Texas

My Testimony on #SB303 (Conscience, Rights, Medical Judgment and Law)

Note: I’ve heard that there’s a new Committee Substitute that will soon be introduced that is more explicit on DNR’s, especially on informed consent and on competent patients.

If laws demand that physicians perform acts against our consciences, you will end up with only doctors without consciences willing to perform the acts in question.

After a few more words about the meeting of the 83rd Texas Legislature Public Health Committee, I’ll post my written testimony that I turned in to the Committee. You can watch the video of the meeting, here. My testimony begins about 4:59/8:20.

I spoke just before midnight, after many others had covered the good (or bad, depending on their opinions) reforms in SB 303, so I didn’t really go in to those when I talked. Instead, I explained how I handled the few times I’ve had to write DNR’s without consent from the patient or a surrogate.

I also talked about the medical judgement of physicians, about the definition of the “right to life”as a negative right. This means that I can be prohibited from killing, but not that I can be forced to indefinitely act against my conscience and medical judgment. It’s a tough concept, meaning no one can claim that their right to life means that they can take my food and shelter, my labors or my liberty to keep them alive.

Then, I explained that yes, doctors have a special relationship, a covenant or, at least, a professional relationship due to our privilege of practicing medicine. But the duties aren’t unlimited and they are not all one way. The 10 days plus 21 days in the version of SB303 that we were discussing that night should be a sufficient time trial or test of time for the patient and the doctor’s decisions about the medical treatment, including DNR’s, that the family demands.

The explanation about the nature of medical judgment that I gave is in the written testimony:

May 13, 2013

Chair Kolkhorst and members,

The Texas Advance Directive Act of 1999, created a procedure for resolving disagreements between doctors and their patients or surrogates about which interventions are medically appropriate. The experiences of patients and doctors during the few times that procedure has been invoked over the years, revealed some problems.

The reforms in SB 303 improve the Advance Directive Act by

·      Giving patients and their surrogates much more time and assistance than current law provides in order to prepare for the ethics committee meeting and, if necessary, to find a new doctor willing to accept responsibility for the care of the patient,

·      Clarifying the succession of surrogates under state law,

·      Protecting the patient’s access to artificially administered hydration and nutrition,

·      Restating Texan’s belief that patients should be treated equally regardless of age, disability or ability to pay,

·      Adding a whole new section regulating the implementation of Do Not Attempt Resuscitation orders, which our State law hasn’t addressed at all in the past, and

·      By protecting the conscience rights of doctors from undue threat of civil, criminal and regulatory liability.

 

After all, while the hospital provides structure in the form of policies and the medical committee provides oversight about ethics and standard of care, it’s doctors like me, not hospitals or committees, who practice medicine using our medical education and experience guided by conscience, or medical judgment. Medical judgment, not lawyers and paperwork at the bedside, is what enables me to predict the effectiveness of interventions before I order them.

Like all but a handful of Texas doctors, I’ve never had to ask for a medical ethics committee review, but I have had to ask another doctor to co-sign a DNR when I couldn’t find a legal surrogate. As a family doctor, I’ve found that algorithms and “cookbook medicine” or lines of succession for absent family members sometimes aren’t enough when a patient’s physical condition is deteriorating quickly or even when disease runs its expected course, causing organ system after organ system to fail. 

Ethics and laws generally lag behind medical advances. Once upon a time, people who couldn’t breathe for themselves were considered to have died a “natural death,” but we keep changing the rules about what we expect human bodies and the “art” of medicine to do. Please support the necessary and important reforms in SB 303.

Thank you for your time and attention,

Beverly B. Nuckols, MD, FAAFP, MA (Bioethics)

Public Health Hearing on #SB303

Last night, an emergency meeting ot the 83rd Texas Legislature’s Public Health Committee addressed Senate Bill 303, by Senator Duell in a 12 hour long meeting. Representative Susan King, who authored the Companion Bill in the House and sponsored SB303 in this meeting, appeared only one day after a fracture of her tibia. This woman is a hero!

I also want to thank Chair Lois Kolkhorst for ensuring that the meeting was held so that SB303 – and all the people who are so passionate about patients rights and good medicine in Texas could be heard.

It was wonderful to see all the people who volunteer so much of their time to influence Texas law – even when they disagreed with me. What a pleasure to meet new friends, including a gentleman whose name I can’t recall (will fix this later) and Jacqueline Harvey, Ph.D.

Here’s an excerpt from Dr. Harvey’s testimony,

While opponents say that S.B.303 grants power to providers to remove care patients in irreversible conditions, I’d remind them again that one cannot extend to providers power which they already legally possess. Opponents claim that S.B. 303 adds this broad definition, when in fact; this broad definition was established in TADA and is current Texas Law. What S.B. 303 does is add protections to prohibit discrimination against persons with disabilities by ensuring that care may be removed only when harmful (i.e. treatment would fail, hasten patient death, exacerbate another medical condition or cause unnecessary pain). These conditions are standard medical ethics a la “do no harm.”

I’ll write more after I get a chance to review the video of the hearing. There’s some sort of glitch at the Legislature Audio and Video page. (Might have something to do with 12 hours of recordings, ending after 2 AM)

Going Too Far with DNR? | Texas Catholic Conference

“Father Tad” is the Director of Education at the National Catholic Bioethics Center. The Texas Catholic Conference published his commentary on “DNR’s” on May 10, 2013.

These judgments are tricky to make, because the specifics of each case differ, and those specifics change with time and disease progression. DNR’s should be put in place only when the circumstances warrant it, that is to say, on a case-by-case, patient-specific basis. In other words, when CPR/resuscitation can reasonably be determined to no longer offer a hope of benefit to the patient or if it entails an excessive burden to him, at that time a DNR can be put into place.

