Tuesday, April 21, 2009

The conscience clause.

This may be one of my last posts to Sinus. But I’d like to get involved in one more nurseblog debate on the conscience clause and the discussion as to whether Obama should work to undo this legislation.

Namely, Emergiblog Kim’s initial post here

And subsequent ‘rebuttals’ (if you will):

Duncan Cross wrote.
And Manchmedic wrote.

I agree with Manchmedic.

I think that the government has no place regulating …as part of a state Constitution (much less Federal)…what private American worker should do as part of their job description for a private employer. Legal precedent exists to protect workplace safety (OSHA, child labor, harassment). The government can direct a soldier to war, because that soldier enlisted for that job description. (I don’t like the draft, either.) There are laws about taxation on income, and discrimination.

But this conscience clause is about driving contractual details (i.e. job description and responsibiities) between private corporations (i.e. non-VA hospitals) who hire citizens as employees.

Despite the fact that all civilized people believe that workplaces should be equal opportunity, the need for actual LAWS within a state or federal constitution that direct how workplace equality is to take place is still debated.

California nurse to patient ratio laws are new. Some CA nurses have said that their ratios are better, and they've lost ancillary staff and charge roles as hospitals even out the bottom line. That the ER's overflow. Government with good intent is slower than private enterprise. Perhaps not the optimal solution.

In my opinion, Dubya confused church and state and understood neither. Our founding fathers were very clear on this whole church-state separation thing. This issue is not about God, or beliefs, or hot-button Roe v. Wade.

It’s about what your employer expects that you do for them.

Do you really want the state constitution getting involved in that?

On this ground, I think the clause is a horrible idea and should be un-done.


There’s a secondary reason why I disagree with the conscience clause.

I believe with every molecule comprising my body that every human being should be treated that way when they leave. That they should be treated in a way that THEY direct. That we should do the utmost to provide for THEIR needs. That they are free of pain. That they are treated with dignity and respect. That we do everything we can to alleviate the other horrible undignified ‘symptoms’ of the dying process: nausea, vomiting, incontinence, wakeful coughing, clinical anxiety. And in the best situations, people are surrounded by love. The reality is that not everybody’s gonna get that. But I believe it’s what we need to aim for.

Some nurses like sunrises. I like sunsets.

Babies are great, fun, joyful. When I am the best nurse I'm capable of being, it's often with a patient who has made a decision that they're ready for their next big adventure. I am a rabid advocate for pain and symptom management.

I don’t believe in flogging bodies through endless complex procedures that have poor chances for positive outcomes. But sometimes I do it. I'm dialysis, for chrissakes.

There are many situations where I have participated in medical care that violates my humanist beliefs in the right for a patient's dignity and self-direction. Every ICU nurse has participated in cases that have gone before ethics boards. The young person who is HIV+ and after long, protracted illness, wishes to die. A parent wants everything done. Ethics board decides to go for the gusto. Dialyze!

A patient whose family has such financial interest in keeping patient alive that they are able to get him declared mentally incompetent under suspicious circumstances. When clinical psychiatrist, after thorough evaluation of patient, finds patient (to no surprise from staff) to be not only sound, but erudite and thoughtful about his own care, lawsuit by family ensues.

The dialysis patient who is a social work nightmare who becomes pregnant…the highest risk pregnancy I have ever seen. Patient has multiple hospital readmissions since the birth. Have we done that child any favors? Will the child become president or did we bring a human being into terrible suffering and adversity?

I find it morally reprehensible to paralyze a patient with vecuronium and provide no pain medication. I have done so and charted the hell out of the calls to the cardiovascular (bastard) surgeon who had me perform this odious torture. I advocated for my patient in much gentler ways through the family (uneducated in such medications) as well.

I have NOT given blood to a Jehovah’s Witness with a hemoglobin of 5, because the patient does not want that intervention. The patient understood that a lot of physical suffering could be alleviated. To the patient, the spiritual suffering would have been worse.

At no point in time did it ever occur to me to refuse to care for any of these patients. My point here isn’t that any good nurse would not have provided the same care. My point is that a pro-lifer's moral difficulties with abortion are very like my moral difficulties with the 92 year old CABGx5.

But here’s the rub:


If I don’t want to do the job, I can find a different job. There are nursing jobs that will not put me into a situation that violates my humanist values. My chosen nursing path so far is one of the least morally obstacle free I could have chosen for myself: critical care and dialysis.

However, if I am not going to choose to get a different job where I find such tasks ‘morally repugnant’, I choose to be a professional. You do your job. You prolong the life, you give the person comfort AND advanced intervention of Western medicine. Chemo. Or dialysis. Or intubation. Or surgery. Whatever.

It is not for me to decide whether or not a woman should have an abortion, or a 92 year old should undergo a cardiac bypass graft times five. It’s not for me to decide a crack addict has any business going home with her premature baby. It’s not for me to refuse to take care of an critically ill withdrawing alcoholic/any-other-substance-abuser because I think alcoholism/substance is ‘bad’. Or whatever.

I volunteered at a health fair today and a man asked me which substance be more 'okay' for his heart condition: cocaine, marijuana, alcohol or speed? I answered his question indirectly: cocaine and speed will kill you. No, I don't want him to go smokin pot.

It is for me to provide the best clinical and compassionate care for the patient that I can. I’m not giving up my personal rights as a nurse. Nobody’s asking me to have open heart surgery. Or do anything with my body. Or take up heroin. If I find somebody else’s medical choices to be repugnant, that is entirely my problem.


Nobody LIKES abortion. Think about it. Whether you’re pro-life or pro-choice, nobody thinks abortion sounds like a fun time, or something that’s really cool. Nobody says, “Hey! Let’s murder a fetus/baby (whichever you prefer) today!” No. Nobody wants to have one. Nobody wants their daughter to have one. We are all in agreement on this point.

The great thing is that we don’t have to agree on whether abortion should be available to women or not. Abortion is available to women by law and has been since Steely Dan was cool and I was still in diapers. In 2003, one method of abortion was made illegal, thanks to Dubya. Nobody is asking any of you nurses to ‘participate’ in that procedure, as no one is performing it in this country.


I don't need a clause in the constitution of my state to tell me that I can refuse to participate in a medical procedure.

If I have a problem doing my job, I can refresh my resume.


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Chris said...

I hope this isn't one of your last posts. It was a good one. Keep blogging.

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