Tag Archives: reproductive rights

Speech at Stop the War on Women Rally II, Huntsville, AL

text of my speech from rally on March 17, 2013, in case you missed us!

It seems like only a few weeks ago we were right here, joining together and ready to fight for a better Alabama.  Same beautiful spring weather.  Last year, we were successful in preventing a great many bad bills from passing—I think we caught Montgomery by surprise.


They weren’t expecting us last year.  This year, they were.  Now it seems they believe they can just do whatever they want to do.   They might even think we will give up, when we see how much power they have.  Will we give up?  No!  Because we’ve learned a few things also.  We’ve got power they’ve never even dreamed of.


We won’t give up because we know the truth about their agenda.  We won’t give up because we know silence leads to death.  We won’t give up because we know we have a duty to stand together, and that when any one of us is threatened by injustice, all of us are called to speak.


Some of our elected leaders say they want to make abortion safer.  The truth is that they want to close down the only remaining women’s health clinics that provide safe and legal abortion.  Because they can’t do that for real safety or legal reasons, they are twisting the law to suit themselves, using whatever arbitrary fire and sedation codes they think will work.  They are lying to the press, implying current clinic physicians are not licensed in our state.  Meanwhile, they are attempting to restrict abortion provider licenses to one community in the state, which has not been done for any other type of medical care.  No other doctors are required to have hospital privileges to practice outpatient medicine.


They say they want to protect freedom of religion and conscience, by allowing only one type of religion and conscience to override patient and employee rights.  I hope I don’t shock any of you by saying I’m more concerned with trying to learn how to love my neighbor better in the here and now than I am about the 10 Commandments—but I know the 10 Commandments.  I know them, and not one of them says “Thou shalt force your neighbor to do whatever you want her to do, by lying or intimidating or throwing her in prison.”  There is no 11th Commandment that says to be a bully or to punish or to steal another person’s free will.


It’s hard for me to believe they really want to decrease abortion, when at the same time they are throwing women in prison for NOT aborting.  In prison not for possession of drugs, but for the crime of being sick with addiction while pregnant and choosing to give birth to a baby.


It’s hard for me to believe they want women to carry a pregnancy to term and at the same time write bills to cut off their food stamps and Medicaid, pregnant or not, if they test positive for drugs.  It’s hard for me to believe they want families to have children at all, when they are steadily dismantling and defunding the services our children need to thrive, like schools and mental healthcare systems.


I don’t think any of this is about health, safety, freedom, religion, drugs, life, abortion or even about women.  I say it is all about power.  Women, especially women in poverty, seemed like a convenient target.  There are always people in the world who want to control others, just to show they can.


Lots of people are scared.  Scared to lose their jobs if they speak up, and it can happen—some of my friends have lost their jobs.  Scared of death threats.   I’m a pediatrician, and I can tell you some of my doctor friends are frightened.  Some ob-gyn doctors I know fear being killed if they tell the truth about women’s health.  Even some of our leaders are scared, and with good reason.  They’ve seen Alabama take political prisoners.


But we who are here today have chosen to be stronger than our fear.


I’d be wrong if I told you this next couple of years will be easy.  It won’t.  There are powerful people opposing us.  Things are probably going to get much harder than they are now.  We need to be ready.


What I do know is that their kind of power, the kind that depends on lying and twisting the facts and fear and prison is not REAL power—it is false power.  It cannot last.  Never in human history has that sort of power lasted.  It rises, and it falls, always.


There’s a different kind of power that DOES last, and we have it right here.  Let’s take just a moment to remember it.  If you have a cold or a health risk and should not hold hands, don’t— you might place your hands over your heart if you like.  You are still connected to the rest of us.  Everyone else, if you want to, reach out and take the hands of your neighbors.  Notice how you are connected to the earth here, connected to our state, connected to each other. You belong here, no matter who you are.  Now lift your hands up high.  Feel how strong we are, together.


This is our power, the power that can never be defeated—the power of truth, the power of respect, the power of inclusiveness, the power of connection, the power of community.  When false power has risen and has fallen, we will still be here, standing by each other. We know we are not alone.  The power of our community will prevail.


Filed under Alabama Legislative Session 2013, women's healthcare

Alabama HB 360: It’s Not About the Truth

Long before I entered medical school, physicians in the US were under no professional obligation to be truthful to patients.  They prescribed placebos, kept secrets from the dying, and made decisions without expecting or wanting input from patients.  The rules have changed—no more Dr. God, and thank goodness for that!


There is still a power imbalance though.  We have the almighty power of the prescription, the referral, and the scalpel.  Even more, we have the power of knowledge and experience our patients usually don’t possess.  That power carries enormous responsibility.  No matter how much my non-medical parents and patients read, they are in my exam room because they require my honest, best assessment of their health and my honest, best advice.


It is, therefore, absolutely critical that physicians attempt to avoid using knowledge manipulatively.


A legislator’s job is different.  Even the most sincere elected leader must construct convincing reasons for action, depending on what will resonate with voters.  Sometimes it’s the only way to get good policy through.  Like it or not, that’s politics!  HB 360 is an attempt to have physicians play politics, in the exam room, by giving women carefully selected information about abortion and leaving out what our legislators don’t like.


