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Beyond Politics: A Social and Cultural History of Federal Healthcare Conscience Protections

Published online by Cambridge University Press:  06 January 2021

Kimberly A. Parr
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Extract

The day before the inauguration of his Democratic successor, President George W. Bush oversaw the promulgation of an administrative rule that extended “sweeping” new conscience protections to healthcare providers, one which would allow them to refuse to participate in or refuse to refer for medical services to which they morally or religiously object. Enacted in a funding regulation through the Department of Health and Human Services (“HHS”), the rule – commonly called the Provider Conscience Regulation (“Regulation”) – purported to clarify and implement existing federal law; by its own terms; however, the Regulation pushed the boundaries of those laws, granting protections to a broader class of individuals and across a wider range of services. In so doing, the Regulation sought to resolve an ongoing tension between patient access and provider autonomy, yet it served to reignite a long-standing debate over the proper role of morals in medicine.

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Article
Information
American Journal of Law & Medicine , Volume 35 , Issue 4 , December 2009 , pp. 620 - 650
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 2009

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References

1 Robert Pear, Protests over a Rule to Protect Health Providers, N.Y. Times, Nov. 18, 2008, at A14.

2 Ensuring That Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices, 45 C.F.R. § 88 (2009)Google Scholar; see also Press Release, U.S. Dep't of Health and Human Servs., Regulation Proposed To Help Protect Healthcare Providers from Discrimination (Aug. 21, 2008).

3 See 45 C.F.R. § 88 (2009).

4 Compare Letter from Sharon L. Camp, President and CEO, Guttmacher Institute, to U.S. Dep't of Health and Human Servs., Office of Public Health and Servs. (Sept. 24, 2008) with Letter from Denise M. Burke, Vice President & Legal Director, Am. United for Life, to Dep't of Health and Human Services, Office of Public Health and Science (Sept. 22, 2008).

5 Rescission of the Regulation Entitled “Ensuring that Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Practices in Violation of Federal Law,” 74 Fed. Reg. 10207-01 (March 10, 2009).

6 See discussion infra Part III.

7 See, e.g., Lin, Tom C.W., Treating an Unhealthy Conscience: A Prescription for Medical Conscience Clauses, 31 Vt. L. Rev. 105, 110 (2006)Google Scholar (“The rebirth of the Republican Party (and social conservatives), with their strong convictions concerning religious values and abortion rights, will most likely solidify the place of conscience clauses in the years to come. The Party's control of the executive and legislative branches in the federal government, as well as the Party's majority in state governorships, in the early part of the new millennium will likely result in a reinforcement of the Party's values and agenda.”) (internal citations omitted).

8 These provisions assume many names, including “refusal clauses” and “abandonment clauses.” See Appel, Jacob M., ‘Conscience’ v Care: How Refusal Clauses Are Reshaping the Rights Revolution, 88 Med. & Health R.I. 279, 279 (2005)Google Scholar; Green, Jason, Note, Refusal Clauses and the Weldon Amendment, 26 J. Legal Med. 401, 404 (2005)CrossRefGoogle ScholarPubMed. Though recognizing the arguments for and against each term, this Note will employ the phrase “conscience clause” throughout.

9 Black's Law Dictionary 345 (9th ed. 2009).

10 Jody Feder, U.S. Cong. Research Serv., The History and Effect of Abortion Conscience Clause Laws 1 (2005) (citing White, Katherine A., Note, Crisis of Conscience: Reconciling Religious Health Care Providers’ Beliefs and Patient's Rights, 51 Stan. L. Rev. 1703, 1703 (1999)CrossRefGoogle Scholar).

11 See 42 U.S.C. § 300a-7 (2000).

12 Swartz, Martha S., “Conscience Clauses” or “Unconscionable Clauses”: Personal Beliefs Versus Professional Responsibilities, 6 Yale J. Health Pol’y & Ethics 269, 284 (2006)Google ScholarPubMed.

13 Lin, supra note 7, at 107; see also Wilson, Robin Fretwell, Essay: The Limits of Conscience: Moral Clashes over Deeply Divisive Health-Care Procedures, 34 Am. J.L. & Med. 41, 42 (2008)CrossRefGoogle Scholar.

14 See Lin, supra note 7, at 121; Swartz, supra note 12, at 326 (suggesting that proponents of conscience protections “base their reasoning on whether participation in the treatment will harm the healthcare professional; that is, whether such treatment will offend the healthcare professional's personal sense of morality”).

