Division in Rural America: Understanding the Difference Between Refusal to Treat Based on Medical Conscience Versus Discrimination and How to Overcome It
by
Melanie Kuder, PharmD, Alexander X. McMillen
and Sarah A. McMillen, PsyD.
Introduction
The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‑CoV‑2) pandemic has resulted in divisions within the country not only down political lines, but in many other areas, such as medical, social, religious, and interpersonal relationships. This paper will look at the impact of the pandemic on medical care in rural America. Specifically, the refusal to treat unvaccinated individuals when they present for emergency care. What happens when your local hospital refuses to treat unvaccinated people and the nearest regional hospital is over two hours away? What happens to those who are unable (physically or financially) to make this drive?
Rural care of SARS‑CoV‑2 has been unethically, purposefully, and politically manipulated by those trusted with the sanctity of life. This paper will provide an exploration of the Emergency Medical Treatment and Labor Act (EMTALA), how the guidelines on what constitutes adequate care have changed since the Centers for Medicare and Medicaid Services (CMS) issued a revision on March 30, 2020, the use of medical conscience as the right to refuse, and how the communities in Kansas have responded to this.
A recent White House briefing highlights the divisions seen across America. “If you are vaccinated, you could test positive. But if you do get COVID, your case will likely be asymptomatic or mild. We are intent on not letting Omicron disrupt work and school for the vaccinated. You’ve done the right thing, and we will get through this. For the unvaccinated, you’re looking at a winter of severe illness and death for yourselves, your families, and the hospitals you may soon overwhelm”1 (Emphasis added by author) Typically rural, conservative states are assumed to be cohesive in their beliefs and standings. However, there is an extreme division that exists currently. Healthcare professionals each have their own understanding of the situation which unfortunately is frequently driven by politics and media. Currently there is the threat from healthcare facilities that all workers must be vaccinated or they will lose their jobs due to fines from CMS. Many are being told no medical or religious exemption will be accepted. This is coming at a time when medical facilities are significantly understaffed and overworked. In Kansas, facilities that accept CMS funding have until February 13, 2022 to have ninety percent of their staff vaccinated.2
Responsibilities of Medical Professionals
The 68th World Medical Association General Assembly (2017) revised the Hippocratic Oath highlighting the autonomy and dignity of the patient. Included in the oath is the following:
AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient3 (Emphasis added by author)
The medical profession is founded on these principles to ensure there are no blurred lines when treating patients. Without them, a medical professional could decide on whom deserves treatment based on arbitrary principles. This could include not treating pedophiles, murderers, homeless, uninsured, unvaccinated, and anyone else who might deviate from the typical way of life or go against these arbitrary principles.
EMTALA
The right for an individual to receive emergency medical treatment is often assumed by society4. The development of the Emergency Medical Treatment and Labor Act (EMTALA) was enacted in 1986 by Congress to ensure this right. EMTALA is specifically for hospitals that participate in Medicare. When a person presents to an emergency department, the emergency department is required to provide appropriate medical screening by a qualified medical professional and utilize any ancillary services that are available to determine if there is an emergency medical condition. If the medical screening shows the person has a medical emergency, it is the duty of the medical professional to stabilize the patient or provide an appropriate transfer to another facility.5 The patient should not have the medical screening or stabilization delayed based on insurance or ability to pay. The participating hospital is required to provide the assessment and stabilization or risk fines for both the healthcare professional and the facility.6 Due to the pressures the pandemic has had on the healthcare system, in March 2020, CMS updated the requirements of what qualifies as appropriate treatment. This is referred to as 1135 waivers. The importance of these waivers is to allow more people to be treated by changing the definition of what determines a qualified treatment. This should not result in any real or perceived lack of access to care based on signage or posts or lack of qualified medical screening.7 The current changes now state that the medical screening is no longer required to occur in the emergency department but may occur at other locations. The waiver does not allow the hospital to display signage that would dissuade a patient from seeking services. It does not take away or lessen the standards of the medical screening. It does allow a patient who has not been medically stabilized to be transferred to a different hospital.8
Rural Responses
In one town in Kansas, some emergency department physicians have taken it upon themselves to limit care to only those who are fully vaccinated. This care does not even have to be for SARS‑CoV‑2 specific medical emergencies. These physicians have taken to social media to make their stance clear to everyone within the community and verbally attack unvaccinated patients who present for care. Caryn Tyson for State Treasurer of Kansas posted “It is heartbreaking and concerning that healthcare workers would post about tricking Republicans into getting vaccinated or an upside is that they will not be able to vote after they die. It should be up to each individual as to whether they get vaccinated. While these terrible and divisive posts do not reflect the vast majority of healthcare workers, it is deeply concerning seeing these posts.”9 See Figure 1
The result is the immediate screening for vaccination status upon presenting to the emergency department. Those who report being unvaccinated have then been turned away with no assessment or treatment by these same medical providers referred to by Caryn Tyson. This refusal to treat has resulted in several deaths. The public debate then revolves around “what makes one’s life have value?” The split is if one is unvaccinated, they do not deserve any medical care and are a direct threat to those who are vaccinated versus the belief that regardless of vaccination status, all individuals are deserving of medical care. The desire to treat regardless of what patient believes or who they are is the very essence of the oath taken by these medical providers. The medical providers claim they are following their beliefs by not providing care to the unvaccinated. This is similar to what occurred in the 1980’s where some physicians refused to treat marginalized populations.1011
A recent amendment proposed by Kansas State Senator Mark Steffen (who is also a physician) was voted down. The proposed amendment would have made it illegal for healthcare professionals to discriminate or refuse to treat a patient based on vaccination status.12 Dr. Johnathan Moreno is a medical ethics professor at the University of Pennsylvania. He pointed out that in the past, the medical field has chosen to perform behaviors that are technically legal but are immoral or unethical, such as refusing to treat based on race, sexual orientation, and other factors. Moreno emphasized the danger that is present when physicians begin deciding whom they will treat. This approach undermines the foundation of medicine.13
Caryn Tyson for State Treasurer
It is heartbreaking and concerning that healthcare workers would post about tricking Republicans into getting vaccinated or an upside is that they will not be able to vote after they die.