Here’s what they want women to be told, before consenting to abortion:


“Your chances of getting breast cancer are affected by your pregnancy history. If you have carried a pregnancy to term as a young woman, you may be less likely to get breast cancer in the future. However, you do not get the same protective effect if your pregnancy is ended by an abortion. The risk may be higher if your first pregnancy is aborted”; “If you have a family history of breast cancer or clinical findings of breast disease, you should seek medical advice from your physician before deciding whether to remain pregnant or have an abortion. It is always important to tell your doctor about your complete pregnancy history”; “Abortion terminates the life of a whole, separate, unique, living human being”; and “There are many public and private agencies willing and able to help you to carry your child to term, and to assist you and your child after your child is born, whether you choose to keep your child or place him or her for adoption. The State of Alabama strongly urges you to contact those agencies before making a final decision about abortion. The law requires that your physician or his or her agent give you the opportunity to call agencies like these before you undergo an abortion.”


The bill is full of problems, everything from calling a fetus a child to determining that “psychological” emergencies and suicide risks are not real.  It prohibits a woman from being coerced into abortion and in the next breath urges her to let pro-birth “counseling centers” coerce her into giving birth.  Of all the possible risks to disclose, it goes for the jugular—a woman’s fear of breast cancer—and repeats false information as well.  If the goal is to present risks, benefits and alternatives in an honest and non-coercive manner, HB 360 is unacceptable.


Here is a more honest version—bear in mind that I’m not an obstetrician and am not proposing this as legislation.  It is by no means comprehensive, and it has some editorializing at the end. You may have seen infection risks of 1 in 10 on some pro-birth sites—however, this is not the risk of upper tract infection and mainly reflects infections already present prior to the procedure.  There are also much higher quotes of “retained products of conception” in some studies—this may reflect excessive findings on ultrasound of uncertain clinical significance.  The correct way to get a standardized consent/ education form, if we need one, is to ask the Department of Public Health to create or select a reputable, updated version they can distribute to physicians.  But here goes:


“You are pregnant with an embryo or fetus which is incapable of living outside of your body.  The United States of America recognizes your right to a safe, legal termination of this pregnancy or a decision to continue the pregnancy and give birth to a baby.


The risk of breast cancer if you have an abortion is the same as if you never have a child.  If you are under twenty, giving birth can lower your risk of breast cancer.  If you are over thirty, giving birth for the first time can increase it.


Some of the health risks of pregnancy include intractable vomiting (0.5 to 2%), high blood pressure (2 to 3%), diabetes or impaired glucose regulation (3 to 10%), severe bleeding from placental abruption (0.4 to 1%),  rupture of your uterus (0.07%), and severe tears of your vagina and/or rectum (0.25%).


Risks of abortion include perforation of the uterus (0.009%), heavy bleeding (0.007%), infection (0.5%), a cervical tear (0.01%) and incomplete abortion (0.03%).


You have a risk of death from abortion of about 0.6 in 100,000.  The average risk of death from giving birth in the United States ranges from 12 to 15 in 100,000.


The average risk of major depression and other mental health problems after abortion is the same as for women in the general population.


If you are addicted to illegal substances, there is a chance you will go to prison if you decide to give birth.


If you continue your pregnancy, you may be instructed by your physician to reduce work hours or take bed rest, causing you to miss time from work.  The average risk of a cesarean section is about 32%.


If you give birth and decide to keep your baby, you should know that the average parent has lower income and higher expenses than a childless person.


There are families in our state who want to have children and cannot give birth to their own.  You may decide to take the physical, emotional and financial risks of giving birth out of compassion for one of those families.  However, you should be aware that the bonds between a parent and child are not easily disrupted and that you may experience chronic grief.  You have no duty to provide a child for another person.


Most women who have abortions already have children whose needs they must consider.  Others want to have children later, when they can plan ahead to take good care of them.  Abortion does not decrease your chance of being able to have healthy children later.


Being a parent is one of the most meaningful, joyful, difficult and life-changing experiences a human can have.  It requires great dedication, responsibility, self-sacrifice, and effort.  People who are willing to take the work of parenting seriously provide a critical service to humanity.  It is not a task to be entered into lightly.


If you live in Alabama, do not keep up with what your legislators are doing in Montgomery, and say nothing to change their minds, your risk of losing access to honest, safe, and legal reproductive care is high.”


We’ve asked our legislators not to play doctor—now we need to remind them not to make doctors play politician.  Y’all do your job, and let us do ours.


Filed under Alabama Legislative Session 2013, citizen responsibility, women's healthcare

Think Tank: About Laws and Lawmaking

Every so often, I get the irresistible urge to try and figure out why we do what we do and think what we think.  What about you?  Sometimes this happens on long drives during legislative sessions—I just returned from a 2 day advocacy meeting.  Between listening to the radio and practicing my yodeling, I had some ideas about laws—the purpose of laws, what makes them fail and what makes them work well.  I’m writing about it so I can remember my ideas and get some feedback from you.

My other purpose is to find some general principles, separate from partisanship and ideologies,which could be used as a starting point for conversations with those on an entirely different end of the political spectrum.  Even though, in the midst of a session, it feels like there isn’t time to step back and get a big picture look, we really don’t have time NOT to.  Under pressure, we get driven into our respective corners.  Nothing will change about that unless we can change our own thinking.

Let’s play think-tank and reinvent the wheel.  I’m quite sure all this has been much better thought out by people who actually study the law, but most voters are NOT legal experts!  I’ve done this exercise before, and my ideas have definitely changed over time.  Warning:  this is a LONG post.  Before you read on, maybe take a few minutes to jot down your own ideas about lawmaking or pull out your own blog posts about the same thing.  What do you see as the core myths about laws, their valid purposes, and why they succeed or fail?  What are your personal tests when you read a law? Please draw a line through any thought with a political party or label in it, just for today, and see what comes up instead.

