Commentary Health Systems

Competing Rights: Exploring the Boundaries of ‘Conscientious Objection’

Wendy Chavkin

Earlier this month, Joyce Arthur and Christian Fiala argued in a piece for Rewire that clinicians should not be permitted to claim "conscientious objection" as grounds for refusing to provide abortion or contraception, taking issue with any tolerance of it. Global Doctors for Choice thinks differently on both philosophic and strategic grounds.

Earlier this month, Joyce Arthur and Christian Fiala argued in a piece for Rewire that clinicians should not be permitted to claim “conscientious objection” as grounds for refusing to provide abortion or contraception. They take issue with any tolerance of conscientious objection as expressed by Global Doctors for Choice in a white paper, and by the other authors of a set of articles published in the December special issue of the International Journal of Gynecology and Obstetrics. Global Doctors for Choice thinks differently on both philosophic and strategic grounds.

We are all concerned that conscience-based refusal to provide contested components of reproductive health care exacerbates limited access to such care and thus threatens women’s health and rights. Where we differ with Arthur and Fiala is in our analysis of the issues at stake. We believe that there are competing rights here, and that resolution of such tension is primarily a societal, not individual, responsibility. We also differ in our pragmatic assessment of how best to proceed.

From the human rights perspective, we see the ability to exercise conscience as fundamental to individual integrity. In fact, allegiance to this principle undergirds our collective defense of the individual woman’s right to autonomy in reproductive decision-making. The international and human rights covenants cited all concur that the individual’s right to hold and manifest beliefs and religion are essential, and subject only to limitations necessary to protect the fundamental rights of others. International and national professional associations have similarly defended the individual clinician’s right of conscience while also asserting that it should be circumscribed by the primary duty to the patient, including requirements to disclose, refer, and impart accurate information, and provide care in cases of emergency.

The obvious tension here is when the rights of individuals collide: the objecting clinician’s right to refuse, another clinician’s conscience-based commitment to providing that care, the woman’s right to follow through on her conscientiously chosen course of action. In a secular society, we consider it the state’s responsibility to negotiate the boundaries of these competing rights. This means that the health-care system is obligated to assure that all patients have access to legal services and thus to implement systems for oversight, staff, and resource allocation in order to make that a reality.

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We do have areas of agreement: that conscience-based refusal to provide specific elements of reproductive health care is a topic of concern, because in some contexts it aggravates limited access to needed health services and thus most threatens the health and rights of those with least access to care. As described in thwhite paper, conscientious objection too often is ill defined, unregulated, and inconsistently practiced. The white paper examines conscientious objection to prenatal diagnosis, assisted reproductive technologies, care of ill pregnant women, care in cases of inevitable spontaneous abortion, as well as to induced abortion and contraception. However, reproductive health care is not the only area of medicine affected, as end-of-life palliative care and hematologic/oncologic and other treatments involving stem-cell therapies are other areas of medicine where conscientious objection has been invoked. Nor are physicians the only group claiming this right, as nurses, midwives, and pharmacists have invoked it as well.

We also concur that we should collectively think through whether health care has unique features that distinguish it from other domains where conscientious objection is invoked. Some argue that state licensure gives clinicians a monopoly over essential universally needed services and thus confers a special level of obligation. The white paper outlines a range of regulatory efforts by health systems and professional organizations such as requiring registration, specifying performance of abortion as a job criterion, or conditioning specialty certification on proficiency in all components of care. Again, we agree that health-care institutions have an obligation to provide all components of care and to define the limits of refusal as outlined above, but we disagree about whether that obligation rests primarily at the practitioner or the institutional level.

This brings us to the strategic and pragmatic. Definition, oversight, and enforcement of regulations on conscientious objection in health care are rarities, limited mostly to a few European countries. The white paper reviews the evidence about the patchy nature of monitoring and regulation in most of the world and highlights the practical difficulties in advancing such systemic supervision and responsibility.

Moreover, health systems officials and studies report that many clinicians do not fully understand the concept of conscientious objection and might provide at least some of the components of sexual and reproductive health care if other systemic supports were in place. They argue that provider attitudes are often fluid and that it would be most useful to concentrate on educating them about the law, patients’ rights, providers’ obligations, and teaching technical skills. Global Doctors for Choice considers this type of engagement with clinicians and health systems a key strategic approach; we appeal to clinicians’ primary fiduciary duty to patients and their aspirations to provide care in keeping with the highest professional ethical and evidence-based standards.

Given the messiness, limited infrastructure, and lack of consensus characterizing the real world, how would the ban proposed by Arthur and Fiala be implemented? Would such a ban advance our shared overarching goal of providing good access to high-quality sexual and reproductive health care for all? Might it have the inadvertent consequence of worsening access by hardening the opposition of those who might be incrementally persuaded to provide these services?