Some of the possible burdens that may need to be considered in deciding whether to pursue resuscitative interventions for a patient would include some of the following: the risk of rib or other bone fractures, puncture of the lungs by a broken bone (or from the trauma of lung compression and decompression), bleeding in the center of the chest, cerebral dysfunction or permanent brain damage, the small risk (about 3 or 4 percent) that the patient might end up entering a vegetative state, and subsequent complications if the patient ends up staying on a ventilator for an extended period following the resuscitation.

During resuscitative efforts, elderly patients are more likely to experience complications or to have ribs break during CPR. Younger patients, on the other hand, tend to show a greater resilience and are often better able to tolerate CPR. Patients suffering from advanced cancer are also known to fare poorly following resuscitative efforts.

In terms of overall statistics, when a patient codes in the hospital and all resuscitative measures are taken, patients frequently do not end up leaving the hospital, especially when they are elderly or have other co-accompanying conditions. Based on data from the National Registry of Cardiopulmonary Resuscitation (NRCPR), studies have determined that patients who undergo cardiac arrest in the hospital have an overall survival to discharge rate of about 17 percent. The rate drops even lower (to around 13 percent) for cancer patients. In other words, the benefits are oftentimes few and short-lived, while the burdens tend to be high. There are, of course, exceptions — while many patients do not experience significant benefits from resuscitative measures, a small percentage do.

So when death is imminent, and disease states are very advanced (perhaps with multiple organ failure), and assuming other spiritual matters, such as last sacraments, have been addressed, a DNR order may not raise any moral problems. The key consideration in making the judgment will be to determine whether the benefits of resuscitation outweigh the burdens. So when death is imminent, and disease states are very advanced (perhaps with multiple organ failure), and assuming other spiritual matters, such as last sacraments, have been addressed, a DNR order may not raise any moral problems. The key consideration in making the judgment will be to determine whether the benefits of resuscitation outweigh the burdens.

DNR orders can be misused, of course, if they are broadly construed as calling on medical professionals to abandon or otherwise discontinue all care of a patient. Even as patients may be declining and dying of serious underlying illnesses, we must continue to care for them, support and comfort them, and use the various ordinary means that they may have been relying on, such as heart and blood pressure medications, diuretics, insulin, etc.

We should always seek to do what is ethically “ordinary” or “proportionate” in providing care for our loved ones, though we are never obligated to choose anything that would be heroic, disproportionate or unduly burdensome when it comes to CPR or other resuscitative measures.

via Going Too Far with DNR? | Texas Catholic Conference.

More than “a list of endorsements” (with Addendum)

An opponent of SB 303 and I have been discussing the Bill on an earlier post. She referred to my “list of endorsements.”  This is a fairly strong list of endorsements, at least for those of us who are believers, don’t you think?

The Texas Baptist Christian Life Commission is ” is pleased that SB 303 was recently voted out of the senate.”

Texas Catholic Bishops letter to members of the Texas House of Representatives urging support for SB 303

The Morality and Wisdom of Incremental Legislation: The Case for SB 303 by Rev. Tadeusz Pacholczyk, Ph.D.

Point by Point Refutations of Criticisms to SB 303

Texas Catholic Conference Handout comparing SB 303 with current law

Texas Catholic Conference’s response to NRLC’s analysis of SB 303

National Catholic Bioethics Center letter supporting SB 303

National Catholic Partnership on Disability letter supporting SB 303

Texas Catholic Conference Policy Backgrounder on Advance Directives Reform

Texas Catholics Bishops Conference been very active over in the many efforts over the years to reform of the Texas Advance Directive Act and all have signed the endorsement strongly urging passage of SB303 http://www.txcatholic.org/press-releases/336-texas-catholic-bishops-strongly-urge-house-vote-on-end-of-life-care.

I’ve relied on the National Catholic Bioethics Center ( Marie Hilliard and Father Tad) for their consistent and coherent efforts to preserve traditional medical ethics. NCBC has also endorsed the Bill, and written an excellent response to criticism of SB303.

Added 5/11/13 at 11:00 AM, more endorsements and information:

• Senate Bill 303
• House Bill 1444
• John M. Haas, Ph.D., President, National Catholic Bioethics Center, letter supporting SB 303
• Texas Catholic Bishops letter to members of the Texas House of Representatives urging support for SB 303

End-of-Life Ethics: Preparing Now for the Hour of Death – Catholic Update August©2006

Here is another discussion about the end of life for my Catholic friends who are trying to decide whether to support SB 303.

Life, however, is not an absolute good.

Treatment and life support

Questions about the use of medical treatments and life-support systems are distinct from—and yet often associated with—euthanasia. The scriptural insights can be very helpful with these issues, even if they cannot give details. As good stewards, we believe that death is not the final word, that life is not an absolute good. Therefore, we do not have to keep someone alive “at all costs.”

The Catholic tradition helps with the details, providing this guidance: ordinary means must be used; extraordinary means are optional. Ordinary means are medicines or treatments that offer reasonable hope of benefit and can be used without excessive expense, pain or other inconvenience. Extraordinary means do not offer reasonable hope of benefit or include excessive expense, pain, or other inconvenience. What is important to remember is that “ordinary” and “extraordinary” refer not to the technology but to the treatment in relation to the condition of the patient, that is, to the proportion of benefit and burden the treatment provides the patient (see the Vatican’s Declaration on Euthanasia, #IV, 1980).

Many people remember when Cardinal Joseph Bernardin of Chicago decided to stop the treatment for his cancer. The treatment had become extraordinary. He did not kill himself by this choice but did stop efforts that prolonged his dying. He allowed death to occur. (This distinction between allowing to die and killing, as in euthanasia or assisted suicide, is of great significance in the Catholic tradition. The rejection of this distinction by several U.S. courts raises serious concerns.)

Within the Catholic Church, debate still surrounds the question of providing medical nourishment through a feeding tube. Let’s look at two positions.

