Today's Christian Doctor - Fall 2009 by Christian Medical & Dental Associations

Editorial

by David Stevens, MD, MA (Ethics) – Chief Executive Officer

More Than Justice I still remember my first night on call after returning from a month of medical missions during my family practice residency. I was jet lagged and tired. The evening was busy but things slowed down around midnight. I was pleased to be able to get to sleep in the house staff quarters at about 1 a.m. A half-hour later I was called back to the emergency room. A single Medicaid mom had brought her two year-old in with a two-week-history of runny nose. When I asked what prompted her to bring the child in at that time, she told me that Johnny Carson had just gone off. Since she couldn’t sleep, she decided it was a good time to have her son seen. She also expressed concern that he might wake her up when she finally did go to sleep. My initial inclination was to administer justice. I had just spent a month taking care of desperately sick people and now this woman had the nerve to get me up in the middle of the night. There was nothing fair about what she was doing to me, or to the government who was paying for her expensive, unnecessary ER visit. Then God whispered in my ear, “It is not about justice, it is about mercy.” Justice is cold, analytical, and equitable. Mercy is loving the unlovable and serving the undeserving. Throughout the gospels the sick came to Christ. We don’t read where the blind man, the woman with the daughter with an evil spirit, the man with a son with seizures, or the lepers asked, “Master, give us justice.” No, they pleaded, “Have mercy on me.” As we look at the plight of the poor in this country, we need to realize that the banner of justice will never take us to where God wants us to go. Our cry should be for mercy. That is the best motivation. Justice is but a poor substitute. These days, we hear the word “justice” bantered around more than ever in the context of healthcare, with less emphasis on treating people with fairness and reasonableness, and more emphasis on an individual’s or a group’s “rights.” This word carries with it the imposition of an obligation on society or to an individual who claims a right to justice. Don’t get me wrong. I support the biblical concept of justice, which teaches:

• To not pervert justice by favoring the rich, the crowd, or the poor (Ex. 23:2; Lev. 19:15). • To not deprive the foreigner, the fatherless, or widow of justice in court (Deut. 24:17). • That the righteous should care about justice for the poor (Pr. 29:7). • That those in authority – judges, kings, and religious rulers – should maintain justice and righteousness (1 King 10:9; Matt 23:23). • God is just and will govern with justice on His return (Psalm 9:8, 33:5; Is. 9:7; Rev. 19:11; Acts17:31). Many who advocate for healthcare reform often speak of justice and the “right” of everyone to healthcare. While I see biblical teaching on how we are to treat others justly, I do not find a basis for individuals demanding that treatment. (Before writing me to protest, please read on.) Justice is giving people what they deserve. Many of our illnesses are self-inflicted, e.g., smoking, drug abuse, overeating, lack of exercise, sexual promiscuity, violence, and other behaviors. While not unique, these problems are common among the poor. If justice were our primary guide, how should we care for these souls? Applying justice, do they merit care? And what of those with insurance or other means to pay? When they have self-inflicted illnesses is it just to care for them simply because they have the resources to pay for treatment or prevention? No, the poor don’t need “healthcare justice,” they need mercy – compassionate treatment. They need someone to come alongside and help bear their burden when they are ill. There are times when the poor in our country can be demanding and irresponsible. There are times when we don’t feel merciful towards those who take much of our time and seem ungrateful. It is then that we need to remember our source of mercy. “Compassion doesn’t originate in our bleeding hearts or moral sweat, but in God’s mercy” (Rom. 9:16, The Message). When I recognize God’s great mercy for undeserving me, it overflows to undeserving others! ✝ I n t e r n e t W e b s i t e : w w w. c m d a . o r g

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Fall 2009

table of

CONTENTS

V OLUME 4 0 , N O. 3

Fall 2009

The Christian Medical & Dental Associations® – Changing Hearts in Healthcare – since 1931.

Features 14 The Most Important Bioethical Issue You Face by David Stevens, MD, MA (Ethics) Your Right of Conscience is Under Attack The Time to Act is Now!

18 Nationalized Healthcare – Prescription or Problem? A Debate Two Christian Doctors Share Divergent Views on How Best to Approach the US Healthcare Crisis

23 Healthcare Justice for the Poor by Scott Morris, MD The Poor Face Many Healthcare Justice-Related Issues

26 Seeking Justice for Modern Day Slaves by Jeffrey J. Barrows, DO, MA (Bioethics) When You Treat a Victim of Human Trafficking, Will You Recognize the Symptoms?

29 Professionalism in Peril Second in a Six-Part Series by Gene Rudd, MD Inequality in Charges is an Issue of Justice

32 Pro-Choice Politics in the Back Alleys of Africa by Michael Johnson Why Outside Political Views Should Not be Forced on Africa

Departments 5 34

T o d a y ’s C h r i s t i a n D o c t o r

Progress Notes Advertising Section

Editor: David B. Biebel, DMin Editorial Committee: Gregg Albers, MD; Elizabeth Buchinsky, MD; John Crouch, MD; William C. Forbes, DDS; Curtis E. Harris, MD, JD; Rebecca Klint-Townsend, MD; Bruce MacFadyen, MD; Samuel E. Molind, DMD; Robert D. Orr, MD; Richard A. Swenson, MD Vice President for Communications: Margie Shealy Classified Ad Sales: Margie Shealy 423-844-1000 Display Ad Sales: Margie Shealy 423-844-1000 Design: Judy Johnson Printing: Pulp CMDA is a member of the Evangelical Council for Financial Accountability (ECFA). TODAY’S CHRISTIAN DOCTOR ®, registered with the US Patent and Trademark Office. ISSN 0009-546X, Fall 2009 Volume XL, No. 3. Printed in the United States of America. Published four times each year by the Christian Medical & Dental Associations ® at 2604 Highway 421, Bristol, TN 37620. Copyright © 2009, Christian Medical & Dental Associations ®. All Rights Reserved. Distributed free to CMDA members. Non-doctors (US) are welcome to subscribe at a rate of $35 per year ($40 per year, international). Standard presort postage paid at Bristol, Tenn. Postmaster: Send address changes to: Christian Medical & Dental Associations, P.O. Box 7500, Bristol, TN 37621-7500. Scripture references marked (NASB) are taken from the New American Standard Bible. Copyright© 1960, 1962, 1963, 1968, 1971, 1972, 1973, 1975, 1977 by the Lockman Foundation. Used by permission. Scripture references marked (KJV) are taken from King James Version. Scripture references marked Living Bible are from The Living Bible© 1971, Tyndale House Publishers. All rights reserved. Undesignated biblical references are from the Holy Bible, New International Version®. Copyright© 1973, 1978, 1984 by the International Bible Society. Used by permission. All rights reserved. Other versions used are noted in the text.

For membership information, contact the Christian Medical & Dental Associations at: P.O. Box 7500, Bristol, TN 37621-7500; Telephone: 423-844-1000, or toll-free, 1-888-230-2637; Fax: 423-844-1005; E-mail: memberservices@cmda.org; Website: http://www.joincmda.org. Articles and letters published represent the opinions of the authors and do not necessarily reflect the official policy of the Christian Medical & Dental Associations. Acceptance of paid advertising from any source does not necessarily imply the endorsement of a particular program, product, or service by CMDA. Any technical information, advice or instruction provided in this publication is for the benefit of our readers, without any guarantee with respect to results they may experience with regard to the same. Implementation of the same is the decision of the reader and at his or her own risk. CMDA cannot be responsible for any untoward results experienced as a result of following or attempting to follow said information, advice, or instruction.

Member Awards CMDA member Warren Heffron, MD, has received the prestigious F. Marian Bishop Leadership Award given by The Society of Teachers of Family Medicine. The award is given to a person each year who has made outstanding contributions over a sustained period of time to the academic discipline of family medicine. The award is named after one of the early founders of the organization and an early leader in family medicine education. The Society of Teachers of Family Medicine is the academic organization for persons who are teaching in family medicine programs, both in medical schools and hospital based residencies.

100th Baby Celebration The National Embryo Donation Center (NEDC) recently achieved a significant milestone. There have been over 100 babies born since 2003 in the NEDC adoption program through the remarkable process of embryo donation. Steve and Debbie Burner of Troutman, NC are the proud parents of the NEDC’s 100th baby. In February they welcomed Tristan into the world with open arms. Over 100 people, including other families who have conceived through embryo donation and adoption, celebrated with them in Knoxville, TN. When couples go through IVF and have completed their families, they often have embryos remaining from the process. The couples who have these extra embryos after their families are complete can choose to donate them to another infertile couple through an embryo adoption program. Through this revolutionary program the woman 100th baby family, Steve and receiving embryos can become Debbie Burner, and Tristan who pregnant with her adopted child. was born in February, 2009.

Discover medical missions and networking in a whole new way at this year’s Global Missions Health Conference!

November 12-14, 2009 – Louisville, KY Plenary speakers: Dr. Charles Fielding; Florence Muindi & Brother Daniel; Dr. Russ White; and, Dr. David Stevens. For more information, visit: www.medicalmissions.com, or e-mail: info@medicalmissions.com.

I n t e r n e t W e b s i t e : w w w. c m d a . o r g

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Fall 2009

Steury Scholarship Awarded This year’s Steury Scholarship was awarded to Ms. Sarah Jean Fort, an MK (missionary kid), born in Botswana and now a first year medical school student at The University of Alabama Birmingham School of Medicine. Her experiences growing up on the mission field in Botswana and later in Zimbabwe opened her heart to be a missionary doctor. “Seeing poverty and suffering on a daily basis instilled in me a deep sense of compassion for those in pain. The need for medical aid in those countries is overwhelming. I have a deep desire to fulfill that need. My first inspiration came from my grandparents, who were medical missionaries, when I set foot in the hospital they founded in Sanyati, Zimbabwe and saw the AIDS patients and their hopelessness. I knew then that I was blessed in order to be a blessing by using my gifts to help others like them.” Sarah has participated in a wide variety of missions work from the US to India. Her mission work in the US strengthened her calling when she volunteered at the Foundry Clinic in Birmingham, which helps recovering addicts. And while shadowing her uncle, an OB/Gyn in Louisiana, her commitment to becoming a physician deepened. While working in India, Sarah shared Christ with Hindus and Muslims in the midst of riots, bombs going off nearby, and encountering cobras. Her pastor, Todd Harrington, wrote to the review committee, “She is clearly called into a life of mission serv-

ice and has a clear direction and passion to study medicine. I sense within Sarah a dynamic relationship with Christ. This is evident in her love and passion for others, her faithfulness in living in the way of Jesus, and her desire for the things of God.” His words are evident. While in college Sarah led a Bible study for two years. Through an internship at Mission Birmingham, she has organized neighborhood clean up events, rebuilt a roof, fellowshipped over barbecue, and volunteered at mission clinics in the inner city of Birmingham, AL. The purpose of the “Dr. and Mrs. Ernest Steury Medical Scholarship Fund” is to assist with the tuition of medical students who are committed to a career in foreign or domestic missions. Applications are evaluated on the basis of academic record, spiritual maturity, cross-culture experience, leadership ability, the student’s sense of call, references, and extracurricular activities/talents. For information regarding the Steury Scholarship, contact the office of the Chief Executive Officer, or download the application at: www.cmda.org/scholarships.