First, I tried to think of some core myths about laws—ideas that are counter to the best evidence but which seem very sticky anyway.  Most of these have examples in policy championed by either of the main parties.  I gave up use of writing or speaking ideological political labels for Lent, just to see if that challenged me to think differently, and it has.  Here is my list—please help me add to it.

Myth #1: Carrots and Sticks work.  Don’t get me wrong—rewards and punishments DO have an effect.  They just don’t have quite the effect we expect them too, because humans are much more complicated than lab rats.  You don’t have to take my word for it—the evidence is abundant.  Read Daniel Pink’s excellent summary, Drive, for a primer.  In a nutshell, extrinsic motivators disrupt the system and misdirect our motives.  If punished, we often respond by getting sneakier, more fearful or angry, and less trusting—we learn to be driven by avoiding bad outcomes instead of aiming for a meaningful goal.  If a carrot is dangled in front of us, we might run towards it, but we consistently lose interest in the real goal the carrot was supposed to point us toward.  If I tell you “hey, eat all this pie and I’ll give you some candy”, your mind will automatically downgrade the pie—something is wrong with it if you must be rewarded for eating it.

I don’t know why we are like that.  Maybe because if we were lab rat-like, we would be far too easy to manipulate.  Our oppositional tendencies are not always a bad thing—we’ve evolved them for a reason. All I know is, every time I read about some new “incentive” devised for doctors to practice good medicine, it makes me want to bite somebody.

Pink proposes (and gives evidence for) three motivating factors that are more likely to get us towards a meaningful goal, which I’ll paraphrase: a sense of mastery/ accomplishment, a sense of making a social contribution, and a sense of some degree of autonomy/ personalization of the work done.  These come about intrinsically in the process of working.  Furthermore, when the worker has a subjective sense of being paid/ treated fairly, he/she tends to forget about the money part—unless carrots and sticks get thrown into the mix.  Then we start getting misdirected and the quality of work suffers.  A well known example is the No Child Left Behind disaster.

Myth #2The individual can be a free agent. In truth, there is really no such thing as an independent individual or the kind of ideal freedom some people dream of.  We are all affected, like it or not, by what other people do.  Even something as basic as the air we breathe is changed by the combined actions of those around us.  In a world with more than one person, some person or group is always going to get a degree of upper hand, a larger share of the power, and our freedom will be thus further restricted.  The choice isn’t exactly between government and the market—in the US, those two are getting merged more and more anyway.  The choices are more about how the power is distributed and what the counting system for that power is.  Do we count power only in money?  Do we count it in votes?  In muscle?  In number of guns? In brain-power? In family lineage? Some combination?  What sort of rights/ freedoms are we going to mutually agree to protect, and how far will we go to protect those?  At what level of proximity (individual, family, neighborhood, city, county, state, nation, world) should a given decision be made?  To make such decisions, we have to get over the belief that there is some ideal state in which no one would be able to control us.

This myth tends to rise up more, from what I can tell, when individuals feel un-counted in the power games—disenfranchised, if you will.  The converse is that the more buy-in a decision has, the more the sense of having contributed to it, and the less a need to protect one’s self by oppositional behavior.  Even with kids, this works—figure out how to get them to put in two cents to an agreement, and they will stand by it more often.  So when we hear groups getting panicked over threatened freedom, even when we don’t agree with the particular freedom they want, we need to listen—there is probably a real trigger to that panic which could affect the rest of us.

Myth #3:  We can be wholly rational.  Sorry, just doesn’t happen.  We are in the animal kingdom.  Our rational thought is only one element of decision making.  Some of the decisions we think we are making were made by our brains before we consciously took notice of them, and we confabulate our reasons after the fact.  It is not a reasonable goal to believe your rational cortex can learn constantly to overcome the other parts of your brain or body.  Without our emotions, intuitive thinking (based likely on input happening so quickly we don’t identify the source), and evolved thinking patterns, we would not be human.  Be a human and don’t get so hung up when you see other humans thinking emotionally  or bodily.  You do it too.

Myth #4:  Money can represent the true cost of goods, services and all tangible/ intangible things of value.  If that were correct, a pure free market system would probably work just fine.  This can never happen though, and it has partly to do with Myth #1—money is a carrot and stick tool, not just a medium of exchange. It is also because some things of value are not quantitative by nature, but qualitative.   Mind you, I am not saying people can’t sell out their non-monetary valuables for money—their integrity, self-respect, creativity or compassion.  We’ve probably all done it.  But we’ll be left with a nagging sense of a bad trade, no matter how many dollars we got.  Some social valuables we have evolved to require—although there are some with various degrees of sociopathy and lack of conscience who don’t, most of us have an intrinsic need for friendship, love, community, mutual respect, and representation in social decision-making.  No amount of money will substitute.

Some of you may have fallen into the same rut I did awhile back—worry that money is the only thing that talks.  I got out of the rut when I heard about certain political decisions being motivated not by money but by sex.  I don’t have to specify, because those rumors are constantly in the news—I just hadn’t realized what it meant.  Even though illicit affairs are not really how I want decisions affecting me to be made, I found it weirdly reassuring that something so deeply human could wriggle in to the halls of power.  And it’s not just sex either.  Even though some legislators have been corrupted by long exposure to the carrot/stick world, many can still be influenced by an appeal to goodness.  Because we are human, money will never totally rule the world.

Myth #5:    Science is static.  This could be partly overcome by better science education in schools, focusing more on the process of science and not testing “fact” knowledge without reminding students there is not quite such thing as an unmodifiable fact.  Misunderstanding this principle leads to producing laws that try to legislate science.  It can’t be done—science can’t be micromanaged.  It will defy us every time.  Science changes so much more quickly than law or even public opinion.  I’d love to have a science advisory board for every legislative body, to help catch goofs related to misuse of science.

