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Why Do We Need the VA?
The weather grows colder, the leaves are changing colors then falling, and it is time to gather close all we hold dear and to remember those who have gone before and those who have given for us—it is November. Across the world nations set aside a day to honor fallen heroes and wounded warriors. In Canada and Australia, it is Remembrance Day, in the US, it is Veterans Day, November 11.
War is older than recorded history, and every culture has experiences of violent conflict. Thus, every society has those men and women who have been harmed in body and mind and soul in mortal combat and yet survived and those who have perished on the battlefield or in its aftermath or wished they had.
The bloody, brutal human toll of organized strife has led many a society to recognize a moral obligation to develop a dedicated means of delivering medical care and social support to not just those who are serving actively but to those whose days in action are past. The utilitarian rationale for military medicine is clearly stated in the United States Army Medical Command mission, “Army Medicine provides sustained health services and research in support of the Total Force to enable readiness and conserve the fighting strength while caring for our Soldiers for Life and Families.”1 It is a measure of the self-sacrifice of those who have sworn to defend their homeland and their healing brothers and sisters in arms that they deliberately make this commitment to each other and their fellow citizens. Yet we cannot easily extend this logic to the care of veterans. Why have diverse countries across millennia seen fit to carve out a special space for veteran health care? In this column, we will seek an answer in culture and history.
Related: Why VA Health Care Is Different
The Roman Empire, which relied heavily on its soldiers for the peace and prosperity of the empire was among the first political entities to recognize the need for military health care and to dedicate human and financial capital to subsidize care for veterans. Among the first hospitals in the world were built to care for Roman legions and the ancient medics like their modern counterparts advanced medical and especially surgical progress that benefited the public.2Today it is not only the US that has special systems of health care for veterans. The Australia Department of Veterans’ Affairs provides many of the same health and social service benefits as those of the US Department of Veterans Affairs (VA). Likewise, Veterans Affairs Canada (VAC) offers those who served and are eligible a variety of resources, including health care. Why does VAC provide health care for veterans?
Veterans Affairs Canada deeply values the contribution that Veterans have made to the development of our nation and we honour the sacrifices they have made.... In expressing Canada’s gratitude to them, we strive to exemplify many of the same principles which they represent–integrity, respect, service and commitment, accountability, and teamwork. 3
Many of these same motifs are repeated in the legislation that officially changed the November 11th commemoration from Armistice Day to Veterans Day. The holiday originated to mark the ending of the terrible First World War in which so many young men’s futures ended in the stench and mud of European trenches. Where Armistice Day celebrated the peace of the Treaty of Versailles and Memorial Day commemorates those in uniform who made the ultimate sacrifice; Veterans Day honors all veterans those still with us and those who have gone before. At the urging of veterans service organizations, as President, the great Army general Dwight D. Eisenhower declared in 1954 November 11 to be Veterans Day with these words:
On that day let us solemnly remember the sacrifices of all those who fought so valiantly, on the seas, in the air, and on foreign shores, to preserve our heritage of freedom, and let us reconsecrate ourselves to the task of promoting an enduring peace so that their efforts shall not have been in vain. 4
From these and other political proclamations, we can discern 4 ethical purposes that have motivated so many eras and states to maintain institutions to protect the health and promote the well-being of veterans. The first is gratitude, for those who lost something precious—be it health, function, soundness of mind, wholeness of limb, even life itself. The soldiers, airmen, sailors, marines, and others deserve not only our thanks, but also giving of our substance through taxes and the discharge of our democratic duties to support them through health care and housing, benefits, and burial.
Related: Am I My Brother’s/Sister’s Keeper?
The second purpose is that we owe all veterans a debt, a debt we can never fully repay, because no price can be placed on mental health, on freedom from pain and suffering, from being without a husband or a mother, and yet that is the price that many veterans paid. The least we can do is ensure that they have a health care system that understands the nature of their narratives and invests in the development of expertise particularity in psychophysical sequelae of war like traumatic brain injuries, amputations, posttraumatic stress disorder, and substance use.
The third purpose is that those who carried weapons, who were shot at, and who suffered so many other assaults outside the range of expected human experience fought to secure for all generations the 2 most precious qualities of civilization: freedom and peace. Once their work was done and the uniform hung in the closet and the medals put in a drawer, service men and women passed on to all of us—especially those who are committed to provide their medical care—that cause.
The fourth purpose is the simplest yet perhaps the most morally compelling—to remember the history of sacrifice. In my VA and in many others, unlike any private hospital on the planet, the walls are filled with military memorabilia. There is a memorial statute of a Medal of Honor winner for whom the facility is named in front of the main hospital with a giant American flag waiving proudly. All these symbols tell the veteran walking through the halls that this he or she is the primary ethical justification for this health care organization.
Related: The VA Cannot Be Privatized
These are the most powerful arguments to refute the many recent articles that question the very existence of the VA. Many of those authors, including one of my mentors, have ethical grounds for their calls for an end to a separate health care system for veterans.5 Believe me, after nearly 2 decades in the VA, I know firsthand we have much to improve in efficiency, responsiveness, and accountability. But is it really an ethical or even a scientific truth that veteran health care can be delivered more successfully by the private sector? That depends on the terms in which success is defined. Many of those who so blithely and at times irresponsibly proclaim that “we do not need a VA” display in the words of my own admired commander, “the reckless courage of noncombatants.” Solid health care research from independent sources suggests that the VA offers most community health care organizations a run for their money in terms of economies of scale and quality of outcomes in many areas.6 Yet this column contends that the measure of success for veteran health care is that the majority of VA and US Department of Defense health care professionals and administrators remain dedicated to these 4 core purposes. Success for these institutions is to seek and to strive through research, teaching, and clinical care to discover and deliver those therapies and medicaments with the most potential to preserve and enhance freedom of body and peace of mind that veterans deserve every day, not only on November 11.
