Physicians professional values require them to put the interests of their individual patients ahead of all else, including the physicians' self interest. The AMA Principles of Medical Ethics, for example, includes
VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
Similarly, in health policy and public health, the goal ought to be putting the health of patients as a group, and the public at large, ahead of other considerations.
However, we have often discussed how leaders of large health organizations seemed to put other considerations ahead of individual patients', patients' collectively, or the public's health. Most of those examples of mission-hostile management involved putting organizational finances, or the leaders' own finances ahead of patients' and the public's health. For example, in 2017 we discussed a New York hospital CEO who seemed to put revenue generation in support of his own very generous paycheck ahead of quality of care and patient safety (look here). Also, the revered Mayo Clinic seemed to let patients with more remunerative commercial insurance coverage get attention before poor patients who have only government insurance, despite its stated mission "providing the best care to every patient" (look here). Before November, 2016, our examples of mission-hostile management were mainly hospitals and health systems, insurance companies, and pharmaceutical, biotechnology and device companies.
That was then. This is now.
A Physician Who Seemed to Put Her Religious Beliefs Ahead of Patients' Interests
Late this spring, we noticed the appointment of a US government health care leader which raised concerns about mission hostile management, but in a new dimension. The appointment was summarized by Rewire on May 30, 2018,
Diane Foley, who ran a Christian organization operating two Colorado anti-choice 'crisis pregnancy centers,' or fake clinics, was quietly installed on Tuesday as deputy assistant secretary for population affairs, where she will lead the office responsible for the Title X federal family planning program.
The U.S. Department of Health & Human Services (HHS) said little about Foley in its announcement of her appointment to the Office of the Assistant Secretary for Health, saying she 'has a long and distinguished career working in the healthcare and the public health arenas.'
Foley will oversee the Office of Population Affairs (OPA), which administers Title X, a program providing family planning and related services to more than 4 million primarily low-income people in the United States, many of whom face systemic barriers to health care.
While Dr Foley's purview would be providing family planning services, she seems to opposed to the provision of most conventional family planning services,not only abortion, which is admittedly controversial, but also including contraception, and adoption. For example, as reported by Tonic (a part of Vice News) on June 5, 2018, she said in a speech on 2016 that a pregnant woman has three choices
parent the child, give it up for adoption, or have an abortion .... She said that having the baby is thought of as 'death to [the parents] and the life they thought they were going to have,' adding, 'The next choice is, let’s do an adoption plan. Well, that’s a double death, because not only does it interrupt [the parents] plans for the next several months, right? But then their child is going to be adopted, and they’re going to grow up thinking they’ve been abandoned by their parents. So they’re going to have all kinds of issues with their life. So that’s a double death. That’s worse.'
Given her opposition to adoption, it is not much of a surprise that she seems opposed to even talking about the simplest forms of contraception. The Rewire article stated,
Foley suggested that it may be considered 'sexually harassing' to demonstrate in a classroom how to use a condom on a banana, the Colorado Springs Independent reported in 2010.Foley is a physician. Another Tonic (from Vice) article on June 5, 2018, noted that an official DHHS statement about Dr Foley's hiring stressed,
that Foley is a board-certified pediatrician with 30 years of experience, most recently in private practice in Colorado.
The DHHS official leadership bio for Dr Foley went into more detail,
Dr. Foley is a graduate of Marion College (now Indiana Wesleyan University) and of Indiana University School of Medicine. She is a Diplomat of the American Board of Pediatrics, a member of the Society of Adolescent Health, and served on numerous other national boards and committees.
Dr. Foley has spent her professional career in the clinical practice of pediatrics with a focus on adolescent health. Originally from Indiana, Dr. Foley founded and served as medical director of Northpoint Pediatrics shortly after completing a residency in pediatrics. She spent the next seventeen years establishing what is still one of the largest pediatric practices in central Indiana. During this same period, she also served as a pediatric clinical instructor for pediatric and family practice residency programs at the Indiana University School of Medicine. Dr. Foley’s areas of special interest are adolescent gynecology, prevention and treatment of sexually transmitted diseases, healthy family formation, and global health, all of which she continued to focus on after her move to Colorado in 2004.As a physician, Dr Foley's prime directive was to put the interests of individual patients ahead of her self-interest. If Dr Foley had religious convictions that would not allow her offering women patients mainstream management approaches to family planning, for example, adoption or contraception planning, Dr Foley could have chosen to practice in a setting where she need not have ever offered those options, for an example relevant to pediatrics, neonatology. However, it seemed that Dr Foley chose to explicitly put herself in situations where she could combine proselytizing with practice. As described in a Slate article of June 1, 2018, stated,
Most recently, she was in part-time clinical practice at a certified Centers for Medicare & Medicaid Services Critical Access Hospital in Lamar, Colorado.
