Source: https://www.consciencelaws.org/law/commentary/legal040-008-01.aspx
Timestamp: 2020-06-05 05:58:26
Document Index: 403546606

Matched Legal Cases: ['§ 88', '§ 88', '§ 245', '§ 508', '§ 245', '§ 245', '§ 508', '§ 508', '§ 2', '§ 508', '§ 101', '§ 245', '§ 245', 'arts 74']

Home : Law : Legal Commentary : USA : FEDERAL LAWS : HHS Nondiscrimination Regulation : Bush HHS Conscience Reg. : Institution of : Dept. of HHS
From the Federal Register / Vol. 73, No. 245 / Friday, December 19, 2008 / Rules and Regulations: Part VI, 78072-78101.
Conscience Clauses/Church Amendments
[Concern about intolerance]
[Concern about discriminatory exclusion/isolation]
[Concern about access to care]
[Physician-patient relationship]
[Balancing of interests]
[Intentions of Dept. of HHS]
[Scope of rule]
[Investigation of non-compliance]
[Resolution of non-compliance]
[Religious Belief/Moral Conviction]
C. Comments on Proposed New Â§ 88.3- Applicability
E. Comments on Proposed New Â§ 88.5- Written Certification of Compliance
[Access Hotline]
[Providing Information/Informed Consent]
[Hindering Research]
Church Amendments, 42 U.S.C.300a-7 (2000)
PHS Act Â§ 245, 42 U.S.C. 238n (1996)
The Weldon Amendment, Consolidated Appropriations Act, 2008,Public Law 110-161, Â§ 508(d), 121 Stat.1844, 2209 (2008)
Section 88.5 Written Certification of Compliance Section
88.6 Complaint Handling and Investigating
Headings/comments in red text in square brackets added by Project Administrator for convenience.
Several provisions of federal law prohibit recipients of certain federal funds from coercing individuals in the health care field into participating in actions they find religiously or morallyobjectionable. These same provisions also prohibit discrimination on the basis of one's objection to, participation in, or refusal to participate in, specific medical procedures, including abortionor sterilization. In addition, there is a statutory provision that prohibits the federal government and State and local governments from discriminating against individual and institutional providers who refuse, among other things, to receive training in abortions, require or provide such training, perform abortions, or refer for or make arrangements for abortions or training in abortions. More recently, an appropriations provision has been enacted (and reenacted or incorporated into every appropriations act since the appropriations act for Fiscal Year 2005) that prohibits certain federal agencies and programs and State and local governments that receive certain federal funds from discriminating against individuals and institutions that refuseto, among other things, provide, refer for, pay for, or cover, abortion. These statutes are collectively referred to as the ''federal health care conscience protection statutes.'' This rule isintended to ensure that, in the delivery of health care and other health services, recipients of Department funds do not support coercive or discriminatory practices in violation of these laws.
The conscience provisions contained in 42 U.S.C. 300a-7 (collectively known as the ''Church Amendments'') were enacted at various times during the 1970s in Response to debates overwhether receipt of federal funds required the recipients of such funds to perform abortions or sterilizations. The first conscience provision in the Church Amendments, 42 U.S.C. 300a-7(b),provides that ''[t]he receipt of any grant,contract, loan, or loan guarantee under [certain statutes implemented by the Department of Health and Human Services] * * * by any individual or entity does not authorize any court or any public official or other public authority to require'':
(1) The individual to perform or assist in a sterilization procedure or an abortion, if it would be contrary to his/her religious beliefs or moral convictions;
(2) the entity to make its facilities available for sterilization procedures or abortions, if the performance of sterilization procedures or abortions in the facilities is prohibited by the entity on the basis of religious beliefs or moral convictions; or
(3) the entity to provide personnel for the performance of sterilization procedures or abortions, if it would be contrary to the religious beliefs or moralconvictions of such personnel.
The second conscience provision in the Church Amendments, 42 U.S.C. 300a-7(c)(1), prohibits any entity which receives a grant, contract, loan, or loan guarantee under certain Department implemented statutes from discriminating against any physician or other health care personnel in employment, promotion, termination of employment, or the extension of staff or other privileges because the individual either ''performed or assisted in the performance of a lawful sterilization procedure or abortion, or because he refused to perform or assist in the performance of such a procedure or abortion on the grounds that his performance or assistance in the performance of the procedure or abortion would be contrary to his religious beliefs or moral convictions, or because of his religious beliefs or moral convictions respecting sterilization procedures or abortions.''
The third conscience provision, contained in 42 U.S.C. 300a-7(c)(2), prohibits any entity which receives a grant or contract for biomedical or behavioral research under any program administered by the Department from discriminating against any physician or other health care personnel in employment, promotion, termination of employment, or extension of staff orother privileges ''because he performed or assisted in the performance of any lawful health service or research activity, or because he refused to perform or assist in the performance ofany such service or activity on the grounds that his performance of such service or activity would be contrary to his religious beliefs or moral convictions, or because of his religiousbeliefs or moral convictions respecting any such service or activity.''