1. US, Department of Defense, US Army Medical Command. Army Medicine Public Affairs. New Army Medicine mission, vision. https://www.army.mil/article/173974/new_army_medicine_mission_vision. Published August 25, 2016. Accessed October 29, 2018.
2. MNT Editorial Team. What is ancient Roman medicine? https://www.medicalnewstoday.com/info/medicine/ancient-roman-medicine.php. Updated January 25, 2016. Accessed October 29, 2018.
3. Veterans Affairs Canada. https://www.canada.ca/en/veterans-affairs-canada.html. Accessed October 298th, 2018.
4. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. History of Veterans Day. https://www.va.gov/opa/vetsday/vetdayhistory.asp. Updated July 20, 2015. Accessed October 29, 2018.
5. White BD. To properly care for veterans do we really need a VA health care system? http://www.amc.edu/BioethicsBlog/post.cfm/to-properly-care-for-veterans-do-we-really-need-a-va-health-system. Published June 6, 2014. Accessed October 28, 2018.
6. Shulkin DJ. Beyond the VA crisis: Becoming a high-performance network. NEJM. 2016;374(11):1003-1005.
The weather grows colder, the leaves are changing colors then falling, and it is time to gather close all we hold dear and to remember those who have gone before and those who have given for us—it is November. Across the world nations set aside a day to honor fallen heroes and wounded warriors. In Canada and Australia, it is Remembrance Day, in the US, it is Veterans Day, November 11.
War is older than recorded history, and every culture has experiences of violent conflict. Thus, every society has those men and women who have been harmed in body and mind and soul in mortal combat and yet survived and those who have perished on the battlefield or in its aftermath or wished they had.
The bloody, brutal human toll of organized strife has led many a society to recognize a moral obligation to develop a dedicated means of delivering medical care and social support to not just those who are serving actively but to those whose days in action are past. The utilitarian rationale for military medicine is clearly stated in the United States Army Medical Command mission, “Army Medicine provides sustained health services and research in support of the Total Force to enable readiness and conserve the fighting strength while caring for our Soldiers for Life and Families.”1 It is a measure of the self-sacrifice of those who have sworn to defend their homeland and their healing brothers and sisters in arms that they deliberately make this commitment to each other and their fellow citizens. Yet we cannot easily extend this logic to the care of veterans. Why have diverse countries across millennia seen fit to carve out a special space for veteran health care? In this column, we will seek an answer in culture and history.
Related: Why VA Health Care Is Different
The Roman Empire, which relied heavily on its soldiers for the peace and prosperity of the empire was among the first political entities to recognize the need for military health care and to dedicate human and financial capital to subsidize care for veterans. Among the first hospitals in the world were built to care for Roman legions and the ancient medics like their modern counterparts advanced medical and especially surgical progress that benefited the public.2Today it is not only the US that has special systems of health care for veterans. The Australia Department of Veterans’ Affairs provides many of the same health and social service benefits as those of the US Department of Veterans Affairs (VA). Likewise, Veterans Affairs Canada (VAC) offers those who served and are eligible a variety of resources, including health care. Why does VAC provide health care for veterans?
Veterans Affairs Canada deeply values the contribution that Veterans have made to the development of our nation and we honour the sacrifices they have made.... In expressing Canada’s gratitude to them, we strive to exemplify many of the same principles which they represent–integrity, respect, service and commitment, accountability, and teamwork. 3
Many of these same motifs are repeated in the legislation that officially changed the November 11th commemoration from Armistice Day to Veterans Day. The holiday originated to mark the ending of the terrible First World War in which so many young men’s futures ended in the stench and mud of European trenches. Where Armistice Day celebrated the peace of the Treaty of Versailles and Memorial Day commemorates those in uniform who made the ultimate sacrifice; Veterans Day honors all veterans those still with us and those who have gone before. At the urging of veterans service organizations, as President, the great Army general Dwight D. Eisenhower declared in 1954 November 11 to be Veterans Day with these words:
On that day let us solemnly remember the sacrifices of all those who fought so valiantly, on the seas, in the air, and on foreign shores, to preserve our heritage of freedom, and let us reconsecrate ourselves to the task of promoting an enduring peace so that their efforts shall not have been in vain. 4
From these and other political proclamations, we can discern 4 ethical purposes that have motivated so many eras and states to maintain institutions to protect the health and promote the well-being of veterans. The first is gratitude, for those who lost something precious—be it health, function, soundness of mind, wholeness of limb, even life itself. The soldiers, airmen, sailors, marines, and others deserve not only our thanks, but also giving of our substance through taxes and the discharge of our democratic duties to support them through health care and housing, benefits, and burial.
Related: Am I My Brother’s/Sister’s Keeper?
The second purpose is that we owe all veterans a debt, a debt we can never fully repay, because no price can be placed on mental health, on freedom from pain and suffering, from being without a husband or a mother, and yet that is the price that many veterans paid. The least we can do is ensure that they have a health care system that understands the nature of their narratives and invests in the development of expertise particularity in psychophysical sequelae of war like traumatic brain injuries, amputations, posttraumatic stress disorder, and substance use.