15 Lin, supra note 7, at 121; Swartz, supra note 12, at 326.

16 Lin, supra note 7, at 121.

17 Swartz, supra note 12, at 326.

18 Refusal Clauses: Dangerous for Women's Health (NARAL Pro-Choice America), (Dec. 1, 2007) at 5, available at http://www.prochoiceamerica.org/assets/files/Abortion-Access-to-Abortion-Refusal-Clauses-Refusal-Clauses-Dangerous.pdf [hereinafter NARAL].

19 Lin, supra note 7, at 106; Denise M. Burke, A Primer on Protecting Healthcare Rights of Conscience, Amns. United for Life, http://www.aul.org/ROC_Primer (last visited Apr. 4, 2009).

20 Lin, supra note 7, at 106; see also NARAL, supra note 18, at 3.

21 Burke, supra note 19.

22 Id. (describing an incident where an ambulance driver in Illinois was fired following the driver's refusal to transport a patient to an abortion clinic); see also Carlson, Heather L., Freedom at Risk: The Implications of City of Boerne v Flores on the Merger of Catholic and Non-Catholic Hospitals, 17 St. Louis Univ. Pub. L. Rev. 157, 167 (1997)Google Scholar (referencing Kenny v. Ambulatory Centre of Miami, Florida, Inc., 400 So. 2d 1262 (Fla. Dist. Ct. App. 1981) (denying claim for reinstatement by registered nurse in Florida demoted for refusing to assist in abortions)).

23 Posting of Matthew Eppinette to Americans United for Life Blog, http://blog.aul.org/2008/09/24/conscience-protections-essential-to-healthcare-systemamericans-united-for-life-argues-in-comments-filed-with-hhs/ (Sept. 24, 2008); see also Lin, supra note 7, at 120-22.

24 See NARAL, supra note 18, at 3; Green, supra note 8, at 409.

25 See NARAL, supra note 18, at 3 (identifying conditions that may significantly increase the risks associated with pregnancy).

26 Green, supra note 8, at 409.

27 See Id. at 410.

28 Swartz, supra note 12, at 332-33 (citing Guttmacher Inst., State Center, State Facts about Abortion: Pennsylvania, available at http://www.guttmacher.org/pubs/sfaa/pdf/pennsylvania.pdf).

29 Id.

30 Id.

31 Lin, supra note 7, at 106.

32 See Duvall, Melissa, Pharmacy Conscience Clause Statutes: Constitutional Religious “Accommodations” or Unconstitutional “Substantial Burdens” on Women?, 55 Am. U. L. Rev. 1485 (2006)Google Scholar; Lin, supra note 7, at 112; Smearman, Claire A., Drawing the Line: The Legal, Ethical and Public Policy Implications of Refusal Clauses for Pharmacists, 48 Ariz. L. Rev. 469, 526-39 (2006)Google Scholar.

33 U.S. Const. amend. I.

34 “An examination reveals at least three distinct schools of thought which influenced the drafters if the Bill of Rights: first, the evangelical view that ‘worldly corruptions … might consume the churches if sturdy fences against the wilderness were not maintained’; second, the Jeffersonian view that the church should be walled off from the state in order to safeguard secular interests [ ] ‘against ecclesiastical depredations and incursions’; and third, the Madisonian view that religious and secular interests alike would be advanced best by diffusing and decentralizing power so as to assure competition among sects rather than dominance by one.’” Laurence H. Tribe, American Constitutional Law 1158-59 (2d ed. 1998).

35 Cutter v. Wilkinson, 544 U.S. 709, 719 (2005).

36 Id.

37 Smearman, supra note 32, at 530.

38 403 U.S. 602 (1971).

39 Id. at 612.

40 Id. at 613.

41 See Lamb's Chapel v. Ctr. Moriches Union Free Sch. Dist., 508 U.S. 384, 398 (1993) (Scalia, J., concurring) (“Like some ghoul in a late-night horror movie that repeatedly sits up in its grave and shuffles abroad, after being repeatedly killed and buried, Lemon stalks our Establishment Clause jurisprudence once again, frightening … little children and school attorneys.”)