ICMDA XIV World Congress Punta del Este, Uruguay – July 1-8, 2010

T o d a y ’s C h r i s t i a n D o c t o r

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“Priorities in Professional Practice – For Whom are You Working?” is the theme for 2010’s conference addressing questions like: • Which place has God in our plans? • What are our priorities regarding our family, husband/wife relationship, and parent-children relationship? • Do we aim at excellence and commitment in our task? • Who are we serving in our profession? Plenaries and workshops will address various scientific issues from a Christian-ethical perspective concerning our profession. Speakers include: Dr. David Stevens; Dr. Pablo Martinez; Dr. Aldo Fontao; and, author Philip Yancey. Visit www.icmda2010.org for more information.

Washington Update Missions Conference Jan. 30, 2010 CMDA, Mountain States Foundation, and Wellmont Foundation announced that they will be working together to equip and encourage healthcare professionals to share their professional skills with hurting and needy people. The first annual Partners in Medical Missions Conference, “Discover the JOY,” will be held on Saturday, January 30, 2010, at Meadowview Conference Center in Kingsport, TN. Physicians, dentists, nurses, pharmacists, students, and other healthcare personnel will have the opportunity to learn more about domestic and international missions through a wide selection of experienced missionaries, workshop speakers, exhibitors, and networking. Among the speakers will be Dr. Michael Johnson, who says he has been “held captive” in Africa since he and his wife made their first trip there in1984. “The children and families living on the streets of Nairobi, Kenya, and the need to show compassion and care for these destitute and desperate people are our captors,” Dr. Johnson said. [Editor’s note: See Dr. Johnson’s article in this issue of Today’s Christian Doctor, pages 32-33.] CMDA CEO Dr. David Stevens said, “Discover the JOY is a way that weary healthcare professionals can restore their joy in healthcare as they learn how to serve others through the skills and talents God has given them.” For more information and to register online go to: www.cmda.org/discoverthejoy.

The Christian Medical Association Washington Office recently met at the White House with senior officials in the Obama administration to discuss issues in healthcare. CMA Vice President for Government Relations Jonathan Imbody provided the Obama administration with the perspectives of CMA medical missionaries regarding international health program funding through the US Agency for International Development. CMA has also encouraged the administration to pursue sound policies in healthcare and has challenged attacks on faith-based healthcare professionals. CMA had attended twenty-eight meetings at the White House during the Bush administration, and hopes to continue to build relationships in the Obama administration to advance faith-based principles and values. CMA has also taken the lead in highlighting the health aspects of human trafficking, or modern-day slavery.

CMA’s Vice President for Government Relations Jonathan Imbody at the White House following a meeting with senior Obama officials, along with Kristin Hansen (left) of Care Net and Wendy Wright (right) of Concerned Women for America.

Leaders Wanted to Transform Doctors, to Transform the World If you are interested in serving CMDA as a volunteer leader in the House of Representatives, on a council or commission, and through those ultimately on the CMDA Board of Trustees, you can go to our website at www.cmda.org and click on “About” and then “Leadership” and choose either “House of Representatives” or “Board of Trustees” to find out more and get involved. Be prepared to submit a current CV via e-mail (preferably) or fax to the Executive Assistant, Debra Deyton at: executive@cmda.org; phone: 423-8441000; fax: 423-844-1017. The House of Representatives meets once a year to approve bylaws changes, receive reports, and approve the ethical positions of the organization. During the year, they

serve as two-way channels of communication between CMDA and its members. There is one representative from each state and from many of our local ministries. New trustees are nominated by a joint committee of the House of Representatives and the Board of Trustees. They look at the service record of potential nominees to CMDA, their leadership capabilities, expertise, and Christian testimony. Their nominees then are approved by both the House and the Board. Trustees, who may serve up to two consecutive four-year terms, pay all their own expenses. The Board meets three times a year to set policies, approve the budget, oversee finances, and provide supervision to the CEO. The Trustees’ page lists qualifications, and offers the option of self-referral: www.cmda.org/trustees.

Voice of Christian Doctors Media Training Each year, CMDA provides a two-day workshop to sixteen participants on how to effectively speak with the media. The “Voice of Christian Doctors” workshop is designed to teach participants how to use the media as an educational tool and to sharpen skills as CMDA media representatives. Training includes a methodology that works in the most hostile situations. Real life examples illustrate this method. Each participant receives one-on-one training and practice in the CMDA radio and television studios. The individualized instruction includes tips on crafting your messages, appearance, voice tone, and delivery. Participants also learn how to write effective op-ed pieces and letters to the editor. The next session is scheduled for May 17-18, 2010. You can register by going to www.cmda.org/mediatraining. 2009 Media Training Graduates Back row (left to right): Patrick Stern, MD; J. Grady Crosland, MD; Ron Nabors, CEO of Christian Blind Mission International, Inc.; Ron Bryce, MD; Phillip Ferguson, MD; Richard Johnson, MD; Richard Clifton, Host of Daystar TV. Front row (left to right): Patricia Giebink, MD; John Fulginiti III, MD; Cory Siffring, MD; Rosemary Stein, MD; John G. Pierce, Jr., MD; Trainer: David Stevens, MD. Not pictured: Sandy Christiansen, MD.

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If you haven’t logged into CMDA’s website, www.cmda.org, you are missing out on a lot of valuable resources and services, such as PowerPoint presentations, fact sheets, audio and video segments, and much more, which have been produced exclusively for CMDA members. Our system also allows you to update your member information in our records. Logging in is easy as long as we have your e-mail address in our system. Otherwise, you need to send us your e-mail address at: memberservices@cmda.org so we can continue to send you information that is time sensitive, news you can use, and updates on CMDA.

T o d a y ’s C h r i s t i a n D o c t o r

Practice Justice One Day at a Time

Bruce MacFadyen, MD President – CMDA

As I write this article, the debate about healthcare rages on in the news. The goal is clear – excellent healthcare for everyone at an affordable price. I can express my convictions to my state representative or senator and hope that my input will make a difference. However, where I know I can and must exert influence to do what is right is by the way I decide who

and when I treat and what diagnostic and therapeutic modalities I use. As a follower of Christ, I must, like Him, have respect, compassion, and concern for the sick who come to me, whether they are highly respected or not accepted by people around them. As a Christian, I am to be well-prepared to provide the best care possible regardless of the patient’s ability to pay and to use the resources available to me in a cost-efficient way for all patients. I must keep in mind that they are created in the image of God and are of great value to Him. By the way I treat my patients, I can influence residents and medical students to do the same as they care for patients in the future. I find I am best prepared to be the physician God has called me to be – to answer His call for my life and to meet the needs of my patients with wisdom and compas-

sion – when I commit the day to Him before I leave for the hospital. It is right for me to be prepared to be sensitive to spiritual and physical needs. Our hospital and office situations vary, and we each need to ask God how we should live each day. Recently, Al Weir, MD, addressed the healthcare issue through CMDA in the “4 Percent Solution” whereby he challenged us to donate 4 percent of our practice to treat the uninsured. Many physicians have found this to be a good plan for them. God will give us the wisdom we need to deal with healthcare issues in these challenging times. God promises us in James 1:5, “If any of you lacks wisdom, he should ask God, who gives generously to all without finding fault, and it will be given to him.”

Regional Ministries

I n t e r n e t W e b s i t e : w w w. c m d a . o r g

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Fall 2009

Global Health Outreach (GHO) Who Will Go?

Photo by David Bushong

A team with a heart for the least, the last, and the lost went to Afghanistan in May, 2009. No one knows how long the doors will be open in Afghanistan for us to go and to serve there, and for them to see in a very material way the transforming love of a God filled with grace and mercy. Insurgency cannot succeed where

Women Minister to Women in Pakistan

the people do not want it to. We were blessed to have eleven women step up to say, “Here I am; I will go.” It is essential to have women on our team or we will not be able to treat the women or children, who have been the greatest sufferers from the decades of turmoil and the civil war. A lack of basic infrastructure, government services, and emergency health facilities makes Afghanistan an exceptionally hazardous country. In the midst of all this, we felt the gentle spirit of Jesus as He ministered both to us and to the ones we were privileged to treat. “We all were stretched during this mission,” Mary* said, “but I would not have missed this opportunity to see Jesus at work.” Millie is still looking for ways to continue to be a blessing to

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the people of Afghanistan. Sonya is still keeping in touch with some of the patients that she treated. The Afghan doctors that heard her presentation on diabetes will never forget that lecture, either. We will never forget Debbie as she graciously came alongside a team member to see her safely back home. Yes, we have all been tested, and this is how we know that He is faithful, as David said, “I will not give a sacrifice to the Lord that cost me nothing.” It will be costly in our time, in our talent, and in our treasure to complete the great commission and demonstrate the great commandment, but for those who answer the call, no price is too high for what is returned. *Names changed

www .cmda.orG/GHo

In a small village outside Phnom Penh, children as young as five are bought and sold as sex slaves. Day after day their abuse continues, and their hope slips away. An international team of investigators goes undercover to infiltrate this ring of brothels and gather the evidence needed to free these girls. Meanwhile, skilled legal minds race the clock, working at the highest levels of US and foreign governments to bring the perpetrators to justice. Headed up by a former U.N. war-crimes investigator, the team perseveres against impossible obstacles – police corruption, death threats, and missionthwarting tip-offs – in an effort to bring freedom to the victims.

Terrify No More by Gary A. Haugen President of International Justice Mission

The stories of many victims are told in this book, not for the purpose of aggrandizement or pity, but for the enlightenment of those of us who are safe, free, and happy. You may have heard about people who have been arrested but who languish in jail for years awaiting a trial that may never come, or children who are enslaved and forced to make bricks or roll cigarettes for ten or more hours a day. Are they real to you? Do you think about the lives they are not able to live because of the injustices perpetrated upon them? Do you feel helpless? You can become more informed on one aspect of injustice – human trafficking – by going to www.cmda.org/trafficking. There you’ll find articles, commentaries, and other resources you can use to expand your knowledge of the problem. There is even a self-test to raise your awareness of signs trafficking victims might display as patients. Terrify No More is available in hardcover from www.shopcmda.org for $19.99. Another enlightening book is Not for Sale: The Return of the Global Slave Trade – and How We Can Fight It by David Batstone. It is available in soft cover for $14.95.

CMDA Member Speaks Out in California

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Sacramento Area Director Darilyn Falck, MD, FACEP, joined California lawmakers at the California Capitol in a press conference to build support for the federal conscience protection regulation. The CMA-led coalition Freedom2Care (www. Freedom2Care.org) sponsored the event to demonstrate how the loss of conscience rights could worsen California's healthcare budget crisis by forcing faithbased physicians and clinics out of medicine. Sixtynine faith-based hospitals care for over 9.3 million patients in California each year. “The loss of these faith-based physicians would have a devastating impact on healthcare access and would disproportionately hurt the poor and medically underserved populations, where often faith-based healthcare is their only option,” Dr. Falck explained.