The fourth conscience provision, 42 U.S.C. 300a-7(d), provides that ''[n]o individual shall be required to perform or assist in the performance of any part of a health service program or research activity funded in whole or in part under a program administered by [the Department] if his performance or assistance in the performance of such part of such program or activity would be contrary to his religious beliefs or moral convictions.''
The final conscience provision contained in the Church Amendments, 42 U.S.C. 300a-7(e), prohibits any entity that receives a grant, contract, loan, or loan guarantee under certainDepartmentally implemented statutes from denying admission to, or otherwise discriminating against, ''any applicant (including for internships and residencies) for training or studybecause of the applicant's reluctance, or willingness, to counsel, suggest, recommend, assist, or in any way participate in the performance of abortions or sterilizations contrary to orconsistent with the applicant's religious beliefs or moral convictions.''
Public Health Service Act Â§ 245 [42 U.S.C. 238n]
Enacted in 1996, section 245 of the Public Health Service Act (PHS Act) prohibits the federal government and any State or local government receiving federal financial assistance fromdiscriminating against any health care entity on the basis that the entity
(1) refuses to receive training in the performance of abortions, to require or provide such training, to perform such abortions, or to provide referrals for such training or such abortions;
(2) refuses to make arrangements for such activities; or
(3) attends or attended a post-graduate physician training program or any other training program in the health professions that does not (or did not) perform abortions or require, provide, or refer for training in the performance of abortions or make arrangements for the provision of such training. For the purposes of this protection, the statute defines ''financial assistance'' as including, ''with respect to a government program,'' ''governmental payments provided as reimbursement for carrying out health related activities.''
In addition, PHS Act Â§ 245 requires that, in determining whether to grant legal status to a health care entity (including a State's determination of whether to issue a license or certificate (such as a medical license)), the federal government and any State or local government receiving federal financial assistance deem accredited any post-graduate physician training program that would be accredited, but for the reliance on an accrediting standard that, regardless of whether such standard provides exceptions or exemptions, requires an entity:
(1) To perform induced abortions; or
(2) to require, provide, or refer for training in the performance of induced abortions, or make arrangements for such training.
Weldon Amendment [Consolidated Appropriations Act, 2008, Public Law110-161, Div. G, Â§ 508(d), 121 Stat. 1844, 2209 (Dec. 26, 2007)]
The Weldon Amendment, originally adopted as section 508(d) of the Labor-HHS Division (Division F) of the 2005 Consolidated Appropriations Act, Public Law 108-447 (Dec. 8, 2004), has been readopted (or incorporated by reference) in each subsequent HHS appropriations act. Title V of the Departments of Labor, Health and Human Services, and Education, andRelated Agencies Appropriations Act, 2006, Public Law 109-149, Â§ 508(d), 119 Stat. 2833, 2879-80; Revised Continuing Appropriations Resolution of 2007, Public Law 110-5, Â§ 2, 121 Stat. 8, 9; Consolidated Appropriations Act, 2008, Public Law 110-161, Div. G, Â§ 508(d), 121 Stat. 1844, 2209; Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009, Public Law 110-329, Div. A, Â§ 101, 122 Stat. 3574, 3575.
The Weldon Amendment provides that ''[n]one of the funds made available under this Act [making appropriations for the Departments of Labor, Health and Human Services, and Education] may be made available to a federal agency or program, or to a State or local government, if such agency, program, or government subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions.'' It also defines ''health care entity'' to include ''an individual physician or other health care professional, a hospital, a provider sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.''
On August 26, 2008 (73 FR 50274), the Office of the Secretary, Department of Health and Human Services, published a Notice of Proposed Rulemaking (proposed rule) entitled, ''Ensuring That Department of Health and Human Services Funds Do Not Support Coercive or DiscriminatoryPolicies or Practices In Violation of Federal Law.'' The proposed rule set forth the purpose of the proposed rule, proposed definitions to clarify the meaning of statutory requirements, and proposed to require certain recipients and sub-recipients of Departmental funds to certify their compliance with the statutory requirements. The Comment: period closed on September 25, 2008.
[Concern about intolerance] As noted in the preamble to the proposed rule, the Department is concerned about the development of an environment in sectors of the health care field that is intolerant of individualobjections to abortion or other individual religious beliefs or moral convictions. Such developments may discourage individuals from entering health care professions. Such developments also promote the mistaken belief that rights of conscience and self-determination extend to all persons, except health care providers.
[Concern about discriminatory exclusion/isolation] Additionally, religious and faith-based organizations have a long tradition of providing medical care in the United States, and they continue to do so today-some of these are among the largest providers of health care in this nation. Such institutions may have traditions of issuing clear public guidance which informs the members of their workforces, including physicians having privileges at their institutions, of the parameters under which they should operate in accordance with the organization's overall mission and ethics. A trend that isolates and excludes some among various religious, cultural, and/or ethnic groups from participating in the delivery of health care is especially troublesome when considering current and anticipated shortages of health care professionals in many medical disciplines and regions of the country.