42 Lin, supra note 7, at 113. Some scholars have also analyzed conscience clauses under Justice O’Connor's “endorsement” test for the Establishment Clause. See Harrington, Maxine M., The Ever-Expanding Health Care Conscience Clause: The Quest for Immunity in the Struggle Between Professional Duties and Moral Beliefs, 34 Fla. St. U. L. Rev. 779, 828-30 (2007)Google Scholar. As articulated in Lynch v. Donnelly, 465 U.S. 668, 690 (1984) (O’Connor, J. concurring), the “endorsement test” considers “whether the government intends to convey a message of endorsement or disapproval of religion” and whether it has sent a message of endorsement to the objective observer. One scholar suggests that, since they “appear to be offered to a broad range of personal beliefs,” conscience clauses do not violate the Establishment Clause under an endorsement test analysis. Id. at 829-30.

43 Lin, supra note 7, at 113.

44 Id. at 113-14.

45 Id.

46 Lemon, 403 U.S. at 619.

47 Lin, supra note 7, at 114 (quoting Lemon, 403 U.S. at 619).

48 Cantwell v. Connecticut, 310 U.S. 296, 303-04 (1940).

49 494 U.S. at 878.

50 Id. at 874.

51 Id. at 878.

52 Id. at 890.

53 Smearman, supra note 32, at 528.

54 Harrington, supra note 42, at 790.

55 Id.

56 Lin, supra note 7, at 116.

57 Id.

58 Id.

59 Id.

60 Smearman, supra note 32, at 529.

61 Id.

62 Smith, 494 U.S. at 870.

63 Smearman, supra note 32, at 530.

64 Id. at 530.

65 Cutter, 544 U.S. 709, 713.

66 Id. at 719.

67 544 U.S. at 720, 723 (reasoning that the statute “alleviates exceptional governmentcreated burdens on private religious exercise,” which does not “differentiate among bona fide faiths”). Opponents of conscience regulations make similar use of Estate of Thornton v. Caldor, 472 U.S. 703 (1985), and Texas Monthly Inc. v. Bullock, 489 U.S. 1 (1989), both of which support the notion that a legislative accommodation may violate the Constitution where it imposes “substantial burdens on non-beneficiaries.” See Smearman, supra note 32, at 531-32.

68 Smearman, supra note 32, at 531.

69 Cutter, 544 U.S. at 720.

70 Smearman, supra note 32, at 532.

71 U.S. Const. amend. XIV.

72 Duvall, supra note 32, at 1496.

73 381 U.S. 479 (1965).

74 405 U.S. 438 (1972).

75 Duvall, supra note 32, at 1489 (citing Eisenstadt, 405 U.S. at 453).

76 431 U.S. 678 (1977).

77 Id. at 688.

78 Id.

79 Id.

80 Duvall, supra note 32, at 1497-98; see also Smearman, supra note 32, at 534-37.

81 448 U.S. 297 (1980).

82 492 U.S. 490 (1989).

83 Duvall, supra note 32, at 1497 (referencing Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833, 875-76 (1992)).

84 Smearman, supra note 32, at 535.

85 505 U.S. at 876-78.

86 Duvall, supra note 32, at 1497 (referencing Casey, 505 U.S. at 878).

87 Id. ( referencing Casey, 505 U.S. at 876-77).

88 Id.

89 42 U.S.C. § 300a-7 (1973).

90 Swartz, supra note12, at 279-80.

91 410 U.S. 113 (1973).

92 Walker, Jane, The Bush Administration's Midnight Provider Refusal Clause: Upsetting the Emerging Balance in State Pharmacists Refusal Laws, 46 Hous. L. Rev. 939, 948 (2009)Google Scholar.

93 H.R. Rep. No. 93-227, reprinted in 1973 U.S.C.C.A.N. 1464, 1473 (“The background for subsection (b) of section 401 of the bill is an injunction issued in November 1972 by the United States District Court for the District of Montana in Taylor v. St. Vincent's Hospital.”) [hereinafter House Report]; see also Swartz, supra note 12, at 281.

94 369 F. Supp. 948 (D. Mont. 1973).

95 Id. at 949.

96 Id. at 950; see also Wilson, supra note 13, at 48 (explaining that “the Hill-Burton Act made funds available to hospitals to modernize and construct medical facilities in exchange for the facilities’ promise to provide certain community benefits”).