Dr. Falck speaking at the California Capitol I n t e r n e t W e b s i t e : w w w. c m d a . o r g

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Fall 2009

Medical Education International (MEI) Ministering Cross-Culturally North American Ways Are Not Always God’s Ways! by the Director of MEI Ministering Cross-Culturally, by Lingenfelter and Mayers, was one of those life-changing books for me. It confronted me with the fact that most of my North American/Western ways were not shared by much of the world. Even more convicting was the fact that my ways differed from Jesus’ ways in almost every area discussed! We North Americans are very time and achievement oriented. Jesus and most of the world are much more person and relationship oriented. If we are to be like Jesus and conformed to His Image, we need to be person and relationship oriented, too! MEI team members often comment that the pace where they served was

much more relaxed than in their practice. They didn’t see as many patients or teach or operate as much as in North American medical schools, hospitals, and clinics. However, most soon adjusted. After all, they went to serve, not to have their way, and to love international colleagues. We should also be mindful that the teaching MEI does, though more limited in quantity than might be the case in North America, is beneficial in improving health care and practice. Those we teach have a continuing impact on patient care after our brief visit, since we are “teaching them to fish,” rather than fishing for them. MEI team members also soon realize the opportunities God is giving them. We may consider tea breaks, delays in the start of clinic or surgery, office meetings with

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medical leaders, or meals together as “down time.” But the Holy Spirit soon reveals to team members the advantage these times can give for building relationships and sharing their lives and faith with international colleagues. Sometimes it is hard to communicate the benefits of these differences in expectations and practice to doctors. Some who inquire about MEI have even told me they will go on “more productive” clinical trips when they hear about these differences! But MEI’s purpose is to serve the international medical institutions and colleagues who invite us, and to be Jesus to them, not to focus on how much we do while there. We are guests and not in control (a good lesson for many doctors). Would you like to join us?

www.cmda.orG/meI

The Most Important Bioethical Issue You Face by David Stevens, MD, MA (Ethics)

Healthcare workers’ right of conscience is under attack. Here’s a way to fight back.

How would you concisely and competently communicate with a colleague, a friend, or your local newspaper about right of conscience (ROC)? Since this is the most important bioethical issue you face – your very ability to practice medicine is at stake – it is something you need to learn to do. Let me share an acronym that I teach members during media training to help them formulate messages concisely and effectively. It is a lot easier than learning the Kreb Cycle! We call it putting together your DiMES. “Di” What is the Dilemma? Why should somebody care about this issue? “M” What is your main Message? What sub-points support it? “E” What Examples – analogies, statistics, quotes, sound bites – validate your message? “S” Solution – how can this dilemma be solved? What does the listener need to do?

T o d a y ’s C h r i s t i a n D o c t o r

Let’s put some flesh on these bones. The dilemma is that doctors and other healthcare professionals are being pressured and discriminated against by employers and colleagues because of their deeply held religious or moral beliefs. Almost one in four (23 percent) faith-based professionals state they have been discriminated against by employers, educators, or others in the healthcare system. Nearly two out of five have been pressured to violate their beliefs by referring, writing a prescription, or doing a procedure. Planned Parenthood, the ACLU, and other radical abortion organizations have well-funded projects to do away with what they call “The Right of Refusal.” A good number of their allies in the administration, Congress, and the courts are eager and willing to help them accomplish their goal to force faith-based and other professionals out of healthcare. For example, a family practice doctor in San Antonio felt that she should NOT dispense contraceptives to unmarried women. She referred them to a colleague

account of religious belief or worship, nor shall any national religion be established, nor shall the full and equal rights of conscience be in any manner, nor on any pretext infringed.” Do we want the government to ethically neuter doctors of all morality that is not approved by the state? What Hippocrates knew was that the moral integrity of the doctor is the patient’s best protection, and this is especially true in a healthcare system increasingly being driven by cost. When the state demands that any citizen yield their conscience or moral beliefs, to that degree it becomes totalitarian and dangerous. The greatest atrocities in the last hundred years have taken place in regimes that have done just that, from Nazi Germany to Communist Russia. You don’t have to agree with a person’s position on a moral issue to protect their right to exercise it. I might be willing to bear arms in the military, but I will defend the right of a Quaker to conscientiously object. Abolishing right of conscience is dangerous for our healthcare system. Many of our most compassionate faith-based doctors, nurses, and pharmacists, who more often work in rural areas and with the poor, would be driven out of healthcare. Hospitals could close. One in six patients in the US get healthcare at a Catholic hospital. Look across the hospital listings in many communities and it is likely you will find Baptist, Methodist, Seventh Day Adventist, and other facilities started or run by religious groups. Many would shut their doors before violating their beliefs. Doing away with right of conscience is dangerous because everyone will sooner or later be a patient. You don’t want to go to your doctor or hospital and find a sign hanging on the door, “Out of business! Wouldn’t do abortions or physicianassisted suicide.” In a recent survey of over 2,800 faithbased doctors, pharmacists, physician assistants, and nurses, 95 percent of them said they would quit medicine before violating their conscience. As we look at a healthcare system already facing personnel shortages in the face of an aging population, losing these professionals would be catastrophic resulting in healthcare rationing, suffering, and death.

I n t e r n e t W e b s i t e : w w w. c m d a . o r g

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Fall 2009

The Most Important Bioethical Issue You Face

across the hall. Her employer learned of this, called her in, and forced her to resign within a week. An anesthesiologist in NC was seeing pre-op patients on Saturday call coverage. A woman, who the OB/Gyn had listed as an elective D & C, said, “No, this is an elective abortion.” When the anesthesiologist contacted the scheduling physician, the doctor was irate that he wouldn’t handle the case. He contacted the medical director, administrators, and even board members, and the doctor got calls threatening that he would lose his hospital privileges if he didn’t provide the anesthesia. A hospital administrator, after hearing a talk on ROC by a CMDA staff member a few days later, stated, “I thought we had to pressure him to do this case. I didn’t know we were breaking the law.” A medical school applicant in a NYC interview was asked only one question, “How would you advise a 16-year-old pregnant girl?” When he didn’t offer an abortion, the interview was quickly over and he wasn’t accepted. He was accepted to Harvard Medical School, instead. After spelling out the dilemma, your key message could be, “Abolishing right of conscience is dangerous,” with the sub points that it is dangerous for our country, our healthcare system, and for every patient. It is dangerous for our country because it does away with one of our most basic inalienable liberties, the “free exercise of religion,” that is guaranteed in the first amendment of the US Constitution. James Madison, its author, made this very clear in the original version of the amendment that was later made more concise. He wrote: “The Civil Rights of none shall be abridged on

The Most Important Bioethical Issue You Face

Doctors should also not be required to refer patients for morally objectionable procedures. A medical referral is not like telling someone where to get a product a store may not carry. It means the referring doctor endorses the competency and ethics of the doctor they are referring to. It means they enter into a formal relationship with that doctor and expect a report about the diagnosis or treatment rendered. It means the referring doctor has facilitated an abortion, a suicide, or other intervention, and now is morally complicit in what occurred. Each professional and every patent can protect this right by educating themselves with resources on www.Freedom2Care.org (see sidebar, pg. 17), talking about the issue with their friends, writing or calling their Representatives, Senators, or the White House, or writing a letter to their local newspaper. As Thomas Jefferson said, “The Religion of every man must be left to the conviction and conscience of every man; and it is the right of every man to exercise it as these may dictate.” Now that wasn’t too hard, was it? If we speak to patients, colleagues, friends, and elected officials we can protect what James Madison called, “The most sacred of all property.” If we don’t, we have shirked our duty to protect our liberty and this great democracy from those blinded by their ideology. They want to wipe away any criticism of their actions. I’m going to stand up and be counted. Won’t you? ✝ So what is the solution? The majority of people (two to one) oppose rescinding healthcare right of conscience laws and regulations. The same percentage see it as an inalienable right. They oppose it to the point that 54 percent of Democrats, Republicans, and Independents say they will punish politicians that try to abolish this right. Nine to one, people want a healthcare professional who shares their moral beliefs. Protecting right of conscience gives patients choice. We wouldn’t require Target to carry everything that Walmart carries, or vice versa. Patients who want an abortion will find plenty of doctors who are willing to provide this to them. There are no lines outside abortion clinics. Sterilizations and contraception also are readily available. Health and Human Services put $1.8 billion dollars into contraception services last year. We dare not take away one of our most precious liberties merely to avoid inconvenience to a patient.

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David Stevens, MD, MA (Ethics) is the CEO of CMDA. From 1981 to 1991, Dr. Stevens served as a missionary doctor in Kenya, helping to transform Tenwek Hospital into one of the premier mission healthcare facilities in that country. As a leading spokesman for Christian doctors in America, Dr. Stevens has conducted hundreds of television, radio, and print media interviews. Dr. Stevens holds degrees from Asbury College and the University of Louisville School of Medicine. He is board certified in family practice. He earned a master’s degree in bioethics from Trinity International University in 2002.

“On some positions cowardice asks the question, ‘Is it safe?’ Expediency asks the question, ‘Is it politic?’ Vanity asks the question, ‘Is it popular?’ But conscience asks the question, ‘Is it right?’ And there comes a time when one must take a position that is neither safe, nor politic, nor popular. But . . . because it is right.” – Martin Luther King

“The one thing that doesn’t abide by majority rule is a person’s conscience.” – Harper Lee, 1960 To Kill a Mockingbird

Why are pro-abortion groups pushing this? Abraham Lincoln gives us insight in his 1960 Cooper Union address. Just substitute the word slavery with the word abortion. What would truly satisfy the proslavery (abortion) faction?: “[W]hat will convince them? This, and this only: cease to call slavery (abortion) wrong, and join them in calling it right. And this must be done thoroughly – done in acts as well as in words. Silence will not be tolerated – we must place ourselves avowedly with them . . . . The whole atmosphere must be disinfected from all taint of opposition to slavery (abortion), before they will cease to believe that all their troubles proceed from us.”

CMA Spearheads Coalition to Protect Conscience Rights To counter the assault on conscience rights in healthcare, in early 2009 CMA obtained a foundation grant and launched a national coalition, Freedom2Care. Over forty groups representing over 5 million constituents joined the coalition. As an immediate goal, the coalition aimed at preserving the conscience rights regulation implemented late in 2008 by the US Department of Health and Human Services (HHS). For the long-term, the coalition continues to educate policy makers, the public, and the medical community on conscience rights. During the one-month public comment period on the HHS conscience protection regulation, nearly 50,000 healthcare professionals and patients used the www.Freedom2Care.org website to send comments to HHS urging the administration to keep the regulation. After the HHS regulation public comment period ended April 9, the website action center switched to offering visitors a means to send a message to the President and to their legislators. The Polling Company, Inc., conducted two national surveys for CMA – one of the American public and another of faith-based healthcare professionals. The public poll revealed that Americans support the conscience regulation by a margin of two to one. In the faith-based survey, 95 percent of physicians agreed, “I would rather stop practicing medicine altogether than be forced to violate my conscience.” Full results are available at www.Freedom2Care.org. A Freedom2Care press conference on April 8 at the National Press Club in Washington, DC, helped generate extensive media coverage, including CNN, Fox News, the Washington Times, and many others. Congressional staff packed out a Freedom2Care briefing the same day on Capitol Hill. Lab coat-outfitted physicians and others visited the offices of sixty-four key legislators and others to provide educational resources on the conscience regulation. After the HHS public comment period ended in April, Freedom2Care launched the campaign’s second phase - educating Congress and the President. In June 2009, the coalition held a press conference in California and two education days at the US Congress in Washington, DC.