What I’d really like to know about all these myths—what is their purpose?  Why are they so sticky?  Is it possible to revise them?  If so, how can that be done?

Ok.  Now on to the purposes of law as I understand them.  Again, please fill in what I’ve missed or correct my errors.

Purpose #1:  Permit identification and stopping of “cheaters” in areas of mutually accepted conduct.  In this case, the mutual social standards precede the big laws to some degree if the laws are going to work—these are what we think of as “rights” of life and property, as well as various social behaviors.  I’m not talking about traffic rules here—I mean the heavy duty stuff—murder, theft, etc.  Things most of us “just know” we are not supposed to do.  Not believing in a supernaturally designed system, I don’t think there is any such thing as a “natural right” in the usual way.  But it does seem we have evolved to have certain broad types of “rights expectations”, in that we will have rebellions/ wars/ civil disobedience when our social systems tread on those deeply held expectations.

Because those types of law such as “no murdering people except in an approved war or to defend yourself” or “don’t take things that don’t belong to you” mostly come from commonly held beliefs instead of the law creating the beliefs, the law doesn’t serve so much to discourage the behavior as to allow for an approved way to stop those who break the rules.  It identifies those who have not bought in to the social contract and who put those who do in danger.  If we are going to accuse someone of breaking the law, we must have something codified to point to as proof.  Otherwise the accused person could just say “show me where it is written that I can’t do this.”  Those laws also serve as part of our cultural education for newcomers to society, both adults and children—“this is the type of way we expect you to act around here.”

The consequences don’t often change the likelihood a person will break this category of law.  I did not have to stop and think, “hey I shouldn’t go sneak into my neighbor’s yard and snag his rose-bush, because the law says not to.”  Remember, punishment is not the best directional behavior modification tool in humans—it misses the mark.  Having consequences allows us to protect the willing participants in a social contract and to satisfy an evolved need for subjective justice.  It’s more civilized and stability-promoting to put someone who has stolen from us in jail or require community service than to have to go and steal something back from them.  If someone is not happy with my medical work, I’d far rather them sue me than shoot me. Sometimes the consequences can include rehabilitative efforts as well, re-motivating someone to legitimize the social contract by helping them find their place in it.

Purpose #2:  To correct or prevent power imbalances which threaten the stability of a social contract system.  Unchecked, power can gravitate towards those with the most resources for a given issue.  Stability is threatened by loss of legitimacy and extremes of disparity.  Shifting decision making in a certain area towards a vote-based one instead of resource-based is one way to correct imbalances.  Shifting it from individual to local to national or vice-versa is another.  Many safety regulations are in this category, when an unsafe practice by one person could result in disproportionate power over others.

Some resource access laws fall into this category, such as attempting to restrict antibiotic access to prescription by a trained healthcare provider instead of putting them over the counter as in some countries—because excessive antibiotic use drives up resistance and affects us all, giving them out without any controls puts excessive power over public health in the hands of individuals (of course, the current driver of antibiotic resistance is overuse in the animal food production industry).

Sometimes there is the opposite problem—individuals are micromanaged inappropriately and feel the power system is unbalanced against them.  Attempts to make the system “fair” or “safe” that go subjectively too far can have this effect. These can be the trickiest laws to make work—they aren’t nearly so intuitive as the first group.  Significant public education and buy-in at all levels is needed for them to be effective—more participatory democracy.  Gun laws, driver’s license laws, corporate regulations, public safety nets, environmental protections, and union rights fall into this category.  There is great temptation to apply carrot and stick principles in enforcement, with predictably undesirable results.

Purpose #3: To legitimize a social contract.  Laws don’t have to be written to do this, if the social system is small, but in groups over a family level, formal rules seem to be needed.  This isn’t just for purpose #1, to catch cheaters.  It is to make the agreed-on system itself legitimate and more stable.  I’d say this is another evolved characteristic of humans– we have a deep expectation that whatever governance we submit to must demonstrate itself to be legitimate, or the game is off.  The more laws that get broken, whether the lawbreakers are punished or not, the less legitimate the system is perceived to be.  I try to explain this to parents—don’t make rules you can’t enforce.  Punishing is evidence of weakness.  Having your rule broken undermines your authority, and your child has a developmental need for a trusted authority.  You can’t stop the tantrum screams from coming out of the kid’s mouth, so don’t make that rule.  All you can do is decide where he can be while screaming, and I hope it is not in the restaurant where I am eating.

When you hear someone say a person shouldn’t do something just because “it’s the law”, I’d say this is what they mean.  I follow some laws I think are silly for this very reason, because I want to continue and improve upon our representative democracy and feel a duty to safeguard it by following rules the majority of my fellow citizens wanted.  I wouldn’t follow them if they were hurtful, but if they are just silly and annoying, I see a civic duty to toe the line.

On to the ways in which we change laws or make them fail.  First is by formal advocacy, using the processes set out in the social contract itself—legislation, policy-making, elections and so forth.  Second is by intentional civil disobedience, a respected use of power re-balancing.  Third, we often see casual disregard of a law which never got our joint buy-in or which we have outgrown.  This includes all manner of black markets and underground economies.  Marijuana use seems to be in this category.  A fourth, sometimes a response to disregard, is lack of enforcement.  Sometimes even a good-sounding law is just unenforceable from the get-go, and sometimes there is the lack of will to enforce it.  To regain legitimacy, the law must then be changed to reflect current social agreements and ability to enforce them.  Preferably, we could avoid writing laws we know will not be enforced.  Leaving such failed laws on the books, if they accumulate (as in Alabama’s out-dated Constitution), undermines our social contract by threatening the legitimacy of the rest.

