Medicine

Autonomy and aiding self-harm

​It’s very rarely good medicine to encourage a symptom of disease, especially one that leads to harm. I don’t help raise a patient’s temperature when they have a fever. I treat the infection and to keep the temperature from going up to dangerous levels.
In every case of cutting and self harm that I saw in my practice, the several girls and one boy had already been the victim of sexual abuse and were also abusing alcohol or drugs. The cutting was a symptom of depression, post-traumatic stress and the victimization that started the cascade.

And yet, the Journal of Medical Ethics has published an article arguing that since cutters are going to cut, doctors should aide them by providing sterile knives or razors. 

The Journal  is actually a forum for public arguments on controversial topics in bioethics, rather than a policy manual or review of facts and best practices. However, far too often the subjects are treated with respect and support those same controversial ideas. 

The online bioethics newsletter, Mercatornet, disputes this normalization of pathology and outlines the history of support and opposition to the concept of “safe” self harm.

Indeed, the argument for limiting harm is often given as the reason for elective abortion, physician assisted death and other forms of euthanasia.

Please, apply the suicide or cutting to illegal drug use. Does the rationale follow through? If a person is only happy after heroin, should we assist him by allowing and providing a cleaner, more pure product – as well as the needles so many State laws have made possible?

Cook sarcastically sums up with an imaginary Tweet:

“Bioethics is broken. Doctors respecting patients who make really BAD decisions. All because of AUTONOMY. DUMB!!! Back to human dignity!!!” 

I have long described Bioethics as “the formal study of who we can kill.” Now, we can add, “and aid in harming.”

Pay attention: it’s policy, not bias

The consensus of media pundits and bloggers, as well as quite a few liberal and even Conservative op-ed authors, is that Donald J.Trump was elected President out of some misguided national populism and anger at Congress, fueled with a lot of racism, misogyny and hate. The fact that those same voters elected a Republican majority in the House and Senate  – sending virtually every eligible Republican incumbent back to DC – is glossed over.

The idea that Conservatives really believe in small government and equal opportunity supported by personal responsibility is rarely voiced. That we might actually vote, not only for President but consistently down ballot, in order to defend the Bill of Rights and the right to life is ignored while we are accused of xeno-, homo-, and poly-whatever-phobia. I read that I am “afraid” of other lifestyles, religions, and losing my “privilege” based on being a White Christian.

Personally, I approve of most of the Republican Platform, especially where it addresses core Conservative issues, such as low taxes and equal treatment under the law. I want a Legislature that will uphold the Constitution as it’s written and defend against the infringement of inalienable rights. I don’t want activist judges nominated or confirmed at any level of the Federal Court system, especially the Supreme Court. I hope President Trump and the Republican Congress majority will decrease the hassle factors and threats placed on the practice of medicine and business in general by an overreaching Federal bureaucracy.

And, yes, my sense of fairness hopes that our existing immigration laws will finally be enforced, as an outcome of the”equal treatment under the law.”

Instead of facile clichés fed by cherry-picked sound bites and the latest talking points from the Left, try looking at and listening to the 59 Million voters across the country who elected a Republican candidate for President, and ensured a Republican majority including all those “establishment” candidates in both the House and Senate. 

It’s the Republican platform and Conservative policy that we Conservatives voted for, not one man.

I hope you can recall this

The future includes so much more than a 10 year old video, for people who don’t have memory problems.

Forget the Clinton’s sale of nights in the Lincoln Bedroom and misplaced furnishings from the White House and, later, the State Department offices. Go ahead, laugh at the “Reset button.”

But don’t forget the pay-for-access that continues to this day. Please don’t dismiss Clinton’s complicity with the sale of US uranium and her own dismissal of the deaths of four Americans at Benghazi or of “our posterity” in the case of the unborn children whose lives are ended by elective, intentional abortion.

These recollections make a difference today and for the future.

What place will there be in a Clinton II Administration for people who oppose abortion or who prefer to continue to include “under God” in the Pledge of Allegiance? Can we tolerate another 4 years of IRS discrimination against conservative non-profits? Do we need to have more lawsuits against nuns or regulations forbidding Christians from praying in the name of Jesus?

We certainly won’t be invited to any closed door meetings on HillaryCare. And there’s no telling how many boxes of FBI files and billing records will disappear never to be “recalled” if Clinton gets another shot at the White House.

I would much rather hold Donald Trump to his promises than watch Hillary Clinton keep hers.

Beverly B Nuckols, MD

Obama’s Abortion Cronyism 

Obama’s new Health and Human Services regulations will prohibit consideration of whether a provider does abortions – or sells body parts – or not.

Kansas and Texas, among other States, attempted to prioritize their limited tax dollars, preferring to steer money – and patients – toward continuing and comprehensive caregivers – primary care providers- over  reproductive health “boutiques:”

When PP sued, they lost. But Obama arbitrarily stripped the State’s Title X funds and gave the money to PP, anyway.

The “most transparent Administration ever” went further:

 In New Hampshire, the administration even refused to disclose information about its direct Planned Parenthood grant, claiming disclosure would harm the nonprofit’s “competitive position.”””

What competition??? That’s pure cronyism and blatant support of the Democrat’s  – and Obama’s – pro-abortion political ideology.

Edited 11/12/16: misspelling of Services in first sentence BBB

Trust me, I don’t have a conscience (yes, THAT again)

Speaking of CS Lewis’ “conditioners” in my last post, a small group of “philosophers and bioethicists” got together in Geneva, Switzerland last June and came up with a “Consensus Statement on Conscientious Objection in Healthcare.”

On the “consensus” from less than 20 self-selected individuals, we’re supposed to advocate the move from shaming doctors for objecting (to acts that have been considered shameful by Western society since Hippocrates) to some sort of judgment by tribunals.

From the BioEdge.org blog:

“After a special workshop held at the Brocher Foundation in Geneva, Switzerland, over a dozen bioethicists signed a ten-point“Consensus Statement on Conscientious Objection in Healthcare.” The group stated that “healthcare practitioners’ primary obligations are towards their patients, not towards their own personal conscience”. As a consequence, “healthcare practitioners who are exempted from performing certain medical procedures on conscientious grounds should be required to compensate society and the health system for their failure to fulfil their professional obligations by providing public-benefitting services.” They also stated that “Medical students should not be exempted from learning how to perform basic medical procedures they consider to be morally wrong.”

What’s to enforce those guidelines if the physician has no conscience? What place does “should” or “ought” – words that are flung about in the “Consensus” – have if the conscience is to be dismissed?

As Wesley Smith points out  at his blog on National Review, any objectors would be re-“conditioned.” The “Consensus” demands that  doctors not only be forced to explain their rationale, perform “public-benefitting services” (in addition to their jobs as doctors), and teach medical students those morally controversial procedures, they would be sent to re-education classes.

Oh, and they might not be able to get a job in the first place if they aren’t morally pure – excuse me – able to “fulfil (sic) their professional obligations,” according to this little club:

“This implies that regional authorities, in order to be able to provide medical services in a timely manner, should be allowed to make hiring decisions on the basis of whether possible employees are willing to perform medical procedures to which other healthcare practitioners have a conscientious objection.”

I sincerely doubt that any representatives were invited – or allowed – to attend. (At least, that’s my experience.)

More on “conscience” by searching the “Categories” on this page.

Department of Defense Transgender Plans – Bottom Line

United States Secretary of Defense, Ash Carter, declared the US military Independence Day from biology and human development. There will be a necessary increase in the military’s dependence on medicine, however.

“In an historic and controversial move, the Pentagon on Thursday lifted its longstanding ban on transgender troops and began outlining how the military will begin allowing — and paying for — service members to transition, medically and officially, from one gender to another.

“Now transgender troops will no longer be considered “medically unfit” for military service. By October, transgender troops may begin an official process to change gender in the military personnel management systems.”

****

“”The most common treatment for gender dysphoria is hormone therapy.”

This shouldn’t be a problem, other than a few hot flashes here and there – wherever.  After all, the American Medical Association has decided that neither genetic nor physical sex – also known as”anatomy,” trump feelings – or official birth records.

”

““Breast implants may be medically necessary” for some individuals, said another defense official familiar with the medical aspects of transgender treatment.

“Cosmetic surgery for gender transition, however, would in most cases be considered an elective procedure and not be covered by the military health system, defense officials said. Many transgender individuals do not opt for a full sex-change operation to include “bottom” surgery that changes genitalia.” (Emphasis mine.)

So, the DOD may buy some estrogen and testosterone and a few “medically necessary” breast implants, they don’t plan to pay for “bottom surgery.”.   In light of current insurance criteria, a huge of ” the standard practice in the civilian medical community,” however, I’m not sure how long that plan will last. (See the excellent and thorough discussion of medical necessity for gender reassignment surgery, provided online by Aetna, here.)

Right now, the question seems to be more about what the well dressed transgendered soldier, sailor or Marine will be wearing next year.

I haven’t served, but it seems to me that the solution is a truly *uniform* we of “grooming standards and uniform-wear,” job descriptions and fitness requirements. If genetic or physical sex is irrelevant to”gender identity,” then they should certainly be irrelevant as to readiness standards.

BTW, this may just be the justification for “access to 100 percent of America’s population” for future drafts.

Texas’ Women’s Health, UT Study: Other than that*, the story was true.

*The authors of a study published in the New England Journal of Medicine admit to a narrow focus that ignored the multiple methods of funding Family Planning in Texas,  looking instead at a single type of “provider” – Title X clinics like Planned Parenthood (“PP”) – and a single source of funding for a specific set of services: long-acting reversible contraceptives such as the IUD and implants and injectables.

Yet, in typical fashion, the reports about the study claim much more. For example, the Texas Tribune has an article out, “Texas disavows Controversial Women’s Health Study,”  about the political fallout due to the skewed conclusions of the authors and the even more skewed editorializing in the media.

While the NEJM article (free article!) states in the “Methods” section that,

“After the exclusion, the provision of injectable contraceptives fell sharply in counties with Planned Parenthood affiliates but not in counties without such affiliates; subsequently, the numbers of claims in both groups of counties remained relatively stable during the next 2 years. In contrast, the provision of short-acting hormonal methods changed little in the two groups of counties in the quarter after the exclusion and declined steadily thereafter.” (Emphasis mine. )

the Tribune article reports that in answer to criticism,

Joseph Potter, one of the UT researchers who co-authored the study, said in an email that the paper addressed the “specific question” of how the exclusion of Planned Parenthood from the Texas Women’s Health Program affected women. Nothing raised in Traylor’s letter, he said, contradicted the researchers’ conclusions.

“We made no claims about access to reproductive health care as a whole in Texas,” he said, and he stood by the finding that claims for long-acting contraceptives fell after Planned Parenthood was excluded from the women’s health program.

The law in question, SB7, was passed with bipartisan support in 2011, a year when Texas, along with State budgets all over the Nation were tight. Although family planning was cut, no specific vendor was “excluded” and PP was not even mentioned in the legislation. Only because PP did not offer continuing, comprehensive care, that business would effectively be cut out.

The Obama Administration took great offense at our State’s attempt to take care of the whole woman and refused all Family Planning Title X money for Texas Medicaid.

Instead, Obama intervened to specifically direct $13 Million of Title X funds to a private organization,the Women’s Health and Family Planning Association of Texas (“WHFP”) which funds only Title X clinics, almost all of which are now Planned Parenthood businesses), so no money was lost even at PP.

The State Health Services no longer managed those Medicaid matching dollars once allowed by a special Medicaid waiver. Instead, State funding for the Family Planning programs and the Texas Women’s Health Program, was replaced by State dollars and directed toward programs and doctors that offer continuing, comprehensive care, such as Federally Qualified Health Centers (FQHC), State, County and local clinics and hospitals, and fee for service doctors that participate with Medicaid. Women could be diagnosed and treated for a much broader spectrum of health problems and their families were welcome at the same clinics.