1) “Life must almost always be sustained.” This position holds that the withdrawal of medically assisted nutrition and hydration cannot be ethically justified except in very rare situations. The fundamental idea for this position is the following: Remaining alive is never rightly regarded as a burden because human bodily life is inherently good, not merely instrumental to other goods. Therefore, it is rarely morally right not to provide adequate food and fluids.

This position acknowledges that means of preserving life may be withheld or withdrawn if the means employed is judged either useless or excessively burdensome. The “useless or excessive burden” criteria can be applied to the person who is imminently dying but not to those who are permanently unconscious or to those who require medically assisted nutrition and hydration as a result of something like Lou Gehrig’s or Alzheimer’s disease. Providing these patients with medical nourishment by means of tubes is not useless because it does bring these patients a great benefit: namely, the preservation of their lives.

2) “Life is a fundamental but not absolute good.” This approach rejects euthanasia, judging deliberate killing a violation of human dignity. On the other hand, while it values life as a great and fundamental good, life is not seen as an absolute (as we saw in the section on scriptural foundations) to be sustained in every situation. Accordingly, in some situations, medically assisted nutrition and hydration may be removed.

This position states that the focus on imminent death may be misplaced. Instead we should ask if a disease or condition that will lead to death (a fatal pathology) is present. For example, a patient in a persistent vegetative state cannot eat enough to live and thus will die of that pathology in a short time unless life-prolonging devices are used. Withholding medically assisted hydration and nutrition from a patient in such a state does not cause a new fatal disease or condition. It simply allows an already existing fatal pathology to take its natural course.

Here, then, is a fundamental idea of this position: If a fatal condition is present, the ethical question we must ask is whether there is a moral obligation to seek to remove or bypass the fatal pathology. But how do we decide either to treat a fatal pathology or to let it take its natural course? Life is a great and fundamental good, a necessary condition for pursuing life’s purposes: happiness, fulfillment, love of God and neighbor.

But does the obligation to prolong life ever cease? Yes, says this view, if prolonging life does not help the person strive for the purposes of life. Pursuing life’s purposes implies some ability to function at the level of reasoning, relating and communicating. If efforts to restore this cognitive-affective function can be judged useless or would result in profound frustration (that is, a severe burden) in pursuing the purposes of life, then the ethical obligation to prolong life is no longer present.

Disagreements in the Church

How are these significantly different positions judged by the Roman Catholic Church? There is no definitive Catholic position regarding these two approaches. Vatican commissions and Catholic bishops’ conferences have come down on both sides of the issue. Likewise, there are Catholic moral theologians on both sides.

via End-of-Life Ethics: Preparing Now for the Hour of Death – Catholic Update August©2006.

Emphasis by underlining is mine. Edited 5/10/13 BBN

Opponents of SB303 Promote Doctors Without Conscience

The opponents of Senate Bill 303 may not realize it, but they are promoting the very thing they claim to oppose: elevating the patient’s right to determine his own care above the doctor’s conscience will result in doctors who practice medicine without consciences.

The consequences of elevating autonomy above non-maleficence (“first do not harm”)  go to the very heart of medical ethics. In fact, the promotion of patient autonomy is the common justification for euthanasia and elective abortion on demand.

The doctor is the one whose hands, conscience, and medical judgment will be writing the orders for or actually carrying out the resuscitation. Just as it’s not ethical to force doctors to cause the death of patients, it’s not ethical to demand that doctors write orders and perform interventions when their medical judgment indicates that the intervention will not be successful and will increase pain and suffering while prolonging the process of death.

As ethicist Gilbert Meilaendar noted at the President’s Bioethics Council Meeting in September 12, 2008,

[T]he reason for a physician being willing to risk his life in an epidemic was precisely that he didn’t think staying alive was the most important thing, that there was something else that was morally more compelling and obligatory even than preserving his existence. And that would have something to do with the personal integrity that you seem willing to think may be — one should be willing to set aside in embracing what one thinks is evil.

Dying, Naturally, in the Emergency Department

Here’s an excellent professional article about end of life care for patients that’s relevant to our discussion about SB 303.

Two Roads to Death

Two major pathways to death have been described: The easy and the difficult road Figure 1. Depending on the road a patient takes, the intensity of ED management may vary significantly. For instance, some patients are highly symptomatic at the EOL, requiring intravenous medications and even continuous drips to maintain comfort while others can be managed by relatively simple oral regimens in the home setting, with the support of hospice services.For symptoms like pain, the EM skill set proves sufficient as the management of healthy patients and those at the EOL is similar. EM treatment algorithms are less relevant, however, for symptoms like dehydration, delirium and dyspnea in the dying patient. For this reason, we will focus our attention on the unique approach to these common and often troublesome EOL issues.

via Dying, Naturally, in the Emergency Department.

Man shot and killed at Houston’s Bush Intercontinental Airport – CNN.com

This looks like the man chose to commit suicide, but the story might change.
(CNN) — A man was shot and killed Thursday in a pre-screening area at Bush Intercontinental Airport in Houston, authorities said.

Houston Police Department spokesman Kese Smith told reporters that the man had just come through the doors in Terminal B when he fired at least one shot into the ceiling.

A Homeland Security Investigations agent was working in an office near the scene, came out and told the man to drop his weapon. The agent fired once at the suspect, who appeared to try to shoot himself at the same time.

An autopsy will determine whose bullet killed the man, who has not been identified, police said.

via Man shot and killed at Houston’s Bush Intercontinental Airport – CNN.com.