The third purpose is that those who carried weapons, who were shot at, and who suffered so many other assaults outside the range of expected human experience fought to secure for all generations the 2 most precious qualities of civilization: freedom and peace. Once their work was done and the uniform hung in the closet and the medals put in a drawer, service men and women passed on to all of us—especially those who are committed to provide their medical care—that cause.
The fourth purpose is the simplest yet perhaps the most morally compelling—to remember the history of sacrifice. In my VA and in many others, unlike any private hospital on the planet, the walls are filled with military memorabilia. There is a memorial statute of a Medal of Honor winner for whom the facility is named in front of the main hospital with a giant American flag waiving proudly. All these symbols tell the veteran walking through the halls that this he or she is the primary ethical justification for this health care organization.
Related: The VA Cannot Be Privatized
These are the most powerful arguments to refute the many recent articles that question the very existence of the VA. Many of those authors, including one of my mentors, have ethical grounds for their calls for an end to a separate health care system for veterans.5 Believe me, after nearly 2 decades in the VA, I know firsthand we have much to improve in efficiency, responsiveness, and accountability. But is it really an ethical or even a scientific truth that veteran health care can be delivered more successfully by the private sector? That depends on the terms in which success is defined. Many of those who so blithely and at times irresponsibly proclaim that “we do not need a VA” display in the words of my own admired commander, “the reckless courage of noncombatants.” Solid health care research from independent sources suggests that the VA offers most community health care organizations a run for their money in terms of economies of scale and quality of outcomes in many areas.6 Yet this column contends that the measure of success for veteran health care is that the majority of VA and US Department of Defense health care professionals and administrators remain dedicated to these 4 core purposes. Success for these institutions is to seek and to strive through research, teaching, and clinical care to discover and deliver those therapies and medicaments with the most potential to preserve and enhance freedom of body and peace of mind that veterans deserve every day, not only on November 11.
The weather grows colder, the leaves are changing colors then falling, and it is time to gather close all we hold dear and to remember those who have gone before and those who have given for us—it is November. Across the world nations set aside a day to honor fallen heroes and wounded warriors. In Canada and Australia, it is Remembrance Day, in the US, it is Veterans Day, November 11.
War is older than recorded history, and every culture has experiences of violent conflict. Thus, every society has those men and women who have been harmed in body and mind and soul in mortal combat and yet survived and those who have perished on the battlefield or in its aftermath or wished they had.
The bloody, brutal human toll of organized strife has led many a society to recognize a moral obligation to develop a dedicated means of delivering medical care and social support to not just those who are serving actively but to those whose days in action are past. The utilitarian rationale for military medicine is clearly stated in the United States Army Medical Command mission, “Army Medicine provides sustained health services and research in support of the Total Force to enable readiness and conserve the fighting strength while caring for our Soldiers for Life and Families.”1 It is a measure of the self-sacrifice of those who have sworn to defend their homeland and their healing brothers and sisters in arms that they deliberately make this commitment to each other and their fellow citizens. Yet we cannot easily extend this logic to the care of veterans. Why have diverse countries across millennia seen fit to carve out a special space for veteran health care? In this column, we will seek an answer in culture and history.
Related: Why VA Health Care Is Different
The Roman Empire, which relied heavily on its soldiers for the peace and prosperity of the empire was among the first political entities to recognize the need for military health care and to dedicate human and financial capital to subsidize care for veterans. Among the first hospitals in the world were built to care for Roman legions and the ancient medics like their modern counterparts advanced medical and especially surgical progress that benefited the public.2Today it is not only the US that has special systems of health care for veterans. The Australia Department of Veterans’ Affairs provides many of the same health and social service benefits as those of the US Department of Veterans Affairs (VA). Likewise, Veterans Affairs Canada (VAC) offers those who served and are eligible a variety of resources, including health care. Why does VAC provide health care for veterans?
Veterans Affairs Canada deeply values the contribution that Veterans have made to the development of our nation and we honour the sacrifices they have made.... In expressing Canada’s gratitude to them, we strive to exemplify many of the same principles which they represent–integrity, respect, service and commitment, accountability, and teamwork. 3
Many of these same motifs are repeated in the legislation that officially changed the November 11th commemoration from Armistice Day to Veterans Day. The holiday originated to mark the ending of the terrible First World War in which so many young men’s futures ended in the stench and mud of European trenches. Where Armistice Day celebrated the peace of the Treaty of Versailles and Memorial Day commemorates those in uniform who made the ultimate sacrifice; Veterans Day honors all veterans those still with us and those who have gone before. At the urging of veterans service organizations, as President, the great Army general Dwight D. Eisenhower declared in 1954 November 11 to be Veterans Day with these words:
On that day let us solemnly remember the sacrifices of all those who fought so valiantly, on the seas, in the air, and on foreign shores, to preserve our heritage of freedom, and let us reconsecrate ourselves to the task of promoting an enduring peace so that their efforts shall not have been in vain. 4
From these and other political proclamations, we can discern 4 ethical purposes that have motivated so many eras and states to maintain institutions to protect the health and promote the well-being of veterans. The first is gratitude, for those who lost something precious—be it health, function, soundness of mind, wholeness of limb, even life itself. The soldiers, airmen, sailors, marines, and others deserve not only our thanks, but also giving of our substance through taxes and the discharge of our democratic duties to support them through health care and housing, benefits, and burial.
Related: Am I My Brother’s/Sister’s Keeper?