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The Most Important Bioethical Issue You Face

“Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof . . .” – Bill of Rights, First Amendment

Nationalized Healthcare

Prescription or Problem? Editor’s note: We asked two Christian physicians to share their divergent perspectives on nationalized healthcare. References for Dr. Emil’s answers are first in the endnote section, in Arabic numerals; Dr. Van Mol’s notes follow, in Roman numerals. Reader response is welcome.

A Debate

TCD: What are the three biggest issues facing the United States’ healthcare system? Dr. Emil: 1. Medical ethics: An increasing number of physicians are yielding to the seduction of corporatized medicine and advocating for their financial status rather than for patients.1 They see healthcare as another commodity to be bought and sold on the free market, rather than an essential humanitarian service. In my opinion, this crisis of advocacy underlies and contributes to all other issues. 2. Access to healthcare: Millions of Americans have no or little access to healthcare, unless an emergency ensues. Conservative estimates put the number of deaths due to lack of access at 18,000 people per year.2 The number of non-insured is estimated at 44 million by the US Census Bureau,3 and the number of underinsured is thought to be as high. These numbers are expected to rise significantly in a bad economy. 3. Lack of choice: Millions of Americans with insurance are locked into their plans, unable to choose their physicians, find a medical home, or enjoy continuity of care. In a country that values freedoms, there is little freedom in healthcare services. 18

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Dr. Van Mol: 1. Healthcare cost: It is 17 percent of the American economy as the nation’s top employer,i,ii but the expense to the patient for services rendered can be ruinous. 2. Insurance availability and price: Former Surgeon General Dr. C. E. Koop asserts it is down to the “insured, uninsured, and the uninsurable.”iii Insurance has mutated from risk pooling to a skimming up of the lowest risk. 3. Financing existing government entitlements: No industrialized nation can meet existing entitlement promises. In two years Medicare will start covering the first wave of 78 million Baby Boomers. By 2020, Medicare and Social Security will require 25 percent of all tax dollars. By 2050, Medicare and Medicaid will demand all of the federal budget.iv

Dr. Emil: Medicare for all. In Medicare, the rich and poor elderly alike have similar access and similar services, and all socioeconomic groups within Medicare express similar rates of satisfaction. Do you know of any rich Medicare recipient who refuses to use Medicare in lieu of a private plan?! This can become the case for the entire US population if there is a universal, single-payer, tax-financed plan, with the ability to buy supplemental insurance for services not covered by the plan.4

Dr. Van Mol: Even the liberal Kaiser Family Foundation corrects the number to under 14 million, not the often quoted 47 million, for involuntarily uninsured legal residents not qualifying for government programs and making below $50,000 yearly.v No US emergency department can decline services due to inability to pay, a fact well enough known to motivate tens of thousands of “healthcare tourists” yearly from Canada and Europe to obtain services their national health system refused or unacceptably delayed. The issue is not access to healthcare, but the manner of the interface. The Obama administration deems preservation of the employer-based system covering 177 million Americans a priority.vi How to provide for those without coverage requires a multifaceted approach.

TCD: How can we expect a system that is profit-driven to provide healthcare based on need, and not based on means? Dr. Emil: We can’t. The reason healthcare cannot be treated as a commodity is that the more healthcare you provide, the more you lose financially. That is why it is different from any other commodity where the more you sell, the more you profit. If we look at “healthcare services” rather than “health insurance” as the product, as we should, then it is obvious that profit-driven healthcare can never produce justice. Patching the present system is doomed to failure. A new system is needed.4

Nationalized Healthcare Debate

TCD: Millions of Americans are said to lack access to healthcare, which is often framed in the context of justice. If this is so, how can this injustice be best redressed?

Dr. Van Mol: Government means are precisely the constraining point for nationalized healthcare, thereby leading to rationing and over regionalizing. Columnist Mark Steyn calls it “universal lack of access, equality of non-care,” and further laments, “We believe it’s more moral to take poor government healthcare than to make arrangements for our own.”vii Winston Churchill conceded the inherent vice of capitalism to be the unequal sharing of blessings, while that of socialism was the equal sharing of miseries. The past sixty years of American medicine has been anything but exclusively profit-driven. Yet for all its shortcomings, our record is remarkable for innovation, positive results, providing a framework which integrates numerous non-profit delivery entities, and makes feasible continuous improvements. Try that with government-driven medicine’s heartless juggernaut.

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Nationalized Healthcare Debate

TCD: It is often noted that America spends the most per capita out of any industrialized nation on healthcare, while leaving millions uninsured and achieving inferior public health outcomes. Does the evidence endorse continuation of our system? Dr. Emil: We spend more because a third of every dollar is spent on nothing that has to do with actual provision of services, but on fueling the enormous healthcare industry bureaucracy. Medicare has an overhead of 3-4 percent and is one of the most efficient insurance plans (ask any biller!). The private industry has overhead ranging from 15 percent to 35 percent, and that is why we are spending much more than other countries.5 Detractors of a universal single-payer system often claim that Canadians flood the US seeking healthcare services. This has been looked at statistically in at least two welldesigned American studies, and has been shown to be completely false propaganda.6,7 Meanwhile, these same detractors fail to recognize tens of thousands of Americans who travel overseas to seek essential healthcare services each year.8 Finally, despite our heavy expenditure, our public health outcomes, and even many of our tertiary outcomes such as for cancer treatment and transplantation are inferior to other industrialized countries.9,10 We have been told for sixty years, since Truman advanced a public plan, that the free market will solve the problem. It hasn’t and it won’t.

Dr. Van Mol: Our primary statistical liability is integrity – we keep honest records for all to see and criticize. Case in point, infant mortality, which we document from birth on despite prematurity, not as most countries do.viii Our peri- and neonatal medicine is the world standard. Severely premature infants are most likely to survive here, resulting in further statistical corrosion, as such have more problems than term babies.ix,x The Economist noted Americans die about two years earlier than west Europeans,xi which is irrelevant, as people die from all manner of causes unrelated to medical care. Examine specific outcomes for specific disease states, like cardiovascular and cancer, and we are number one.xii,xiii The US is home to most of the planet’s best physicians, hospitals, and research facilities.xiv

TCD: Is there sufficient proof that a market-based approach has failed to provide comprehensive, effective, and socially just healthcare to the American people? Dr. Emil: Is there sufficient proof?! Half of all bankruptcies in America are due to healthcare bills.11 Three quarters of those bankrupt by illness had health insurance when they fell ill. America is the only industrialized nation with a large uninsured population. Even children have been sacrificed on the altar of corporate medicine. Any random issue of Pediatrics is likely to have an article on the ill effects of the non-system on pediatric health.12-14 There is more than sufficient proof. 20

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Dr. Van Mol: US medicine is not a study in the free market process. We have five levels of nationalized provision - Medicare, Medicaid, Public Health Service, US Military, and the Veterans Administration. Government already spends over 50 percent of American healthcare dollars.xv Even as it is, our care is attractive enough to generate “health tourists” from Europe and Canada. It is the most comprehensive and effective in existence when examined at the level of results for specific disease state. No ED can turn away a needy patient. Our system includes numerous non-profit organizations supporting the poor through charity hospitals (e.g., Shriner’s and St. Jude’s) and clinics, community health centers, Indian healthcare clinics, Christian rescue missions, and pregnancy centers.

Dr. Emil: Of course it is. The government does not authorize every medical act before it can be accomplished. The government pays the agreed on schedule and does not harass physicians by delaying payments for months, in the hope of saving a few dollars. The government does not play physicians against each other by forcing them to compete for lower rates, not higher quality.

Dr. Van Mol: Yes, a government plan is more efficient. There is enormous economy in saying “no” or “later” to service inquiries. Saves a fortune. It has also been said that death is the ultimate economy in medicine, but I am no fan. More to the point, there is considerable need to streamline and standardize a good deal of the administrative interface between private insurance and patients, or for that matter insurance and providers.

TCD: Is nationalization the best solution to America’s healthcare situation? Dr. Emil: It is the best solution and it is about time!15

Dr. Van Mol: No. Rationing and extreme regionalizing would be ruinous in the unique US environment as the world’s third largest and third most populous nation. Canada’s Fraser Institute calls American hospitals Canada’s safety valves.xvi The Canadian government spends over $1 billion for US treatment of their citizens.xvii A 2008 report on Canadian medicine found diminishing care, increasing waits for specialists, and slower fielding of approved drugs.xviii,xix Canadian women with high risk gestations often come to the US for care.xx A 2000 report on Britain’s National Health Service found its cardiovascular disease and cancer outcomes among Europe’s worst.xxi The NHS limits to eighteen weeks the wait for hospitalization,xxii and 750,000 Brits fill the waiting list.xxiii Even Sweden’s universal health system is languishing.xxiv We won’t do better with nationalization.

Nationalized Healthcare Debate

TCD: Is the private health insurance industry not vastly more bureaucratic and inefficient than a government plan?

TCD: Would Jesus support the concept of healthcare as a commodity bought and sold according to means, or as a service provided and received according to need? Dr. Emil: Jesus was a Healer. He healed first, and asked questions later! He directed His disciples to heal the sick anywhere they enter in His name. The Jesus I know would be saddened with what America has done with its many blessings when it comes to healthcare, and with what many Christians have supported over the last few decades. WWJD with our healthcare system? I believe He would treat it the same way He treated those who were buying and selling outside the temple!