Senator Jane Nelson, Chair of the Senate Finance Committee and sponsor of the Bill, objects to the implication by the NEJM that the authors were writing on behalf of the State. In her letter to the Executive Commissioner of Texas’ Department of Health and Human Services, Chris Traynor, Senator Nelson noted,

“This study samples a narrow population within the Texas Women’s Health Program (TWHP) — which represented only 33 percent of the overall number of women enrolled in our women’s health programs in Fiscal Year (FY) 2014. This ignores hundreds of thousands of women being served through the Expanded Primary Health Care Program; the Family Planning Program; and the 628,000 women of child-bearing age receiving full Medicaid benefits, 75 percent of which received contraceptive services in FY 14. Women often rotate in and out of our state programs, so we must look across our entire system to determine whether we are truly meeting their needs. Just because a claim for service was not submitted to TWHP does not mean a woman went without that service.
The study also creates an impression that fewer Texas women are accessing long-acting reversible contraceptives (LARCs). That’s simply not true. Across our state programs, there were more claims for LARCs in FY 2014 than there were in FY 2012 when Planned Parenthood was still a provider.”

In other words, women with private insurance and women who never had access to PP had similar numbers.

And another thing: Potter, a sociologist at UTAustin and the co-author quoted above, was the one who told the LA Times that,  “It’s not like there is a large, over-capacity of highly qualified providers of effective contraception out there just waiting for people to show up.”

On behalf of Texas’ Family Physicians, OB/Gyns, Pediatricians and Internists who accept traditional Medicaid and who had been unable to access the money in those competitive Title X grants awarded to PP, I’d like to inform him that yes, we have been waiting – for a chance to offer our patients this care.

But other than that ….

Human rights for this class of persons?

How human is human enough for human rights?

Justice Taney on slavery, in the ruling on the Dred Scott case:
“”

The question before us is, whether the class of persons described in the plea in abatement [people of Aftican ancestry] compose a portion of this people, and are constituent members of this sovereignty? We think they are not, and that they are not included, and were not intended to be included, under the word “citizens” in the Constitution, and can therefore claim none of the rights and privileges which that instrument provides for and secures to citizens of the United States. On the contrary, they were at that time considered as a subordinate and inferior class of beings, who had been subjugated by the dominant race, and, whether emancipated or not, yet remained subject to their authority, and had no rights or privileges but such as those who held the power and the Government might choose to grant them. “

Nevertheless,  today’s Supreme Court hearing didn’t deal with the question of whether the zygote/embryo /fetus is human enough. It dealt with the regulations for abortion businesses and the doctors who work for them. These are essentially the same rules imposed on Federally Qualified Healthcare Centers.

Doctors must offer continuing care and the buildings should allow safe egress and sanitary standards of care.  The challenge is against State protections for the women who have chosen abortion.

Posted from WordPress for Android. Typos will be corrected!

Gardisil vaccine works in young women

The article contains a (free!) link to the study report in “Pediatrics.”

“”For young women aged 14–19, the presence of those four strains of HPV (and some others) were found to drop by an incredible 64 percent overall, and by 34 percent in women aged 20–24.””

There’s also a link to a study that indicates that there is no increase in sexual activity or early sexual activity after the vaccination, “as measured by pregnancy, sexually transmitted disease infections and/or contraceptive counseling for up to three years after vaccination.”

I do strongly disagree with the author about abstinence -based sex-ed:  Abstinence works 100% of the time it is use correctly and consistently.

Death Politics

News: “U.K. Scientists Given Green Light To Edit Human Embryos” | IFLScience

http://www.iflscience.com/health-and-medicine/uk-scientists-given-green-light-edit-human-embryos

Cute. We’re assured that it’s still illegal to implant these “edited,” engineered embryos – but until now, it wasn’t legal to edit them! See the pattern?

The experiments are only supposed to only  use “surplus” embryos conceived by in vitro fertilization. Next will come the argument that embryos should by designed “from scratch” as a couple’s right (or group marriage partner’s rights.

The only embryos that will be helped as a result of this line of experimentation wold be extracorporeal embryos that are to be edited, themselves! Job security for the experimenters, perhaps.

We can be sure implantation will happen, moving closer to “designer babies.” Lots of science fiction has often dealt with the good and bad, the intended and unintended consequences of “editing” the humans or transhumans we conceive.

The unintended consequences can’t be known, but we can know that they will occur. And yet, that child of tomorrow can’t consent, his or her contemporaries can’t consent and their off spring certainly can’t consent.

The nascent  human once again unquestionably becomes the means to another’s end, rather than an end in himself.

Yes, someone will point out that  many or even most parents may have children for their own purposes other than to truly become one with their spouse or to reproduce and pass on their genes. The mere fact that anyone can contemplate “spare” or “excess” human beings is proof of that. (And don’t forget the “unwanted” child the abortion advocates constantly remind us of.)

Will there be a money-back guarantee for the “failed” comodified child?  Will those future generations think better of us than we regard past efforts at breeding a better human? Let’s hope that if we live among them, they tolerate us!

Death, lies and video

Death, lies and video

Supported only by his imagination, what he saw in videos produced by Texas Right to Life lawyers, and a news article,Dr. Phillip Hawley, Jr., M.D., wrote “A Tragic Case of Modern Bioethics; Denying Life-Sustaining Treatment to a Patient Who Wanted to Live” about the truly tragic, but inevitable death of Chris Dunn. Hawley erred by pretending to read the minds of doctors and hospital representatives and calling complete strangers “utilitarian” “murderers.” Before discussing the ethics of his accusations, it’s necessary to explain the meaning of the documented facts, available in news sources, blog posts and court records:

1. Dunn was not “alert and cognizant” as he had documented delirium secondary to hepatic encephalopathy and over a month on the ventilator with sedation and pain meds
2.  The hospital voluntarily, without a court judgement, promised to continue life-sustaining treatments in place until the legal guardianship question was settled.
3.  Food and water, legally termed as “Artificially Administered Nutrition and Hydration” or AANH and including total parenteral nutrition, cannot be removed against the objection of patients or surrogates, under Texas law.
4. The doctors stated that they believed the “life-sustaining treatments,” were causing suffering.
5. The hospital never sought guardianship for themselves, only for “a qualified family member,” and listed their names and locations in the original petition.

It is very unlikely that Chris understood his condition, the questions the lawyers were asking or the consequences of his “prayer.” That he was unable to make medical decisions is supported by the fact that his parents had been making his medical decisions. The Harris County judge agreed with the hospital’s request that a single legal guardian be named by a separate court.
“Life-sustaining treatment,” “medically inappropriate” and “Artificially Administered Nutrition and Hydration” are legal terms defined in the Texas Advance Directive Act (TADA), which outlines the exact procedure and language for communications between doctors, the hospital committee, and patients or their surrogates. The use, monitoring and adjustment of a mechanical ventilator is in the definition of “life-sustaining treatments.” TADA specifically excludes “Artificially Administered Nutrition and Hydration” (AANH) in the definition of “life sustaining treatments,” which would argue against the accusation that his doctors planned to withdraw “food and water.”
The only legal reason under TADA to remove any “life-sustaining treatment” is that it is deemed “medically inappropriate” by the attending physician and then only if the hospital medical or ethics committee “affirms” that decision. If and when they are withheld, the Act specifically prohibits “mercy killing” or otherwise intentionally intervening with the intent to cause death by artificial means.
Additional demands by Chris’ mother, Mrs. Kelly, and the lawyers in blogs and news articles would have also fallen under the legal definition of “life-sustaining treatment.” These demands included a biopsy in order to determine a definitive tissue diagnosis for the clinically apparent pancreatic cancer and liver lesions, a surgical tracheostomy and the removal of the ventilator (to be fair, I believe they meant the tube through the vocal chords), less sedation, searches for and trials of treatment of the cancer, and the non-standard use of an indwelling drain for the ascites (large exudates in the abdomen due to high pressures in the liver and the failure of the liver to make necessary proteins). These are invasive, potentially painful and, based on the reported size and effects of the mass, the extent of liver damage visibly evident in the videos as temporal wasting and copper-colored skin, ascites and the GI bleeding – they were very unlikely to lengthen his life, much less cure his cancer. In fact they could be very likely to hasten – or be the immediate cause of – his death.
Chris died in the ICU on full life-sustaining treatments, including the ventilator and intravenous AANH.
The doctors are on record as basing their decision on the suffering caused by the treatments to their patient, Chris. This is consistent with the known side-effects of the ventilator and even reports from Chris’ mother, who told reporters that Chris suffered from the treatments and fluid building up in his lungs despite the ventilator. And yet, Dr. Hawley made sensational statements such as:

“For patients with terminal illnesses, this standard often leads to the utilitarian question: Is the patient’s life still worth living?
“In Chris Dunn’s case, the committee’s answer was “no.” Relative strangers with little or no knowledge of his values and beliefs weighed his “quality of life” and decided that he no longer deserved to live.”
And,
“. . . How did these committee members who had only recently met the patient—if they ever met him at all—know that it was in his best interest for them to end his life?”
And,
“. . . But, somehow, we are to believe that these committee members were able to deduce existential truths about what was in Chris Dunn’s best interest?”

The physicians who cared for Mr. Dunn for over a month had certainly met him and members of the Methodist Hospital Biomedical Ethics Committee met with the family several times. Court documents are clear that the doctors believed the life-sustaining treatments were causing suffering and that the committee agreed that the treatments were medically inappropriate. There certainly is no evidence that the doctors or the committee members sought to intentionally “end” Chris’ life. “Medically inappropriate treatment” is not an “existential truth” and never in the patient’s best interest.
(Some may remind us that suffering can have benefits. However, Mr. Dunn couldn’t consent to suffering, much less benefit from the suffering, whether as a medical treatment or a willing religious self-sacrifice.)

Robert P. George is one of my heroes a conservative tenured professor of law and ethics at Princeton and one of the founders of the Witherspoon Institute, an organization known for its defense of Judeo-Christian ethics based on natural law, and the parent organization of Public Discourse. He has helpfully outlined a “key” to evaluate the withholding or withdrawing of life-sustaining care:

“[T]he key is the distinction between what traditionally has been called “direct killing,” where death (one’s own or someone else’s) is sought either as an end in itself or as a means to some other end, and accepting death or the shortening of life as a foreseen side effect of an action or omission whose object is something other than death—either some good that cannot be achieved or some evil that cannot be avoided without resulting in death or the shortening of life.”

George and Hawley each point to a value in medicine that is higher than autonomy or even preserving life at all costs: the duty of physicians to care for the patient. “Cure when possible, but first, do no harm.”
The lawyers didn’t just sue to maintain “life-sustaining treatments,” or even Mrs. Kelly’s right to force the doctors to treat Chris the way she wanted them to. The lawsuit, blog posts and public statements document the ultimate goal to have TADA declared unconstitutional and to force all doctors to give patients and surrogates the right to demand any and all desired treatment indefinitely. The power of State courts, law enforcement and licensing would be used to force Texas doctors to carry out acts against our medical judgment, education, experience and conscience.
What justification can the lawyers and Dr. Hawley give for not believing the physicians who care for patients daily and hourly when those caretakers document that the patient is suffering?

What kind of physicians will we end up with if the State can force us to act without judgement or conscience?

What kind of State would we have?

Based on a video and his imagined conversations between “malevolent” and “utilitarian” doctors and hospitals, Hawley declares Texas a “morally impoverished society.” Ignoring sworn statements from the physicians and misrepresenting TADA, he distorts the purpose of the Texas Advance Directive Act, which is to address the problems encountered when patients and surrogates disagree., Only by assuming evil intent is he able to force doctors to prove a negative and distract from any possibility of a conflict between the equal and inalienable rights of the patient and the doctor.