Until last year, she was the president and CEO of the Life Network, an organization that operates two anti-abortion crisis pregnancy centers in Colorado Springs that run abstinence-only education programs for teens. The purpose of crisis pregnancy centers is to convince women not to have abortions, sometimes after luring them in with deceptive advertising that makes them seem like abortion clinics or general health facilities. 'Through our pregnancy centers we have the opportunity to see God use the miracle of ultrasound to change and save lives,' Life Network’s website says. The first element of its mission is 'presenting the gospel of Jesus Christ.'The fundamentally deceptive nature of these clinics seem to suggest that Dr Foley violated another provision of the AMA Principles of Medical Ethics
II. A physician shall uphold the standards of professionalism, be honest in all professional interactions,...
Thus, rather than avoid clinical situations in which abortion would be considered to be a management option, she chose to work in such settings in order to try to prevent patients from having abortions, based on religious grounds. She worked in what looked like clinics, but which were dedicated to preaching the gospel.
Furthermore, the organization Dr Foley ran also specifically sought to deter young women from using conventional contraception. Tonic (part of Vice News) reported that the organization Dr Foley led
Life Network, the organization that Foley led until 2017, offers 'sexual risk avoidance programming,' aka abstinence-only sex ed, for middle and high school students, under the moniker Education for a Lifetime. As part of her work with that program, Foley told a reporter in 2010 that it’s too difficult to teach teenagers how to use condoms and that demonstrating how to use a condom on a banana could be considered 'sexually harassing.'
As an aside, in an interview reported by Tonic, Dr Foley seemed to espouse views on adverse effects of abortion that are unsupported by clinical research evidence,
'The way abortions are done, there is not enough supervision or regulation for them and it puts women at risk. There are not the same standards as other surgical centers, there are not the same requirements in terms of having the same hospital privileges in case something goes wrong,' she said. 'What I'm concerned about is that there is a sense that it's healthcare for women and there are a lot of things about it that are not good healthcare," Foley added. Abortion care has significantly lower complication rates than other common procedures (like wisdom tooth extraction and tonsillectomy), and patient satisfaction rates are much higher than they are for general medical care.
Another falsehood Foley has repeated, and that her former company Life Network also claims is true, is that abortion causes lasting mental-health problems. In a September 2016 presentation for Charis Bible College where Foley was introduced as the president of Life Network, she claims ... that this is a condition with an accepted diagnosis:
'There is actually a true, emotional diagnosis that is now starting to be recognized—even though if you look at national media and secular media, they still try to ignore the fact—but there is actually a diagnosis called post-abortion stress and also post-abortion traumatic syndrome, that is a result directly of someone having an abortion or being involved with an abortion that happens,' she said. 'Here is the thing that is incredible to me. I am a trained physician, went through training, got not one single lecture throughout the course of my training about this situation.'
The American Psychiatric Association does not recognize post-abortion syndrome or any related category as an identifiable mental health condition in the DSM-V , a manual that defines and classifies mental disorders.
So Dr Foley seemed to have engineered an ostensibly clinical career that put her in a position to proselytize patients in the guise of medical practice, not only about abortion, but about contraception. It is not at all obvious that Dr Foley limited her anti-abortion, anti-contraception, and presumably even anti-adoption preaching to women who agreed with her religious views and who had no interest in any of these options.
Dr Foley is certainly entitled to her religious views. She is also entitled as a physician to avoid situations in which normal standards of care would push her to provide services to patients that conflict with her religious conviction. But she is not entitled as a physician to proselytize in the guise of medical practice.
Furthermore, as a leader in a government health agency, she is not entitled to use that agency's power to enforce her personal religious beliefs on patients who do not hold such beliefs. Given her career, though, there is every reason to worry that she will do so. Furthermore, it was not clear why she was selected for this powerful government leadership position other than to allow her to proselytize.
We recently discussed other examples of people appointed to top positions in the US Department of Health and Human Services who seemed very hostile to the organization's mission. Again, it seemed unlikely that these people were appointed for any reason other than to attack the mission.
Furthermore, like Dr Foley, they seemed to have been appointed to impose their personal religious views on the American population. As we stated then, they all seem to be in a postion to undermine fundamental principles of US government enshrined in the Constitution, including prohibiting the government from establishing a religion or preventing the free expression of any religion, and equal application of the laws and provision of due process to all people, again regardless of their religious beliefs, race, ethnicity or sex.
We have been writing about health care dysfunction since 2003, and publishing this blog since 2004. A major concern all along has been how threats to health care professionals' core values generate health care dysfunction. Up through 2016, these threats came principally from large private health care organizations. While the US government was not always as good at defending these values as it could have been, at least it rarely presented its own set of active threats. Under Trump, that situation has been changing for the worse. This is obviously hugely dangerous, (and made more so by the regime's threats to other core values of US society, to US law, and the US Constitution.)
To prevent the decline and fall of US health care, and maybe the entire US experiment in representative democracy, health care professionals, academics, patients and citizens concerned about health care will have to join up with the larger populace to defend our core values while they still have any force.