Dr. Van Mol: The limitation of means applies to services as well as commodities. There are a great many legitimate and pressing medical needs to which nationalized systems just say no where our system does not. Jesus said those that are sick need a physician, not a smothering nanny state, and said such when healthcare was exclusively a commodity. Far from fearing profit, Jesus used it as a positive teaching tool (Mark 8:36, Matt. 25:14-30). Luke was called the beloved physician, not the faith-challenged money grubber. The question remains how we can best care for “the least of these.” We are clearly not batting a thousand in this regard, but many superior options and combinations exist over the mistake of nationalizing our healthcare. I n t e r n e t W e b s i t e : w w w. c m d a . o r g

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Nationalized Healthcare Debate

TCD: How can biblical principles like justice and compassion guide a Christian doctor in deciding how to be involved? Dr. Emil: 1. Work on the local level to compensate for the many deficiencies in the system, e.g. volunteering, free clinics, agreeing to see struggling patients, etc. Christians pioneered medical ministry, but means testing was never part of our Christian tradition. Let us return to our roots! 2. Work on the state and national levels to see healthcare become a fundamental human right, and end the travesty of corporate healthcare. ✝

Dr. Van Mol: Jesus did not dictate delivery systems by which we are to love our neighbor. Our ideas matter to God. The body of Christ is not paralyzed from the neck down. We are free to be creative, co-laboring with Abba Father in assisting the needy. Christians pioneered and globally distributed modern hospitals, orphanages, hospices, and a vast number of mercy ministries. CMDA provides a wide variety of missions options at home and abroad, and asks us to offer at least 4 percent of our practice load for the poor. The kingdom of God is that of right relationships. We can all pursue the Lord for direct guidance on how we each might bring our gifts and time to bear. ✝

Dr. Emil Notes 1. Geyman, J. “The corrosion of medicine.” Common Courage Press. Monroe, Maine 2008. 2. “Insuring America’s Health. Institute of Medicine.” The National Academies Press. Washington DC 2004. 3. US Census Bureau Report 2002. 4. Emil, S. “A startling transformation.” Bulletin of the American College of Surgeons. 93: 43-44, 2008. 5. Woolhandler S, Campbell T, Himmelstein DU. “Costs of health care administration in the United States and Canada.” New England Journal of Medicine 349: 768-775, 2003. 6. Katz SJ, Verrilli D, Barer ML. “Canadians’ use of US medical services.” Health Affairs 17: 225-235, 1998. 7. Katz SJ, Cardiff K, Pascali M, et al. “Phantoms in the snow: Canadians’ use of health care services in the United States.” Health Affairs 21: 19-31, 2002. 8. Milstein A, Smith M. “America’s new refugees – seeking affordable surgery offshore.” New England Journal of Medicine 355: 1637-1640, 2006. 9. Health Outcomes Report of the Organization of Economic Cooperation and Development, 2002. 10. Report of the Commonwealth Fund International Working Group on Quality Indicators, 2006. 11. Himmelstein DU, Warren E, Thorne D, et al. “Illness and injury as contributors to bankruptcy.” Health Affairs W5: 63-73, 2005. 12. Satchell M, Pati S. “Insurance gaps among vulnerable children in the United States.” Pediatrics 116: 1155-1161, 2005. 13. Olson LM, Tang S, Newacheck PW. “Children in the United States with discontinuous health insurance coverage.” New England Journal of Medicine 353: 382-391, 2005. 14. Kogan MD, Newacheck PW, Honberg L, et al. “Association between underinsurance and access to care among children with special health care needs in the United States.” Pediatrics 116: 1162-1169, 2005. 15. “Proposal of the physicians’ working group for single-payer national health insurance.” Journal of the American Medical Association 290: 798-805, 2003.

Sherif Emil, MD, CM, is an American academic pediatric surgeon who trained and practiced in Southern California for 15 years, following completion of his medical studies at McGill University in Montreal, Canada. He recently moved back to Canada to occupy the position of Director of Pediatric Surgery at the Montreal Children’s Hospital. He is a member of Physicians for a National Health Program, and an enthusiastic activist in support of single payer universal health insurance. His detailed views, particularly as they relate to his Christian faith, can be read on: www.thisIbelieve.org. 22

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Dr. Van Mol Notes “A Health Reformer’s Scary Diagnosis,” George Will, Jewish World Review, Jan. 1, 2009. i (http://www.jewishworldreview.com/cols/will010109.php3) ii “Ruin Your Health With the Obama Stimulus Plan,” Betsy McCaughey, Bloomberg.com, Feb. 9, 2009. (http://www.bloomberg.com/apps/news?pid=20601039&refer=columnist_mccaughey&sid= aLzfDxfbwhzs) iii Koop, C. Everett Koop (NY: Random House, 1991), p. 302. “A Prescription for American Health Care,” John C. Goodman, Imprimis, March 2009, Vol. 38, No. 3. iv v “Health Care Life: ’47 million Uninsured Americans,’” Julia A. Seymour, Business and Media Institute, 7/18/2007. (http://www.businessandmedia.org/printer/2007/20070718153509.aspx) vi “Consensus emerging on universal healthcare,” Noam N. Levey, Los Angeles Times, Dec. 1, 2008. (http://articles.latimes.com/2008/dec/01/nation/na-healthcare1) vii “Government Health Care is for Sissies,” Mark Steyn, The Western Standard, Oct. 11, 2004. viii http://www.esds.ac.uk/themes/health/case3.asp ix www.tinyurl.com/ck9lz2. http://archive.newsmax.com/archives/articles/2005/3/9/184540.shtml x xi www.tinyurl.com/cujo8l. xii “The Mythology of Health Care Reform,” Michael Tanner, CATO Institute, March 3, 2006. (www.tinyurl.com/ck9lz2). xiii “Another Bogus Report Card for US Medical Care,” John Stossel, Human Events.com, 8/29/2007. (http://www.humanevents.com/article.php?id=22148). xiv “The Mythology of Health Care Reform,” Michael Tanner, CATO Institute, March 3, 2006. (www.tinyurl.com/ck9lz2). xv “Sweden’s Government Health Care,” Walter E. Williams, Townhall.com, March 04, 2009. (http://townhall. com/columnists/WalterEWilliams/2009/03/04/swedens_government_health_care) xvi “Bypassing the Wait,” Michael Cannon, nationalreview.com, Sept. 10, 2004. (http://www.nationalreview. com/comment/cannon200409100700.asp). xvii “Sweden’s Government Health Care,” Walter E. Williams, Townhall.com, March 04, 2009. (http://townhall.com/columnists/WalterEWilliams/2009/03/04/swedens_government_health_care) xviii “What Canada Tells Us About Government Health Care,” Doug Wilson, Townhall.com, Feb. 25, 2008. (http://townhall.com/columnists/DougWilson/2008/02/25/what_canada_tells_us_about_government_ health_care) xix http://www.fraserinstitute.org/commerce.web/product_files/PayingMoreGettingLess2008.pdf. xx http://www.komonews.com/news/10216201.html. xxi http://www.civitas.org.uk/pdf/cw55.pdf. xxii http://www.oxfordradcliffe.nhs.uk/forclinicians/18weeks/18weeks.aspx. xxiii http://townhall.com/columnists/WalterEWilliams/2008/10/22/affordable_health_care. xxiv http://www.jpands.org/vol13no1/larson.pdf. xxv http://www.britannica.com/EBchecked/topic/272626/hospital xxvi Alvin J. Schmidt, How Christianity Changed the World, (Grand Rapids: Zondervan, 2001), p. 132. xxvii Kenneth R. Samples, Without a Doubt, (Grand Rapids: Baker Books, 2004), p. 219.

Andre Van Mol, MD, is a boardcertified family physician in private practice. He speaks and writes on bioethics and Christian apologetics, is experienced in short-term medical missions, and is a former US Naval officer. He and his wife, Evelyn, live in Redding, CA, with their two sons, guardianship daughter, and currently parent their sixth foster daughter. For more of Dr. Van Mol’s writing, see “Obama: change for good?” at http://www.cmf.org.uk/literature/ content.asp?context=article&id=2220. His series “Bioethics and Christian World View” is available at http://www.ibethel.org/store/p2274/Bioethics/product_ info.html.

JUSTICE

Healthcare

I work as a family practitioner at the Church Health Center, which I founded in Memphis, Tennessee in 1987 to provide quality, affordable healthcare to working uninsured people and their families. Recently, I saw a patient named Margaret, who had some good news and some bad news to share with me. The good news was that she had just been promoted to manager of a sandwich shop. She had gotten a small raise, too, and health insurance coverage, which meant she would no longer need our services. Unfortunately, the increase in pay and added benefit had caused her to lose Medicaid coverage for her two sons. When her 12-year-old, Joseph, complained of an earache, she decided to give him an antibiotic she had in her bathroom cabinet rather than take him to a physician. Joseph had an allergic reaction and began having respiratory distress. Margaret took him to the closest hospital, which then transferred him to the children’s hospital. He responded quickly to treatment, but Margaret is now facing two hospital bills she cannot afford to pay. In addition, her 10-year-old, Jason, is autistic. Because of the loss of Medicaid coverage, she can no longer afford the medicine that has kept him functioning at a fairly high level. When I first saw him, he had significantly decompensated. How has the American healthcare system come to the point where a work promotion for a single mother leads to her inability to provide healthcare for one child and the treatment for autism for another? To my mind, advocating for healthcare reform that prevents this scenario is part of a Christian call for justice. During the coming months, there will be much opportunity for people to express their opinions about the direction healthcare reform in America should take. Relentlessly looking for a way to care for the “Josephs” and “Jasons” all around us, I hope, is a matter of justice on which all Christian healthcare providers can agree. Justice in healthcare for Christians is not only about universal healthcare. The issues of justice go far deeper than affordable access. They include issues dealing with prevention, charity care, access to care for immigrants, dental care, repayment of our educational debt to the poor, as well as other matters including inequality in charges to the uninsured, addressed elsewhere in this issue of Today’s Christian Doctor. Each of these topics has a deep and wide reach that touches every Christian physician and healthcare provider at some point in time.

For Christians, the issues of justice in healthcare go far deeper than affordable access

for the Poor

by Scott Morris, MD

Prevention Preventive medicine, as reasonable as it seems, has been stymied because of our healthcare system’s reliance on technology. The demand for more technology to treat acute and existing disease absorbs the majority of the resources in our hospitals and in our research facilities – resources that could be working on preventing disease. We are raising an entire generation of kids who go home from school, sit on the couch, play X–Box, and eat junk food. These obese children will be adults who have hypertension, diabetes, and trouble getting a job, a very expensive outcome on many levels – unless healthcare adjusts its sights and focuses more on teaching healthy lifestyles to them and their parents. Were we willing to dedicate our resources to combating obesity, instead of focusing on developing pharmaceuticals to treat high cholesterol, erectile dysfunction, or the next generation of MRI, we would have a significantly healthier community in short order and for years to come. The church could be part of the solution, with our leadership. Yet in many I n t e r n e t W e b s i t e : w w w. c m d a . o r g

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Healthcare Justice for the Poor

cases, the least healthy meal we eat is at a church supper. How we care about and for God’s children, including bringing hope to the next generation, is an issue of justice. Charity Care Historically, Christian physicians have been very generous with their time and willingness to care for the poor. Yet, in 1965, with the advent of Medicare and Medicaid, all physicians began placing signs in their offices that read, “Payment is expected at the time of service.” Caring for the poor in one’s own community was replaced by taking overseas mission trips on a periodic basis. Local healthcare for the poor fell to community-based and government-funded safety net hospitals that usually were tied to medical education. Before 1965, one-third of every doctor’s practice was expected to be charity care – today, that percentage is usually less than five percent. This shift in care has become increasingly problematic as safety net institutions have struggled financially in the last several years. As a result, both the quality of and access to healthcare for the poor has suffered. There are, however, examples of how Christian physicians have led the way to address these issues motivated entirely by a desire for justice. In Memphis, uninsured patients with simple fractures, until recently, were initially treated in community emergency departments, then referred to the public teaching hospital for follow-up care. Because of recent financial cutbacks, the public teaching hospital is no longer able to provide the follow-up care. As a result, patients who cannot afford a private orthopedist are left to have bones heal without being set. When the extent of the problem was realized (431 fractures from one hospital ED in a two-month period), the orthopedists themselves agreed to see all cases in their offices in follow-up based on the Emergency Department’s call schedule, without regard to the patient’s ability to pay. This is a simple solution based on the common

Dr. Morris examines a patient. 24

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practice before 1965, but one that would not have been implemented were it not for Christian physicians looking to act in a manner motivated by justice.