The second purpose is that we owe all veterans a debt, a debt we can never fully repay, because no price can be placed on mental health, on freedom from pain and suffering, from being without a husband or a mother, and yet that is the price that many veterans paid. The least we can do is ensure that they have a health care system that understands the nature of their narratives and invests in the development of expertise particularity in psychophysical sequelae of war like traumatic brain injuries, amputations, posttraumatic stress disorder, and substance use.
The third purpose is that those who carried weapons, who were shot at, and who suffered so many other assaults outside the range of expected human experience fought to secure for all generations the 2 most precious qualities of civilization: freedom and peace. Once their work was done and the uniform hung in the closet and the medals put in a drawer, service men and women passed on to all of us—especially those who are committed to provide their medical care—that cause.
The fourth purpose is the simplest yet perhaps the most morally compelling—to remember the history of sacrifice. In my VA and in many others, unlike any private hospital on the planet, the walls are filled with military memorabilia. There is a memorial statute of a Medal of Honor winner for whom the facility is named in front of the main hospital with a giant American flag waiving proudly. All these symbols tell the veteran walking through the halls that this he or she is the primary ethical justification for this health care organization.
Related: The VA Cannot Be Privatized
These are the most powerful arguments to refute the many recent articles that question the very existence of the VA. Many of those authors, including one of my mentors, have ethical grounds for their calls for an end to a separate health care system for veterans.5 Believe me, after nearly 2 decades in the VA, I know firsthand we have much to improve in efficiency, responsiveness, and accountability. But is it really an ethical or even a scientific truth that veteran health care can be delivered more successfully by the private sector? That depends on the terms in which success is defined. Many of those who so blithely and at times irresponsibly proclaim that “we do not need a VA” display in the words of my own admired commander, “the reckless courage of noncombatants.” Solid health care research from independent sources suggests that the VA offers most community health care organizations a run for their money in terms of economies of scale and quality of outcomes in many areas.6 Yet this column contends that the measure of success for veteran health care is that the majority of VA and US Department of Defense health care professionals and administrators remain dedicated to these 4 core purposes. Success for these institutions is to seek and to strive through research, teaching, and clinical care to discover and deliver those therapies and medicaments with the most potential to preserve and enhance freedom of body and peace of mind that veterans deserve every day, not only on November 11.
1. US, Department of Defense, US Army Medical Command. Army Medicine Public Affairs. New Army Medicine mission, vision. https://www.army.mil/article/173974/new_army_medicine_mission_vision. Published August 25, 2016. Accessed October 29, 2018.
2. MNT Editorial Team. What is ancient Roman medicine? https://www.medicalnewstoday.com/info/medicine/ancient-roman-medicine.php. Updated January 25, 2016. Accessed October 29, 2018.
3. Veterans Affairs Canada. https://www.canada.ca/en/veterans-affairs-canada.html. Accessed October 298th, 2018.
4. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. History of Veterans Day. https://www.va.gov/opa/vetsday/vetdayhistory.asp. Updated July 20, 2015. Accessed October 29, 2018.
5. White BD. To properly care for veterans do we really need a VA health care system? http://www.amc.edu/BioethicsBlog/post.cfm/to-properly-care-for-veterans-do-we-really-need-a-va-health-system. Published June 6, 2014. Accessed October 28, 2018.
6. Shulkin DJ. Beyond the VA crisis: Becoming a high-performance network. NEJM. 2016;374(11):1003-1005.
1. US, Department of Defense, US Army Medical Command. Army Medicine Public Affairs. New Army Medicine mission, vision. https://www.army.mil/article/173974/new_army_medicine_mission_vision. Published August 25, 2016. Accessed October 29, 2018.
2. MNT Editorial Team. What is ancient Roman medicine? https://www.medicalnewstoday.com/info/medicine/ancient-roman-medicine.php. Updated January 25, 2016. Accessed October 29, 2018.
3. Veterans Affairs Canada. https://www.canada.ca/en/veterans-affairs-canada.html. Accessed October 298th, 2018.
4. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. History of Veterans Day. https://www.va.gov/opa/vetsday/vetdayhistory.asp. Updated July 20, 2015. Accessed October 29, 2018.
5. White BD. To properly care for veterans do we really need a VA health care system? http://www.amc.edu/BioethicsBlog/post.cfm/to-properly-care-for-veterans-do-we-really-need-a-va-health-system. Published June 6, 2014. Accessed October 28, 2018.
6. Shulkin DJ. Beyond the VA crisis: Becoming a high-performance network. NEJM. 2016;374(11):1003-1005.
Discrimination, Dignity, and Duty
This spring, Tennessee became the first state in the union to pass legislation that gives a mental health care professional the right to refuse to see a patient based on “sincerely held principles.” HB 1840 reads:
No counselor or therapist providing counseling or therapy services shall be required to counsel or serve a client as to goals, outcomes, or behaviors that conflict with a sincerely held principles of the counselor or therapist; provided, that the counselor or therapist coordinates a referral of the client to another counselor or therapist who will provide the counseling or therapy.1
Although Tennessee was the first, many other states have enacted similar laws over the past year, which critics believe represent discrimination against lesbian, gay, bisexual, and transgender (LGBT) individuals.2
In Tennessee, a late amendment substituted “sincerely held principles” for “sincerely held religious beliefs.” The change from religious beliefs to principles may seem to attenuate the most discriminatory aspects of the law, while actually expanding both its application and acceptance. Although most civil rights advocates believe the law was designed to target LGBT individuals, “sincerely held principles” could potentially affect veterans and active-duty service members (ADSMs) with any socially stigmatized condition or circumstance from domestic violence to addiction.