[Concern about access to care] The Department is committed to its mission of expanding patient access to necessary health care services. Americans can enjoy healthier, happier, and more productive lives through access to, and appropriate utilization of, all of the life-saving and life-improving procedures and services produced by medical innovation. The Department has a long history of demonstrated success in facilitating the improvement of lives in this way.
[Physician-patient relationship] A necessary element in ensuring the best possible care for patients is protecting the integrity of the doctor patient relationship. Patients need full access to their health care provider's best judgment as informed by practice, knowledge, and experience. This relationship requires open communication between both parties so patients can be confident that the care they seek and receive is endorsed by their health care provider. It is one of the reasons for the common practice of patients meeting with several health care providers in order to find the one in whom they are most confident about entrusting their care. This helps ensure patients receive the care they believe is appropriate, and that doctors provide care that they are comfortable providing.
[Balancing of interests] The doctor-patient relationship requires a balancing of interests. The patient has an interest in obtaining legal health care services-and, in the context of federally funded health care programs, an eligible patient may have the right to obtain certain health care services from certain entities. This must be balanced against the statutory right of the provider in the context of a federally funded entity to not be discriminated against based on a refusal to participate in a service to which they have objections, such as abortion. As stated above, Congress recognized those provider rights in several statutes.
The Department seeks to ensure this balance through raising awareness of federal health care conscience protection laws by specifically including reference to the nondiscrimination provisions contained in the Church Amendments, PHS Act Â§ 245, and the Weldon Amendment incertifications currently required of most existing and potential recipients of Department funds. It also seeks to provide for Departmental enforcement of these three statutes.
[Intentions of Dept. of HHS]Toward these ends, the Department has concluded that regulations and related efforts are necessary, in order to
(2) work with State and local governments and other recipients of funds from the Department to ensure compliance with the nondiscrimination requirements embodied in the Church Amendments, PHS Act Â§ 245, and theWeldon Amendment;
(3) when such compliance efforts prove unsuccessful, enforce these health care conscience protection laws through the various Department mechanisms currently in existence, to ensure that Department funds do not support morally coercive or discriminatory practices or policies in violation of federal law; and
(4) otherwise take an active role in promoting open communication within the health care field, and between providers and patients, fostering a more inclusive, tolerant environment in the health care industry than may currently exist.
[Reproductive health services] The ability of patients to access health care services, including abortion and reproductive health services, is long established and is not changed in this rule. Instead, this rule implements federal laws protecting health care workers and institutions from being compelled to participate in, or from being discriminated against for refusal to participate in, health services or research activities that may violate their consciences, including abortion and sterilization, by entities that receive certain funding from the Department. (It also implements the provisions of federal law which protect health care personnel from being discriminated against for their participation in any lawful health service or research activity, including abortion and sterilization, by entities that receive certain funding from the Department.)
[Transparency] Delivery of health care services is significantly improved when patients and health care providers have full, open, and honest conversations about the services they request and provide. These conversations are particularly useful at the beginning of a patient provider relationship. This rule should help generate greater transparency between patients and providers and foster open discussion, which should strengthen relationships between patients and providers, as well as those between entities and their employees.
[Scope of rule] This final rule sets out, and provides further definition of, the rights and responsibilities created by the federal health care provider conscience provisions. It clarifies the scope of protections to applicable members of the Department's workforce, as well as health care entities and members of the workforces of entities receiving Department funds. This final rule also requires certain recipients and subrecipients of Department funds to certify compliance with these federal requirements. In order to ensure proper enforcement, this final rule defines certain terms for the purposes of this final rule.
[Investigation of non-compliance] As was stated in the preamble to the proposed rule, the Office for Civil Rights (OCR) of the Department of Health and Human Services has been designated to receive complaints of discrimination and coercion based on the healthcare conscience protection statutes and this regulation. OCR will coordinate handling of complaints with the staff of the Departmental programs from which the entity, with respect to whom a complaint has been filed, receives funding (i.e., Department funding component). Enforcement of the requirements set forth in this regulation will be conducted by staff of the Department funding component through the usual and ordinary program mechanisms. Compliance with the requirements promulgated herein will likely be examined as part of any broader compliance review conducted by Department staff.
[Resolution of non-compliance]If the Department becomes aware that a State or local government or an entity may have undertaken activities that could lead to violation of, or may actually be in violation of, the requirements or prohibitions promulgated herein, the Department will work with such government or entity to assist such government or entity to comply or come into compliance with such requirements or prohibitions. If, despite the Department's assistance, compliance is not achieved, the Department will consider all legal options, including termination of funding, return of funds paid out in violation of health care conscience protection provisions under 45 CFR parts 74, 92, and 96, as applicable.