While the video of Chris apparently praying to be allowed to live wrenched at our emotions, it was used to tell a false story upon which Dr. Hawley built his harmful assumptions. We would all do well to remember my Mama’s advice: Don’t believe anything you hear and only half of what you see.”

Edited for grammar and decrease wordiness and formatting (1-15-16). BBN

The Ethics of Texas’ Advance Directive Act

Laws relating to medical ethics debates are generally behind medical advances.

Unfortunately, those debates often become emotional and heated, and the individuals who are affected often face the “hard questions” of ethical dilemmas while reacting to life and death 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 are based on the fact that these inalienable rights are negative rights: they are meant to prevent one person – or the government – from infringing the rights of another. Ethical laws strike a balance between seemingly conflicting rights. They prohibit or punish harmful actions, but they don’t compel a desired action against the will.
However, since there is a hierarchy of rights (the right to life trumps the right to liberty and property, liberty trumps property, etc.), there are very rare circumstances when it is appropriate for laws to compel individuals to act for the benefit of another. These laws should only go so far as to protect the life and freedom of the vulnerable patient or client, for a limited time with the goal of allowing safe transfer of the obligation to someone else.

For instance, parents are required to care for and protect their minor children since they are helpless and unable to legally consent or make contracts. And State laws require that doctors and lawyers be licensed, obtain certain levels of education, and follow specific, positive actions when they wish to withdraw from a professional relationship with or refuse the request of a patient or client.
That brings us to the controversy over the Texas Advance Directive Act of 1999 (“TADA” or “the Act”). In addition to describing “Advance Directives to Physicians” (also known as a “Living Will), TADA also attempts to outline the procedure for resolving any disagreement between a doctor and patients or their surrogates regarding medical treatments, especially concerning 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. There have actually been a few “wrongful prolongation of life” lawsuits against doctors who – knowingly or not – used CPR when the patient had a Living Will.
Most of the time, however, TADA is invoked when the attending physician “refuses” 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 his refusal to the patient or the surrogate, the rules for assisting with transfer of care to another doctor who believes the treatment request is appropriate, and asking for a medical or ethics committee to be convened at the hospital. If no other willing doctor can be found and the committee agrees with the doctor, the treatment can be withheld or withdrawn (after 10 days). During that time, full life-sustaining treatment must continue and the hospital is required to provide medical records and to actively assist in looking for another doctor and/or hospital.

The law does never allow patients to be killed by intentionally stopping breathing. The law does prohibit withholding of pain medicine or comfort care and the removal of “artificially administered nutrition and hydration.”
Medical judgment is how doctors utilize our education, experience, and consciences as we plan and anticipate the effect of each medical intervention or treatment. “Life sustaining treatments are not “basic” or “usual care.” Nor are they one-time events without consequences. The interventions require a physician to administer and maintain. They must be monitored by observation and tests, and adjustments need to be made intermittently so that the treatment is effective and not harmful. They may lead to further more invasive and aggressive interventions and the need for the skills of other doctors in other specialties.

In some cases, patients and their advocates report trouble finding other doctors willing to provide the treatment that the first doctor thought was inappropriate. In my opinion, that difficulty is due to physicians’ common education and shared experiences – to medical reality, not ill intent.

Texas law is clear that only doctors may practice medicine by diagnosing and treating patients directly or “ordering” other medical personnel. Although TADA outlines specific duties for hospitals and hospital medical or ethics committees who determine whether or not the care is medically inappropriate, the process can only be invoked by the “attending physician” who is being asked to act against his medical judgment. The committee acts as a safeguard, to uphold medical ethics and the standard of medical care. In a formal meeting, the committee members review the case and either agree or disagree with the doctor as to whether he or she is correct about what is “medically inappropriate” treatment, for the patient.

Unfortunately, the Act has become known as the “Texas Futile Care Law,” and divides even the pro-life community. One side claims that doctors, hospitals and hospital committees are biased and should not be allowed to determine medically inappropriate care, and that doctors are obligated to give any and all desired treatment “until transfer.” Others want each case to go to court, where lawyers, judges and juries would settle every difference of opinion about “medically appropriate treatment.”

Ultimately, even the lawyers would need to consult doctors, unless the judges start writing orders for doctors, nurses, and medical professionals.

Our laws normally prohibit actions and only very rarely compel people to act. Under the conditions laid out in TADA, it is possible that the doctor can be forced to act against his medical judgment, but only for a limited, stated period of time. TADA is an attempt to balance conflicting rights: the patient’s wishes for medical intervention with liberty of the physician to practice medicine to the best of his judgment and conscience.

(Edited 03/11/18 to add a missing quotation mark. BBN)

Texas Advance Directive Act: What the lawyers really want

I’ll admit that I’m not a lawyer and have to do my homework to even attempt to understand lawyer-speak. (For example, see this definition of “Abatement”) How I wish more lawyers would admit they aren’t doctors, especially when they accuse doctors and entire hospital committees of killing patients.

Earlier this week, I reviewed the latest sensationalized case involving lawyers and lawyer-lobbyists playing doctor in the media and courts to overturn Section 166.046 of the Texas Advance Directive Act (“TADA”).

TADA outlines the process to settle disputes between an attending physician and the patient (or the family of a patient) when the medical judgment of the doctor about what is medically appropriate for the patient conflicts with the demands for treatment that the patient or family wants *that* particular doctor to perform.

Texas law prohibits the removal of “artificially administered nutrition and hydration” and pain medications unless the doctors determine they will cause further harm. However, a ventilator, intubation tubes in the throat, cardio-version (CPR), surgery and invasive procedures or tests are not ordinary or comfort care and are considered “life-sustaining” treatment that may be removed or withheld from a patient with a terminal disease if the patient’s doctor determines that are not medically appropriate. There is certainly no provision in Texas law to intentionally stop a patient’s breathing or to otherwise cause certain death.

The lawyers lobbying and suing against TADA admit in both public statements and legal complaints that they will settle for nothing less than “Due Process,” lawyer-speak reference to the Fourteenth Amendment clause, “due process of law.” They demand that every dispute about medically appropriate care between doctors and patients be argued – by lawyers – in court, preferably with a risk of “liability” for the doctor, any committee member who reviews the case under TADA, and the hospital where the patient is under care. Judges, and possibly juries, would determine the local medical standard of care, which medical procedures are appropriate for which patients, and liability. Lawyers and judges would essentially practice medicine instead of doctors.

To summarize this latest case, court records document** the affidavit from the attending physician of a 46 year old Pasadena, Texas man, Chris Dunn. Mr. Dunn was admitted to the ICU at Houston’s Methodist hospital unresponsive after a major gastrointestinal bleed due to metastatic pancreatic cancer led to his emergency transfer from a hospital in his hometown. Mr. Dunn was on a ventilator and suffering from liver, kidney, and respiratory failure. He had fluid in his lungs, necessitating higher and higher pressures on the ventilator. He had fluid leaking into the abdominal cavity due to the liver failure, ascites, that required intermittent draining. He also suffered from hepatic encephalopathy, a form of variable dementia and delirium.  His doctors and his father agreed that the repetitive, invasive treatments necessary to maintain the ventilator and treat the multi-organ failure should be stopped because they were causing Mr. Dunn harm, while comfort care would continue.

In their lawsuit against the hospital, a group of lawyers brought in by Mr. Dunn’s mother and Texas Right to Life sued the hospital in Mr. Dunn’s name, although there was a question about both Mr. Dunn’s ability to legally consent and the legal status of either parent alone to make medical decisions on Mr. Dunn’s behalf. In fact, the court ruled an “Abatement” or suspension of the lawsuit on December 4, 2015, until the legal guardianship for Mr. Dunn could be settled in another court. And, sadly, in spite of continued treatment in the Intensive Care Unit, on a ventilator, with IV and tube feedings, and all the repetitive blood tests, suctioning, and invasive procedures these treatments required, Mr. Dunn succumbed to his disease before that other court could meet to name a guardian.

In their lawsuit against the hospital, the lawyers even accuse “the facility” (not the attending doctor) of planning to actively euthanize Mr. Dunn by the deliberate use of injections intended to cause his death, rather than to relieve his pain:

“Defendant scheduling . . . and Defendant administering, via injection, a combination of drugs which will end his life almost immediately, thus warranting immediate intervention by this court.” (**p.2)

The lawyers further declared that the doctors and the Methodist Biomedical Ethics Committee – and every doctor or hospital committee – would be corrupted by their affiliation with the hospital:

“The statute does not provide adequate safeguards to protect against the conflict of interest inherently present when the treating physician’s decision is reviewed by the hospital “ethics committee” to whom the physician has direct financial ties.
“Texas Health and Saftey [sic] Code violates Plaintiff’s right to procedural due process by failing to provide an adequate venue for Plaintiff and those similarly situated to be heard in this critical life-ending decision. The law also fails to impose adequate evidentiary safeguards against hospitals and doctors by allowing them to make the decision to terminate life-sustaining treatment in their own unfettered discretion.” (**pp. 5,6)

And,

“Under Tex. Health and Safety Code 166.046, a fair and impartial tribunal did not and could not hear Dunn’s case. “Ethics committee” members from the treating hospital cannot be fair and impartial, when the propriety of giving Dunn’s expensive life-sustaining treatment must be weighed against a potential economic loss to the very entity which provides those members of the “ethics committee” with privileges and a source of income.” (**p. 7)

 

Lawyer-speak notwithstanding, I can’t figure out – and the lawyers don’t tell us – how to ensure that “unfettered” pancreatic cancer presenting with multi-organ failure followed “due process” in Mr. Dunn’s case. Other than lawyers from each side hiring and paying even more doctors to re-examine the patient and re-view the existing medical records, repeated clinical exams and nurses’ notes, lab work and non-invasive scans of the liver and abdomen, what would a judge or jury consider “evidentiary safeguards against doctors and hospitals?”

But in news article after blog post, lawyers (but no doctors) claimed that “the hospital wanted to kill” Mr. Dunn.  Lawyers (but no doctors) claimed there were un-named additional tests and treatments which could have changed the diagnosis, treatment or prognosis. Lawyers (but no doctors) disputed the medical judgment of the very doctors from whom the lawsuit demanded continued intensive care.

In their lawsuit, the lawyers also declared that, “Members of a fair and impartial tribunal should not only avoid a conflict of interest, they should avoid even the appearance of a conflict of interest, especially when a patient’s life is at stake.” (*p. 7) But that didn’t stop them from including an ironic and self-serving demand that Methodist hospital pay their “Attorney fees and costs.” (p. 12)

**(Protected “.pdf” “Images” of the original legal documents quoted below can be found online, here.  The document images aren’t link-able and can’t be copied or printed, so I will have to type up and share quotes. See Family case number 2015-69681. The quotes above are from document number 6796448.pdf, “Plaintiff’s Original Verified Petition and Application for Temporary Restraining Order and Injunctive Relief.”)

Texas Advance Directive Act, when the doctor refuses

Here’s Section 166.046 of the Texas Advance Directive Act,  the part of Texas Law that is in the news, these days. This part only applies when there is a disagreement between the doctor (whom the patient wants to continue treatment) and the patient or his surrogate about treatment decisions.

Sec. 166.046. PROCEDURE IF NOT EFFECTUATING A DIRECTIVE OR TREATMENT DECISION. (a) If an attending physician refuses to honor a patient’s advance directive or a health care or treatment decision made by or on behalf of a patient, the physician’s refusal shall be reviewed by an ethics or medical committee. The attending physician may not be a member of that committee. The patient shall be given life-sustaining treatment during the review.

