. In Burwell v. Hobby Lobby, Hobby Lobby escaped an Obamacare-era mandate to provide connectives to employees because of a religious exemption. In perhaps a converse situation, a New Mexican branch of the Brazilian church União de Vegetal was allowed to import and consume a Schedule I drug as a part of a sacramental ritual, since some Native Americans were already authorized to use peyote, another Schedule I drug, under the doctrine of religious equality. This latter case highlights evidence for the presence of ‘refusable availability’ in a negative sense. A fourth and final presumption is that people who shy away from a particular technology will not be bothered by another group taking advantage of that technological service, unless the group in question is paying for it. This is a large condition, and assumes that there is no in-fighting between minority groups because of what is available, but leaves room for donors of a particular religion (in this case, Irish Catholics) to be choosy when providing certain services that do not adhere to their own religious beliefs. This is perhaps the weakest of my presumptions, and assumes that a Catholic would be content in his complicity to abortion and would continue to donate to the hospital. It assumes a particular American-ness and respect for one’s neighbor that is likely too naïve (Ball 2000).
I would now like to address the likely wants and needs of the minority populations. In some Jewish cultures, ART’s and prenatal testing are largely accepted, with little issue in early fetus termination (Kahn 2000). In terms of the Shia populations, there are religious ways to circumvent the religious red tape associated with reproductive technologies (whose legality in the United States I am not sure of), so the presence of further testing or assistance probably would not bother a Shia in the next room (Clarke 2007). Because the hospital has chosen to become non-denominational, it should no longer refuse services on the basis of religion or to appease religious donors. Based on the tenet that I have alluded to of ‘refusable availability’, hospital ought to provide uniform assistance to the under-insured. It could incorporate religious restriction if it were explicitly a religious institution, but by becoming non-denominational, it has foregone that privilege. If pre-natal exams, IVF, and ART, are being provided at the hospital, it should follow the guidelines for the under-insured that other medical services observe. As the only hospital that services a large area, it carries an analogously large responsibility to serve a diverse community that has no alternative options. The Emergency Medical and Treatment Labor Act (EMTLA) of 1986 guarantees uninsured patients care in both private and public hospitals. However, private hospitals may turn away patients in a non-emergency situation. This means that in the case of a pregnancy that threatens the life of the mother, the hospital should provide an abortion, even in the case of being uninsured.
It is also the hospital’s choice to provide particular services, which then affect different classes or ratings of the hospital (such as being a Level 1, 2, or 3 trauma center depending on trauma-related resources). It is not the place of the ethics committee to tell the hospital which services to provide, but it is my belief that the assistance that the under-insured enjoy should be matched in religiously controversial medical policies. If the line between offering a service is between agreed and disagreed upon practices based on religion, the dispute is protected by the first amendment to the US Constitution. If the line between offering a service is based on ability to pay, both the hospital and the doctor in question could be liable under EMTLA. It is for this reason that I believe the question of being insured should not carry much weight in this conversation. As for hospital employees encouraging families to allow unused embryos to be donated for research, I do not believe there is as much ground to defend such a request. Additionally, the same reasoning can be applied to limiting counseling by the Catholic clergy. There is little precedent to claim clergies from any particular religion should be throttled, as I would not support the same of any other religion. This interpretation upholds the federal First Amendment, which has recently been used to overturn Trump’s travel ban. This recent judicial precedent suggests that the First Amendment not only protects expression of religion, but denies legal judgement or restriction on the basis of religion. Concerning the finances of the hospital and the potential unwillingness of historically Catholic nursing staff to perform abortions, there is no way I can support forcing nurses into performing abortions, but this can perhaps be ameliorated with a combination of switching nurses around departments to maximize abortion-capable nurses in the obstetric department, as well as financially incentivizing performing abortions. Additionally, whether or not any of the prior suggestions are taken up by the hospital’s board, serious investments into cultural competency should be made. In order to meet needs of a mixed community, staff ought to take a cultural competency course so that they can understand “the values, traditions, and faiths of the patient” (Bhattacharyya 2006).
As Dr. Zotovic commented in a prior iteration of this report, a limitation here is that it had no mention of counseling services. Naturally, counseling services should be provided if any sort of abortion is available at the hospital. The stance of abortion for an individual is not likely to change; however, the stance of whether others could is the contentious dialogue we experience today. Therefore, I do not feel its the place of the ethics reviewer to take stance, but rather to determine derivative and parallel issues.
The church has taken a shift to being non-denominational within Christianity. Non-denominational does not suggest ‘secular,’ but it is likely to have similar attention to diverse needs than with which a purely sectarian branch may be concerned. Rather, it means that it is not under the institutional sway and consideration from one body of Christianity, and instead appeals to a more diverse set of backgrounds. In line with this, the hospital has a responsibility to the community as one of the only sources of healthcare in 90 minute radius, assuming use of personal transportation (Bhattacharyya 2006). It does not have an obligation to provide any service on-demand, but ought to consider the needs of the community. At the very least the hospital should provide uninsured patients identical emergency care to insured ones, on a purely legal basis. Since there is not alternative, its morality should not stand in the way of someone getting the treatment they would in any area. These are not mandates, but rather issues and responsibility to a low-access healthcare community to consider when negotiating the future of the institution.
-Chambers, J.. To Raise an Army: The Draft Comes to Modern America. New York: Free Press, 1987.
-“Refusing to Provide Health Services.” Guttmacher Institute. Guttmacher Center for Population Research Innovation and Dissemination, 01 April 2017. Web.