Marylanders deserve better end of life options and full disclosure of which providers decline those options for religious reasons. Mathew Goldstein describes a legislative move expected early next year.

/By Mathew Goldstein/ Many health care facilities in the United States are owned or operated by religious institutions.  About twenty percent of all hospital beds in the United States are owned or controlled by the Catholic church.  Religious health care facilities sometimes opt to give their religious authorities the final say over the provision of health care services.   Religious restrictions on the provision of health care are placed not only on hospitals, but also on HMOs, universities, and social services agencies, which provide a significant amount of care to poor and lower income communities. 

 The difficulty in establishing equal standards of care has been further hindered by an increase in the number of states with health provider religious conscience clauses.  Maryland is one of the states with a health provider religious conscience clause. Both individual and institutional health care providers in Maryland can refuse to provide their customers with "artificial insemination, sterilization, or termination of pregnancy" [MD. CODE ANN., HEALTH-GEN. § 20-214]. 

 The role of religious institutions in restricting health care options goes beyond religious conscience clauses.  One example is the opposition to allowing doctors to prescribe a fatal dose of barbiturates for the purposes of hastening death.  For some people, their religious beliefs only make sense to them if length of life always takes priority over the quality of life.  People who hold different beliefs disagree that surviving as long as possible is always a desirable goal.  As a practical matter, due to the strength of the religious lobby in the U.S., the only way any state can pass a law to accommodate the latter people is by including a health provider religious conscience clause.

 Concerns like this make statewide action a high priority: Maryland patients and their families should have rights to make end of life decisions and should be fully informed which health organizations and providers will refuse to honor some or all of these rights due to claims of religious conscience.

 An "End of Life Options Act" bill legalizing physician assisted dying is expected to be introduced in the 2016 Maryland General Assembly session.  Oregon has been collecting data on physician assisted dying for 21 years.  Under Oregon’s law, every step of the process is in the hands of the patient, and those who interfere with or coerce the patient can face criminal prosecution.  Similar laws were enacted in Washington in 2008, Vermont in 2013, and California in 2015.  The Montana Supreme Court legalized physician aid in dying in 2009.

 In Oregon about 0.3% of deaths are physician-assisted.  About one third of terminally ill patients who receive the barbiturates do not consume them.  People with Lou Gehrig's disease (ALS) are the most likely to deliberately hasten their death with prescribed drugs.  Loss of dignity, inability to enjoy life, lack of autonomy, are the leading motives.

 The provisions of the Maryland End of Life Options Act are expected to be similar to those in the other states.  To qualify the patient must be diagnosed with a terminal illness with a prognosis of death within six months, be mentally competent, and be able to self-administer the drugs.  The qualifying patient makes two oral requests to the prescribing physician separated by at least 15 days.  A written request to the prescribing physician must be signed in the presence of two eyewitnesses, at least one of whom is not a relative.  A prescribing and a consulting physician must agree on diagnosis, prognosis, patient capability, and the patient lacking any psychiatric or psychological disorder that would impair judgment.  Either doctor can refer the patient for psychological examination.  The patient must be informed of alternatives by the prescribing physician (comfort care, hospice care, and pain control).  The prescribing physician must talk privately with the patiently to verify that the patient is freely opting to hastening their own death.

 In addition to enacting a physician aid in dying law, Maryland should consider enacting three more health care laws.  One law would require the Department of Health and Mental Hygiene to publish a booklet that explains end of life options in the state.  Maryland lawmakers may want to also consider enacting a law to publish death certificates without cause of death and to restrict access to the full death certificates containing cause of death.  The current draft End of Life Options Act specifies that the death certificate identify cause of death as pharmacologically accelerated imminent death.  Some states allow death certificates to be issued without cause of death.  An option to omit cause of death helps to allay privacy concerns.   The third law will ensure that patients are informed about what health care services are not provided under the existing medical conscience clauses.

 There is a need to enact a statewide law protecting patients’ right to know about the health care providers that do not provide certain care based on religious or philosophical beliefs. This will better balance the religious liberty of health care providers with the liberty of patients to obtain appropriate health care.  Such a law will require that any health care provider who uses religious beliefs to determine patient care instead of standard medical guidelines and practices, thereby resulting in any health care options being omitted or favored based on these religious beliefs, to inform patients in writing of health care services that are not available to the patients through this particular provider.  Patients must provide signed consent acknowledging they have received this information. Additionally, this law should require health care providers who use religious beliefs to determine patient care to inform health insurance companies of specific health care options that are not provided.  Health insurance companies will share that information with their enrollees and insured participants.