No doubt, we will see the law’s constitutionality argued in court. We do know that the Supremacy Clause (Article VI, Clause 2) of the U.S. Constitution states that the federal constitution and laws take precedence over state laws and constitutions.3 Not being a lawyer, I cannot opine on how this particular piece of legislation will interact with federal law. But as a physician and an ethicist, I can say that it challenges the foundational commitment of all health care practitioners to place the good of the patient above all other considerations.
In an interview shortly before signing the law, Tennessee governor Bill Haslam discussed his decision-making process. It is “all about values,” he said, “therapists cannot and should not be expected to leave those values out of their work.”4 The governor’s statements are based on a fundamental misunderstanding of the ethical obligations and values intrinsic to the health care practitioner-patient relationship.
As citizens and human beings practitioners are entitled to hold any beliefs, preferences, and principles. But it is the respect for patient’s beliefs, preferences, and values over and above those of the practitioner that make health care practice a profession. Professional relationships in health care are not like those in commerce or industry, entertainment, or advertising; these relationships are of a special fiduciary nature that mandates a duty to care that is expressed in both ancient and modern ethical codes.
The American Counseling Association specifically mentioned its ethics code in the organization’s response to the Tennessee legislation. “HB 1840 is an unprecedented attack on the American Counseling Association’s Code of Ethics, something to which nearly 60,000 counselors abide.”5 In addition, more than half a million counselors and thousands of social workers, physicians, nurses, and pharmacists also abide by codes of ethics, professional principles, and organizational policies contained in provisions explicitly prohibiting the clinician from discriminating against any patient. The American Medical Association, for example, states:
A physician may decline to undertake the care of a patient whose medical condition is not within the physician’s current competence. However, physicians who offer their services to the public may not decline to accept patients because of race, color, religion, national origin, sexual orientation, gender identity or any other basis that would constitute invidious discrimination.6
Governor Haslam reportedly signed the law once it addressed 2 of his concerns.7 The first was that the bill must require that practitioners who object to treating LGBT patients or any other patient on principled grounds refer them to another counselor. Undoubtedly, this requirement is of little comfort for those denied mental health care that live in small communities. Many of these communities already face shortages of mental health professionals and higher levels of prejudice and ostracism, which the law will only amplify.
The second provision insisted on by the governor required a counselor to continue treating a patient if the patient is a danger to himself or herself or others. This provision hardly seems exculpatory when we consider that LGBT military and veteran populations already have higher risks of suicide and struggle to access mental health care, problems the DoD and VA are addressing.8 A referral cannot psychologically mitigate or ethically defend the devastating impact of having a therapist refuse help to an already wounded and isolated patient and may well trigger a suicide attempt.
The VA has made an impressive commitment to end health care disparities for veteran LGBT patients, but much less is known about the health care quality gaps for ADSMs. In both cases, legislation like that enacted in Tennessee only places additional obstacles on that steep climb to health care equity.
Not even the most impassioned advocate of social justice would likely say that a counselor or a nurse is not entitled to have personal beliefs and values. Codes of ethics, hospital policies, and state and federal laws often contain “conscience clauses” allowing persons to decline to participate in procedures that violate their religious and moral beliefs—we will explore this further in a later editorial. But a procedure, for example, prescribing a medication or doing a surgery is different from refusing to serve an entire group of persons on the basis of a characteristic that is neither chosen nor changeable.
A conscience clause summoned to defend or disguise clearly discriminatory actions is invalidated and self-contradictory because it violates the most essential ethical principle, that all human beings are worthy of respect and dignity. Conscientious objection on the grounds of personal religion or morality in health care ends where discrimination against a class of persons denying clinically indicated treatment begins.9
There are multiple clinically concerning implications of this legislation for federal practice. We are only too aware that our organizations historically have failed to safeguard the rights and dignity of ADSMs or veterans who belong to many types of minority groups. But recently we have made progress in addressing these health care disparities especially for the VA LGBT community.10 Legislation like that passed in Tennessee and proposed in other states threatens to undermine these gains for those who served honorably and those who still put their life on the line to defend “liberty and justice for all.”
Even if we continue to uphold high moral and legal principles in regards to the patients we treat in our institutions, millions of ADSM and veterans receive their care in the community, especially with the advent of the Choice Act. Our duty to care must begin within our federal auspices to ensure that all those we treat receive health care with dignity, but it must extend outside the walls of our institutions to protect those who have been or are now in uniform against discrimination in health care.
1. An Act to amend Tennessee Code , Title 4; Title 49 and Title 63, relative to conscientious objections to the provision of counseling and therapy. Tennessee Annotated Code. HB 1840 109th Leg (Tenn 2016).
2. Dobuzinskis A. Tennessee law to allow counselors to deny service based on beliefs. Reuters website. http://www.reuters.com/article/us-tennessee-counseling-law-idUSKCN0XO2VH. Published April 28, 2016. Accessed May 9, 2016.
3. Alexander MC. A Short and Happy Guide to Constitutional Law. St. Paul, MN: West Academic; 2013.
4. Inskeep S. For Tennessee governor weighing religious objection bill, it’s all about values. National Public Radio website. http://wnpr.org/post/tenn-gov-weighing-therapist-religious-objection-bill-its-all-about-values#stream/0. Published April 21, 2016. Accessed May 9, 2016.
5. American Counseling Association. Tennessee advances bill that tells counselors to discriminate. American Counseling Association website. https://www.counseling.org/news/updates/2016/03/24/tennessee-advances-bill-that-tells-counselors-to-discriminate. Published March 24, 2016. Accessed May 8, 2016.