97 Eisenstadt, Leora, Separation of Church and Hospital: Strategies to Protect Pro-Choice Physicians in Religiously Affiliated Hospitals, 15 Yale J.L. & Feminism 135, 146 (2003)Google Scholar.

98 369 F. Supp. at 950 n.1.

99 Eisenstadt, supra note 97, at 146-47.

100 Walker, supra note 92, at 948.

101 An Act to Extend Through Fiscal Year 1974 Certain Expiring Appropriations Authorizations in the Public Health Services Act, the Community Mental Health Centers Act, and the Developmental Disabilities Services and Facilities Construction Act, and for Other Purposes, Pub. L. No. 93-94, § 401(B)(1), 87 Stat. 91 (1973) (later codified at 42 U.S.C. 300a- 7).

102 Id. § 401(C).

103 Pub. L. No. 93-348, 88 Stat. 342 (1974) (codified as amended at 42 U.S.C. 300a-7 (2006)).

104 Pub. L. No. 93-348, 88 Stat. 342 (1974) (codified as amended at 42 U.S.C. 300a- 7(d)(2006)).

105 Pub. L. No. 93-348, 88 Stat. 342 (1974) (codified a amended at 42 U.S.C. 300a- 7(c)(2)(2006)).

106 “Despite the potentially broad construction of [the 1974] provision, the Church Amendment has been largely understood (at least until recently) to pertain only to sterilization and abortion.” Walker, supra note 92, at 949.

107 Eisenstadt, supra note 97, at 147.

108 369 F. Supp. 948, 950 (D. Mont. 1973).

109 Taylor v. St. Vincent's Hosp., 523 F.2d 75, 77 (9th Cir. 1975).

110 Id.

111 Id.

112 “By 1978, more than forty states had enacted some form of [conscience] clauses relating to abortion, sterilization, and, in at least one instance, contraception.” Walker, supra note 92, at 950.

113 During this time, Congress did incorporate directives in the 1981 appropriations act for the District of Columbia and the 1988 Danforth Amendment to the Civil Rights Restoration Act, requiring that health insurance plans contain conscience protections and mandating neutrality with respect to abortion funding through Title IX of the Education Amendments of 1972, respectively. See Feder, supra note 10, at 2; Swartz, supra note 12, at 282.

114 See Cody, Alison M., Success in New Jersey: Using the Charitable Trust Doctrine to Preserve Women's Reproductive Services when Hospitals Become Catholic, 57 N.Y.U. ANN. SURV. AM. L. 323, 323 (2000)Google Scholar; Foster, Angel M. et al., Educational and Legislative Initiatives Affecting Residency Training in Abortion, 290 J. Am. Med. Ass’n 1675, 1777 (2003)Google Scholar; Ikemoto, Lisa C., When a Hospital Becomes Catholic, 47 Mercer L. Rev. 1087, 1093 (1996)Google Scholar; Walker, supra note 92, at 950.

115 Henshaw, Stanley K., Abortion Incidence and Services in the United States, 1995-1996, 30 Fam. Planning Persp. 263 (1998)CrossRefGoogle Scholar.

116 Id.

117 Id. (“Between 1992 and 1996 … the number of providers feel 14%, to 2,042 … Between 1988 and 1992, the number of abortion service providers fell by an average of 65 a year, and in 1992, 30% of women lived in a county without an abortion provider.”)

118 Id.

119 See Fogel, Susan B. & Rivera, Lourdes A., Saving Roe is Not Enough: When Religious Controls Healthcare, 31 Fordham Urb. L.J. 725, 727 (2004)Google ScholarPubMed (“The expansion in size and influence of religiously-controlled health systems is impeding patient access to comprehensive health services … “) [hereinafter Fogel & Rivera 2004]; Foster et al., supra note 114, at 1777 (“Legal restrictions, violence and harassment against clinics who perform abortions, and the aging of clinics who provide abortion have all been identified as factors influencing the decreased availability.”).

120 Foster et al., supra note 114, at 1777.

121 Id. (citing Darney, Philip D. et al., Abortion Training in U.S. Obstetrics and Gynecology Residency Programs, 19 Fam. Planning Persp. 139, 158-62 (1987)Google Scholar and MacKay, H. Trent, Abortion Training in Obstetrics and Gynecology Residency Programs in the United States 1991-1992, 27 Fam. Planning Persp. 97, 112-15 (1998)Google Scholar.