We consider these to be thorny issues as conscience, integrity, and autonomy are critically important to all the players involved—to those refusing, to those providing, and to those seeking reproductive health care. We think it useful to broaden the frame beyond the individual and charge pluralistic diverse societies with the task of honoring dissent while limiting its negative impact on others.

Commentary Politics

On Immigration, Major Political Parties Can’t Seem to Agree on What’s ‘Un-American’

Tina Vasquez

As far as immigration is concerned, neither the Democrats nor Republicans are without their faults, though positions taken at the conventions were clearly more extreme in one case than the other.

Read more of our coverage of the Democratic National Convention here.

Immigration has been one of the country’s most contentious political topics and, not surprisingly, is now a primary focus of this election. But no matter how you feel about the subject, this is a nation of immigrants in search of “el sueño Americano,” as Karla Ortiz reminded us on the first night of the Democratic National Convention (DNC). Ortiz, the 11-year-old daughter of two undocumented parents, appeared in a Hillary Clinton campaign ad earlier this year expressing fear that her parents would be deported. Standing next to her mother on the DNC stage, the young girl told the crowd that she is an American who wants to become a lawyer to help families like hers.

It was a powerful way to kick-start the week, suggesting to viewers Democrats were taking a radically different approach to immigration than the Republican National Convention (RNC). While the RNC made undocumented immigrants the scapegoats for a variety of social ills, from U.S. unemployment to terrorism, the DNC chose to highlight the contributions of immigrants: the U.S. citizen daughter of undocumented parents, the undocumented college graduate, the children of immigrants who went into politics. Yet, even the stories shared at the DNC were too tidy and palatable, focusing on “acceptable” immigrant narratives. There were no mixed-status families discussing their deported parents, for example.

As far as immigration is concerned, neither the Democrats nor Republicans are without their faults, though positions taken at the conventions were clearly more extreme in one case than the other. By the end of two weeks, viewers may not have known whether to blame immigrants for taking their jobs or to befriend their hardworking immigrant neighbors. For the undocumented immigrants watching the conventions, the message, however, was clear: Both parties have a lot of work to do when it comes to humanizing their communities.  

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“No Business Being in This Country”

For context, Republican presidential nominee Donald Trump and his running mate Mike Pence are the decidedly anti-immigrant ticket. From the beginning, Trump’s campaign has been overrun by anti-immigrant rhetoric, from calling Mexicans “rapists” and “killers” to calling for a ban on Muslim immigration. And as of July 24, Trump’s proposed ban now includes people from countries “compromised by terrorism” who will not be allowed to enter the United States, including anyone from France.

So, it should come as no surprise that the first night of the RNC, which had the theme of “Make America Safe Again,” preyed on American fears of the “other.” In this case: undocumented immigrants who, as Julianne Hing wrote for the Nation, “aren’t just drug dealers and rapists anymorenow they’re murderers, too.”

Night one of the RNC featured not one but three speakers whose children were killed by undocumented immigrants. “They’re just three brave representatives of many thousands who have suffered so gravely,” Trump said at the convention. “Of all my travels in this country, nothing has affected me more, nothing even close I have to tell you, than the time I have spent with the mothers and fathers who have lost their children to violence spilling across our borders, which we can solve. We have to solve it.”

Billed as “immigration reform advocates,” grieving parents like Mary Ann Mendoza called her son’s killer, who had resided in the United States for 20 years before the drunk driving accident that ended her police officer son’s life, an “illegal immigrant” who “had no business being in this country.”

It seemed exploitative and felt all too common. Drunk driving deaths are tragically common and have nothing to do with immigration, but it is easier to demonize undocumented immigrants than it is to address the nation’s broken immigration system and the conditions that are separating people from their countries of originconditions to which the United States has contributed. Trump has spent months intentionally and disingenuously pushing narratives that undocumented immigrants are hurting and exploiting the United States, rather than attempting to get to the root of these issues. This was hammered home by Mendoza, who finished her speech saying that we have a system that cares more about “illegals” than Americans, and that a vote for Hillary “puts all of our children’s lives at risk.”

There was also Maricopa County Sheriff Joe Arpaio, a notorious racist whose department made a practice of racially profiling Latinos and was recently found to be in civil contempt of court for “repeatedly and knowingly” disobeying orders to cease policing tactics against Latinos, NPR reported.

Like Mendoza, Arpaio told the RNC crowd that the immigration system “puts the needs of other nations ahead of ours” and that “we are more concerned with the rights of ‘illegal aliens’ and criminals than we are with protecting our own country.” The sheriff asserted that he was at the RNC because he was distinctly qualified to discuss the “dangers of illegal immigration,” as someone who has lived on both sides of the border.