6. American Medical Association. E-9.12 patient-physician relationship: respect for law and human rights. American Medical Association website. http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/ama-policy-regarding-sexual-orientation.page? Adopted November 2007. Accessed May 9, 2016.
7. Wagner L. Tennessee enacts law letting therapists refuse patients on religious grounds. National Public Radio website. http://wnpr.org/post/tennessee-enacts-law-letting-therapists-refuse-patients-religious-grounds#stream/0. Published April 27, 2016. Accessed May 9, 2016.
8. Matarazzo BB, Barnes SM, Pease JL, et al. Suicide risk among lesbian, gay, bisexual, and transgender military personnel and veterans: what does the literature tell us? Suicide Life Threat Behav. 2014;44(2):200-217.
9. Dickens BM. Legal protection and limits of conscientious objection: when conscientious objection is unethical. Med Law. 2009;28(2):337-347.
10. Sharpe VA, Uchendu US. Ensuring appropriate care for LGBT veterans in the Veterans Health Administration. Hastings Cent Rep. 2014;44(suppl 4):S53-S55.
This spring, Tennessee became the first state in the union to pass legislation that gives a mental health care professional the right to refuse to see a patient based on “sincerely held principles.” HB 1840 reads:
No counselor or therapist providing counseling or therapy services shall be required to counsel or serve a client as to goals, outcomes, or behaviors that conflict with a sincerely held principles of the counselor or therapist; provided, that the counselor or therapist coordinates a referral of the client to another counselor or therapist who will provide the counseling or therapy.1
Although Tennessee was the first, many other states have enacted similar laws over the past year, which critics believe represent discrimination against lesbian, gay, bisexual, and transgender (LGBT) individuals.2
In Tennessee, a late amendment substituted “sincerely held principles” for “sincerely held religious beliefs.” The change from religious beliefs to principles may seem to attenuate the most discriminatory aspects of the law, while actually expanding both its application and acceptance. Although most civil rights advocates believe the law was designed to target LGBT individuals, “sincerely held principles” could potentially affect veterans and active-duty service members (ADSMs) with any socially stigmatized condition or circumstance from domestic violence to addiction.
No doubt, we will see the law’s constitutionality argued in court. We do know that the Supremacy Clause (Article VI, Clause 2) of the U.S. Constitution states that the federal constitution and laws take precedence over state laws and constitutions.3 Not being a lawyer, I cannot opine on how this particular piece of legislation will interact with federal law. But as a physician and an ethicist, I can say that it challenges the foundational commitment of all health care practitioners to place the good of the patient above all other considerations.
In an interview shortly before signing the law, Tennessee governor Bill Haslam discussed his decision-making process. It is “all about values,” he said, “therapists cannot and should not be expected to leave those values out of their work.”4 The governor’s statements are based on a fundamental misunderstanding of the ethical obligations and values intrinsic to the health care practitioner-patient relationship.
As citizens and human beings practitioners are entitled to hold any beliefs, preferences, and principles. But it is the respect for patient’s beliefs, preferences, and values over and above those of the practitioner that make health care practice a profession. Professional relationships in health care are not like those in commerce or industry, entertainment, or advertising; these relationships are of a special fiduciary nature that mandates a duty to care that is expressed in both ancient and modern ethical codes.
The American Counseling Association specifically mentioned its ethics code in the organization’s response to the Tennessee legislation. “HB 1840 is an unprecedented attack on the American Counseling Association’s Code of Ethics, something to which nearly 60,000 counselors abide.”5 In addition, more than half a million counselors and thousands of social workers, physicians, nurses, and pharmacists also abide by codes of ethics, professional principles, and organizational policies contained in provisions explicitly prohibiting the clinician from discriminating against any patient. The American Medical Association, for example, states:
A physician may decline to undertake the care of a patient whose medical condition is not within the physician’s current competence. However, physicians who offer their services to the public may not decline to accept patients because of race, color, religion, national origin, sexual orientation, gender identity or any other basis that would constitute invidious discrimination.6
Governor Haslam reportedly signed the law once it addressed 2 of his concerns.7 The first was that the bill must require that practitioners who object to treating LGBT patients or any other patient on principled grounds refer them to another counselor. Undoubtedly, this requirement is of little comfort for those denied mental health care that live in small communities. Many of these communities already face shortages of mental health professionals and higher levels of prejudice and ostracism, which the law will only amplify.
The second provision insisted on by the governor required a counselor to continue treating a patient if the patient is a danger to himself or herself or others. This provision hardly seems exculpatory when we consider that LGBT military and veteran populations already have higher risks of suicide and struggle to access mental health care, problems the DoD and VA are addressing.8 A referral cannot psychologically mitigate or ethically defend the devastating impact of having a therapist refuse help to an already wounded and isolated patient and may well trigger a suicide attempt.
The VA has made an impressive commitment to end health care disparities for veteran LGBT patients, but much less is known about the health care quality gaps for ADSMs. In both cases, legislation like that enacted in Tennessee only places additional obstacles on that steep climb to health care equity.
Not even the most impassioned advocate of social justice would likely say that a counselor or a nurse is not entitled to have personal beliefs and values. Codes of ethics, hospital policies, and state and federal laws often contain “conscience clauses” allowing persons to decline to participate in procedures that violate their religious and moral beliefs—we will explore this further in a later editorial. But a procedure, for example, prescribing a medication or doing a surgery is different from refusing to serve an entire group of persons on the basis of a characteristic that is neither chosen nor changeable.