(b) The patient or the person responsible for the health care decisions of the individual who has made the decision regarding the directive or treatment decision:

(1) may be given a written description of the ethics or medical committee review process and any other policies and procedures related to this section adopted by the health care facility;

(2) shall be informed of the committee review process not less than 48 hours before the meeting called to discuss the patient’s directive, unless the time period is waived by mutual agreement;

(3) at the time of being so informed, shall be provided:

(A) a copy of the appropriate statement set forth in Section 166.052; and

(B) a copy of the registry list of health care providers and referral groups that have volunteered their readiness to consider accepting transfer or to assist in locating a provider willing to accept transfer that is posted on the website maintained by the department under Section 166.053; and

(4) is entitled to:

(A) attend the meeting;

(B) receive a written explanation of the decision reached during the review process;

(C) receive a copy of the portion of the patient’s medical record related to the treatment received by the patient in the facility for the lesser of:

(i) the period of the patient’s current admission to the facility; or

(ii) the preceding 30 calendar days; and

(D) receive a copy of all of the patient’s reasonably available diagnostic results and reports related to the medical record provided under Paragraph (C).

(c) The written explanation required by Subsection (b)(4)(B) must be included in the patient’s medical record.

(d) If the attending physician, the patient, or the person responsible for the health care decisions of the individual does not agree with the decision reached during the review process under Subsection (b), the physician shall make a reasonable effort to transfer the patient to a physician who is willing to comply with the directive. If the patient is a patient in a health care facility, the facility’s personnel shall assist the physician in arranging the patient’s transfer to:

(1) another physician;

(2) an alternative care setting within that facility; or

(3) another facility.

(e) If the patient or the person responsible for the health care decisions of the patient is requesting life-sustaining treatment that the attending physician has decided and the ethics or medical committee has affirmed is medically inappropriate treatment, the patient shall be given available life-sustaining treatment pending transfer under Subsection (d). This subsection does not authorize withholding or withdrawing pain management medication, medical procedures necessary to provide comfort, or any other health care provided to alleviate a patient’s pain. The patient is responsible for any costs incurred in transferring the patient to another facility. The attending physician, any other physician responsible for the care of the patient, and the health care facility are not obligated to provide life-sustaining treatment after the 10th day after both the written decision and the patient’s medical record required under Subsection (b) are provided to the patient or the person responsible for the health care decisions of the patient unless ordered to do so under Subsection (g), except that artificially administered nutrition and hydration must be provided unless, based on reasonable medical judgment, providing artificially administered nutrition and hydration would:

(1) hasten the patient’s death;

(2) be medically contraindicated such that the provision of the treatment seriously exacerbates life-threatening medical problems not outweighed by the benefit of the provision of the treatment;

(3) result in substantial irremediable physical pain not outweighed by the benefit of the provision of the treatment;

(4) be medically ineffective in prolonging life; or

(5) be contrary to the patient’s or surrogate’s clearly documented desire not to receive artificially administered nutrition or hydration.

(e-1) If during a previous admission to a facility a patient’s attending physician and the review process under Subsection (b) have determined that life-sustaining treatment is inappropriate, and the patient is readmitted to the same facility within six months from the date of the decision reached during the review process conducted upon the previous admission, Subsections (b) through (e) need not be followed if the patient’s attending physician and a consulting physician who is a member of the ethics or medical committee of the facility document on the patient’s readmission that the patient’s condition either has not improved or has deteriorated since the review process was conducted.

(f) Life-sustaining treatment under this section may not be entered in the patient’s medical record as medically unnecessary treatment until the time period provided under Subsection (e) has expired.

(g) At the request of the patient or the person responsible for the health care decisions of the patient, the appropriate district or county court shall extend the time period provided under Subsection (e) only if the court finds, by a preponderance of the evidence, that there is a reasonable expectation that a physician or health care facility that will honor the patient’s directive will be found if the time extension is granted.

(h) This section may not be construed to impose an obligation on a facility or a home and community support services agency licensed under Chapter 142 or similar organization that is beyond the scope of the services or resources of the facility or agency. This section does not apply to hospice services provided by a home and community support services agency licensed under Chapter 142.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.03, eff. Sept. 1, 1999. Amended by Acts 2003, 78th Leg., ch. 1228, Sec. 3, 4, eff. June 20, 2003.

Amended by:

Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 3.0503, eff. April 2, 2015.

Acts 2015, 84th Leg., R.S., Ch. 435 (H.B. 3074), Sec. 5, eff. September 1, 2015.

Texas Supreme Court Rules on Judicial Bypass for Minors’ Abortions

I am glad that the rules are explicit about the duty to report sexual or physical abuse.

Here’s a statement from Texas Alliance for Life, with links to the ruling:

Austin, TX — Today the Texas Supreme Court released rules for how courts handle judicial bypass proceedings regarding secret abortions on minors girls without parental notification or consent. The rules were created in response to HB 3994, authored by Rep. Geanie Morrison (R-Victoria) and sponsored by Sen. Charles Perry (R-Lubbock) and strongly supported by Texas Alliance for Life.

The following statement is attributed to Joe Pojman, Ph.D., executive director of Texas Alliance for Life:

We are pleased with the Supreme Court’s strong rules regarding the judicial bypass process for abortions on minor girls. These bring to fruition a 10-year effort by Texas Alliance for Life and a coalition of pro-life organizations to protect minor girls in Texas from abortion. In 2005, the Texas Legislature passed a bill requiring doctors to obtain the consent of a parent before performing abortions on minor girls. In 2015, the Legislature passed, and Gov. Abbott signed into law, HB 3994 to reform the judicial bypass process by which a judge can allow abortions on minors without parental consent. The reforms closed loopholes and increased protections for the minors from abuse. The Texas Supreme Court has faithfully implemented House Bill 3994 in a way that will best protect the well being of minor girls.

Here is a link to the Texas Supreme Court’s order issuing the rules: http://www.txcourts.gov/media/1225647/159246.pdf.

HB 3994 was one of five major pro-life bills and numerous other pro-life provisions passed in 2015. Here is a summary.

 

Lawyers, politics, and end of life

Two days before Christmas, 46 year old Chris Dunn died in the ICU at Houston’s Methodist Hospital. Almost everything you’ve read and heard is a deliberate, political skewing of the facts.

Texas Right to Life turned Mr. Dunn’s imminent death from metastatic pancreatic cancer into a crusade against the Texas Advance Directive Act (TADA or the Act). The Act is invoked by the attending doctor – not the hospital or ethics committee – when family members demand that he or she perform acts that go against the conscience because they are medically inappropriate, causing the patient to suffer without changing his course.

In this case, the mother and father disagreed with one another about the care plan and the patient was unable to make legally binding decisions. The father agreed with Mr. Dunn’s doctors that the treatment was causing suffering, objected to surgery to place a tracheostomy, and wanted hospice and comfort care. The mother wanted dangerous, painful procedures performed that would not change the medical outlook except to possibly hasten death.

And, unless you read the court records, you wouldn’t know that the judge ruled that Chris was not mentally competent to make his own medical decisions, that the hospital never wanted guardianship and had voluntarily promised to continue care until the guardianship could be settled.  In fact all the lawyers, including the Texas Right to Life representatives,  signed off on an agreement acknowledging this promise on December 4th.  ( The official court records are available to view free of charge online at the Harris County District Clerk’s website as protected pdf images. See Family case number 2015- 69681.)

Inflammatory headlines falsely claimed that “the hospital” had imposed a “death sentence,” and was actively trying to kill Mr. Dunn by refusing to diagnose, treat or even give a prognosis.  That same blog post mentioned non-standard treatments that some in the family were demanding.

First of all, of course there was a diagnosis. Several, in fact. From the signed affidavit of Mr. Dunn’s attending physician, filed December 2, 2015 in response to the law suit:

“Based on my education, training, experience, as well as my care of Mr. Dunn, I, and members of my team, have advised his family members that Mr. Dunn suffers from end stage liver disease, the presence of a pancreatic mass suspected to be malignant with metastasis to the liver and complications of gastric outlet obstruction secondary to his pancreatic mass. Further, he suffers from hepatic encephalopathy, acute renal failure, sepsis, acute respiratory failure, multi-organ failure, and gastrointestestinal bleed. I have advised members of Mr. Dunn’s family that it is my clinical opinion that Mr. Dunn’s present condition is irreversible and progressively terminal.”

The primary diagnosis was metastatic pancreatic cancer. The cancer was a mass that blocked the ducts and blood vessels coming from the liver as well as the normal function of the intestines. As liver excretions backed up into the liver and the blood pressure in the liver increased, Mr. Dunn suffered a life-threatening gastrointestinal bleed, fluid buildup in the abdomen and lungs, and sepsis (an overwhelming infection). All of these would aggravate respiratory failure, the necessity  of a ventilator and lead to the kidney damage. Liver failure often results in hepatic encephalopathy  and variable delirium.

There was definitely treatment given, including tube and IV feedings, antibiotics, the ventilator, and periodic removal of the abdominal fluid. Again, this was all publicly documented in Court documents, in the media and even on the Texas Right to Life blog that claimed that “Houston Methodist has invested no time or effort in Chris’s health, instead exerting their energies into trying to kill him instead.” [sic]

The Intensive Care doctors as well as the Biomedical Ethics Committee, met with the parents to explain Mr. Dunn’s condition and his prognosis. The family was given notice before the Committee hearing and met with the (not at all “nameless” or “faceless”) Committee to discuss their (differing) wants. Thirty days’ worth of medical records, a hospital case worker and assistance in finding alternative care were made available to the family.

Then, there’s the complaint about the limits on visitors and videotaping. It is not unusual to limit Intensive Care Unit visits to specific times and to allow only close family, especially when the patient can’t consent and there is contention among family members. It is certainly standard to prohibit filming in the Unit, since patients are visible from one area to the next, in various states of undress and undergoing constant or frequent *intensive* treatments.

(BTW, one of the lawyers in the TRTL ICU video proves the basis for the rules: he is not compliant with the usual isolation procedures. Former Senator Joe Nixon didn’t wear the protective gown at all correctly, risking the introduction of infectious contamination into the room and/or taking germs home with him.)

It’s very unusual for patients on a ventilator to be conscious because of the severe discomfort associated with the foreign body – the breathing tube – that is necessary in the airways. It’s difficult to believe that anyone would complain about sedating Mr. Dunn in order to bypass his gag reflex.

Finally, the standard of care in advanced metastatic pancreatic cancer is pain relief and palliative support. The surgery to remove a pancreas is extremely dangerous for even healthier patients. As Mr. Dunn had already had an episode of bleeding and both liver and kidney failure, it’s likely that even a biopsy of the pancreatic mass or liver, much less surgery, would have caused more life-threatening bleeding. With liver and kidney damage, he wouldn’t have been able to tolerate trials of radiation or chemotherapy, either.

In fact, the doctors and nurses gave excellent treatment all along, as shown by his survival beyond the average for patients who presented in such a precarious state and acknowledged by Mrs. Kelly in her statement after Chris’ death.

The truth is that Methodist never made plans to “kill” Mr. Dunn. Mr. Dunn was never in danger of the hospital “pulling the plug.” The real problem was a disagreement between Mr. Dunn’s divorced parents over who would legally make medical decisions. That rift is bound to have been made worse by TRTL and the lawyers turning Chris’ illness into a public political battle. The accusations about euthanasia, killing and murder may cause other future patients harm, if they are reluctant to seek care because of these stories.

Ben Carson on Terri Schiavo

I suspect that there is more to this story than a couple of quotes. I really would like to see the video or, at least, read the entire transcript.

However, Dr Carson, as quoted here, is mistaken.

It was appropriate for government to intervene, as Mrs Schiavo’s right not to be killed was being infringed.