“We have terrorists coming in over our border, infiltrating our communities, and causing massive destruction and mayhem,” Arpaio said. “We have criminals penetrating our weak border security systems and committing serious crimes.”

Broadly, the takeaway from the RNC and the GOP nominee himself is that undocumented immigrants are terrorists who are taking American jobs and lives. “Trump leaned on a tragic story of a young woman’s murder to prop up a generalized depiction of immigrants as menacing, homicidal animals ‘roaming freely to threaten peaceful citizens,’” Hing wrote for the Nation.

When accepting the nomination, Trump highlighted the story of Sarah Root of Nebraska, a 21-year-old who was killed in a drunk-driving accident by a 19-year-old undocumented immigrant.

“To this administration, [the Root family’s] amazing daughter was just one more American life that wasn’t worth protecting,” Trump said. “One more child to sacrifice on the altar of open borders.”

It should be noted that the information related to immigration that Trump provided in his RNC speech, which included the assertion that the federal government enables crime by not deporting more undocumented immigrants (despite deporting more undocumented immigrants than ever before in recent years), came from groups founded by John Tanton, a well-known nativist whom the Southern Poverty Law center referred to as “the racist architect of the modern anti-immigrant movement.”

“The Border Crossed Us”

From the get-go, it seemed the DNC set out to counter the dangerous, anti-immigrant rhetoric pushed at the RNC. Over and over again, Democrats like Congressional Hispanic Caucus Chair Rep. Linda Sánchez (D-CA) hit back hard against Trump, citing him by name and quoting him directly.

“Donald Trump believes that Mexican immigrants are murderers and rapists. But what about my parents, Donald?” Sánchez asked the crowd, standing next to her sister, Rep. Loretta Sánchez (D-CA). “They are the only parents in our nation’s 265-year history to send not one but two daughters to the United States Congress!”

Each speech from a Latino touched on immigration, glossing over the fact that immigration is not just a Latino issue. While the sentiments were positiveillustrating a community that is thriving, and providing a much-needed break from the RNC’s anti-immigrant rhetoricat the core of every speech were messages of assimilation and respectability politics.

Even in gutsier speeches from people like actress Eva Longoria, there was the need to assert that her family is American and that her father is a veteran. The actress said, “My family never crossed a border. The border crossed us.”

Whether intentional or not, the DNC divided immigrants into those who are acceptable, respectable, and worthy of citizenship, and those—invisible at the convention—who are not. “Border crossers” who do not identify as American, who do not learn English, who do not aspire to go to college or become an entrepreneur because basic survival is overwhelming enough, what about them? Do they deserve to be in detention? Do their families deserve to be ripped apart by deportation?

At the convention, Rep. Luis Gutiérrez (D-IL), a champion of immigration reform, said something seemingly innocuous that snapped into focus the problem with the Democrats’ immigration narrative.

“In her heart, Hillary Clinton’s dream for America is one where immigrants are allowed to come out of the shadows, get right with the law, pay their taxes, and not feel fear that their families are going to be ripped apart,” Gutiérrez said.

The Democratic Party is participating in an all-too-convenient erasure of the progress undocumented people have made through sheer force of will. Immigration has become a leading topic not because there are more people crossing the border (there aren’t) or because nativist Donald Trump decided to run for president, but because a segment of the population has been denied basic rights and has been fighting tooth and nail to save themselves, their families, and their communities.

Immigrants have been coming out of the shadows and as a result, are largely responsible for the few forms of relief undocumented communities now have, like Deferred Action for Childhood Arrivals, which allows certain undocumented immigrants who meet specific qualifications to receive a renewable two-year work permit and exemption from deportation. And “getting right with the law” is a joke at this point. The problem isn’t that immigrants are failing to adhere to immigration laws; the problem is immigration laws that are notoriously complicated and convoluted, and the system, which is so backlogged with cases that a judge sometimes has just seven minutes to determine an immigrant’s fate.

Becoming a U.S. citizen is also really expensive. There is a cap on how many people can immigrate from any given country in a year, and as Janell Ross explained at the Washington Post:

There are some countries, including Mexico, from where a worker with no special skills or a relative in the United States can apply and wait 23 years, according to the U.S. government’s own data. That’s right: There are people receiving visas right now in Mexico to immigrate to the United States who applied in 1993.

But getting back to Gutierrez’s quote: Undocumented immigrants do pay taxes, though their ability to contribute to our economy should not be the one point on which Democrats hang their hats in order to attract voters. And actually, undocumented people pay a lot of taxes—some $11.6 billion in state and local taxes last year, according to the Institute on Taxation and Economic Policy—while rarely benefiting from a majority of federal assistance programs since the administration of President Bill Clinton ended “welfare as we know it” in 1996.