122 Id.

123 Id.

124 Id.

125 Accreditation Council for Graduate Medical Education, The ACGME at a Glance, http://www.acgme.org/acWebsite/newsRoom/newsRm_acGlance.asp (last visited Nov. 19, 2009).

126 Frank, Michael J., Note, Safeguarding the Consciences of Hospitals and Health Care Personnel: How the Graduate Medical Education Guidelines Demonstrate a Continued Need for Protective Jurisprudence and Legislation, 41 St. Louis U. L.J. 311, 320 (1996)Google Scholar.

127 Foster et al., supra note 114, at 1777.

128 Id.

129 Frank, supra note 126, at 324 (citing Memorandum from the Accreditation Council for Graduate Medical Education, Program Requirements For Residency Training In Obstetrics And Gynecology 16 (Apr. 4, 1995) (on file with author)).

130 Id.

131 Id.

132 42 U.S.C. § 238n (1996). The Provider Conscience Regulation refers to this Amendment by its formal name, § 245 of the Public Health Services Act.

133 See Foster et al., supra note 114, at 1777.

134 42 U.S.C. § 238n(c)(2) (1996).

135 Id. §238n(a).

136 Id. § 238n(b)(1) (1996); see Feder, supra note 10, at 4 (explaining that this law is “somewhat different from traditional conscience clauses because medical providers can refuse to provide training or services for any reason, not just on moral or religious grounds”).

137 Frank, supra note 126, at 328 (describing the revised Guidelines as “allowing programmes the right to refuse to teach abortion and requiring only that programmes ‘must not impede’ residents from learning the procedure elsewhere”).

138 Ikemoto, supra note Error ! Bookmark not defined.., at 1093.

139 Cody, supra note Error ! Bookmark not defined.., at 325-26.

140 Id. at 325.

141 Ikemoto, supra note Error ! Bookmark not defined.., at 1093.

142 Id.

143 Id.

144 Id.

145 Id.; see also Carlson, supra note 22, at 158.

146 Sloboda, Monica, The High Cost of Merging with a Religiously-Controlled Hospital, 16 Berkeley Women's L.J. 140, 142 (2001)Google Scholar.

147 Carlson, supra note 22, at 159.

148 Sloboda, supra note 146, at 142.

149 Fogel & Rivera 2004, supra note 119, at 730.

150 Id.

151 Id.

152 Id.

153 Sloboda, supra note 146, at 142-43; see also Carlson, supra note 22, at 160 (“Catholic hospitals have leverage to impose such limitations because of their strong financial position. The non-Catholic hospital often agrees as part of a consolidation agreement to follow Catholic doctrine and refrain from participating in procedures explicitly prohibited by the Church.”).

154 See United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (4th Ed. 2001), available at http://www.usccb.org/bishops/directives.shtml [hereinafter DIRECTIVES].

155 Id.

156 Ikemoto, supra note Error ! Bookmark not defined.., at 1096.

157 Boozang, Kathleen M., Deciding the Fate of Religious Hospitals in the Emerging Health Care Market, 31 Hous. L. Rev. 1429, 1439 (1995)Google ScholarPubMed.

158 Directives, supra note 154.

159 Id.

160 See Carlson, supra note 22, at 161.

161 Id.

162 Sloboda, supra note 146, at 143.

163 Fogel, Susan Berke & Rivera, Lourdes A., Religious Beliefs and Healthcare Necessities: Can They Coexist?, 30 Hum. Rts.8, 9 (2003)Google Scholar [hereinafter Fogel & Rivera 2003].

164 Fogel & Rivera 2004, supra note 119, at 727.

165 Feder, supra note 10, at 3.

166 Id. (referencing 42 U.S.C. § 1395w-22(j)(3)(A) and 42 U.S.C. §1396u-2(b)(3)(A)).

167 Id. (referencing 42 U.S.C. § 1395w-22(j)(3)(B) and 42 U.S.C. § 1396u-2(b)(3)(B)).

168 See Fogel & Rivera 2004, supra note 119, at 730.

169 Grimes, Brittany L., Note, The Plan B for Plan B: The New Dual Over-the-Counter and Prescription Status of Plan B and Its Impact upon Pharmacists, Consumers and Conscience Clauses, 41 Ga. L. Rev. 1395, 1398 (2007)Google Scholar.