The case was a show trial, an act (actually, a series of acts) intended to cause death, supported by the euthanasia activists and went much beyond “the right to die.”  No, this was about the right to kill.

Mrs Schiavo wasn’t allowed to die due to the progressive breakdown of her organ systems. Instead, a woman who was able to swallow and breathe was subjected to medical and law enforcement intervention – the act of removal of her feeding tube rather than simply ceasing to use it,  morphine injections and – most egregious of all –  the judge’s order requiring local Sheriff’s deputies to prevent her mother and loved ones from giving her oral hydration and nutrition.

The only outcome possible was to cause her intentional death and to infringe on her inalienable right not to be killed.

There is a huge difference between withholding medical intervention involving repetitive invasive procedures and forbidding care that can be provided by loved ones.

“Duty” to use human tissue?

We should at least have as much care for the donation of tissue from aborted human fetuses and embryos as we do for the donation of organs from those killed by capital punishment. Both scenarios involve purposeful intervention to cause death and the collection of tissues, at least, must be carried out by licensed and regulated medical personnel.

Robin Alta Charo (a law and ethics professor at the University of Wisconsin) has an opinion piece in this week’s New England Journal of Medicine, “Fetal Tissue Fallout.” in which she claims that society has a “duty” to use tissues harvested after elective, intentional abortions.

I object to the idea that society has a “duty” to make use of the end products of either procedure. Both scenarios involve purposeful intervention to cause death by licensed and regulated medical personnel, making those of us who vote for the legislators who write laws complicit in the actions, at least remotely. Under a strict philosophy of ethics based on the protection of inalienable rights, each act should be weighed individually and should only be carried out when the one killed is a proven danger to the life or lives of others.

Robin justifies her elevation of the use of fetal tissues after elective abortion to that of a “duty” by citing past benefits of research using fetal tissues. She is more political and names past Republican supporters in an earlier op-ed, published in the Washington Post on August 4th.

Yes, society has benefited from these tissues.  However,  that picture at the side of this post depicts Dr. Frederick Robbins, one of the scientists who utilized fetal tissue in the 1950’s development of the Salk polio vaccine. Dr. Robbins is depicted smoking at work in the laboratory, while handling test tubes without gloves. We know better than that, now.  Isn’t it time that science and medicine researchers catch up with our knowledge that the human fetus is a human being from the moment of fertilization?

Where are the Ethics Review Boards that monitor for the unethical behavior we’re hearing about in the videos from the Center for Medical Progress?

In 2013, the science journal, Nature, published an article covering the history and evolution of informed consent and compensation for donors of human tissues, including the fetal tissue culture, WI-28.  Ms. Charo was quoted as supporting monetary compensation:

But, says Charo, “if we continue to debate it entirely in legal terms, it feels like we’re missing the emotional centre of the story”. It could be argued, she says, “that if somebody else is making a fortune off of this, they ought to share the wealth. It’s not a legal judgment. It’s a judgement about morality.”

Yes, “It’s not a legal judgment. It’s a judgement about morality.”

Corker’s “Iran S.Amdt.1140 to H.R.1191” (text)

“Is not this a lamentable thing, that of the skin of an innocent lamb should be made parchment?” (William Shakespeare, Henry VI, Part 2, just after the more famous, “The first thing we do, let’s kill all the lawyers.)  

The Senate took a House Bill, H.R. 1191, that originally amended ObamaCare  (so that the IRS would know for certain that volunteer firefighters, paramedics, and other emergency personnel aren’t counted as employees) and changed it completely in order give birth to the  “Iran Nuclear Agreement Review Act of 2015.”

It’s appropriate that a bill that originally amended ObamaCare was changed this way, since ObamaCare was passed in the first place by Harry Reid’s Senate amendment to a bill that as originally titled, “Service Members Home Ownership Tax Act of 2009.”

From the Senate record:

SA 1140. Mr. CORKER (for himself and Mr. Cardin) proposed an
amendment to the bill H.R. 1191, to amend the Internal Revenue Code of
1986 to ensure that emergency services volunteers are not taken into
account as employees under the shared responsibility requirements
contained in the Patient Protection and Affordable Care Act; as
follows:

Strike all after the enacting clause and insert the
following:

SECTION 1. SHORT TITLE.

This Act may be cited as the “Iran Nuclear Agreement
Review Act of 2015”.

SEC. 2. CONGRESSIONAL REVIEW AND OVERSIGHT OF AGREEMENTS WITH
IRAN RELATING TO THE NUCLEAR PROGRAM OF IRAN.

The Atomic Energy Act of 1954 (42 U.S.C. 2011 et seq.) is
amended by inserting after section 134 the following new
section:

“SEC. 135. CONGRESSIONAL REVIEW AND OVERSIGHT OF AGREEMENTS
WITH IRAN.

“(a) Transmission to Congress of Nuclear Agreements With
Iran and Verification Assessment With Respect to Such
Agreements.–
“(1) Transmission of agreements.–Not later than 5
calendar days after reaching an agreement with Iran relating
to the nuclear program of Iran, the President shall transmit
to the appropriate congressional committees and leadership–
“(A) the agreement, as defined in subsection (h)(1),
including all related materials and annexes;
“(B) a verification assessment report of the Secretary of
State prepared under paragraph (2) with respect to the
agreement; and
“(C) a certification that–
“(i) the agreement includes the appropriate terms,
conditions, and duration of the agreement’s requirements with
respect to Iran’s nuclear activities and provisions
describing any sanctions to be waived, suspended, or
otherwise reduced by the United States, and any other nation
or entity, including the United Nations; and
“(ii) the President determines the agreement meets United
States non-proliferation objectives, does not jeopardize the
common defense and security, provides an adequate framework
to ensure that Iran’s nuclear activities permitted thereunder
will not be inimical to or constitute an unreasonable risk to
the common defense and security, and ensures that Iran’s
nuclear activities permitted thereunder will not be used to
further any nuclear-related military or nuclear explosive
purpose, including for any research on or development of any
nuclear explosive device or any other nuclear-related
military purpose.
“(2) Verification assessment report.–
“(A) In general.–The Secretary of State shall prepare,
with respect to an agreement described in paragraph (1), a
report assessing–
“(i) the extent to which the Secretary will be able to
verify that Iran is complying with its obligations and
commitments under the agreement;
“(ii) the adequacy of the safeguards and other control
mechanisms and other assurances contained in the agreement
with respect to Iran’s nuclear program to ensure Iran’s
activities permitted thereunder will not be used to further
any nuclear-related military or nuclear explosive purpose,
including for any research on or development of any nuclear
explosive device or any other nuclear-related military
purpose; and
“(iii) the capacity and capability of the International
Atomic Energy Agency to effectively implement the
verification regime required by or related to the agreement,
including whether the International Atomic Energy Agency will
have sufficient access to investigate suspicious sites or
allegations of covert nuclear-related activities and whether
it has the required funding, manpower, and authority to
undertake the verification regime required by or related to
the agreement.
“(B) Assumptions.–In preparing a report under
subparagraph (A) with respect to an agreement described in
paragraph (1), the Secretary shall assume that Iran could–
“(i) use all measures not expressly prohibited by the
agreement to conceal activities that violate its obligations
and commitments under the agreement; and
“(ii) alter or deviate from standard practices in order to
impede efforts to verify that Iran is complying with those
obligations and commitments.
“(C) Classified annex.–A report under subparagraph (A)
shall be transmitted in unclassified form, but shall include
a classified annex prepared in consultation with the Director
of National Intelligence, summarizing relevant classified
information.
“(3) Exception.–
“(A) In general.–Neither the requirements of
subparagraphs (B) and (C) of paragraph (1), nor subsections
(b) through (g) of this section, shall apply to an agreement
described in subsection (h)(5) or to the EU-Iran Joint
Statement made on April 2, 2015.
“(B) Additional requirement.–Notwithstanding subparagraph
(A), any agreement as defined in subsection (h)(1) and any
related materials, whether concluded before or after the date
of the enactment of this section, shall not be subject to the
exception in subparagraph (A).
“(b) Period for Review by Congress of Nuclear Agreements
With Iran.–
“(1) In general.–During the 30-calendar day period
following transmittal by the President of an agreement
pursuant to subsection (a), the Committee on Foreign
Relations of the Senate and the Committee on Foreign Affairs
of the House of Representatives shall, as appropriate, hold
hearings and briefings and otherwise obtain information in
order to fully review such agreement.
“(2) Exception.–The period for congressional review under
paragraph (1) shall be 60 calendar days if an agreement,
including all materials required to be transmitted to
Congress pursuant to subsection (a)(1), is transmitted
pursuant to subsection (a) between July 10, 2015, and
September 7, 2015.
“(3) Limitation on actions during initial congressional
review period.–Notwithstanding any other provision of law,
except as provided in paragraph (6), prior to and during the
period for transmission of an agreement in subsection (a)(1)
and during the period for congressional review provided in
paragraph (1), including any additional period as applicable
under the exception provided in paragraph (2), the President
may not waive, suspend, reduce, provide relief from, or
otherwise limit the application of statutory sanctions with
respect to Iran under any provision of law or refrain from
applying any such sanctions pursuant to an agreement
described in subsection (a).
“(4) Limitation on actions during presidential
consideration of a joint resolution of disapproval.–
Notwithstanding any other provision of law, except as
provided in paragraph (6), if a joint resolution of
disapproval described in subsection (c)(2)(B) passes the
Congress, the President may not waive, suspend, reduce,
provide relief from, or otherwise limit the application of
statutory sanctions with respect to Iran under any provision
of law or refrain from applying any such sanctions pursuant
to an agreement described in subsection (a) for a period of
12 calendar days following the date of passage of the joint
resolution of disapproval.
“(5) Limitation on actions during congressional
reconsideration of a joint resolution of disapproval.–
Notwithstanding any other provision of law, except as
provided in paragraph (6), if a joint resolution of
disapproval described in subsection (c)(2)(B) passes the
Congress, and the President vetoes such joint resolution, the
President may not waive, suspend, reduce, provide relief
from, or otherwise limit the application of statutory
sanctions with respect to Iran under any provision of law or
refrain from applying any such sanctions pursuant to an
agreement described in subsection (a) for a period of 10
calendar days following the date of the President’s veto.
“(6) Exception.–The prohibitions under paragraphs (3)
through (5) do not apply to any new deferral, waiver, or
other suspension of statutory sanctions pursuant to the Joint
Plan of Action if that deferral, waiver, or other suspension
is made–
“(A) consistent with the law in effect on the date of the
enactment of the Iran Nuclear Agreement Review Act of 2015;
and
“(B) not later than 45 calendar days before the
transmission by the President of an agreement, assessment
report, and certification under subsection (a).
“(c) Effect of Congressional Action With Respect to
Nuclear Agreements With Iran.–
“(1) Sense of congress.–It is the sense of Congress
that–
“(A) the sanctions regime imposed on Iran by Congress is
primarily responsible for bringing Iran to the table to
negotiate on its nuclear program;
“(B) these negotiations are a critically important matter
of national security and foreign policy for the United States
and its closest allies;
“(C) this section does not require a vote by Congress for
the agreement to commence;
“(D) this section provides for congressional review,
including, as appropriate, for approval, disapproval, or no
action on statutory sanctions relief under an agreement; and
“(E) even though the agreement may commence, because the
sanctions regime was imposed by Congress and only Congress
can permanently modify or eliminate that regime, it is
critically important that Congress have the opportunity, in
an orderly and deliberative manner, to consider and, as
appropriate, take action affecting the statutory sanctions
regime imposed by Congress.
“(2) In general.–Notwithstanding any other provision of
law, action involving any measure of statutory sanctions
relief by the United States pursuant to an agreement subject
to subsection (a) or the Joint Plan of Action–
“(A) may be taken, consistent with existing statutory
requirements for such action, if, during the period for
review provided in subsection (b), the Congress adopts, and
there is enacted, a joint resolution stating in substance
that the Congress does favor the agreement;
“(B) may not be taken if, during the period for review
provided in subsection (b), the Congress adopts, and there is
enacted, a joint