If Democrats were being honest at their convention, we would have heard about their failure to end family detention, and they would have addressed that they too have a history of criminalizing undocumented immigrants.

The 1996 Antiterrorism and Effective Death Penalty Act and the 1996 Illegal Immigration Reform and Immigrant Responsibility Act, enacted under former President Clinton, have had the combined effect of dramatically increasing the number of immigrants in detention and expanding mandatory or indefinite detention of noncitizens ordered to be removed to countries that will not accept them, as the American Civil Liberties Union notes on its site. Clinton also passed the North American Free Trade Agreement, which economically devastated Mexican farmers, leading to their mass migration to the United States in search of work.

In 1990, then-Sen. Joe Biden introduced the Violence Against Women Act, which passed in 1994 and specifically excluded undocumented women for the first 19 of the law’s 22 years, and even now is only helpful if the victim of intimate partner abuse is a child, parent, or current/former spouse of a U.S. citizen or a permanent resident.

In addition, President Obama is called by immigrant rights advocates “deporter in chief,” having put into place a “deportation machine” that has sent more than two million migrants back to their country of origin, more than any president in history. New arrivals to the United States, such as the Central American asylum seekers coming to our border escaping gender-based violence, are treated with the same level of prioritization for removal as threats to our national security. The country’s approach to this humanitarian crisis has been raiding homes in the middle of the night and placing migrants in detention centers, which despite being rife with allegations of human rights abuses, are making private prison corporations millions in revenue.

How Are We Defining “Un-American”?

When writing about the Democratic Party, community organizer Rosa Clemente, the 2008 Green Party vice president candidate, said that she is afraid of Trump, “but not enough to be distracted from what we must do, which is to break the two-party system for good.”

This is an election like we’ve never seen before, and it would be disingenuous to imply that the party advocating for the demise of the undocumented population is on equal footing with the party advocating for the rights of certain immigrants whose narratives it finds acceptable. But this is a country where Republicans loudly—and with no consequence—espouse racist, xenophobic, and nativist beliefs while Democrats publicly voice support of migrants while quietly standing by policies that criminalize undocumented communities and lead to record numbers of deportations.

During two weeks of conventions, both sides declared theirs was the party that encapsulated what America was supposed to be, adhering to morals and values handed down from our forefathers. But ours is a country comprised of stolen land and built by slave labor where today, undocumented immigrants, the population most affected by unjust immigration laws and violent anti-immigrant rhetoric, don’t have the right to vote. It is becoming increasingly hard to tell if that is indeed “un-American” or deeply American.

News Politics

Tim Kaine Clarifies Position on Federal Funding for Abortion, Is ‘for the Hyde Amendment’

Ally Boguhn

The Democratic Party voiced its support for rolling back the restriction on federal funding for abortion care in its platform, which was voted through this week.

Sen. Tim Kaine (D-VA), Hillary Clinton’s running mate, clarified during an interview with CNN on Friday that he still supports the Hyde Amendment’s ban on federal funding for abortion care.

During Kaine’s appearance on New Day, host Alisyn Camerota asked the Democrat’s vice presidential nominee whether he was “for or against” the ban on funding for abortion. Kaine replied that he had “been for the Hyde Amendment,” adding “I haven’t changed my position on that.”

Robby Mook, Clinton’s campaign manager, told CNN on Sunday that Kaine had “said that he will stand with Secretary Clinton to defend a woman’s right to choose, to repeal the Hyde amendment.” Another Clinton spokesperson later clarified to the network that Kaine’s commitment had been “made privately.”

The Democratic Party voiced its support for rolling back the restriction on federal funding for abortion care in its platform, which was voted through this week.

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“We will continue to oppose—and seek to overturn—federal and state laws and policies that impede a woman’s access to abortion, including by repealing the Hyde Amendment,” reads the platform.

Kaine this month told the Weekly Standard that he was not aware that the party had put language outlining support for repealing Hyde into the platform, noting that he had “traditionally been a supporter of the Hyde amendment.”

Clinton has repeatedly said that she supports Hyde’s repeal, calling the abortion care restriction “hard to justify.”

Abortion rights advocates say that Hyde presents a major obstacle to abortion access in the United States.

“The Hyde amendment is a violent piece of legislation that keeps anyone on Medicaid from accessing healthcare and denies them full control over their lives,” Yamani Hernandez, executive director of the National Network of Abortion Funds, said in a statement. “Whether or not folks believe in the broken U.S. political system, we are all impacted by the policies that it produces. … Abortion access issues go well beyond insurance and the ability to pay, but removing the Hyde Amendment will take us light years closer to where we need to be.”