Did You Know . . . ? Christian Community Health Fellowship (CCHF) is a nationwide network of health professionals who focus on living out the gospel through providing healthcare to the poor. They provide technical assistance for groups looking to start distinctively Christian health clinics for the underserved, and work extensively with student groups around the country to raise the awareness of our responsibility as Christians to care for the poor. CCHF functions as the primary domestic missions partner of CMDA. Learn more about CCHF by visiting www.CCHF.org, or by contacting the executive director, Steve Noblett, at (901) 271-6400, or: Info@CCHFmail.org.

Healthcare Needs of Immigrants Similar solutions must be sought for equally troubling problems, such as the poor healthcare received in America by the immigrant population. Regardless of a person’s immigration status, when someone is building our offices, caring for our children, cleaning our homes, and they or their children get sick, surely we have an obligation to care for them. Currently, this is not the case. The Latino population in America receives poor healthcare because they are afraid of being asked for their green card, and because they are often not fluent in English. Jesus’ call for hospitality to strangers surely implores us to improve the quality of care for those who work and live among us. Dental Care Certain areas of healthcare remain essentially not available to the poor. The most obvious of these is dentistry. There are very few dental practices that offer a quality service to people in low paying jobs. Yet, dentistry is extremely important to the poor. Most minimum wage jobs are working with the public, and if a person’s mouth is a mess, it can be hard to get a job or get a better job. The poor only see the dentist’s office as a place to go to have their teeth extracted. The long-term benefits of dentistry, including preventative treatment, are simply not available or realized. Dental care should not be a luxury. This is an issue of justice for all Christian dentists and healthcare professionals.

Healthcare Justice for the Poor

never be repaid. Long after the medical school loan is paid off, the poor who continue to be with us deserve the benefit of the knowledge gained from those who gave of themselves to help you and me become doctors.

Dr. Morris listens to a patient’s breathing.

Our Educational Debt to the Poor The cost of a medical education these days is a substantial sum for even upper-middle class students. The cost of a private school education can be staggering. The debt that is accrued over four years can take many years to pay off, especially if a young physician or dentist enters a relatively low paying primary care specialty. For this reason, it is easy to understand why many medical and dental school graduates are choosing not to enter primary care and why caring for the poor seems a luxury for a young doctor. What many doctors forget, however, is that every doctor in America acquires his or her medical or dental education because poor people provide their bodies for students and residents to learn from while they are in training. This gift from the poor is an educational debt that can

Conclusion Many Christian physicians and dentists are very generous with their time when asked to take overseas medical mission trips or to care for an individual when someone who is a friend advocates on their behalf. But, justice and charity are not the same. The Bible does not call for charity to roll down like an ever flowing stream, but, rather, insists that justice is the duty of all who seek to follow God’s call. For many, healthcare has become nothing more than a business. I hope that for Christian physicians it continues to be a calling that is grounded in God’s justice. ✝

Scott Morris, MD, is the founder and executive director of the Church Health Center, whose ministries provide healthcare for the working uninsured and promote healthy bodies and spirits for all. Dr. Morris is also the associate minister at St. John's United Methodist Church. For more information about the Church Health Center, call (901) 272-7170 or visit www.churchhealthcenter.org.

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Seeking Justice for Modern Day Slaves by Jeffrey J. Barrows, DO, MA (Bioethics)

Healthcare professionals are in the best position to identify victims of human trafficking, and to intervene on their behalf.

When Jill was 14, she was forced to run away from home to escape repeated physical and sexual abuse. She ended up in the home of Bruce who found her alone at a local mall and promised her a job in his home “business.” Unfortunately for Jill, Bruce’s home business involved prostitution. Jill initially refused to be used in this way, but was tortured to the point that she ended up having scars on both

Signs that a patient may be a victim of human trafficking: • Does the patient present with unique health problems that TIP victims might have? P Evidence of trauma P Multiple STIs P Unusual infections such as TB P Late presentation of illness • Does the patient have poor hygiene or show evidence of malnutrition? • Is the patient accompanied by another person who seems controlling? • Does the person accompanying the patient insist on giving information to health providers? • Can you see or detect any physical abuse? • Does the patient seem submissive or fearful?

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her wrists, ankles, and across her neck and larynx from being hung from the ceiling rafters. Over the course of the next several months, Jill was forced to have sex with many different clients brought into the house by Bruce. Eventually, Jill became pregnant. When Bruce found out, he attempted to abort the pregnancy, but was only successful in causing Jill to bleed profusely to the point that Bruce was forced to take Jill to the emergency room to prevent her from bleeding to death. Upon arriving in the emergency room, Bruce told the staff that Jill was his sister and also suffered from schizophrenia due to the recent death of their parents in an automobile accident. Because of the schizophrenia, Jill was prone to delusions and erratic behavior that forced Bruce to tie her up to keep her from running away. Without investigating any further, the emergency department personnel accepted the story without hesitation. Jill was admitted to the hospital after having a D&C to control her bleeding and was sent home after three days during which time Bruce was rarely out of her presence. No psychiatric consult was ordered and no further investigation of the obvious bondage scars on Jill was ever undertaken. Jill was freed eighteen months later when the police arrested Bruce on separate drug charges. This true story illustrates not only the horrors of modern day slavery (now known as human trafficking), but also the important role that healthcare professionals play in identifying and freeing victims caught in the web of human trafficking. There are several reasons that Jill was not recognized as a victim of trafficking in this busy ER setting, but prominent among those reasons is lack of proper training of healthcare professionals regarding human trafficking, as documented

Caring for Trafficked Persons: Guidance for Health Providers CMDA members Drs. Clydette Powell and Katherine Welch participated in the development of a handbook entitled Caring for Trafficked Persons: Guidance for Health Providers, with the International Organization for Migration Expert Group on Health and Human Trafficking and the London School of Hygiene and Tropical Medicine. The handbook, funded by the United Nations Global Initiative to Fight Human Trafficking and bringing together a broad range of experts working on the issue, provides practical, non-clinical advice to help a health provider understand the phenomenon of human trafficking, recognize some of the associated health problems, and consider safe and appropriate approaches to providing healthcare for victims. Caring for Trafficked Persons can be downloaded at: http://publications.iom.int/bookstore/free/CT_ Handbook.pdf.

ally millions of people across the world enslaved today, with the US itself containing hundreds of thousands of these victims who need to be found, freed, and cared for.

What to include in a proper protocol on intervening with a potential victim of trafficking: • Measures to separate the patient from the accompanying party • Identification and training of personnel to do the interview • Established criteria regarding when to contact law enforcement • Contact information for local law enforcement agencies • Contact information on local service organizations that specialize in helping human trafficking victims

We in healthcare can learn to recognize these victims in part through their clinical presentation. Depending on the type of trafficking scenario the victim may be trapped within, they may present with findings of repetitive chronic and acute physical trauma that may be the result of a labor trafficking situation. A victim of sex trafficking may present with multiple sexually transmitted infections in association with signs of physical or sexual trauma. They may also present, as Jill did, with the complications of an attempted or illegal abortion. It is also important to remember that victims are not brought to the attention of healthcare until their problem or complaint is severe enough to threaten their well-being. In other words, these victims tend to present late in the course of an illness or injury, often at times when the ER is busiest to reduce the risk of discovery. Keep in mind that your first response as a healthcare professional will not be to immediately recognize the person as a victim of trafficking. In fact, your first response may be a form of revulsion to a person who smells bad from having not bathed in several days, who is dressed shabbily, and acting very strangely. They will typically be accompanied by someone claiming to be a relative or spouse and very controlling of the person and the encounter. That person will answer most, if not all, of your questions and will give some good reason for the appearance of the patient. You will most likely walk out of the initial encounter with the thought that something very strange is going on, but will have no category in which to initially fit the situation. I n t e r n e t W e b s i t e : w w w. c m d a . o r g

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Seeking Justice for Modern Day Slaves

in a study done of two emergency departments in Los Angeles in 2007.1 If the emergency room personnel in Jill’s case had been trained on the existence of human trafficking and how to recognize victims, they could have potentially intervened and saved Jill from experiencing an additional eighteen months of trauma. One study of women coming out of sex trafficking in Eastern Europe found that 28 percent of victims had encountered a healthcare professional at some point during their trafficking experience, yet unfortunately, none of those encounters had resulted in their release, due to the failure of the healthcare professional to recognize the situation as trafficking.2 If healthcare professionals are going to be involved in providing justice to victims of human trafficking, they must first learn to recognize the victims that may be within their own patient population. The US State Department estimates that between 14,500 and 17,500 victims of human trafficking are brought into the United States every year, and between 600,000 to 800,000 victims are transported across international borders around the world every year.3 In terms of the total number of people in the world living in slavery today, the International Labor Organization estimated that number in 2005 as 12.3 million4 while two other researchers put that number closer to 28 million.5,6 The type of slavery illustrated so graphically in Jill’s story is known as domestic minor sex trafficking (DMST). A university study estimated that over 300,000 American youth are either actively involved in DMST, or are at high risk of becoming involved.7 The conclusion is that there are liter-

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Resources to help investigate organizations that specialize in helping human trafficking victims: International: • US State Department TIP report http://www.state.gov/g/tip/ • International Justice Mission http://www.ijm.org • Shared Hope International http://www.sharedhope.org Domestic: • HHS Rescue and Restore Coalition http://www.rescueandrestore.org • Salvation Army http://www.salvationarmyusa.org • Polaris Project http://www.polarisproject.org

cious patient or client, and more efficiently and safely investigate and help this potential victim. These victims deserve justice and freedom to live their lives to their full potential. Physicians and dentists are among the few groups who are likely to encounter them while they are still in captivity. Therefore, it is incumbent on us within the healthcare profession to learn what we can about this issue and be prepared to the best of our ability to identify and intervene when the Lord should allow our paths to cross with these modern day slaves. ✝ Chisolm-Strike, M. and Richardson, L. “Assessment of Emergency Department Provider Knowledge about Human Trafficking Victims in the ED.” Acad Emerg Med 2007;14(5), Supplement 1: 134.

Turning Pain into Power: Trafficking Survivors’ Perspectives on Early Intervention Strategies. Family Violence Prevention Fund in Partnership with the World Childhood Foundation, March 2005.