It should be up to each individual as to whether they get vaccinated.
While these terrible and divisive posts do not reflect the vast majority of healthcare workers, it is deeply concerning seeing these posts.
Figure 1. Facebook post sharing social media statements by ED medical professionals
Right of Conscience
Moral conscience is defined within the scope of three different lenses. Martin Benjamin outlines them as the following: a subjective, internal belief of right and wrong; a societal belief of right and wrong; or the relationship between the emotional impact of performing a behavior that goes against one’s ethical beliefs.14 The difference between these definitions is that the third definition is not based solely on a religious or personal belief. It also demonstrates the significant impact the action would have on the provider.
This is not the first time a debate has emerged over when and how a medical provider can execute their right to moral conscience. This debate tends to focus on the performance of reproductive services such as abortion or sterilization or regarding physicians participating in state-ordered executions. Patients seek out medical care assuming the medical provider will help regardless of the provider’s personal beliefs on the perceived worthiness of the patient. Numerous states have implemented protection concerning the rights of conscience in health care. These laws, however, are focused on specific medical procedures such as abortion. The Church Amendment enacted by Congress not only protected entities from being denied funding due to its stance on abortions, but also expanded into protecting medical students from being discriminated against based on their moral and religious beliefs on abortion. This was the first of several legislative actions regarding rights of conscience.15
Opposition to these rulings emerged prominently in 2008. A major argument against rights of conscience revolves around the fact that physicians are aware they may treat patients or provide services they do not agree with from the moment they begin their training. Julie Cantor stated “Conscientious objection makes sense with conscription, but it is worrisome when professionals who freely choose their field parse care and withhold information that patients need...”16 While her statement is regarding the participation of physicians in abortive procedures, her statement is even more applicable to the current state of affairs. While the decision to not provide abortive services are based on the fundamental moral and religious beliefs concerning life, the refusal to treat based on vaccination status is instead rooted in political disagreement, regardless of the patient’s reason for not being vaccinated.
Discrimination
Rural areas often lack alternative treatment options or only have treatment options that are owned by the same hospital system. The closest options are typically hours away. If someone is sick or does not have access to transportation, then there is no other viable option. The vulnerability of a patient by force circumstance does not extend medical providers a license for unjustifiable segregation, shunning, or abstention.