170 Id. at 1397.

171 Griffin, Leslie C., Conscience and Emergency Contraception, 6 Hous. J. Health L. & Pol’y. 299, 300 (2006)Google Scholar.

172 Green, supra note 8, at 403.

173 Griffin, supra note 171, at 300.

174 Grimes, supra note 169, at 1399.

175 Id.

176 Id.

177 Id. at 1396, 1404. The current dual-use scheme incorporates an over-the-counter option for women eighteen years of age and older. Id.

178 Knestout, Brian P., An Essential Prescription: Why Pharmacist-Inclusive Conscience Clauses are Necessary, 22 J. Contemp. Health L. & Pol’y 349, 360 (2006)Google ScholarPubMed.

179 Id.

180 Id.

181 See Smearman, supra note 32, at 471.

182 Id.

183 Id. at 471 n.10 (citing Editorial, Moralists in Pharmacy, N.Y. Times, Apr. 3, 2005, § 4, at 12).

184 Id. at 471.

185 “Arkansas enacted the earliest refusal clause covering pharmacists in 1973 as part of the Arkansas Family Planning Act,” which “permits a pharmacist or physician to refuse to ‘furnish any contraceptive procedures, supplies or information,’ without requiring the refusal to be based on religion, conscience or moral convictions.” Smearman, supra note 32, at 478. In 1988, South Dakota was the first state to incorporate conscientious refusals for pharmacists, allowing them “to refuse to dispense emergency contraceptives for moral and religious reasons.” Griffin, supra note 171, at 304. “As of September 2006, eighteen states were considering forty bills that would permit healthcare providers, including pharmacists, to refuse to provide medical care that conflicts with religious or moral beliefs.” Smearman, supra note 32, at 473.

186 Emergency Amendment to Pharmacy Practice Act of 1989, 29 Ill. Reg. 5586 (Apr. 1, 2005) (codified at Ill. Admin. Code tit. 68, §1330.91(j) (2005)).

187 Smearman, supra note 32, at 483 (citing Treasury and General Government Appropriations Act, 1999, Pub. L. No. 105-277, § 656, 112 Stat. 2681, 2681-530 (1999)).

188 Treasury and General Government Appropriations Act, 1999, Pub. L. No. 105-277, § 656, 112 Stat. 2681, 2681-530 (1999)).

189 Smearman, supra note 32, at 483 (referencing Treasury and General Government Appropriations Act, 1999, Pub. L. No. 105-277, §656(b), 112 Stat. 2681, 2681-530 (1999)).

190 Treasury and General Government Appropriations Act, 1999, Pub. L. No. 105-277, § 656(b)(2), 112 Stat. 2681, 2681-530 (1999)).

191 Treasury and General Government Appropriations Act, §656(c).

192 Smearman, supra note 32, at 480. The first, a House Resolution entitled The Compassionate Care for Female Sexual Assault Survivors Act, sought to require that all hospitals receiving federal funds provide “medically and factually accurate and unbiased” information about emergency contraception and offer emergency contraception to victims of sexual assault. H.R. 4113, 107th Cong., § 3(b)(1)-(2) (2002). The second, The Emergency Contraception Education Act introduced in both the House and the Senate, sought to introduce an educational campaign with the Secretary of Health and Human Services “develop[ing] and disseminat[ing] … public information on emergency contraception.” H.R. 3887, 107th Cong. § 3(b) (2002); S. 1990, 107th Cong. § 3(b) (2002).

193 Consolidated Appropriations Resolution, 2003, Division J, Title VI, § 635(a), (b)(2), Pub. L. No. 108-7, 117 Stat. 11, 472 (2003).

194 Id. § 635(c).

195 Consolidated Appropriations Act, 2005, Pub. L. No. 108-447, §507(d)(1), 118 Stat. 2809, 3163 (2004). Congress has incorporated this Amendment into each subsequent Appropriations Act. See Consolidated Appropriations Act, 2008, Pub. L. No. 110-161, §508(d)(1), 121 Stat. 1844, 2209 (2007); Revised Continuing Appropriations Resolution, 2007, Pub. L. No. 110-5, §2, 121 Stat. 8, 8; Dep't of Labor Appropriations Act of 2006, Pub. L. No. 109-149, §508(d)(1), 119 Stat. 2833, 2879-80 (2005).