A conscience clause summoned to defend or disguise clearly discriminatory actions is invalidated and self-contradictory because it violates the most essential ethical principle, that all human beings are worthy of respect and dignity. Conscientious objection on the grounds of personal religion or morality in health care ends where discrimination against a class of persons denying clinically indicated treatment begins.9
There are multiple clinically concerning implications of this legislation for federal practice. We are only too aware that our organizations historically have failed to safeguard the rights and dignity of ADSMs or veterans who belong to many types of minority groups. But recently we have made progress in addressing these health care disparities especially for the VA LGBT community.10 Legislation like that passed in Tennessee and proposed in other states threatens to undermine these gains for those who served honorably and those who still put their life on the line to defend “liberty and justice for all.”
Even if we continue to uphold high moral and legal principles in regards to the patients we treat in our institutions, millions of ADSM and veterans receive their care in the community, especially with the advent of the Choice Act. Our duty to care must begin within our federal auspices to ensure that all those we treat receive health care with dignity, but it must extend outside the walls of our institutions to protect those who have been or are now in uniform against discrimination in health care.
This spring, Tennessee became the first state in the union to pass legislation that gives a mental health care professional the right to refuse to see a patient based on “sincerely held principles.” HB 1840 reads:
No counselor or therapist providing counseling or therapy services shall be required to counsel or serve a client as to goals, outcomes, or behaviors that conflict with a sincerely held principles of the counselor or therapist; provided, that the counselor or therapist coordinates a referral of the client to another counselor or therapist who will provide the counseling or therapy.1
Although Tennessee was the first, many other states have enacted similar laws over the past year, which critics believe represent discrimination against lesbian, gay, bisexual, and transgender (LGBT) individuals.2
In Tennessee, a late amendment substituted “sincerely held principles” for “sincerely held religious beliefs.” The change from religious beliefs to principles may seem to attenuate the most discriminatory aspects of the law, while actually expanding both its application and acceptance. Although most civil rights advocates believe the law was designed to target LGBT individuals, “sincerely held principles” could potentially affect veterans and active-duty service members (ADSMs) with any socially stigmatized condition or circumstance from domestic violence to addiction.
No doubt, we will see the law’s constitutionality argued in court. We do know that the Supremacy Clause (Article VI, Clause 2) of the U.S. Constitution states that the federal constitution and laws take precedence over state laws and constitutions.3 Not being a lawyer, I cannot opine on how this particular piece of legislation will interact with federal law. But as a physician and an ethicist, I can say that it challenges the foundational commitment of all health care practitioners to place the good of the patient above all other considerations.
In an interview shortly before signing the law, Tennessee governor Bill Haslam discussed his decision-making process. It is “all about values,” he said, “therapists cannot and should not be expected to leave those values out of their work.”4 The governor’s statements are based on a fundamental misunderstanding of the ethical obligations and values intrinsic to the health care practitioner-patient relationship.
As citizens and human beings practitioners are entitled to hold any beliefs, preferences, and principles. But it is the respect for patient’s beliefs, preferences, and values over and above those of the practitioner that make health care practice a profession. Professional relationships in health care are not like those in commerce or industry, entertainment, or advertising; these relationships are of a special fiduciary nature that mandates a duty to care that is expressed in both ancient and modern ethical codes.
The American Counseling Association specifically mentioned its ethics code in the organization’s response to the Tennessee legislation. “HB 1840 is an unprecedented attack on the American Counseling Association’s Code of Ethics, something to which nearly 60,000 counselors abide.”5 In addition, more than half a million counselors and thousands of social workers, physicians, nurses, and pharmacists also abide by codes of ethics, professional principles, and organizational policies contained in provisions explicitly prohibiting the clinician from discriminating against any patient. The American Medical Association, for example, states:
A physician may decline to undertake the care of a patient whose medical condition is not within the physician’s current competence. However, physicians who offer their services to the public may not decline to accept patients because of race, color, religion, national origin, sexual orientation, gender identity or any other basis that would constitute invidious discrimination.6
Governor Haslam reportedly signed the law once it addressed 2 of his concerns.7 The first was that the bill must require that practitioners who object to treating LGBT patients or any other patient on principled grounds refer them to another counselor. Undoubtedly, this requirement is of little comfort for those denied mental health care that live in small communities. Many of these communities already face shortages of mental health professionals and higher levels of prejudice and ostracism, which the law will only amplify.
The second provision insisted on by the governor required a counselor to continue treating a patient if the patient is a danger to himself or herself or others. This provision hardly seems exculpatory when we consider that LGBT military and veteran populations already have higher risks of suicide and struggle to access mental health care, problems the DoD and VA are addressing.8 A referral cannot psychologically mitigate or ethically defend the devastating impact of having a therapist refuse help to an already wounded and isolated patient and may well trigger a suicide attempt.
The VA has made an impressive commitment to end health care disparities for veteran LGBT patients, but much less is known about the health care quality gaps for ADSMs. In both cases, legislation like that enacted in Tennessee only places additional obstacles on that steep climb to health care equity.
Not even the most impassioned advocate of social justice would likely say that a counselor or a nurse is not entitled to have personal beliefs and values. Codes of ethics, hospital policies, and state and federal laws often contain “conscience clauses” allowing persons to decline to participate in procedures that violate their religious and moral beliefs—we will explore this further in a later editorial. But a procedure, for example, prescribing a medication or doing a surgery is different from refusing to serve an entire group of persons on the basis of a characteristic that is neither chosen nor changeable.