Margaret Little and Anne Lyerly stated “Core to medical communication is a fundamental asymmetry of knowledge between physician and patient; crucially, this is increased by a lack of knowledge on the patient’s part about what she does not know. Patients are thus not able to assess the import or implications of a clinician’s disclosure that there is information their conscience precludes them from sharing. Medical professionals do not have the right to curtail the patient’s knowledge or exploit its limits based on their moral worldviews.”17 In 2007, the American College of Obstetricians and Gynecologists stated that physicians are not allowed to deny care based on the right of conscience if this would ”constitute an imposition of religious or moral beliefs on patients”. 18 The refusal to treat and to withhold information on treatment options (i.e. monoclonal antibodies) available to unvaccinated patients in this Kansas community appears to be based on the perceived religious and political beliefs of the patient.19
The community response has been as divided as the medical community. This response is not limited to rural Kansas but is worldwide. A recent article in The Atlantic focused on the importance of not denying medical care to unvaccinated patients. Dr. Matt Wynia is quoted as stating “We don’t use the medical-care system as a way of meting out justice. We don’t use it to punish people for their social choices.”20 Dr. Sara Murray stated, “We have an ethical obligation to provide care for people regardless of the choices they made, and that stands true for our unvaccinated patients.”21 The article points out that people who are unvaccinated also tend to not have economic means and lack resources such as health insurance. Discrimination towards these communities would only compound the lack of resources they already experience. ”Vaccinated people might have low personal risk of severe illness, but they can still slingshot the virus to vulnerable people who then end up in hospitals. They might not be occupying emergency rooms with their bodies, but they can still help fill those rooms through their actions.”22
John Coggon, Professor of Law at the University of Bristol, reinforced the need to treat those who are unvaccinated. The refusal of the vaccine does not constitute the refusal of treatment. Denying treatment or making necessary treatment difficult – financially or regarding access – would be punitive and discriminatory.23 Important to note is continued referencing of not only providing treatment but also providing information regarding what treatment options are available. The Chief Medical Officer of Salina Regional Medical Center, Rob Freelove, in an interview with Kansas State Representative Clarke Sanders stated an adequate emergency room evaluation by a physician can be conducted in less than five minutes and without the physician needing to physically assess the patient.24 This was in follow-up to his admission that a patient was “treated” adequately after spending less than 15 minutes in the emergency department. This patient was driven by his family to another medical facility several hours away where he was immediately hospitalized and died.25
Community protests and rallies have been held outside community medical facilities protesting medical discrimination.26 There were several requests for news coverage of both the discrimination and the protests, which were either declined or ignored. Even when coverage was obtained, the interviews of the medical professionals regarding the discrimination they had seen were removed. This has led to the push for legislative help as well as higher levels of activism at both the local and state level.
Unfortunately, the consequences of making a public stand have had financial, social, and medical implications. Those who voiced their concerns within the medical systems have reported being threatened with the loss of their jobs, the threat of losing their license. Fear to the point they are afraid to reach out to even offer condolences to those who have lost loved ones.272829 Dr. Festus Krebs testified in front of the Senate Public Health and Welfare Committee on January 26, 2022, regarding the fear medical professionals experience regarding speaking out against what they see. ”Kansas providers are in total fear of losing their licenses, hospital privileges, and the means to support their families so they cannot show their faces here.”30
People needing basic and emergency medical care now must figure out how they are going to obtain these services. The fear of mistreatment or no treatment stops them from obtaining help in the community. A nurse currently employed at the local hospital reported the medical records for two patients who had made known their experience of being refused access to treatment based on vaccination status were shared in a department staff meeting. This department was not involved in any way with the events. The family of these individuals were also named in this meeting.31 One of the family members that was named stated she is fearful to use any provider connected to the healthcare system. She has had two life-threatening emergencies since she found out about this meeting and chose to risk traveling over 100 miles where she knew she would be treated.32 The closest regional medical center not affiliated with the local one is over two and half hours away. In response to hearing about the experiences patients are having, medical centers from other locations are began reaching out to offer treatment and support. These providers are also making it known on social media that offer treatment and welcome all patients.33 34
Recommendations
Regardless of one’s position on vaccinations, the current medical discrimination that exists is of great concern to everyone. It violates the Hippocratic oath, ethics, and laws alike. The lack of access to quality care, especially during an emergency, is causing a significant problem (and in some cases death) for many people.
Members of this community have joined together to oppose the vaccination discrimination. They are also focusing on other concerns. The main struggle that they are facing is the lack of organization and agreement on how to proceed. This leaves them focusing on many different concerns at one time with little progress in changing any of them. Organization on how to stand up and advocate change is essential.
Healthcare providers who are unafraid to voice the importance of care no matter vaccination status is imperative. A clear understanding of what constitutes adequate medical care needs to be established, particularly in an emergency setting. A patient cannot be adequately assessed, stabilized, and provided treatment options in an emergency department setting in less than 5 minutes. Facilities and providers who are willing to treat all patients need to make this known so patients are aware of safe places to seek treatment.
We need journalists who are willing to report on these issues. Media coverage will help bring this to light and hold those involved accountable. Those who voice their concerns should be able to do so without fear of retaliation. While there are many areas of concern that are being addressed, those that involve life threatening consequences should be addressed first. Clear legislature establishing the need for all healthcare providers to treat patients regardless of vaccination status needs to be passed and enforced.
The public needs to support the senators and representatives who are standing up for medical freedom. There needs to be clear support as well for the healthcare providers who are brave enough to testify about what is going on in the medical community. Healthcare providers who refuse to treat patients, particularly those in life and death situations, based solely on vaccination status should be met with significant consequences. These consequences should have both legal and professional implications. The lack of such consequences opens a door that will become exceedingly difficult to close. At what point will the public (and legal system) decide a life is worth saving? What must a person believe or do to be seen as worthy of life?
Page Break
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