Update on the Texas Advance Directive Act (SB 303)

The Texas Advance Directive Act of 1999 (TADA) describes “Advance Directives to Physicians” (what most people would call a “Living Will”) and contains Section 166.046, an attempt to outline the procedure for resolving a disagreement between a doctor and patients or their surrogates about what is medically appropriate treatment.
The law currently in effect requires the doctor to notify the patient or the surrogate when he or she believes that their request is medically appropriate. If there is still a disagreement, the doctor asks the hospital to convene a meeting of their ethics committee. If the committee agree agrees with the doctor, and no other doctor is willing to take over the care of the patient, the treatment in question can be withheld or withdrawn. TADA doesn’t allow “Physician Assisted Suicide” and certainly doesn’t allow euthanasia, where the patient might be killed on purpose.

The Texas Senate passed Senator Bob Duell’s Senate Bill 303, which significantly improves current law.  SB 303

• Requires the doctor to notify the patient or his surrogate before writing a “Do Not Attempt Resuscitation” order,
• Prohibits the withdrawal of artificially administered hydration and nutrition except in extreme circumstances and
• Gives families 5 days instead of 2 to prepare for the ethics committee meeting and 21 days instead of 10 before the patient must transfer care to another doctor,
• Outlines the duties of the hospital to  treat all patients the same, regardless of age, disability, or ability to pay, to provide a trained liaison to assist the family, and requires timely copies of the medical records.

Because SB 303 still needs to pass in the House, Texas Alliance for Life asked me to help them make a video explaining how it reforms current law.

If you agree that SB 303 is a pro-life reform Bill please call your State Representative at 512-463-4630 and ask him or her to support SB 303.

My “Ethics 101″ on the law: “Back to Basics on Texas Advance Directive Act”

Thank your Texas Senators for a Good Bill!

From Texas Alliance for Life:

 

Texas Senate Passes Pro-Life SB 303 to Help Families

Protect Loved Ones Near the End of Life

 

Lt. Governor David Dewhurst and Sen. Donna Campbell M.D. Deserve Thanks!

 

April 24, 2013

 

Dear Larry and Beverly:

 

Very good news! Last week the Texas Senate passed SB 303, a strong pro-life bill that will change current law to help families protect their loved ones near the end of life. Supported by pro-life Lt. Governor David Dewhurst and authored by Sen. Bob Deuell (R-Greenville), the full Senate passed SB 303 on a decisive 24-6 vote.

Your Texas state senator, Sen. Donna Campbell M.D., voted to support SB 303, a pro-life vote. Please thank Lt. Governor Dewhurst and Sen. Campbell for their support. See sample messages below.

SB 303 is strongly supported by broad coalition of pro-life and provider organizations including Texas Alliance for Life, the Texas Catholic Conference of Bishops, and the Texas Baptist Christian Life Commission. 

 

Voting for SB 303 were: Campbell, Carona, Davis, Deuell, Duncan, Ellis, Eltife, Estes, Fraser, Garcia, Hinojosa, Huffman, Lucio, Nelson, Nichols, Rodriguez, Schwertner, Seliger, Uresti, Van de Putte, Watson, West, Whitmire, and Zaffirini.Voting against SB 303 were: Hancock, Hegar, Patrick, Paxton, Taylor, and Williams. Senator Brian Birdwell was absent.

 

(snip)

Border Patrol now counts getaways – Beaumont Enterprise

Note the estimated 85,000 who escaped the Border Patrol in 2011. Secure the border, first, then we can talk about how to get a Green Card. (Hint: it begins by getting in line legally and in their own country.)
A recent Government Accountability Office report cites Border Patrol data from fiscal 2011, the latest available, that 61 percent of estimated illegal crossings on the southern border resulted in capture, 23 percent turn back to Mexico and 16 percent got away.

Of the 85,467 who got away, 70,980 (83 percent) were counted by sign-cutting, with nearly all the rest from cameras and plain sightings.

Despite such precise tallies, Border Patrol Chief Mike

via Under pressure, Border Patrol now counts getaways – Beaumont Enterprise.

Dr. Donna Campbell at San Antonio Tea Party

Big crowd!

Lieutenant Governor David Dewhurst at San Antonio Tea Party

Dr. Donna Campbell at San Antonio Tea Party

Big crowd!

Obama Gives $13 Million Grant to Texas Planned Parenthood! @txprolife

We’ve all been hearing about the supposed “War on Women” by Conservative law makers – and, by extension, voters – in Texas. Well, President Obama and Secretary of Health Kathleen Sebellius just fired another shot in the war against Texas and State’s rights.

UPDATE: In an emailed statement, Texas Department of State Health Services spokeswoman Carrie Williams says that the agency just received notice that it will lose the Title X grant and is “reviewing the information to get a sense of the full impact.” The agency hopes the transition is smooth and the provider base remains strong, she wrote.
EARLIER: The federal government has pulled from the state of Texas millions in family planning funding, granting the money instead to a coalition led by the Women’s Health and Family Planning Association of Texas, which says it can serve a greater number of women with the available funds.
For more than four decades, federal Title X funding has been dedicated to funding family planning services and covering clinics’ infrastructure costs. The funds are generally granted to providers (like Planned Parenthood) and/or to state health agencies. In Texas since 1980, the majority of the funding has been administered by the Department of State Health Services — roughly $18 million in 2012, for example; since 2009, DSHS has been the sole grantor of Title X funds.

(Edit, maybe it’s only half of that.)

A Little History

Before this year, Federal tax dollars came back to Texas in two major funds: the Women’s Health Program and Family Planning, or Title X funds. Texas “matched” a certain amount and the Texas Department of Health and Human Services administered the dispersion of the money. Because the money paid for or freed up other funds for staff, marketing, and “infrastructure” or office overhead, PP was helped to keep their abortion clinics running. The overall effect was that State matching tax dollars helped PP to funnel patients, if not dollars, to their abortion clinics.

Texas was forced to make severe Budget cuts across the board in 2011, including Family Planning funds. This led to prioritizing what little money we had:

“State lawmakers cut funding for family planning services by two-thirds in the last legislative session, dropping the two-year family planning budget from $111 million to $37.9 million for the 2012-13 biennium. They also approved a tiered budget system for family planning funds, which gives funding priority to public health clinics, such as federally qualified health centers and comprehensive clinics that provide primary and preventative care over clinics that only provide family planning services.”