How can we identify those laws which have inherent flaws and will be likely to fail?  If we can figure that out, we will know which pieces of legislation to support and which to oppose, without having to resort to ideologies.

Test #1:  Does the law rely heavily on one of the myths—carrot/stick, free agent, pure rational behavior, money rules all, or fact-based science?  If so, it is likely a bad law and will fail.  The current healthcare law is FULL of these errors.  In our current Alabama legislative session, take your pick.  The well intended bill, SB 22, about breast cancer gives an actual script women are supposed to be given if they have “dense” breasts on mammography.  What’s the problem?  Nobody really knows how to define dense breasts, and even if they did, the understanding could change tomorrow.  Another bill, HB 236, would say that two episodes of treatment for addiction plus one incident of substance use in a five year period is proof a parent can never become able to care for a child and should have parental rights terminated.  There’s no science behind that, and I bet it is designed for some specific case.  Further, it misplaces motivation in a carrot/stick manner, so that seeking treatment becomes something one can be punished for.  It is easy to catch errors when the bill contains a known misstatement of fact, but harder when it tries to codify currently accepted “fact.”

Test #2:  Does the law have broad enough buy-in?  Would people be willing to follow it under most reasonably occurring circumstances, even if they thought it was silly?  If not, it will fail.  A good example is Alabama’s latest TRAP bill, HB 57/ SB 130, designed to close abortion clinics.  Because the women denied access to safe/ legal abortion would seek it anyway, the result would be a net increase in deaths—embryos/ fetuses, plus women.  Any meaningful healthcare reform will also have to have a strong buy-in from the great majority of us, or it will fail.  Imposing something from the outside is a guaranteed flop.  The same is likely true of some (not all) elements of gun control.

Test #3:  Is the law enforceable? That one is obvious.  “Personhood”, as in SB 205, would be unenforceable, because it would require bizarre monitoring of women’s bodily secretions to make sure we weren’t killing off zygotes.  Attempting to turn health insurance corporations into moral creatures through regulation is unenforceable, because they will always find a path around the law.

Test #4:  Does the law correct a power imbalance (without invoking one of the myths) or does it worsen one?  The proposed drug-testing of foodstamp and Medicaid recipients narrows enforcement of a broad law to a single category of individuals based on income.  Drug laws are already applied in a highly uneven way.  Aside from the money-wasting and person-hurting aspects, this one is likely unconstitutional and would just be struck down in court.  Remember, even if you do not want to give power to a certain group that lacks it—increased power imbalance destabilizes governments.  We are not talking here about making everything “equal”, which is just as delusional and generally involves a power imbalance against individuals anyway.

Test #5:  Does the law coincide with our deeply held values?  I have a hard time thinking of a law currently on the table which meets the first four tests and would not meet test #5.  Some of my friends (who have slogged to the end of this) will say this should be test #1.  The reason I put it near the end is we make this test automatically—I don’t have to tell you to do it.  But sometimes we misattribute the effect of a law on our values and need to think more deeply.  Those of you who are against abortion at a visceral level should not be expected to want to increase it.  However, you may be able to look at data that a particular law would not work for some other reason or would possibly work counter to your objectives.

Test #6:  Is the law needed, or is there a better way to meet the goal?  Public education would be a better way to get working knowledge about breast health out, rather than giving scripts to doctors.  The fewer laws we have, the less work we will have to do enforcing them and keeping our overall system legitimate.

If you’ve stuck with me to the end of this, thanks!  Now, what do you think?

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Filed under Alabama Legislative Session 2013, Politics

HB 108: It’s Not About Religion

Everything you thought about our legislature and women’s health is wrong.  Not only do our legislators plan to make abortion “safer”, they want to increase demand!  They want to make it hard for women to get birth control, so they will have more unwanted pregnancies and seek abortion more often. Since the “safer” clinics under HB 57/SB 130 will be imaginary, having been shut down, these abortions may be done by unlicensed providers or DIY methods.  That’s great, because it gets them a twofer, a dead fetus AND a dead momma.  I wonder if they’ve considered another benefit—an increased arrest rate for women who are addicted to drugs, get pregnant, and don’t abort—a boon to our burgeoning prison industry.  A winner, all around, right?  Pro-choicers, rejoice!

Except they’ve misunderstood us a bit.  Pro-choice does NOT mean pro-unplanned pregnancy or pro-abortion.   Women don’t yearn to have abortions any more than men want to have prostate procedures or open-heart surgery.  We know the best option is prevention—safe, accessible contraception with good public education about safe sex.

Let’s read HB 108.  We have a new category of employers created—religiously affiliated or motivated employers.  Under the definition section, it turns out that any “entity that has 10 or less shareholders, members, or partners who have religious beliefs which oppose contraceptive or abortifacient drugs, devices, or methods” is included.  10 or less—that means 0 to 10, right?  So a business with 100 shareholders, all atheists, is religiously motivated but one with 100% anti-contraception shareholders is not.  Interesting twist!

Businesses meeting the criteria can refuse to provide insurance coverage for any form of birth control.  Let’s say they fix their typo, and it becomes 10 or more shareholders, members or partners.  A business with 1000 shareholders, 990 of whom have no religious objection to birth control, could refuse to cover contraception for its employees. Considering where we live, how many businesses would fall into that category?

Here’s an article about the whole religious exemption bit with the ACA.  One of the strongest arguments—the First Amendment does not preferentially protect employers vs. employees.  It is not a capitalist right—it applies to all of us, whether we have big bucks or not.  Allowing an employer to refuse to provide a mandated coverage brought about through our representative democratic process, without regard to the religion of an employee, seems unconstitutional.