[[Page S2410]]

resolution stating in substance that the Congress does not
favor the agreement; or
“(C) may be taken, consistent with existing statutory
requirements for such action, if, following the period for
review provided in subsection (b), there is not enacted any
such joint resolution.
“(3) Definition.–For the purposes of this subsection, the
phrase `action involving any measure of statutory sanctions
relief by the United States’ shall include waiver,
suspension, reduction, or other effort to provide relief
from, or otherwise limit the application of statutory
sanctions with respect to, Iran under any provision of law or
any other effort to refrain from applying any such sanctions.
“(d) Congressional Oversight of Iranian Compliance With
Nuclear Agreements.–
“(1) In general.–The President shall keep the appropriate
congressional committees and leadership fully and currently
informed of all aspects of Iranian compliance with respect to
an agreement subject to subsection (a).
“(2) Potentially significant breaches and compliance
incidents.–The President shall, within 10 calendar days of
receiving credible and accurate information relating to a
potentially significant breach or compliance incident by Iran
with respect to an agreement subject to subsection (a),
submit such information to the appropriate congressional
committees and leadership.
“(3) Material breach report.–Not later than 30 calendar
days after submitting information about a potentially
significant breach or compliance incident pursuant to
paragraph (2), the President shall make a determination
whether such potentially significant breach or compliance
issue constitutes a material breach and, if there is such a
material breach, whether Iran has cured such material breach,
and shall submit to the appropriate congressional committees
and leadership such determination, accompanied by, as
appropriate, a report on the action or failure to act by Iran
that led to the material breach, actions necessary for Iran
to cure the breach, and the status of Iran’s efforts to cure
the breach.
“(4) Semi-annual report.–Not later than 180 calendar days
after entering into an agreement described in subsection (a),
and not less frequently than once every 180 calendar days
thereafter, the President shall submit to the appropriate
congressional committees and leadership a report on Iran’s
nuclear program and the compliance of Iran with the agreement
during the period covered by the report, including the
following elements:
“(A) Any action or failure to act by Iran that breached
the agreement or is in noncompliance with the terms of the
agreement.
“(B) Any delay by Iran of more than one week in providing
inspectors access to facilities, people, and documents in
Iran as required by the agreement.
“(C) Any progress made by Iran to resolve concerns by the
International Atomic Energy Agency about possible military
dimensions of Iran’s nuclear program.
“(D) Any procurement by Iran of materials in violation of
the agreement or which could otherwise significantly advance
Iran’s ability to obtain a nuclear weapon.
“(E) Any centrifuge research and development conducted by
Iran that–
“(i) is not in compliance with the agreement; or
“(ii) may substantially enhance the breakout time of
acquisition of a nuclear weapon by Iran, if deployed.
“(F) Any diversion by Iran of uranium, carbon-fiber, or
other materials for use in Iran’s nuclear program in
violation of the agreement.
“(G) Any covert nuclear activities undertaken by Iran,
including any covert nuclear weapons-related or covert
fissile material activities or research and development.
“(H) An assessment of whether any Iranian financial
institutions are engaged in money laundering or terrorist
finance activities, including names of specific financial
institutions if applicable.
“(I) Iran’s advances in its ballistic missile program,
including developments related to its long-range and inter-
continental ballistic missile programs.
“(J) An assessment of–
“(i) whether Iran directly supported, financed, planned,
or carried out an act of terrorism against the United States
or a United States person anywhere in the world;
“(ii) whether, and the extent to which, Iran supported
acts of terrorism, including acts of terrorism against the
United States or a United States person anywhere in the
world;
“(iii) all actions, including in international fora, being
taken by the United States to stop, counter, and condemn acts
by Iran to directly or indirectly carry out acts of terrorism
against the United States and United States persons;
“(iv) the impact on the national security of the United
States and the safety of United States citizens as a result
of any Iranian actions reported under this paragraph; and
“(v) all of the sanctions relief provided to Iran,
pursuant to the agreement, and a description of the
relationship between each sanction waived, suspended, or
deferred and Iran’s nuclear weapon’s program.
“(K) An assessment of whether violations of
internationally recognized human rights in Iran have changed,
increased, or decreased, as compared to the prior 180-day
period.
“(5) Additional reports and information.–
“(A) Agency reports.–Following submission of an agreement
pursuant to subsection (a) to the appropriate congressional
committees and leadership, the Department of State, the
Department of Energy, and the Department of Defense shall,
upon the request of any of those committees or leadership,
promptly furnish to those committees or leadership their
views as to whether the safeguards and other controls
contained in the agreement with respect to Iran’s nuclear
program provide an adequate framework to ensure that Iran’s
activities permitted thereunder will not be inimical to or
constitute an unreasonable risk to the common defense and
security.
“(B) Provision of information on nuclear initiatives with
iran.–The President shall keep the appropriate congressional
committees and leadership fully and currently informed of any
initiative or negotiations with Iran relating to Iran’s
nuclear program, including any new or amended agreement.
“(6) Compliance certification.–After the review period
provided in subsection (b), the President shall, not less
than every 90 calendar days–
“(A) determine whether the President is able to certify
that–
“(i) Iran is transparently, verifiably, and fully
implementing the agreement, including all related technical
or additional agreements;
“(ii) Iran has not committed a material breach with
respect to the agreement or, if Iran has committed a material
breach, Iran has cured the material breach;
“(iii) Iran has not taken any action, including covert
action, that could significantly advance its nuclear weapons
program; and
“(iv) suspension of sanctions related to Iran pursuant to
the agreement is–

“(I) appropriate and proportionate to the specific and
verifiable measures taken by Iran with respect to terminating
its illicit nuclear program; and
“(II) vital to the national security interests of the
United States; and

“(B) if the President determines he is able to make the
certification described in subparagraph (A), make such
certification to the appropriate congressional committees and
leadership.
“(7) Sense of congress.–It is the sense of Congress
that–
“(A) United States sanctions on Iran for terrorism, human
rights abuses, and ballistic missiles will remain in place
under an agreement, as defined in subsection (h)(1);
“(B) issues not addressed by an agreement on the nuclear
program of Iran, including fair and appropriate compensation
for Americans who were terrorized and subjected to torture
while held in captivity for 444 days after the seizure of the
United States Embassy in Tehran, Iran, in 1979 and their
families, the freedom of Americans held in Iran, the human
rights abuses of the Government of Iran against its own
people, and the continued support of terrorism worldwide by
the Government of Iran, are matters critical to ensure
justice and the national security of the United States, and
should be expeditiously addressed;
“(C) the President should determine the agreement in no
way compromises the commitment of the United States to
Israel’s security, nor its support for Israel’s right to
exist; and
“(D) in order to responsibly implement any long-term
agreement reached between the P5+1 countries and Iran, it is
critically important that Congress have the opportunity to
review any agreement and, as necessary, take action to modify
the statutory sanctions regime imposed by Congress.
“(e) Expedited Consideration of Legislation.–
“(1) In general.–In the event the President does not
submit a certification pursuant to subsection (d)(6) or has
determined pursuant to subsection (d)(3) that Iran has
materially breached an agreement subject to subsection (a)
and the material breach has not been cured, Congress may
initiate within 60 calendar days expedited consideration of
qualifying legislation pursuant to this subsection.
“(2) Qualifying legislation defined.–For purposes of this
subsection, the term `qualifying legislation’ means only a
bill of either House of Congress–
“(A) the title of which is as follows: `A bill reinstating
statutory sanctions imposed with respect to Iran.’; and
“(B) the matter after the enacting clause of which is:
`Any statutory sanctions imposed with respect to Iran
pursuant to ______ that were waived, suspended, reduced, or
otherwise relieved pursuant to an agreement submitted
pursuant to section 135(a) of the Atomic Energy Act of 1954
are hereby reinstated and any action by the United States
Government to facilitate the release of funds or assets to
Iran pursuant to such agreement, or provide any further
waiver, suspension, reduction, or other relief pursuant to
such agreement is hereby prohibited.’, with the blank space
being filled in with the law or laws under which sanctions
are to be reinstated.
“(3) Introduction.–During the 60-calendar day period
provided for in paragraph (1), qualifying legislation may be
introduced–
“(A) in the House of Representatives, by the majority
leader or the minority leader; and

[[Page S2411]]

“(B) in the Senate, by the majority leader (or the
majority leader’s designee) or the minority leader (or the
minority leader’s designee).
“(4) Floor consideration in house of representatives.–
“(A) Reporting and discharge.–If a committee of the House
to which qualifying legislation has been referred has not
reported such qualifying legislation within 10 legislative
days after the date of referral, that committee shall be
discharged from further consideration thereof.
“(B) Proceeding to consideration.–Beginning on the third
legislative day after each committee to which qualifying
legislation has been referred reports it to the House or has
been discharged from further consideration thereof, it shall
be in order to move to proceed to consider the qualifying
legislation in the House. All points of order against the
motion are waived. Such a motion shall not be in order after
the House has disposed of a motion to proceed on the
qualifying legislation with regard to the same agreement. The
previous question shall be considered as ordered on the
motion to its adoption without intervening motion. The motion
shall not be debatable. A motion to reconsider the vote by
which the motion is disposed of shall not be in order.
“(C) Consideration.–The qualifying legislation shall be
considered as read. All points of order against the
qualifying legislation and against its consideration are
waived. The previous question shall be considered as ordered
on the qualifying legislation to final passage without
intervening motion except two hours of debate equally divided
and controlled by the sponsor of the qualifying legislation
(or a designee) and an opponent. A motion to reconsider the
vote on passage of the qualifying legislation shall not be in
order.
“(5) Consideration in the senate.–
“(A) Committee referral.–Qualifying legislation
introduced in the Senate shall be referred to the Committee
on Foreign Relations.
“(B) Reporting and discharge.–If the Committee on Foreign
Relations has not reported such qualifying legislation within
10 session days after the date of referral of such
legislation, that committee shall be discharged from further
consideration of such legislation and the qualifying
legislation shall be placed on the appropriate calendar.
“(C) Proceeding to consideration.–Notwithstanding Rule
XXII of the Standing Rules of the Senate, it is in order at
any time after the committee authorized to consider
qualifying legislation reports it to the Senate or has been
discharged from its consideration (even though a previous
motion to the same effect has been disagreed to) to move to
proceed to the consideration of qualifying legislation, and
all points of order against qualifying legislation (and
against consideration of the qualifying legislation) are
waived. The motion to proceed is not debatable. The motion is
not subject to a motion to postpone. A motion to reconsider
the vote by which the motion is agreed to or disagreed to
shall not be in order. If a motion to proceed to the
consideration of the qualifying legislation is agreed to, the
qualifying legislation shall remain the unfinished business
until disposed of.
“(D) Debate.–Debate on qualifying legislation, and on all
debatable motions and appeals in connection therewith, shall
be limited to not more than 10 hours, which shall be divided
equally between the majority and minority leaders or their
designees. A motion to further limit debate is in order and
not debatable. An amendment to, or a motion to postpone, or a
motion to proceed to the consideration of other business, or
a motion to recommit the qualifying legislation is not in
order.
“(E) Vote on passage.–The vote on passage shall occur
immediately following the conclusion of the debate on the
qualifying legislation and a single quorum call at the
conclusion of the debate, if requested in accordance with the
rules of the Senate.
“(F) Rulings of the chair on procedure.–Appeals from the
decisions of the Chair relating to the application of the
rules of the Senate, as the case may be, to the procedure
relating to qualifying legislation shall be decided without
debate.
“(G) Consideration of veto messages.–Debate in the Senate
of any veto message with respect to qualifying legislation,
including all debatable motions and appeals in connection
with such qualifying legislation, shall be limited to 10
hours, to be equally divided between, and controlled by, the
majority leader and the minority leader or their designees.
“(6) Rules relating to senate and house of
representatives.–
“(A) Coordination with action by other house.–If, before
the passage by one House of qualifying legislation of that
House, that House receives qualifying legislation from the
other House, then the following procedures shall apply:
“(i) The qualifying legislation of the other House shall
not be referred to a committee.
“(ii) With respect to qualifying legislation of the House
receiving the legislation–

“(I) the procedure in that House shall be the same as if
no qualifying legislation had been received from the other
House; but
“(II) the vote on passage shall be on the qualifying
legislation of the other House.