196 Consolidated Appropriations Act, 2005, Pub. L. No. 108-447, §507(d)(2), 118 Stat. 2809, 3163 (2004).

197 The American College of Obstetrics and Gynecology changed its name to the American Congress of Obstetrics and Gynecology some time after this exchange with Secretary Leavitt.

198 American Board of Obstetrics and Gynecology, http://www.abog.org/ (last visited Oct. 25, 2009).

199 Id.

200 American Board of Obstetrics and Gynecology, About Us, http://www.abog.org/about.asp (last visited Oct. 25, 2009).

201 Physician Conscience Blog III, Secretary Mike Leavitt's Blog, http://archive.hhs.gov/secretarysblog/my_weblog/physician_conscience/index.html (Aug. 21, 2008).

202 Id.

203 American Congress of Obstetricians and Gynecologists, About ACOG, http://www.acog.org/from_home/acoginfo.cfm (last visited Oct. 25, 2009).

204 Id.

205 Id.

206 See Code of Professional Ethics of the American College of Obstetricians and Gynecologists, available at http://www.acog.org/from_home/acogcode.pdf (last visited Nov. 19, 2009).

207 See American Congress of Obstetricians and Gynecologists, Committee on Ethics Committee Opinions, available at http://www.acog.org/from_home/publications/ethics/ (last visited Nov. 19, 2009).

208 Press Release, U.S. Dep't of Health and Human Servs., HHS Secretary Calls on Certification Group to Protect Conscience Rights (Mar. 14, 2008) [hereinafter HHS Press Release]. See American Board of Obstetricians and Gynecologists, Bulletin for 2008 Maintenance of Certification, available at www.abog.org/pdf/MOC2008.pdf (last visited Nov. 19, 2009).

209 American College of Obstetricians & Gynecologists, Committee Op. 385, at 2 (2007) available at http://www.acog.org/from_home/publications/ethics/co385.pdf.

210 Id.

211 Id.

212 HHS Press Release, supra note 208.

213 Id.

214 Id.

215 Letter from Norman Gant, Executive Dir., American Board of Obstetrics and Gynecology, to Michael Leavitt, Sec’y, U.S. Dep't of Health and Human Servs. (Aug. 22, 2008), available at http://www.abog.org/publications/leavitt.Response.2008.pdf; News Release, American College of Obstetricians and Gynecologists, New HHS Regulation Poses Threat to Women's Health, Sept. 25, 2008, available at http://www.acog.org/from_home/publications/press_releases/nr09-25-08.cfm [hereinafter ACOG News Release].

216 Gant, supra note 215.

217 Id.

218 ACOG News Release, supra note 215.

219 45 C.F.R. § 88 (2009).

220 Ensuring that Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices, 74 Fed. Reg. 50,274, 50,276 (Aug. 26, 2008).

221 Id. at 50,276 n.1.

222 Id. at 50,276.

223 Id. at 50,276-77.

224 45 C.F.R. § 88.5 (2008).

225 Id. § 88.6.

226 See id. § 88.4.

227 Id.

228 Id. § 88.4(d)(1).

229 Id. § 88.2; see ACOG News Release, supra note 215 (“This regulation extends the conscience protection well beyond physicians and others directly involved in patient care – the personal beliefs of pharmacists, schedulers, even volunteers and custodians could influence the info patients receive or stop patient care.”).

230 45 C.F.R. § 88.2.

231 Id.

232 Id.

233 Id.

234 Id. § 88.1.

235 The Regulation applies to 584,294 hospitals, nursing homes, physicians offices, outpatient centers, pharmacies, graduate schools, residency programs, health insurance carriers, grant awards, contractors and state and territorial governments. 73 Fed. Reg. at 50,280.

236 See Dep't of Health & Human Servs., Draft, available at http://www.rhrealitycheck.org/emailphotos/pdf/HHS-45-CFR.pdf [hereinafter HHS Draft].

237 Walker, supra note 92, at 967.

238 Id. at 967.

239 HHS Draft, supra note 236, at 16.

240 Id.

241 Walker, supra note 92, at 967.

242 42 U.S.C. § 300a-7 (1973).

243 45 C.F.R. § 88.4(d)(1).

244 42 U.S.C. § 238n (1996).

245 Consolidated Appropriations Act, 2005, Pub. L. No. 108-447, §507(d)(2), 118 Stat. 2809, 3163 (2004).