From where I stand, allowing any sort of exemption was a big error.  Are we going to start letting employers who oppose blood transfusions restrict insurance coverage? What about employers who think all medical care beyond prayer is wrong?  Should those who believe cars are immoral skip out on their taxes since some part is used for highways and licensing drivers?  How about religious pacifists—they should get to pro-rate income tax for the proportion spent on the military, right?  I would personally like a refund for all of my taxes used to prevent marriage equality.  Direct deposit will be fine.

HB 108 goes beyond fighting the ACA, which provides for contraception without co-pays—it would allow employers to completely deny coverage.  Some employers, whether religiously motivated or not, might see a financial opportunity and get converted.  Sure, women can usually afford the generic oral contraceptives if they are not poor, but those are not the most effective—for most reliable results, we use long term treatments like the IUD or implants in the skin.  Those cost more as a single, up-front payment, although over time they are cheaper than other methods.  How many women would turn to less reliable oral medication because of the up-front costs?  How many would become pregnant as a result?

As you know, the best way to keep employers from limiting our health insurance coverage for religious or financial reasons is Medicare for All.  Until you all get serious about pushing single payer, we are stuck twiddling with this stuff.

The bill says our government has no “compelling interest” to act against an employer’s religious freedom in this case.  I was snarky in the beginning and it was fun, but let’s be real.  I don’t think our legislators want to kill women or increase abortions.  I just don’t think they fully understand the consequences of these bills.  Alabama has a woefully high infant mortality, in some counties as high as 3rd world countries.  Some of the most important factors include lack of prenatal and pre-conception healthcare, plus unplanned pregnancy.  This is serious.  We have got to get more focused on reducing these deaths.  Now is NOT the time to make birth control harder to get.  How can our infant mortality rate not count as a compelling interest?

If some people really think we should never have sex without an intention to create a baby, we must grant them their First Amendment right to believe.  The numbers say it must be a pretty small percentage who practice what they preach.  That’s how I know this bill is not about religion.  No matter what we each think about personal responsibility and who should pay for what, can we agree that dead babies are not a good goal?

Please contact your legislator and ask for a no vote on HB 108.


Filed under Alabama Legislative Session 2013, women's healthcare

On the Legislation of Conscience

Among the several bills pending Alabama legislative action this spring, I am sorry to say our state has decided to extend its long arm into the realm of conscience.  There are two bills pending, SB 105 and HB 375, titled Health Care Rights of Conscience.  If you live here, you need to know about them in detail—please read for yourself. 

Conscience is no small matter—without conscience, we become sociopaths.  We’ve learned the hard way in history how blind allegiance to any authority can lead to tragedy.  The exercise of individual conscience through civil disobedience is a vital protection in democracy against a majority gone wrong.  Without bravery like that of Rosa Parks, evil laws can be hard to change by ordinary channels. 

The problem is that consciences differ between persons, sometimes wildly.  If that were not the case, we would have no need of law at all, nor police nor courts.  These are all required to protect us, by mutual consent, from the failure of individual conscience.  If Rosa Parks had done something different—if she had used her personal conscience to rob someone of money she thought they didn’t deserve to have—she would have been rightly arrested and would not have inspired social change.  That is why people who choose to perform civil disobedience must expect arrest—their acts are not meant to ignore the law but to expose it for examination.

 SB 105 and HB 375 seek to override critical citizen protections by allowing individual conscience to run amok, without the restraint of social or professional ethics.

These bills say the State must protect the right of conscience for individuals who provide health care services related to abortion, human cloning, human embryonic stem cell research and sterilization.  They say nothing whatsoever about the State’s obligation to protect patients from medical care below the established standard in our profession or to allow employers the ordinary freedom to hire people who can and will do the work required by a specific job description.

It is odd that basic science research has been mixed with regular patient services in the same bill. I can’t tell you the last time my boss ordered me to go down the hall and clone a human or do something with a stem cell, between treating children for asthma and ear infections.  If he did, I’d have no clue how to proceed.  People don’t accidentally go into training to clone humans or stem cells.  But if these bills pass, a researcher who studies human cloning will have to consider hiring a lab assistant who refuses to do the assigned work on equal footing with one who will do it. 

Under these bills, a healthcare provider is allowed to omit all types of counseling and advice for these particular services.  For cloning and stem cell research, this would imply the researchers no longer have to get consent using the IRB (Institutional Review Board) protocols meant to protect us from unethical research, as long as they say doing so would violate their conscience.  They would be free to collect our cells for these purposes without even asking us.  Bet the bill drafters didn’t realize this!

A doctor could sterilize a man or woman without getting informed consent, because the wording allows any part of a service related to sterilization to be omitted.  That’s as long as it is not because the doctor thinks the patient is less valuable due to being elderly, disabled or terminally ill.  The language leaves it open for docs to practice eugenics by sterilizing a smoker, an obese person or a conservative without consent.

A doctor could perform an abortion on a woman without getting informed consent.  That’s right—bills that were designed to limit access to abortion would allow them to be performed without counseling.  On the bright side, at least the doctor could omit the medically unneeded ultrasound and state-mandated but incorrect written information (except in abortion clinics, to which these bills don’t apply).