“(B) Treatment of a bill of other house.–If one House
fails to introduce qualifying legislation under this section,
the qualifying legislation of the other House shall be
entitled to expedited floor procedures under this section.
“(C) Treatment of companion measures.–If, following
passage of the qualifying legislation in the Senate, the
Senate then receives a companion measure from the House of
Representatives, the companion measure shall not be
debatable.
“(D) Application to revenue measures.–The provisions of
this paragraph shall not apply in the House of
Representatives to qualifying legislation which is a revenue
measure.
“(f) Rules of House of Representatives and Senate.–
Subsection (e) is enacted by Congress–
“(1) as an exercise of the rulemaking power of the Senate
and the House of Representatives, respectively, and as such
are deemed a part of the rules of each House, respectively,
but applicable only with respect to the procedure to be
followed in that House in the case of legislation described
in those sections, and supersede other rules only to the
extent that they are inconsistent with such rules; and
“(2) with full recognition of the constitutional right of
either House to change the rules (so far as relating to the
procedure of that House) at any time, in the same manner, and
to the same extent as in the case of any other rule of that
House.
“(g) Rules of Construction.–Nothing in the section shall
be construed as–
“(1) modifying, or having any other impact on, the
President’s authority to negotiate, enter into, or implement
appropriate executive agreements, other than the restrictions
on implementation of the agreements specifically covered by
this section;
“(2) allowing any new waiver, suspension, reduction, or
other relief from statutory sanctions with respect to Iran
under any provision of law, or allowing the President to
refrain from applying any such sanctions pursuant to an
agreement described in subsection (a) during the period for
review provided in subsection (b);
“(3) revoking or terminating any statutory sanctions
imposed on Iran; or
“(4) authorizing the use of military force against Iran.
“(h) Definitions.–In this section:
“(1) Agreement.–The term `agreement’ means an agreement
related to the nuclear program of Iran that includes the
United States, commits the United States to take action, or
pursuant to which the United States commits or otherwise
agrees to take action, regardless of the form it takes,
whether a political commitment or otherwise, and regardless
of whether it is legally binding or not, including any joint
comprehensive plan of action entered into or made between
Iran and any other parties, and any additional materials
related thereto, including annexes, appendices, codicils,
side agreements, implementing materials, documents, and
guidance, technical or other understandings, and any related
agreements, whether entered into or implemented prior to the
agreement or to be entered into or implemented in the future.
“(2) Appropriate congressional committees.–The term
`appropriate congressional committees’ means the Committee on
Finance, the Committee on Banking, Housing, and Urban
Affairs, the Select Committee on Intelligence, and the
Committee on Foreign Relations of the Senate and the
Committee on Ways and Means, the Committee on Financial
Services, the Permanent Select Committee on Intelligence, and
the Committee on Foreign Affairs of the House of
Representatives.
“(3) Appropriate congressional committees and
leadership.–The term `appropriate congressional committees
and leadership’ means the Committee on Finance, the Committee
on Banking, Housing, and Urban Affairs, the Select Committee
on Intelligence, and the Committee on Foreign Relations, and
the Majority and Minority Leaders of the Senate and the
Committee on Ways and Means, the Committee on Financial
Services, the Permanent Select Committee on Intelligence, and
the Committee on Foreign Affairs, and the Speaker, Majority
Leader, and Minority Leader of the House of Representatives.
“(4) Iranian financial institution.–The term `Iranian
financial institution’ has the meaning given the term in
section 104A(d) of the Comprehensive Iran Sanctions,
Accountability, and Divestment Act of 2010 (22 U.S.C.
8513b(d)).
“(5) Joint plan of action.–The term `Joint Plan of
Action’ means the Joint Plan of Action, signed at Geneva
November 24, 2013, by Iran and by France, Germany, the
Russian Federation, the People’s Republic of China, the
United Kingdom, and the United States, and all implementing
materials and agreements related to the Joint Plan of Action,
including the technical understandings reached on January 12,
2014, the extension thereto agreed to on July 18, 2014, the
extension agreed to on November 24, 2014, and any materially
identical extension that is agreed to on or after the date of
the enactment of the Iran Nuclear Agreement Review Act of
2015.
“(6) EU-iran joint statement.–The term `EU-Iran Joint
Statement’ means only the Joint Statement by EU High
Representative Federica Mogherini and Iranian Foreign
Minister Javad Zarif made on April 2, 2015, at Lausanne,
Switzerland.
“(7) Material breach.–The term `material breach’ means,
with respect to an agreement described in subsection (a), any
breach

[[Page S2412]]

of the agreement, or in the case of non-binding commitments,
any failure to perform those commitments, that
substantially–
“(A) benefits Iran’s nuclear program;
“(B) decreases the amount of time required by Iran to
achieve a nuclear weapon; or
“(C) deviates from or undermines the purposes of such
agreement.
“(8) Noncompliance defined.–The term `noncompliance’
means any departure from the terms of an agreement described
in subsection (a) that is not a material breach.
“(9) P5+1 countries.–The term `P5+1 countries’ means the
United States, France, the Russian Federation, the People’s
Republic of China, the United Kingdom, and Germany.
“(10) United states person.–The term `United States
person’ has the meaning given that term in section 101 of the
Comprehensive Iran Sanctions, Accountability, and Divestment
Act of 2010 (22 U.S.C. 8511).”.
______

via S.Amdt.1140 to H.R.1191 – 114th Congress (2015-2016) – Amendment Text | Congress.gov | Library of Congress.

Regulate anti-vaccine docs?

We may not ever solve the problem of an irresponsible tabloid press and sensation-seeking media, since the freedom of speech is too important to infringe.  But we do have power over those we license as physicians.

Dr. Walt Larimore enters the vaccine debate in his blog, not by suggesting forced vaccination, only the regulation of physicians. I wouldn’t support the recommendation without some leeway — I’m certainly not going to approve of every vaccine without a time trial in this very diverse lab that is the United States.

However, Dr. Larimore and his guest author, Dr. Russell C. Libby, are right to raise the ethical and medic0-legal responsibility of physicians who are licensed by the State and who advocate against good science and medical standards.

From the article:

“State medical boards must decide if the actions of healthcare practitioners who advocate against vaccination and undermine the public health efforts of their communities warrant investigation and intervention. There are a number physicians and other licensed healthcare professionals who trivialize and discourage immunization, whether it be for philosophical, financial, or self-promotional reasons.

“When the patients they influence contract preventable disease and have bad outcomes or they cause the spread to a vulnerable population, they should be held liable for malpractice. If it is in the midst of an outbreak or epidemic, medical boards need to sanction or suspend licenses.”

 

I’ve spent quite a bit of time — especially over the last week – attempting to educate interested people (including a family member) about the safety and usefulness or efficacy of vaccines.  My motto for these arguments has always been that, “Truth will out,” and, “If we’re right, we should be able to teach and convince.”

However, within the last week, an irresponsible Texas radio host trotted out the discredited and un-licensed doctor who fabricated the MMR/autism fraud and a Canadian newspaper published a hit piece on Gardasil. (You can find them easily on Google – I won’t give them “hits” from my page.)

When licensed physicians – men and women who should know better – spread demonstrable lies, even after being found guilty of fraud or when demonstrably spreading harmful misinformation, there should be consequences.

Boards of Family Medicine and Pediatrics in Collusion?

You’ve got to see this! From the blog, rebel.md:

“The same boards that treat doctors like criminals during our “secure board examinations” blatantly copy each other’s press releases. They’re more than “fellow members of the community of medical boards”, they’re in collusion against their own diplomats. Each board claims they are independently responding to their individual specialties, but they are clearly well-organized as a single entity against us. I’m not sure what the CEO of the ABP does for that $1.2 million salary, but writing original press releases doesn’t appear to be within his scope.”

You’ve heard it said that Doc So-and-So is “Board Certified,” right? That means that he (or she) has taken a test or two – the Board exams for his (- assume I’ve said, “or she,” from now on) specialty  – and maintains a certain level of credentialing and Continuing Medical Education (CME). While not mandated by law, in many cases, it’s a necessary hoop through which to jump if a doc plans to get hospital privileges or insurance contracts.

For Family Physicians, that used to mean that we took 50 hours of CME each year and re-took our Boards each 6 or 7 years. (The “security” around those “secure board examinations” became so onerous that I was fingerprinted several times on the day I took my third set: Once on entry to the exam room, once when I returned from lunch and then when I returned from a trip to the bathroom. They graciously supplied facial tissues, since we weren’t allowed to bring in our own into the room. In fact, we were required to place purses, wallets, etc., in a locker during the exams!)

Over the last 7 or so years, the American Board of Family Physicians has phased in a convoluted system of make-work and extra tests to assure our “Maintenance of Certification” or “MOC.” (Believe it or not, that’s a trademarked name, belonging to the American Board of Medical Specialties, the overlord of all Certifications.) It’s expensive and time consuming and frankly, is of no practical use other than as a source of the CME, which we were getting anyway.  That didn’t stop the Boards from attempting to convince the Feds that our licenses and/or pay should be tied to their certification.

And the profit is a big deal. MOC is a great source of revenue for the Boards, which used to only receive our $1000 or so when we took the Boards. Now, they make much more.  In 2010 (according to the latest tax form I can find), the ABFM took in $24Million from family docs, paid the President of the Board just shy of $800,000, socked away $12M in “excess” revenue, and has over $72 M in assets. Family docs who work hard don’t earn 1/4 of what Dr. Puffer is paid.

Many of us refuse to play any more. When I resigned from the American Academy of Family Physicians, I decided to drop the pretense of Board Certification, also.  The MOC process was impossible for my practice as a locum tenens, working in other doc’s offices.

And I’m not alone in my dissent. See Dr. Charles Kroll’s video on the corruption within the American Board of Internal Medicine (ABIM), here,  and the letter from Dr. David D Fitzpatrick at the Authentic Medicine blog.

Well, the ABIM, unlike the ABFM which jumped on MOC before all the other specialties, sort of heard its members and has pledged to hold its fees stable (and struggle along on $43 Million a year in revenues) and delay a couple of requirements. The ABIM even apologized!

Well (again), the ABFM and the American Board of Pediatrics  (ABP) certainly heard that! And they evidently were in the same meeting when it happened. How else to explain the fact that each sent out nearly identical letters to their members, including 120 matching words in phrases from 9 to 31 words long?

Plagiarism?

“How Government Killed the Medical Profession”

Contrast the Hippocratic ethic in which a physician recommends treatment to his patient, based on his best medical judgement in the patient’s interest, with that of the “veterinary ethic,” where decisions are made by the “payor” — or owner. Now, consider the effect of Government regulations which arbitrarily force doctors to learn protocols and guidelines (rather than adjust to the patient’s course of illness), to fit a patient’s illness into International Clinical Diagnoses (out to the nth decimal place) and which withhold payment when a patient becomes ill enough to need readmission to the hospital within 30 days of the last admission.