United States Department of State. Trafficking in Persons Report: June 2004.

Belser P., de Cock, M. and Mehran, F. ILO Minimum Estimate of Forced Labour in the World. ILO, Geneva. April 2005. Available online at: http://www.ilo.org/dyn/declaris/DECLARATIONWEB. DOWNLOAD_BLOB?Var_DocumentID=5073.

Bales, Kevin, Disposable People, New Slavery in the Global Economy, University of California Press, Berkeley and Los Angeles, California, 1999.

If, however, because of learning more about human trafficking, you decide that possibly a particular patient may be a victim, you are in a unique position of being able to free that patient, but only if you have made the proper arrangements in advance. Without prior critical preparations, you may in fact do more harm than good to this patient by alerting the trafficker so that he/she takes the patient out of the clinic before medical therapy and proper intervention can be undertaken. What does the proper preparation to handle a victim of human trafficking entail? The first step is setting up a protocol within your office, clinic, or hospital that specifically lays out steps to undertake when you suspect a patient may be a victim of human trafficking. A good protocol will include how to separate the patient from the accompanying party, proper training on how to interview a patient to see if they are a victim of trafficking, and who to contact in regards to law enforcement and other service provider organizations specializing in the care of human trafficking victims. Secondly, someone from your office, clinic or hospital should meet personally with representatives from those service organizations who specialize in the investigation and care of victims of human trafficking. They can help you as you design your protocol, and be specific in regards to the types of trafficking you will encounter in your area, local law enforcement officials you should contact, and how to specifically contact their own organization when needed. With the proper preparations in place, you can activate your protocol when you have a suspi-

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Siddharth, Kara. Sex Trafficking: Inside the Business of Modern Slavery. Columbia University Press: New York, 2009.

Estes, R.J. and Weiner, N.A. The Commercial Sexual Exploittion of Children In the US, Canada and Mexico. University of Pennsylvania, 2001. Available online at: http://www.sp2. upenn.edu/~restes/CSEC_Files/Complete_CSEC_020220.pdf.

Jeffrey J. Barrows, DO, MA (Bioethics), was asked in 2005 by the State Department’s Office to Monitor and Combat Trafficking in Persons to research the health consequences of human trafficking. This research resulted in the publication of an article entitled “Human Trafficking and the Healthcare Professional” in the May 2008 issue of the Southern Medical Journal. Since December 2005, Dr. Barrows’ work against human trafficking has also included teaching healthcare professionals to recognize potential human trafficking victims, through public speaking and by producing the first online CME program regarding human trafficking specifically directed towards healthcare professionals. He also serves as Founder and Executive Director of Gracehaven (http://www.gracehavenhouse.org), a nonprofit organization working to build a shelter for adolescent girls who have been commercially sexually exploited in central Ohio.

PROFESSIONALISM IN PERIL Part 2 – Unjust Scales in Healthcare by Gene Rudd, MD

“Hear this, you who trample the needy and do away with the poor of the land . . . boosting the price and cheating with dishonest scales. . . . The LORD has sworn by the Pride of Jacob: ‘I will never forget anything they have done.’” – see Amos 8:4-7

Professionalism in Peril

Editor’s Note: This article has been added to the series on Professionalism in Peril. It is article number two of six.

If God detests dishonest scales, ought not we? If God cares about how the poor are treated, ought not we? If so, then we must take action against the dishonest scales routinely applied in healthcare to the disadvantage of those who have the least resources. The dishonest scales I am referring to are the inflated, non-discounted charges that the uninsured are expected to pay.1 For years it has been common practice for hospitals to charge the uninsured and other self-pay patients 2.5-3 times what government and high-volume thirdparty payers are expected to pay. A similar or greater charging discrepancy occurs in other healthcare systems. This has occurred while we bemoan the plight of our 40+ million uninsured neighbors. Despite years of promises to reform this injustice, the practice remains entrenched in healthcare. As a result, healthcare costs remain our major contributor to personal bankruptcy2 with effects lingering for generations. As one writer opinioned, we have gone from “soak the rich” to “soak the poor.” Through the years, healthcare systems gradually inflated charges above costs. While hospital charges were increasing at an average rate of 10.7 per annum, actual costs increased an average of 6.3 percent. Compounding this difference over time has led to charges that range from two to ten times costs.3 Inflated charges occur partly as a negotiating strategy. Payers contracting with healthcare systems could expect to receive steep discounts. Payers without this relationship were encouraged to commit a share of their business in exchange for the discounts to be gained. Inflated charges made negotiated contracts even more attractive.

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As for government payment, the Centers for Medicare and Medicaid Services (CMS) seek to determine an actual cost basis for each service. This varies by region, patient-mix, and other factors. Heretofore, the goal of Medicare was to pay hospitals slightly above their costs, approximately one percent.4 (Many argue that current Medicare payments are below costs.) Looked at from the billing perspective, for every $100 in Medicareallowable costs, hospitals average charging $307. While high-volume third party payers (e.g., Blue Cross/Blue Shield) have knowledge of actual costs, their payment structure is based on negotiated discounts for the services and items on the hospital’s chargemaster – a document typically obscure to the public. In general, discounts to high-volume, third-party payers result in payments of around 5 percent above costs. Since hospital charges average nearly three times cost, these high-volume payers enjoy discounts of 60 percent and greater. While it is easier to collect and report on hospital data, this same pattern of inflated charge-to-cost ratio is seen throughout healthcare – with ratios as high as 11:1! So where does that leave the self-payer: the uninsured and under-insured? A generation or more ago, self-pay patients commonly received discounted healthcare services, ranging from charity care to payment expectations less than those of third-party payers. Today, these individuals are presented charges two to three times the discounted rates of public and private payers. So what happened? As implied above, charges became inflated above costs as part of the negotiating/contracting process; not primarily as a means to gouge the uninsured. Nevertheless, that has been the result. As this happened, many healthcare systems saw an increasing stream of income from the selfpay as a result of the inflated charges. While many selfpay patients are economically overwhelmed by the unfair pricing, many attempt to pay the inflated charges. The net result is that some hospitals actually have higher collection-to-cost ratios for the uninsured than they have for the public and private insured.5 Hospitals often try to dispute this by claiming a poor collection rate from the uninsured. However, their biased data compares collections to their inflated charges rather than to actual costs. It is a mistake to assume that all hospitals actually do “lose” money on the uninsured. Transparency is not normative. Gaining accurate data and proper perspective are challenging. After I recently spoke on this issue, the CEO of the medical center was confronted by concerned staff. His defense was that their hospital provided a significant amount of charity care each year. As proof, he stated that any uninsured person who asked for a discount could get a twenty percent reduction on their charges.

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What the unwary listener might not realize is that the discounted charge he referenced was still more than twice what third-party payers are required to pay. Hospitals have other arguments to justify their inflated charges to the uninsured. For example, they claim patients have the right to negotiate charges just as other payers do. This excuse does not pass the “smirk-test.” Most hospitals have grown to depend on income from the uninsured to meet their financial goals, or in some cases, to remain solvent. But the desire to meet financial goals is not sufficient justification for a charging policy that takes advantage of the poor. It is also claimed that some of the uninsured are capable of paying the higher charges. While true, again, this is not justification for abusing all uninsured, most of whom are not well-to-do. If needed, a simple means-test could be applied to determine those who can pay more. That still leaves the question of whether this group should be expected to pay more than that charged to third-party payers. Additionally, some have argued that the uninsured should simply shop for the best deal. In essence, caveat emptor. This notion naively fails to consider the need for urgent/emergent care and the onerous complexity of comparative healthcare shopping, even if pricing structures were transparent – which they are not. In 2004, Congressional hearings were held to address abusive charges to the uninsured. At that time the CEOs of several healthcare systems promised that they would correct the problem, thus heading off Congressional action. However, little has changed since then. In 2006, the American Hospital Association (AHA) published guidelines to encourage hospitals to correct the problem. AHA called for a sliding scale: self-pay patients below 100 percent of the federal poverty level should receive free care; and those between 100-200 percent should pay no more than public or private insurer pay, or no more than 125 percent of the Medicare rate. Above 200 percent, the hospital could use its discretion. The document confirmed that hospitals are free to be

Amos 8:7 reminds us that God does not forget what we have done! I am concerned that healthcare reform may bring more harm than good. I even wonder if the evils potential in reform might not be the consequences of our failure to remedy our abuse of the poor. So what should we do? For the many of us who do not have decision-making authority in the system in which we work, we should nevertheless be a persistent voice of righteousness, calling on the system to do the right thing toward the uninsured. For those of us who have policy-making influence over a healthcare system (sole proprietors, partners, owners, etc.), we should take immediate steps to introduce a fair, God-honoring charging policy. To begin with, the policy should charge the self-payer no more than what high-volume payers are required to pay. It is not necessary that we go through the complexity of changing the chargemaster; we simply need to provide the same discounts (or more) to the uninsured that we do to the insured. And for the uninsured poor, they should be billed on a sliding scale that includes a willingness to provide free care to the truly needy. Will some take advantage of you? Of course. But that is a small price to pay to avoid exploiting the poor (see Proverbs 22:22), those to whom God says, “Therefore I command you to be openhanded toward your brothers and toward the poor and needy in your land” (Deuteronomy 15:11). ✝

Professionalism in Peril

more generous if they wish. Because these guidelines are not binding, there is little evidence of change. Many have labored under the perception that lowering charges for the uninsured would somehow violate Medicare or Medicaid laws. In 2004, the Inspector General of Health and Human Services issued a ruling to clarify that healthcare systems are free to provide discounts or free care to self-pay patients. Despite this, I continue to hear this excuse used to justify inflated charges for the poor. So why do not hospitals simply adjust their charges to the cost of service plus some reasonable mark-up? The simplest answer may be that this is not the way the system has evolved. To change now would mean renegotiating numerous contracts. There is fear of the unknown – fear of economic loss – fear of a competitive disadvantage. It is unlikely hospitals will change without legislative action. For more than a year I tried, via a letter writing campaign, to gain an audience with policy-makers at our regional hospital system. The letters elicited no response. When an uninsured friend was over-charged by this system and then subjected to abusive collection efforts, only our threat of public exposure and/or legal recourse caused the institution to cancel the debt. A tipping point occurred in New York State in 2006 when an uninsured individual died subsequent to being denied care because of an outstanding debt. The public outcry led to the passage of the 2007 Manny’s Law intended to stop the overcharging of the uninsured. The law stipulated several reforms including disclosures of patient rights and options for financial assistance, adjusted charges (based on a sliding scale up to 400 percent of the federal poverty level), and non-abusive collection policies. Sadly, a survey done a year after the law went into effect showed significant non-compliance. As the failed healthcare reforms of 1993 demonstrated, healthcare has significant inertia against change. There are many hands in the pot; many who benefit greatly. Reform of any kind will be difficult. Nevertheless, the current conventional wisdom is that the political scene is ripe for change. I anticipate the process will be underway by the time this article is published. Hence, some have questioned the wisdom of addressing this specific problem (overcharging the uninsured) when a solution might occur as part of a paradigm shift to more federal control. I am not willing to wait to see. Who knows what and when reform will occur and how much of the old system will linger. Perhaps the practice of overcharging the poor will continue in the new system. And in the meantime, charging abuses will occur and families will be economically wiped out. Also, addressing this problem now may stimulate the reformers to deal with this issue.