Texas Tribune

Finance Chairman Representative Jeb Henserling of Texas

SPEAKING to National Pawnbrokers Association in Washington, School.

Our Texas Senators Cornyn and Cruz at Capitol

The Senators spoke to a group including Larry Nuckols and I, who were in DC representing the National Pawnbrokers Association.

Texas will pay for destructive human embryo cloning at Texas Universities

The Committee Substitute was passed this afternoon with 9 yes votes in the House State Affairs Committee. The Chairman of the Committee, Byron Cook voted “yes,” after assuring the Committee that the Bill (which is not available online or in the Committee) will not outlaw human cloning at Universities.

Voting “no” were four brave Republicans – I’ll list them all as soon as I can verify and make sure I don’t miss anyone. Unfortunately, some of our conservative members weren’t present. I will also name them when I can do so without missing anyone.

I worked with Representative Raymond’s office to come up with good definitions, but I don’t know how much of those definitions made it into the final Bill.

Luckily, in spite of the lies we’ve read over the years, no one has yet been able to clone a human embryo.

What is now encouraged is the purposeful creation of a human embryo by cloning. The embryo may never be implanted, but the Bill declares that the nascent human should be killed and broken up

Lieutenant Governor David Dewhurst

Talking about Texas’s history of conservative pro-life and pro-family laws.

Texas Alliance for Life Leadership Luncheon

Joe Pojman, standing at the podium. Our President, Davida Stike is seated at the head table. Next up, our Lieutenant Governor, David Dewhurst.

Back to Basics on Texas Advance Directive Act

Laws relating to ethics debates are generally behind medical advances. This is good because it means that there *are* medical advances.

However, the debates often become emotional and heated, and the individuals who are affected face real dilemmas and emergencies. When law-making is controversial, it’s best to go back to the basics of ethics for guidance: the inalienable rights to “Life, Liberty and the Pursuit of Happiness,” the Declaration of Independence, and Constitution.

 
All laws limit our rights, but good laws strike a balance between seemingly conflicting rights: they are meant to prevent one person from harming another. Most laws prohibit or punish harmful actions, they don’t *compel* a desired action against our will. Nor do they prohibit actions based on thoughts and opinion. In other words, laws prohibit harming or taking from another, but they usually don’t make you protect, nurture or give to another.

 
However,since the right to life trumps the right to liberty and property, there are very rare circumstances when it is appropriate for laws to compel individuals to act for the benefit of another. Parents are required to care for and protect their minor children. Doctors and lawyers must be licensed, obtain certain levels of education, and follow specific, positive actions when they wish to withdraw from a professional relationship with a patient or client. These laws should only go so far as to protect the life and safety of the vulnerable, for a limited time with the goal of allowing safe transfer of the obligation of the person with more power to someone else.

 
On Tuesday, March 19, 2013, the Texas Senate Health and Human Services Committee, under Chair Senator Jane Nelson, heard testimony on two Bills that would change TADA: SB 303 from Senator (Dr.) Bob Duell’s  and SB 675 by Senator Kelly Hancock.

 
The Texas Advance Directive Act of 1999 (TADA), in addition to describing “Advance Directives to Physicians” (a “Living Will),  was an attempt to outline the procedure for resolving the disagreement between a doctor and patients or their surrogates regarding end of life care.

When I first read the Act, I (naively) thought it was malpractice protection for doctors who did not want to withdraw or withhold care, such as the Houston Methodist Hospital doctors who invoked the act when they repaired Dr. Michael Debakey’s aortic aneurysm against his previously stated wishes – http://www.theheart.org/article/762619.do – in 2006.

 
Most of the time, however, TADA is invoked in cases when the attending physician disagrees with a request to actively administer medical treatment that he or she believes is medically inappropriate. The steps laid out in the law involve the doctor’s notification of the patient or the surrogate, rules for assisting with transfer of care to another doctor who believes the treatment request is appropriate, and convening an ethics committee at the hospital. If there is no other willing doctor can be found and the ethics committee agrees with the doctor, the treatment can be withheld or withdrawn. It does not allow patients to be killed by medicines.

 
Unfortunately, the Act has become known as the “Texas Futile Care Law,” and divides even the pro-life community. One side says doctors and hospitals have too much power and are killing people. While I’ve heard horror stories about doctors who have abused or broken the law, I maintain that there is no “Futile Care Law,” only a difference of opinion as to who should decide what is medically appropriate treatment. In the few cases that have come under the Act, patients and their advocates report trouble finding other doctors willing to provide the treatment the first doctor thought was inappropriate. In my opinion, that difficulty is due to physicians’ common education and shared experiences.

Although TADA lays out requirements for hospitals and hospital medical ethics committees, the fact is that it applies to the “attending physician” who could be forced to act against his conscience. Texas law is clear that only doctors may practice medicine by diagnosing and treating patients directly or “ordering” other medical personnel. These treatments are not one-time events and they aren’t without consequences. They are interventions that must be monitored by observation and tests, and adjustments need to be made so that the treatment is effective and not harmful. Medical judgment is how doctors utilize our education, experience, and consciences as we plan and anticipate the effect of each medical intervention.

Senator Duell’s Bill, SB 303, significantly improves TADA. Among other things, the Bill would add protection of the patient’s right to artificially administered hydration and nutrition, increased access to assistance, records, and time before and after the ethics committee meeting, and prohibits so-called “secret DNR’s.”

Senator Hancock’s Bill, SB 675, focuses on the intentions and motives of the doctor, requiring the medical committee to decide whether the disagreement is due to: “(1) the lesser value the physician, facility, or professional places on extending the life of an elderly, disabled, or terminally ill patient compared to the value of extending the life of a patient who is younger, not disabled, or not terminally ill; or “(2) a disagreement between the physician, facility, or professional and the patient, or the person authorized to make a treatment decision for the patient under Section 166.039, over the greater weight the patient or person places on extending the patient ’s life above the risk of disability.”