In an article published online by Cato, Dr. Jeffery Singer lays out the history of the destruction of Medicine as  a profession. In the past, Dr. Singer described the ethical transition toward the “veterinary ethic.”

Each of these articles is worth your time and consideration. The first article gives one of the best explanations of the Government move to “coding” of medical diagnoses in exchange for payment “reimbursement,” on through the forced move to Electronic Medical Records without evidence that patients will benefit and Accountable Care Organizations which assign patients to employee “providers.” The second, earlier article, reviewed the necessary change in medical ethics to allow doctors to practice without – or in contradiction to – their conscience.

Forget patient autonomy, long elevated by the lawmakers, lawyers and  Ph.D’s (in the name of “Bioethics”) above the traditional physician Hippocratic values of beneficence and its foundation, non-maleficence. In the world of Government medicine, your life is in the hands of the “payor:” the Golden Rule of “He who has the gold makes the rules.”

NEJM admits “ObamaCare” isn’t “Affordable” without subsidies

The New England Journal of Medicine has some free articles you might want to read this week. (I’m afraid you will have to register – will you let me know if you do?)
The first asserts that we’re stuck with ObamaCare – but it calls ObamaCare, “ObamaCare.” The author, Jonathan Oberlander, Ph.D, also acknowledges that the only way the ACA (the Affordable Care Act) is “Affordable” is if the Federal government hands out cash subsidies. In fact, if the Supreme Court rules that the language of the law forbids subsidies in States that don’t have their own exchanges,

Here’s an excerpt:
“The calendar cannot be turned back to 2009. The ACA has made some irreversible changes in U.S. health care.

“Even if they have unified control of the federal government in 2017, Republicans will confront the reality that Obamacare has redefined U.S. health policy and the terms of the debate. In practice, future repeal legislation would probably not scrap the whole ACA, but rather remove specific provisions and remake other policies to conform to a more conservative vision. A Republican President could, through waivers and other means, undermine Obamacare in important ways, but he or she could not eliminate it.

“The Supreme Court’s decision to hear a case (King v. Burwell) challenging the legality of providing premium subsidies in federal exchanges is crucial to the GOP precisely because the chances for legislative repeal of Obamacare are so remote. The Court can seriously damage the ACA in a way that congressional Republicans cannot. A decision to prohibit subsidies for helping the uninsured to purchase coverage in the 34 states that have federally run exchanges would destabilize the health insurance marketplaces and unravel the individual and employer mandates in those states, exacerbating the already large disparities in insurance coverage among states. It would cause both a sizable increase in the uninsured population and sizable losses for the insurance industry and medical care providers as millions of Americans lost their health coverage.  Such a ruling could, in turn, produce enormous pressures on affected states and Congress to adopt measures to stave off those outcomes. Yet the ACA’s shaky political foundations would complicate policymakers’ responses, and Obamacare’s opponents would be emboldened to resist any fixes. A ruling against federal subsidies could have a spillover effect, dampening the chances for Medicaid expansion in some states.“ (Emphasis mine)

 

The ACA appears to be on track to destroy the financing of health care in our country, whether or not it is fully implemented.

Dreams of 2017

What “executive priorities” would you like to see implemented by Executive Order of the new Republican President, beginning January 20, 2017?

Even as a “dream,” it’s not easy to write all this. It’s easy to see the objections and possible pitfalls. I need help. I suggest not enforcing any law that can’t be justified in 2 to 3  sentences, using “Life, liberty and the pursuit of happiness” and a plain reading of the Constitution and the Bill of Rights. No “penumbras,” no nuances. Make it plain and transparent enough that even Gruber’s criteria of  “the stupidity of the American voters” is met.

Same 90 day deadline Obama set for his immigration fiat?

Here’s a short list:

• Close the border.  Should we deport the “over-stayers” and those on Obama’s “deferment” lists?
• The IRS should phase out, shut down, beginning with Obamacare enforcement.
• The Secret Service will limit it’s scope to protection of dignitaries.
• Tell the EPA, OSHA, EEOC, HHS, Education Energy and others to plan on shutting down as States take over their functions – the way the States want to do those functions.
• Foreign aid should be held until Congress makes new, individual appropriations.
• Any aide that goes to abortion-favorable services stops immediately.
• ?????

The Ethics of Quarantine

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.–That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed . . .”

Yes, I’m using the Declaration of Independence to explain the ethics of quarantine. In fact, I suggest that the inalienable rights to life, liberty and “the pursuit of happiness” actually requires that a “just government” quarantine people who endanger the life of others, while doing as much as possible to preserve the rights of those who are quarantined.
The threat of the Ebola virus has spurred the discussion about quarantine in the United States, due to the high mortality rate of the disease. We’ve forgotten the quarantines of the past and most people are unaware of the existence of Presidential Executive Orders concerning formal lists of “Quarantinable Diseases.”
Inalienable or fundamental rights are negative rights. Consider the proverb that “Your (inalienable) right to swing your fist ends at my nose.”
Negative rights are limited to prohibiting action, in contrast to positive rights, which would force others to act for our benefit. That means that we have the right not to be killed, enslaved, or coerced into acts by others – you have the right to swing that fist as long as you don’t hit anyone else by intention or accident.

However, when a third party’s action or negligence threatens to infringe on our fundamental rights we have the right to protect ourselves and our fellow citizens, in the form of government, have a duty to assist us.
This protection should involve the use of the least force possible, for the least time possible, and we must take care not to become guilty ourselves of unnecessarily infringing the inalienable rights of others by abusing the government enforcement of quarantine. When government acts to limit the liberty of people by quarantine, it is imperative to ensure that there is a real threat to the lives of others, to limit the time of quarantine to the time the person is a possible threat, and to protect the lives of those people by providing food, shelter and medical assistance for those who can’t provide for themselves.
Not only is it ethical to implement restrictions on people coming to this country from areas where the disease is epidemic, it is the duty of government to protect the right to life of our citizens by implementing procedures for involuntary quarantine within our borders.

Fifth Circuit upholds Texas abortion regulations (HB 2)

Here’s a link to the ruling https://www.texasallianceforlife.org/wp-content/uploads/HB2-Stay-Ruling-CLEAN.pdf

Unfortunately, the Court allowed the El Paso abortion business to stay open, even though currently half of women seeking abortion travel to near-by New Mexico abortion businesses. Those women who go to the El Paso business will not have the protections guaranteed other women in Texas:

  “Because of the long distance between El Paso and the nearest in-state abortion clinic, as well as the doubt that Jackson casts on whether we may
look to out-of-state clinics, the State has not shown a strong likelihood of success on the merits of the challenge to the physical plant requirements of
the ambulatory surgical center provision as applied to El Paso. Thus, the district court’s injunction of the physical plant requirements of the ambulatory surgical provision will remain in force for El Paso.”(Page 29)

Hopefully, women (and men) will protect themselves from unintended pregnancies now that more travel is involved to reach the abortion business sites.

If there is a market for the abortion businesses in other areas of the State, they will adapt. And Texas will prove whether or not there’s that market.

The Insider – FeatureID 383

Read this article for a history (you probably don’t know about)  of the many attempts and failures in healthcare reform over the last 20+ years.

In 2001, Rep. Bill Thomas (R-Calif.), chair of the House Ways and Means Committee, brought a tax credit bill to the House floor and passed it over objections of congressional liberals favoring Medicaid expansion. In the Senate, however, Majority Leader Tom Daschle (D-S.D.) blocked the tax credit bill twice. Nonetheless, as a political matter, conservatives were playing offense on health care policy for the first time in memory. While small, the proposal was a psychological victory for those who wanted to fix health care with more free markets.

via The Insider – FeatureID 383.

AJC: Julio Jones Received Experimental Stem Cell Procedure On Ankle – The Falcoholic

A slightly tongue-in-cheek report about autologous stem cell therapy for an athlete:

Only three years ago Peyton Manning underwent stem cell therapy, a procedure so successful his neck is now strong enough to hold up a crippling Super Bowl loss. According to D. Orlando Ledbetter of the Atlanta Journal-Constitution, Falcons wide receiver Julio Jones received a similar, experimental procedure.

via AJC: Julio Jones Received Experimental Stem Cell Procedure On Ankle – The Falcoholic.

(Here’s a free site with that info on Jones – BBN edit.)

These therapies really are experimental at this point. However, veterinarians have been treating animals with their own stem cells for years.

The bone marrow cells for a bone injury seem less extreme than using fat stem cells that may not be functionally identified by the researchers.

I’m watching and have high hopes for the future, though!

I say “fertilization,” you say “conception”

Forty years ago the words “fertilization” and “conception” meant the same thing to doctors, lawyers, and embryologists alike: the joining of the 23 chromosomes in the sperm with the 23 chromosomes in the oocyte (“egg”) to form a new complete, unique human organism. “Contraception” was defined as any method that worked before the existence of the embryo by preventing fertilization. These were the hormonal treatments and devices that prevent ovulation of the egg and condoms, diaphragms and sterilization that serve as “barriers” between the sperm and egg.   Drugs and devices that may or may not end the life of the embryo after fertilization were legally and correctly called “abortifacients.”

However, legalized abortion and the ability to accomplish fertilization through in vitro methods led to new legal definitions of “pregnancy” and “conception” as beginning at implantation rather than fertilization.   Even in vivo, healthy human embryos in healthy mothers were deprived of legal protection as human beings for at least the first 5 – 10 days of their lives, the window of opportunity for implantation when the developing embryo grows to hundreds of cells organized in 2 or 3 recognizable tissue layers and interact with the mother’s body in ways that may affect the timing of birth or risk of diabetes and other health concerns. Possible abortifacients that work after fertilization but before implantation were redefined as “emergency contraception.”

In spite of what you may have heard on the news, the June 30, 2014 Burwell v. Hobby Lobby decision by the Supreme Court of the United States (SCOTUS) didn’t deny birth control for anyone. Everyone may still purchase his or her own FDA-approved birth control.  SCOTUS simply ruled that the government can’t force some employers to buy things that they believe are immoral.

In fact, Hobby Lobby only asked to be exempt from purchasing insurance plans that paid for specific drugs and devices used for “emergency contraception.” Before the passage of the Affordable Care Act (“ObamaCare” or ACA), the company purchased insurance that included true forms of contraception, including,

• Those that prevent ovulation by preventing the normal ups and downs of the hormones estrogen and progesterone, such asBirth-control pills with estrogen and progestin (“Combined Pill”),Birth-control pills with progestin alone (“The Mini Pill”),Birth control pills (extended/continuous use), Contraceptive patches, Contraceptive rings,Progestin injections, andImplantable rods

and

• Those that act as “barriers” to fertilization by preventing the union of sperm and egg: Male condoms, Female condoms, Diaphragms with spermicide, Sponges with spermicide, Cervical caps with spermicide, Spermicide alone, Vasectomies, Female sterilization surgeries, and Female sterilization implants.

The problem is that regulations written by the Obama Administration mandated that all insurances pay for all pregnancy “preventatives” approved by the FDA, including drugs and devices that may function after fertilization to end the life of the new human embryo:

• Pills that mainly delay ovulation but may impair implantation and development of the placenta if fertilization takes place, such as over-the-counter Plan B and generic levonorgestrel tablets, and ella, which requires a prescription, and
• Devices that mechanically and hormonally make the uterus inhospitable to implantation by the embryo, such as intrauterine devices like the copper-T, Mirena, and ParaGuard. These are inserted up to 5 days after unprotected intercourse to prevent implantation and then left in place to prevent fertilization and implantation for as long as 5-10 years.

Although the words we use do not change the fact that the human embryo is the same human life before implantation as after, they can change his or her legal status.