A doctor could refuse to tell a man with prostate cancer that removing the testicles is part of treatment in some cases, or a woman with ovarian cancer that she can have her ovaries removed.   A doctor can omit any part of a medical procedure related to abortion or sterilization, as long as it is not an immediately life-threatening situation.  This could include doing procedures like vasectomies or hysterectomies without anesthesia or pain control.  Screaming would be ok, just not dying.  Yes, it is hard to imagine that any doctor would have such a bizarre conscience—it is hard to imagine that a doctor would sexually abuse a patient too, but it happens.  With this law, we’d have no way of removing such a person from medical practice and an employer would have no way to fire him or her.

We could learn from the words of E.H. Chapin, a 19th century Christian preacher:  Let every man be free to act from his own conscience; but let him remember that other people have consciences too; and let not his liberty be so expansive that in its indulgence it jars and crashes against the liberty of others.

By licensing health care providers, the State is assuring its citizens that the license holder meets a certain professional standard of care and ethics.  To this end, Alabama has established various oversight agencies such as the Alabama Board of Medical Examiners and the Board of Nursing, boards with a long history of competent duty.  SB 105 and HB 375 would prevent them from intervening to stop malpractice related to abortion or sterilization if the perpetrator can justify such malpractice on grounds of conscience. 

When a medical provider’s personal ethics conflict with the ethics of his or her profession, the public and the profession itself have a right to be protected from harm.  Please contact your legislator and ask for a “no” vote.



Filed under Alabama legislative session 2012, Politics, women's healthcare

Rally Against the War on Women, Huntsville, Alabama

Great rally today at Big Spring Park in Huntsville– speakers of every age, beautiful pear trees, music– here’s the text of my speech.  The YouTube is at http://www.youtube.com/watch?v=P5gp9j7kFo8&feature=share

This is what Spring in Alabama looks like!

This winter, some of our state legislators came down with a bad virus—let’s call it chicken farmer flu.  The symptoms are breaking out in a rash of bad bills and having delusions that we won’t notice.  Guess what?  We noticed!


We know the truth about these bills. 


We know that personhood has nothing to do with making fetuses persons—it is about trying to take away the personhood of women.


We know that putting women in jail for testing positive for drugs during pregnancy has nothing to do with stopping chemical endangerment of children- – it is about criminalizing addiction and controlling women.   If they wanted to stop chemical endangerment, they would spend more money on treatment centers and less on prisons.


We know that requiring drug testing for people who need Medicaid and denying coverage if the test is positive—including for pregnant women– is not about reducing drug use or saving money—it is about throwing these women and men and babies under the bus.   If they really wanted healthy babies, they would fund Medicaid and All Kids and our Department of Mental Health.


We know that prohibiting insurers from offering abortion coverage or making them charge extra has nothing to do with being pro-life—it is about being pro-Power and anti-Woman.


We know that the Health Care Provider Conscience bill has nothing to do with protecting doctor and pharmacist rights or preventing abortions—it is about preventing women from getting prescription birth control and reproductive healthcare.  It is about punishing women, and women only, for sex between women and MEN.   If they really wanted to cut down abortions, they would make it easy to get birth control.  But let’s talk conscience—it is against my conscience to practice bad medicine.


We know that making rules about exactly how physicians can provide abortions with prescriptions instead of surgery is not about making those darn doctors do it right.  It is about forcing doctors, at risk of prison, to use FDA protocols that are outdated as soon as they are published—it is about denying doctors and women the right to evidence-based, science-based medicine.  It makes malpractice on women not just legal but mandatory.  If they really wanted doctors to do it right, they would give us the freedom to use our training and our brains.


We know that the forced vaginal ultrasound bills have nothing to do with the right to see and know.  They are about using a woman’s own doctor as a hired gun and forcing doctors to rape, assault, shame, emotionally torture and defraud their patients or go to prison. These are hate crimes!


 Make no mistake—doctors do not want to rape our patients.  We do not hate our patients.   But apparently some legislators do.   I don’t know about you, but I don’t want the Alabama Legislature all up in my vagina.  As a doctor, I don’t want them in the privacy of my exam room.


The state-mandated hate crime bills have nothing to do with preventing abortion.   I will never believe these legislators want to prevent abortion until they do the things that are PROVEN to reduce abortion—real sex education in schools and easy access to effective contraception.  I will never believe they care about life until they make our state a place where families can afford to feed their children, get medical care for them, and educate them.


But I’m glad they put the rape and torture bills out there.  I’m glad because now we can all see what kind of people they really are, so we can get them out of Montgomery as quickly as possible.  I’m glad because now we know the truth, and now we can do something about it.


We’ve been embarrassed enough by our state.  This, right here, is the Alabama I’m proud of.


These bills are not grassroots.  They were written by out-of-state special interest groups.   But we do have a grassroots bill now!


It’s called the Right to Professional Medical Judgment Act, SB 413.  It’s so grassroots that the main body was written by an ordinary Alabama citizen—me—and proofread on Facebook by you!  Real women write bills.  Senator Linda Coleman, the bill sponsor, actually read it, unlike Clay Scofield.   Real women read their bills.  She got 9 co-sponsors, unlike Scofield who got none.  Real women and men work together.   This is not the Abston Bill or the Coleman Bill—it is OUR bill.


Let me read you the main text of our bill:


“No physician or health care provider licensed to practice in the State of Alabama shall be forced by state or local regulatory authority to perform any medical service or component of medical service if the service or component of service is not medically necessary or would be harmful to the patient AND the patient does not desire the medical service.  The right to practice within the scope of a medical license supersedes any existing or future legislative act.”


We shouldn’t have to explain to our legislature that they can’t practice medicine without a license.  We shouldn’t have to explain to them that they can’t legislate science anymore than they can change the law of gravity.  We already have the Alabama Board of Medical Examiners, a Board with medical training, to supervise the quality of care by doctors.  It looks like we need this bill to remind them of that.