Our laws normally prohibit actions and only very rarely compel people to act. Under the conditions laid out in SB 303, the doctor can be forced to act against his conscience and best medical judgment, but only for a limited, stated time. SB 303 improves the Texas Advance Directive Act by protecting the patient’s access to artificially administered hydration and nutrition. It also adds time to prepare for the ethics committee meeting and to transfer care a new doctor. It is an attempt to balance the patient’s wishes for medical intervention with the right of conscience of the doctor. In contrast, SB 675 would attempt to legislate intentions or thoughts, with none of the added protections of SB 303.

Edited 4/27/13 to fix the link to the article about Dr. Debakey and 4/30/13 for grammar and formatting – BBN.

Senate panel OKs abortion bill requiring stricter standards – Houston Chronicle

One woman claimed that the standards shouldn’t be the same as an ambulatory surgical center because they do abortions on 9 year olds!

Minimal standards are considered too much by the abortion industry. They’ve fought every move to keep women and girls safe, and whip out those coat hangers every chance they get.

Women who have D&C’s after a miscarriage have them at a hospital or surgical center, not at in an office setting. But according to the abortionists, healthy mothers having abortions – or 9 year old girls – should be happy with a clinic setting.

AUSTIN – Abortion clinics would be required to meet stricter standards under a bill approved 5-2 by the Senate Health and Human Services Committee Tuesday after emotional testimony over whether the measure would protect women’s health or risk it by causing clinics to close.

“My intent in filing this bill is only to protect Texas women who undergo this procedure,” said Sen. Bob Deuell, R-Greenville, who authored the measure with two fellow doctors, Republican Sens. Donna Campbell of New Braunfels and Charles Schwertner of Georgetown.

Planned Parenthood called the measure, Senate Bill 537, a “back-door abortion ban.”

via Senate panel OKs abortion bill requiring stricter standards – Houston Chronicle.

Cloned “Clone and Kill” Bill

I testified in front of the Texas House State Affairs Committee on Tuesday. The video is here, House State Affairs 2/20/13 (Free RealPlayer program required.) Mr. Raymond comes up at about 3:30 minutes in, and my effort starts at 8 minutes in. It’s short and sweet.)

HB 142, authored by Representative Richard Raymond of Texas’ House District 42 in Laredo, looks a lot like his HB 1829 from 2007. These are “clone and kill bills, which nominally ban cloning, but actually redefine cloning, and would force the killing of any human embryo intentionally killed by nuclear transplantation. HB 142 ignores the history of the last 6 years, and uses inaccurate terminology.

Watch this space for alternative language that would actually ban human cloning.

Office of the Governor Rick Perry – [Press Release] Texas Ranked Top Exporting State for 11th Consecutive Year

Texas is ranked as the number one exporting state for the 11th year in a row, according to 2012 annual trade data released today by the U.S. Department of Commerce.

“The fact that Texas is ranked the nation’s top exporter for the 11th year in a row further demonstrates that our strong economic climate provides a broad range of opportunities for businesses to succeed,” Gov. Perry said. “Our longstanding commitment to holding the line on taxes, keeping our workforce strong, and maintaining reasonable regulations and fair courts has led to more than a decade of leading the nation in exports.”

and …

Texas was recently named the top state to do business by Area Development magazine, and Business Facilities magazine awarded Texas as the “State of the Year” for the aggressive economic development strategies that have helped attract jobs and investment. Texas governor Rick Perry was awarded the “Governor’s Award 2012″ by fDi Magazine for being the most successful in attracting new investments to the state.

 

via Office of the Governor Rick Perry – [Press Release] Texas Ranked Top Exporting State for 11th Consecutive Year.

Gov. Perry Reappoints Seven to Texas Institute of Health Care Quality and Efficiency Board of Directors

Gov. Rick Perry has reappointed seven members to the Texas Institute of Health Care Quality and Efficiency Board of Directors for terms to expire Jan. 31, 2017. The institute improves health care quality, accountability, education and cost to the state by encouraging health care provider collaboration, effective health care delivery models and coordination of health care services.

. . . Beverly Nuckols of New Braunfels is a board certified family physician. She is a member of the Texas Medical Association, Texas Academy of Family Physicians, Comal County Medical Association, and Texas Physicians Resource Council. She is a fellow of the American Academy of Family Physicians, and a board member and secretary of Texas Alliance for Life.

via Office of the Governor Rick Perry – [Appointment] Gov. Perry Reappoints Seven to Texas Institute of Health Care Quality and Efficiency Board of Directors.

 

Office of the Governor Rick Perry – [Appointment] Gov. Perry Reappoints Seven to Texas Institute of Health Care Quality and Efficiency Board of Directors.

This is Leticia Van De Putte, the pro-abort racist

Lest we forget, as Senator Zaffirini reminded us this afternoon, Leticia Van de Putte is a rabid advocate for Planned Parenthood. And, here’s who she was in 2003, when she ran away with the other Democrats to thwart the will of the voters of Texas on redistricting. (Edit -  She’s the one who suggested to the 82nd Legislature that traditional marriage would be strengthened if the State passed a law requiring all marriages to include “some sex.” — clarified for context. BBN)

Here’s the story I wrote in 2003, published online at the time by the Washington Dispatch and on FreeRepublic.com

Racism in Texas Politics? Exclusive commentary by Beverly Nuckols

Aug 7, 2003

From the Op-Ed pages of the Houston Chronicle on August 6, 2003:

To paraphrase one of the greatest civil rights activists of the 20th century, “We are sick and tired of being sick and tired.” Fannie Lou Hamer uttered these infamous words during her crusade in the 1960s and 1970s to encourage political participation and the right to vote by African-Americans, Hispanics and other minorities.