Bibliography Health Affairs 26, no.3 (2007): 780-789; 10.1377/hlthaff.26.3.780. Himmelstein, D, E. Warren, D. Thorne, and S. Woolhander, “Illness and Injury as Contributors to Bankruptcy,” Health Affairs Web Exclusive W5-63, 02 February, 2005. 3 http://www.heartland.org/policybot/results/12775/Investigative_Report_ Overcharging_the_UninsuredPart_1.html. 4 Op. cit. Health Affairs. 5 Op. cit. Health Affairs. 1 2

Gene Rudd, MD, co-author of Practice by the Book, serves as Senior Vice President of the Christian Medical & Dental Associations. A specialist in obstetrics/gynecology, Dr. Rudd has experience in maternalfetal, medical education, and rural healthcare. He has garnered numerous awards including the Gorgas Medal. While working with World Medical Mission, he established the Christian Medical Mission of Russia, directed the rehabilitation of the Central Hospital in Kigali, Rwanda, and served in Belarus, Bosnia, and Kazakhstan.

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Pro-Choice Politics in the

Back Alleys of Africa by Michael Johnson, MD

Outside forces should not dictate abortion policies in Africa

He forcefully took the woman by her arm. She resisted. He persisted. Her 5-foot, 90-pound frame was no match for his 7-foot, 240 pounds. At 80 plus years she refused to allow this 30-year-old man to have his way with her. However, both of them knew she would tire first. She did. He finally got her to agree to allow him to help her across the street. She neither smiled, nor said thank you. Why should she? She had just been dragged to this side by another “do-gooder” and would now miss her bus a second time. This is not the street she wanted to cross. “If they don’t legalize abortions, women will seek them out in the back alleys and die from the complications.” So goes the old mantra that seeks to justify the push for “abortion rights” for poor women in the developing world. As well-meaning, nice people fight for the reproductive health rights of poor women, do they ever ask, “Is that the street they want to cross?” The simple fact is that most maternity facilities in most of these countries are not much better than “back-alley” birthing centers. Why is it that the politically rich and powerful, yet resource-poor nations want to “help” the women of the resource-rich, yet politically poor nations abort their babies? Is it the interest of poor women’s health? Is this a human, women, or civil rights issue? Is it in the interest of the socioeconomic development of the recipient

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nations? Or is this to satisfy and supplement the living standards of the rich? After all, there are limited resources on the planet. Rich donors want to convince poor mothers that it is normal to suck, scrape, and forcibly remove their unborn babies in bloody bits and pieces. Those who could afford the high-end clinics would get anesthesia. The 80 percent plus majority, however, would just have to sweat it out, just as they do when giving birth. Alternatively they could use the intentional ingestion, injection, or insertion of poisons, hormones, or other agents to cause the warm safe uterus to prematurely expel the individual being created inside of their bodies. The “fearfully and wonderfully made” is terminated and disposed of like a piece of rotten meat (Psalm 139:14). These women won’t listen. They want a safe baby, not a dead one. Alternatively, donors could help provide sanitized or even clean environments for childbirth. They could replace the usual birth places of mud huts surrounded by garbage and raw sewage of the city slums, or dusty rural villages. A 20 percent death rate by age 3 could be markedly reduced by such simple measures. African mothers would welcome that help. Abortion on demand (our demand) sends the poor mothers a message. It tells them it is best to abort, because statistically, they die in childbirth at a rate 300 times that of a mother in America or Europe. They will most likely deliver a premature, underweight, infected baby with a 100-200 times the chance of dying compared to those born in those developed nations (maternal death rates are as high as 1 in 15 in Africa versus 1 in 3,750 in America). Should she cross that street?

Michael Johnson, MD, and his wife, Kay, have been involved with overseas missionary work since 1984. Their work has included a brief trip to Zaire (Congo), where they worked in Tandala Hospital for a period of seven weeks and again to Kenya in 1987 for a period of seven weeks. They began full-time work overseas in 1989 when they were accepted with World Gospel Mission of Marion, Indiana, to work at Tenwek Hospital in Kenya, East Africa. The Johnsons now make their home in Kenya to help provide healthcare to the over 30,000 street children of Nairobi and to help in the training of Kenyan physicians. They are also involved with several development projects, providing schools, water sources, farming, and medical assistance to underdeveloped communities. Through these ministries, many orphaned children are now being placed in Christian families by adoption and foster care. The Johnsons have four adult children: Elijah, Christina, Emmanuel, and Keturah, and two grandchildren. Their home church is Tasker Street Missionary Baptist Church in South Philadelphia.

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Pro-Choice Politics in the Back Alleys of Africa

To say it simply, there is a contrast. For African mothers, having children defines them. For American mothers, having children confines them. Mothers in America can legally “plan” their families by eliminating the nuisance of delivering a child. A child may be an inconvenient drain on their personal resources of time and money. They have the luxury of waiting for the convenience of marriage, sperm banks, hormone manipulations and injections, embryonic implants, and even surrogate mothers. Abortion is legal, and as medically safe as normal delivery. Hence a woman can “plan” which child to keep and which to throw away, as easily as updating her wardrobe. These mothers value their independence and personal freedom. Having children confines them. In the developing world, the continuing saga of wars, civil strife, famine, plague, and the almost complete absence of ante-natal care rob mothers of the luxury of planning their families. They have seen and borne enough death. Telling them how to kill their unborn is not the street they want to cross. Their wardrobe is limited by what they have on their backs. Women in these cultures value their interdependence and personal responsibility to family and community. Having children defines them. Children in America are part of a culture of “throwaway” non-recyclables. Whatever is inconvenient or too costly to store somewhere, like in a womb for instance, we throw away. African women don’t have that convenience. African children add value to a mother. A woman is beautiful, mature, rich, and useful

if she bears children. In America, a woman is defined as mature, rich, and useful by how much money she brings home or how “beautiful” she is physically. The sooner she regains her B.C. (before childbearing) hourglass figure back, the sooner she regains her personal value. In Africa, beauty is a woman who bears children. To be childless can mean a woman is useless and even cursed. Being “full figured” is a sign of beauty. Abortion is counter-culture. This is crossing the wrong street. Children are insurance for the mother’s welfare in Africa. They enhance her value as a woman of substance. They don’t have the privilege of insurance, social security, pension plans, unemployment compensation, or medical insurance to assure they will be taken care of in later years. Children are part of continuing the prosperity of the family and community. So as the west prides itself on helping poor mothers obtain their “god-given” rights to abort a child, mothers in the developing world want the right to life for their unborn. We are either naïve or casual and callus in ignoring their pleas. We are imposing our will on their bodies. It is our freedom of choice for their bodies. It is the wrong street. We should not expect a thank you or smile for service rendered. ✝

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Family Practice – Well-respected group of 5 board-certified Christian FP’s near Peoria, IL, looking for additional FP. Independent practice doing full range of family practice excluding OB. Do own hospital admissions. Competitive salary; one in four weekend call. Small town; very good schools. Teaching opportunities available through Peoria School of Medicine. Contact Stacey at: (309) 925-2961 or e-mail her at: tmclinic@verizon.net.

Neurologist – North Carolina. Sandhills Neurologist, PA is seeking two BC/BE Neurologists, exclusively out-patient practice. This practice is interested in the physical and spiritual needs of the patient. Located in south central NC. World-renowned golfing resort, familyoriented community with large draw area. Approx. 2.5 hrs from beaches and mountains. Contact: voss.sandhillsneuro@gmail.com. OB/GYN – Solo OB/GYN in the Woodlands, Texas area taking early retirement for health reasons looking for Christian OB/Gyn to take over my private practice of 20 years. On Call 1:8; Call: 713-594-9202 and leave message. Orthopedic – Well-established practice of three orthopedists and one podiatrist committed to providing care with compassion as well as excellence. Time off for short-term missions. Would like to talk with general and subspecialty orthopedists about the possibility of joining us in practice. On-site surgery center; local hospital within walking distance. Located in a family-oriented city where many recreational and cultural activities are available. Less than a 10 minute commute from any area of the city. Low malpractice rates and cost of living. Vacation at the mountains and the beach; live here and enjoy all four seasons. Please contact our Medical Director, Dr. Chris Wilkinson at 308-627-4664 or cwilkinson@kearneyortho.com. Our clinic manager, Vicki Aten, can be reached at: 308-865-2512; or vaten@kearneyortho.com. Pediatrician – Burlington, North Carolina. Private practice seeking BC/BE pediatrician. Spanish helpful although not necessary. Call 1:5 to 1:6. Good lifestyle. Salary and benefits quite competitive for this sought after area. Contact: Dr. David Stein 336-570-0010; fax 336-570-0012; e-mail: Infamclin@bellsouth.net. Pediatrician – Seeking Christian pro-life pediatrician; board certified or board eligible to practice with four other pediatricians. Full or part-time work available;

T o d a y ’s C h r i s t i a n D o c t o r

location is central rural and semi-rural Pennsylvania. Contact: Dr. Elam Stoltzfus at Lewisburg Pediatrics at 570-490-2569. Pediatric Pulmonologist, Pediatric Intensivist, Allergist/Immunologist, Immunologist, and General Pediatrician with a heart to treat the whole person; body, soul, and spirit and a heart for God. Emphasis on evidence based management combined with a strong physician-patient relationship. Excellence in both specialty and primary care is stressed. Providers are encouraged to integrate faith and medicine in patient care. Would become part of a small physician owned group with four providers. Practice located in Tulsa, OK. Good city to raise children and have a family. Fax resume to: 918-451-6707. Podiatry – Busy Podiatric practice in beautiful Portland, Oregon is seeking a podiatrist. Great area for those who love the outdoors. Contact Julie at: 503-244-7894 or e-mail at shrddhayes@yahoo.com. Seeking licensed Mental Health Professionals and/or Education Consultants – Office Spaces for rent in the Roswell/Alpharetta, Georgia area. Available part-time now and full-time September 1st. Share suite with one board certified child/adolescent/adult psychiatrist and three licensed psychologists. Overhead sharing arrangement. Better to date before getting married! Call Pam Forbes, MD: 678-641-9806. Retinal Surgeon – Become a partner in a highly respected retina only practice in central Indiana. The ideal candidate will be a self-starter who is bright, personable and kind, and an excellent physician and surgeon. Broad referral base which greatly contributes to continued growth. State-of-the-art equipment, including digital and ICG angiography, optical coherence tomography, ultrasound, automated visual fields, etc. Competitive salary plus bonus and partnership offered after 2 years. Please contact Amelia Rogoff at The Eye Group: 561-852-9998 or Amelia@theeyegroup.com.

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