Many health care facilities in the United States are owned or operated by religious institutions. About twenty percent of all hospital beds in the United States are owned or controlled by the Catholic church. Religious health care facilities sometimes opt to give their religious authorities the final say over the provision of health care services. Religious restrictions on the provision of health care are enforced not only on hospitals, but also on HMOs, universities, and social services agencies, which provides a significant amount of care to poor and lower income communities.
Enforcing equal standards of care has been further hindered by an increase in the number of states with health provider conscience laws. Maryland is one of the states with a health provider conscience law. Both individual and institutional health care providers in Maryland can refuse to provide their customers with "artificial insemination, sterilization, or termination of pregnancy" [MD. CODE ANN., HEALTH-GEN. § 20-214].
The role of religious institutions in trying to restrict citizen access to health care options does not stop with conscience clauses. Some religious institutions object to allowing doctors to prescribe a fatal dose of barbiturates for the purpose of hastening the voluntary death of terminally ill people. For some people, their religious beliefs only make sense to them if length of life always takes priority over the quality of life. Other people think surviving as long as possible will sometimes be a misplaced goal for terminally ill people. The strength of the religious lobby in the U.S. ensures that the only way most states can pass and enforce a law to accommodate the latter people is by including a conscience clause to accommodate the former group of people who also work in health care.
An "End of Life Options Act" bill that would legalize physician assisted dying is expected to be introduced in the 2016 Maryland General Assembly session. Maryland patients and their families should be allowed to make their own health care decisions and need to be informed which health organizations and providers will refuse to honor their decisions. Concerns like this make statewide action on health care laws a priority.
Oregon has been collecting data on physician assisted dying for 21 years. Under Oregon’s law, every step of the process is in the hands of the patient, and those who interfere with or coerce the patient can face criminal prosecution. About 0.3% of deaths in Oregon are physician assisted. About one third of terminally ill patients who receive the barbiturates do not consume them. People with Lou Gehrig's disease (ALS) are the most likely to deliberately hasten their death with prescribed drugs. Loss of dignity, inability to enjoy life, and lack of autonomy, are the leading motives. Similar laws were enacted in Washington in 2008, Vermont in 2013, and California in 2015. The Montana Supreme Court legalized physician aid in dying there in 2009.
The provisions of the Maryland End of Life Options Act bill are expected to be similar to those in the other states. To qualify the patient must be diagnosed with a terminal illness with a prognosis of death within six months, be mentally competent, and be able to self-administer the drugs. The qualifying patient makes two oral requests to the prescribing physician separated by at least 15 days. A written request to the prescribing physician must be signed in the presence of two eyewitness, at least one of whom is not a relative. A prescribing and consulting physician must agree on diagnosis, prognosis, patient capability, and the patient lacking any psychiatric or psychological disorder that would impair judgement. Either doctor can refer the patient for psychological examination. The patient must be informed of alternatives by the prescribing physician (comfort care, hospice care, and pain control). The prescribing physician must talk privately with the patient to verify that the patient is freely opting to hastening their own death.
The current draft of the End of Life Options Act specifies that the death certificate identify cause of death as pharmacological accelerated imminent death. Some states allow death certificates to be issued without cause of death. Maryland lawmakers may want to consider enacting a law to publish death certificates without cause of death and to restrict access to the full death certificates containing cause of death. An option to omit cause of death helps to allay privacy concerns that may otherwise dissuade people from seeking physician aid in dying. The Department of Health and Mental Hygiene should be directed to publish a booklet that explains end of life options in Maryland.
To better protect the ability of patients to obtain appropriate health care there is also a need to enact a state law protecting patients’ right to know when a health care provider does not provide certain care based on religious or philosophical beliefs. Such a law could require any health care provider who refuses to follow standard medical guidelines and practices, thereby resulting in any health care options being omitted, to inform patients in writing of health care services that are not available to the patients through this particular provider. Patients could be required to provide signed consent acknowledging they have received this information. Additionally, this law could require health care providers to inform health insurance companies of the specific health care options that are not provided. Health insurance companies will share that information with their enrollees and insured participants.
Maryland's health provider conscience law should be amended to clarify that the clauses granting institutions a conscience right to refusal apply only when the institution is privately controlled. Also, health provider institutions should be allowed to mandate that their employees agree in their employment contracts to provide the medical procedures that the conscience laws otherwise render optional. Freedom of conscience is not a one way street that applies selectively only to the people who adopt one side of the two opposing sides. Whenever institutions objecting to some medical procedures can mandate refusal to provide them on freedom of conscience grounds it necessarily follows that institutions that support those same medical procedures have the corresponding right of conscience to mandate agreement to provide them.