“We and our fellow senators are in Albuquerque, N.M., because the same important issue faces the citizens and state of Texas.”

These words were written by three Houston Democrats: State Senators Rodney Ellis, Mario Gallegos and John Whitmire. They are members of a mixed-race, single-party gang of eleven Texas State Senators who fled across the border to Albuquerque, New Mexico in order to shut down the legislative process of Texas by denying the State Senate a quorum. The group, alternately called the “Killer D’s,” “Chicken D’s,”or “AlbuTurkeys”, panicked Monday afternoon, July 28th, and left the Austin Capitol Building to board two private jets provided by wealthy Texas businessmen, David Rogers, whose family owns the First National Bank of Edinburg, and Greg LaMantia, a partner in L&F Distributors for Anheuser-Busch in McAllen. They have set up camp in $150 to $200 per day rooms and suites at the Marriott Pyramid. The Chair of the 2004 Democratic Convention, who just happens to be New Mexico’s Governor Bill Richardson, immediately sent State Troopers to provide round-the-clock protection so that the Senators would be safe to make statements such as this to the media. Virtually every news article printed, and most of the television or radio reports, about the attempted-coup-by-flying-the-coop quote the flock of eleven about the races of the voters in Texas, but never a word is said about the racial diversity of their own group, much less about the divisive nature of their comments.

Senator Leticia Van de Putte, who is the current Senate Democratic Caucus, former Chair of the Texas Senate Hispanic Caucus and the apparent gang leader of the runaways, engaged in similar rhetoric when I met with her at her hotel hideout on Sunday, August 3. (I drove and stayed in a much cheaper room in the same hotel.) Senator Van de Putte admitted that her constituency in the Bexar County area will not be touched by any of the proposed redistricting maps, because the Hispanic population is protected under Civil Rights laws and locked in by court rulings. However, the Senator with the Dutch surname repeatedly talked about her interests as “Hispanic” “Latino” and “minority,” while using the term, “Anglo” to represent those who oppose her and/or any group of people that she believed I would support. The Senator didn’t know that her use of the word “Anglo” would offend me, because of her own bias. She also doesn’t know how proud I am of my Cherokee ancestry, which gave me a great ability to tan instead of sunburn, and which made my eyes as dark as hers. And she evidently prefers to ignore the fact that 44% of Hispanic voters voted for the brown-eyed Republican Governor Rick Perry in 2002.

And then later, The Fort Worth Star-Telegram contains this little tidbit:

Sen. Rodney Ellis, D-Houston, recalled that in 1993, Senate Democrats were pushing a resolution to have state judges elected from Texas House districts rather than running in countywide elections. At the time, the House had a solid Democratic majority while Republicans were winning countywide elections in many urban areas.

When the resolution came up for a vote in the Senate, most of the Republicans had left the floor, which left the body short of the 21 members it needed for a quorum.

“They didn’t leave the state; they just left the Senate,” Ellis recalled. “But they did succeed in shutting the place down, even if it was just for a day. I remember somebody asking me if it was like the Killer Bees (the nickname for the Senate Democrats who fled for four days in 1979), and I said it was more like the Killer WASPs.” (emphasis mine)

As a citizen of the State of Texas and an American, I am sick and tired of the racist comments and views of the eleven Democrat rogues who have run away to New Mexico in an act of extortion against the Governor and Lieutenant Governor who are only responding to the will of the voting majority. These cowardly partisans seem determined to divide the State along racial lines and blur their own political agenda. They have waged a campaign in the media to deliberately imply that the State’s redistricting effort is an attempt to take the votes from certain racial groups. In fact, the actions of the Democrats – now and in May when 51 Democrats hired buses to take them to Ardmore, Oklahoma – steal the power of the votes of the majority of Texans: those who voted for the Legislators who did show up for work when they were supposed to.

Beverly B. Nuckols, MD is a pro-life pro-human rights Family Practitioner from New Braunfels, Texas. Beverly can be contacted by writing to feedback@washingtondispatch.com

Map: Approved women’s health program providers in North Texas | Dallas-Fort Worth Breaking News – News for Dallas, Texas – The Dallas Morning News

Note that the providers are up to date and much more widespread than the few PP clinics. The numbers of patients served in 2011 are all before the new program was established along with the outreach by DSHS to contract with more doctors and clinics.

The dots represent approved state women’s health program providers as of October, such as clinics or private physician practices. Many have more than than one doctor at the location.The color designates the number of Medicaid Women’s Health Program clients the provider saw in fiscal 2011, the most recent year data is available.

via Map: Approved women’s health program providers in North Texas | Dallas-Fort Worth Breaking News – News for Dallas, Texas – The Dallas Morning News.

Blowin’ Smoke: Willie Nelson and the Constitution

I’m in the middle of reading Willie Nelson’s latest book, the semi-biographic stream of consciousness, Roll Me Up and Smoke Me When I Die: Musings from the Road.

I enjoy the stories about his life and family, but I’m continually irritated by his confused comments on politics and ethics.

It really knocks me for a loop when I encounter someone like Mr. Nelson, who has obviously thought long and hard about certain issues but doesn’t seem to understand the basics of ethics or logic. Because he doesn’t know *why* some things are right and others are wrong, he ends up proving one of the homey proverbs he quotes in the book: if you don’t stand for something, you’ll end up falling for anything.

I love to hear Willie Nelson and his songs. My husband and I went to see his band play at the Majestic Theater in San Antonio last January and were very impressed by the Nelson concerts — both of them. Lukas Nelson’s band, Promise of the Real, opened for his father and sons Lukas and Mikah joined the Nelson family on the stage.