Take a minute and look around you.  You can be proud to be part of this group of women AND men.  You can be proud to say you live in Alabama.  The winter of bad bills and the War against Women will end, right here.  This is Spring in Alabama.


Filed under Alabama legislative session 2012, women's healthcare

HR 676, Part 7: Women’s Reproductive Health Should NOT Be Managed By Chicken Farmers

Before I get to mental health, which I promise is really coming soon, I’m going to reflect on how the current uproar in Alabama and other states over women’s reproductive rights might call for some careful editing of HR 676, the Expanded and Improved Medicare for All Act.  I’ve reviewed the wonderfully long list of covered services previously.  Is it clear enough to stop a conservative administration from limiting reproductive care?  I fear not—I believe it needs to be substantially strengthened.


Contraception would likely be covered without explicit mention.  The bill covers “all medically necessary services”, and preventive care plus prescription drugs are clearly listed.  There is no way we are going to list every medically necessary service in the bill itself, but other services that have been historically limited by insurers are mentioned outright, such as dental care and mental health services.  To be on the safe side, we should go ahead and specify contraception coverage.  Just as for other medications, there would be no co-pay at the point of service—this health plan is pre-paid entirely.


What about abortion? HR 676 needs to specify coverage, very directly.  Single-payer advocates sometimes avoid mentioning abortion, even though NOW is a supporter of HR 676. It has been an uphill battle to try and get Medicare for All on the table—I am sure the thought is probably just “don’t go there.  Don’t make the job even harder than it is.  If it is legal, we can assume it will be ok.”  That is likely a mistake.


Maybe one day, contraception will be so excellent and free of side effects that abortion will become obsolete.  Maybe one day, an embryo or fetus can be painlessly removed and grown in some high-tech incubator, later to be adopted.  Until that time, we must clearly state that we are going to fund a medical procedure the courts have already said is legal.


The best prevention of abortion, a very sad procedure no woman wants to need, is contraception and an educated public.  The Dutch have the lowest abortion rates in the world— they got there by teaching everyone how to prevent unplanned pregnancy and making contraception easily available.  Sure, contraception isn’t perfect, but it really does help, as opposed to delusional attempts to prevent sex itself.  If those who call themselves “pro-life” would quit behaving so irrationally, teens in the US could be just as well-educated, and all women would have access to contraception.  Instead, these forces reveal themselves to be about not life but power.


In Alabama, if you’ve read my recent posts, we are being besieged with a flurry of bills written by out-of-state special interest groups trying to keep women from accessing both contraception and abortion.  At the same time, the State House may cut funding for a range of services to children, including healthcare, education, enforcement of child support, and foster care.  Pregnant women may be unable to get Medicaid if they test positive for drugs, and there are efforts to imprison them as well.  It is a truly bizarre double-bind.


Seeing this dismal script played out has made me re-visit the most common critique of single-payer healthcare—that it would be done poorly, because it is government.  I have said before that our main protection is the requirement for ALL of us to have the insurance, including legislators and administrators.  Will that be enough?  Maybe not.  As long as there are procedures special to women, we are at risk of male legislators attempting to practice medicine without a license.  


In Alabama, we have a chicken farmer—a chicken farmer!—who thinks he knows enough about medicine to tell doctors how to get informed consent for abortion.  I will not come to his farm and try to manage his chickens.  He needs to stay out of our exam rooms.  I mean nothing derogatory about farmers or their chickens.  I would say the same about a nuclear physicist.  These are just very different specialties.


We already have insurers who get away with poor coverage of women’s health needs.  We need to be careful that a national insurance program would not put us at risk for the same problem.  How to do it?  Perhaps we can strengthen the design of the National Board of Universal Quality and Access.  I will go over it again when I get to that section of the bill, but as written it includes a minimum of one health care professional.  This board has many tasks, some of which don’t require significant medical training.  I believe we need to separate out a Board to include both practicing physicians and patients that will oversee the determination of medical necessity.  This board should have a voting majority of physicians and half should be female.  Members should be elected by physicians and patient advocacy groups and should not be employed by potentially conflicting interest corporations (like pharmaceutical and device companies).  They should also not be government employees.


Our nation’s founders attempted to set a balance of powers in place.  I was taught in elementary school this means the legislative, executive and judicial branches.  I’m learning there’s a lot more to it!  There’s the balance of power between citizens and our elected representatives, between states and the federal government, and between private enterprise and the state.  There’s even a balance of power between physicians and patients, one that has evolved markedly for the better in recent decades.  Men and women, adults and children, workers and employers—on and on.  It’s mindless to argue over big and small government—the argument needs to be around the power balance.  Anyone who gets too big, whether that’s government, corporations or a mob, will throw it off.


Power balances can and will get off kilter.  Sometimes the problem can be solved by adding a little more weight to one side or the other.  Sometimes one of the weights must be removed and replaced.  We don’t always know to predict an imbalance until it happens—I doubt if our founders expected Citizens United.  Monarchy might have been just fine if it had always been benevolent.  If we were a different sort of country, ideologically, we might be ok letting a government board determine our health benefits.  I do not trust our current crowd with that job.


Our healthcare balance has been weighted much too heavily in favor of corporate insurers who put their profits ahead of both patients and physicians.   We probably can’t fix the problem without replacing them.  HR 676 replaces them with government—the other side of the scale needs to be firmly weighted with physicians free to practice quality, professional medicine and patients who demand to be treated with respect, as full participants in their medical care.


Filed under Alabama legislative session 2012, HR 676 Analysis, women's healthcare