A conscience clause summoned to defend or disguise clearly discriminatory actions is invalidated and self-contradictory because it violates the most essential ethical principle, that all human beings are worthy of respect and dignity. Conscientious objection on the grounds of personal religion or morality in health care ends where discrimination against a class of persons denying clinically indicated treatment begins.9
There are multiple clinically concerning implications of this legislation for federal practice. We are only too aware that our organizations historically have failed to safeguard the rights and dignity of ADSMs or veterans who belong to many types of minority groups. But recently we have made progress in addressing these health care disparities especially for the VA LGBT community.10 Legislation like that passed in Tennessee and proposed in other states threatens to undermine these gains for those who served honorably and those who still put their life on the line to defend “liberty and justice for all.”
Even if we continue to uphold high moral and legal principles in regards to the patients we treat in our institutions, millions of ADSM and veterans receive their care in the community, especially with the advent of the Choice Act. Our duty to care must begin within our federal auspices to ensure that all those we treat receive health care with dignity, but it must extend outside the walls of our institutions to protect those who have been or are now in uniform against discrimination in health care.
1. An Act to amend Tennessee Code , Title 4; Title 49 and Title 63, relative to conscientious objections to the provision of counseling and therapy. Tennessee Annotated Code. HB 1840 109th Leg (Tenn 2016).
2. Dobuzinskis A. Tennessee law to allow counselors to deny service based on beliefs. Reuters website. http://www.reuters.com/article/us-tennessee-counseling-law-idUSKCN0XO2VH. Published April 28, 2016. Accessed May 9, 2016.
3. Alexander MC. A Short and Happy Guide to Constitutional Law. St. Paul, MN: West Academic; 2013.
4. Inskeep S. For Tennessee governor weighing religious objection bill, it’s all about values. National Public Radio website. http://wnpr.org/post/tenn-gov-weighing-therapist-religious-objection-bill-its-all-about-values#stream/0. Published April 21, 2016. Accessed May 9, 2016.
5. American Counseling Association. Tennessee advances bill that tells counselors to discriminate. American Counseling Association website. https://www.counseling.org/news/updates/2016/03/24/tennessee-advances-bill-that-tells-counselors-to-discriminate. Published March 24, 2016. Accessed May 8, 2016.
6. American Medical Association. E-9.12 patient-physician relationship: respect for law and human rights. American Medical Association website. http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/ama-policy-regarding-sexual-orientation.page? Adopted November 2007. Accessed May 9, 2016.
7. Wagner L. Tennessee enacts law letting therapists refuse patients on religious grounds. National Public Radio website. http://wnpr.org/post/tennessee-enacts-law-letting-therapists-refuse-patients-religious-grounds#stream/0. Published April 27, 2016. Accessed May 9, 2016.
8. Matarazzo BB, Barnes SM, Pease JL, et al. Suicide risk among lesbian, gay, bisexual, and transgender military personnel and veterans: what does the literature tell us? Suicide Life Threat Behav. 2014;44(2):200-217.
9. Dickens BM. Legal protection and limits of conscientious objection: when conscientious objection is unethical. Med Law. 2009;28(2):337-347.
10. Sharpe VA, Uchendu US. Ensuring appropriate care for LGBT veterans in the Veterans Health Administration. Hastings Cent Rep. 2014;44(suppl 4):S53-S55.
1. An Act to amend Tennessee Code , Title 4; Title 49 and Title 63, relative to conscientious objections to the provision of counseling and therapy. Tennessee Annotated Code. HB 1840 109th Leg (Tenn 2016).
2. Dobuzinskis A. Tennessee law to allow counselors to deny service based on beliefs. Reuters website. http://www.reuters.com/article/us-tennessee-counseling-law-idUSKCN0XO2VH. Published April 28, 2016. Accessed May 9, 2016.
3. Alexander MC. A Short and Happy Guide to Constitutional Law. St. Paul, MN: West Academic; 2013.
4. Inskeep S. For Tennessee governor weighing religious objection bill, it’s all about values. National Public Radio website. http://wnpr.org/post/tenn-gov-weighing-therapist-religious-objection-bill-its-all-about-values#stream/0. Published April 21, 2016. Accessed May 9, 2016.
5. American Counseling Association. Tennessee advances bill that tells counselors to discriminate. American Counseling Association website. https://www.counseling.org/news/updates/2016/03/24/tennessee-advances-bill-that-tells-counselors-to-discriminate. Published March 24, 2016. Accessed May 8, 2016.
6. American Medical Association. E-9.12 patient-physician relationship: respect for law and human rights. American Medical Association website. http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/ama-policy-regarding-sexual-orientation.page? Adopted November 2007. Accessed May 9, 2016.
7. Wagner L. Tennessee enacts law letting therapists refuse patients on religious grounds. National Public Radio website. http://wnpr.org/post/tennessee-enacts-law-letting-therapists-refuse-patients-religious-grounds#stream/0. Published April 27, 2016. Accessed May 9, 2016.
8. Matarazzo BB, Barnes SM, Pease JL, et al. Suicide risk among lesbian, gay, bisexual, and transgender military personnel and veterans: what does the literature tell us? Suicide Life Threat Behav. 2014;44(2):200-217.
9. Dickens BM. Legal protection and limits of conscientious objection: when conscientious objection is unethical. Med Law. 2009;28(2):337-347.
10. Sharpe VA, Uchendu US. Ensuring appropriate care for LGBT veterans in the Veterans Health Administration. Hastings Cent Rep. 2014;44(suppl 4):S53-S55.