It’s tempting to reference Laura Ingraham’s book, Shut Up and Sing, along with the theory and demand behind it. Just because a person is a great singer, songwriter and guitar player, doesn’t mean he’s a great person, much less that he’s a great philosopher or thinker. It certainly shouldn’t mean that his philosophy should be given greater weight than that of other people because of his celebrity and access to the press.

The fact is that Mr. Nelson is a leader and he influences a large number of people. It’s a shame it’s not for the right reasons.

In this book, Mr. Nelson praises the Occupy Wall Street protests, says he agrees with Warren Buffet “that it just ain’t fair for people like us to have all the advantages,” and states that the Second Amendment shouldn’t apply to today’s weapons because they aren’t designed for hunting, only for killing people. His religious comments are mostly just silly ramblings.

However, the cause Mr. Nelson is best identified with – and the one for which it would be simplest to correct his logical errors – is the legalization of marijuana. He writes about his founding of the “TeaPot Party” in the book. Mr. Nelson’s reason for legalizing marijuana is simply that people want to smoke it and there are other legal substances that are worse. And he proposes a Statist’s plan as flimsy as his utilitarian ethic: “Tax it, regulate it and legalize it!” to raise money for the Government:

 It’s already been proven that taxing and regulating marijuana makes more sense than sending young people to prison for smoking a God-given herb that has never proven to be fatal to anybody. Cigarettes and alcohol have killed millions, and there’s no law against them, because again, there’s a lot of money in cigarettes and alcohol. If they could realize there is just as much profit in marijuana, and they taxed and regulated it as they do cigarettes and alcohol, they could realize the same amount of profit and reduce trillions of dollars in debt.

Nelson, Willie; Friedman, Kinky (2012-11-13). Roll Me Up and Smoke Me When I Die: Musings from the Road (p. 20). William Morrow. Kindle Edition. (accessed 12/03/2012)

It might surprise some people that I – the self-proclaimed “hot air under the right wing” – agree that marijuana shouldn’t be illegal to grow, own or use. I base my belief on a plain reading of the US Constitution. How on Earth can our Federal government outlaw a plant that literally grows like a weed and doesn’t require manufacturing or processing to use? In fact, my theory as to why the plant is illegal is because it would be hard to regulate and tax.

Or maybe not.

Back in the mid-1990′s, I attempted to grow a traditional herbal medicine garden and ran into trouble obtaining Oriental poppy seeds, Papaver somniferum. Most of the orders I placed were cancelled, so I started doing some research. I learned that the Clinton Administration was raiding gardens and arresting people for growing and sharing the seeds of heirloom plants passed down from their mothers. This was in spite of the age-old use of the plants in gardens and herbal medicine, as well as the ready availability of food grade fertile Oriental poppy seeds for cooking and baking.

The more I thought about it, I came to the conclusion that the Federal government’s “War on Drugs” is not Constitutional and it’s not conservative. I agree with Mr. Nelson that this “war” is a costly abuse of government that strengthens organized crime and too many American freedoms have fallen as collateral damage. But the reason is not because people want to abuse drugs or because the Government could make money off the taxes. It’s because there’s no justification for outlawing a plant in the Constitution.

This is what happens when we the People don’t know our own Constitution and allow our Legislators to habitually pass abusive laws:  the infringement of our inalienable rights.

Office of the Governor Rick Perry – [Press Release] Gov. Perry: Texas Will Not Implement State Insurance Exchange Under Obamacare

Governor Rick Perry wrote a letter to Secretary of Health and Human Services, Kathleen Sibelius:

Gov. Perry’s letter said. “It would not be fiscally responsible to put hard-working Texans on the financial hook for an unknown amount of money to operate a system under rules that have not even been written.”

via Office of the Governor Rick Perry – [Press Release] Gov. Perry: Texas Will Not Implement State Insurance Exchange Under Obamacare.

Medical Regulation, Texas Style

The Texas Institute for Health Care Quality and Efficiency Draft Report is posted for public comment.

You only have a day and a half to comment, since the next meeting of our Board of Directors is Thursday, November 15th. All comments should be sent by 1 PM on Wednesday, November 14th.

Report to the Texas Legislature on Activities to Improve Health Care Quality and Efficiency
Report Number: 2012-001

The following downloads are available:
Report 2012-001: 2012-001-Draft-Report.pdf
Appendix E: AppendixE.pdf
Appendix F: AppendixF.pdf

Instructions on submitting your comments are here.

Now, for a few comments on my observations as a Board member:

Believe it or not, the time frame from the passage of the legislation in SB 7 last June, 2011, to today and in anticipation of preparing for legislation beginning in January, 2013, is too tight. The Institute’s staff and coordinators did a good job of herding cats in the Board. In addition, the Board members worked hard to make all the meetings, to participate, and to contribute. We have met at least once a month, sometimes more than twice, since our appointment. The Board isn’t paid or even reimbursed for expenses by the State, and many gave up work in order to attend meetings far from their homes.

I haven’t commented on the draft until now, because the Board received our first full copy for review and comment on November 2, and comments were due by 5 PM, Election Day, November 6th. We’re all appointed by the Governor — it stands to reason that a few of us would be actively involved in the election and campaigns. I didn’t even open the email until Nov. 7.

I’m not happy with the length of the report, but I guess the nuances of our discussions over the last few months needed to be documented somewhere. Go to the page 34 in the pdf, numbered “26″ in the Draft, for the actual recommendations made by vote in the Board meetings.

Finally, my main concern has been with the bureaucracy and regulation that the members of the Board have sometimes appeared to support. In the end, I believe that we have limited recommendations for regulation and “hassle factors” more than some would like. My hope is that the Legislature will decide to focus initially on implementing any new measures in our own State health plans and not interfere directly in private health care practice and systems, except where and when the State foots the bill.

Since President Obama won reelection, I believe that the ability of the 83rd Texas Legislature to adapt and react to Federal Regulations  – Obamacare – will be improved by the work of the Institute.