[House Hearing, 107 Congress]
[From the U.S. Government Printing Office]



 
  PROTECTING THE RIGHTS OF CONSCIENCE OF HEALTH CARE PROVIDERS AND A 
                         PARENT'S RIGHT TO KNOW
=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 11, 2002

                               __________

                           Serial No. 107-126

                               __________

       Printed for the use of the Committee on Energy and Commerce


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
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                               __________
                    ------------------------------  

                    COMMITTEE ON ENERGY AND COMMERCE

               W.J. ``BILLY'' TAUZIN, Louisiana, Chairman

MICHAEL BILIRAKIS, Florida           JOHN D. DINGELL, Michigan
JOE BARTON, Texas                    HENRY A. WAXMAN, California
FRED UPTON, Michigan                 EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida               RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio                RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania     EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California          FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia                 SHERROD BROWN, Ohio
RICHARD BURR, North Carolina         BART GORDON, Tennessee
ED WHITFIELD, Kentucky               PETER DEUTSCH, Florida
GREG GANSKE, Iowa                    BOBBY L. RUSH, Illinois
CHARLIE NORWOOD, Georgia             ANNA G. ESHOO, California
BARBARA CUBIN, Wyoming               BART STUPAK, Michigan
JOHN SHIMKUS, Illinois               ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico           TOM SAWYER, Ohio
JOHN B. SHADEGG, Arizona             ALBERT R. WYNN, Maryland
CHARLES ``CHIP'' PICKERING,          GENE GREEN, Texas
Mississippi                          KAREN McCARTHY, Missouri
VITO FOSSELLA, New York              TED STRICKLAND, Ohio
ROY BLUNT, Missouri                  DIANA DeGETTE, Colorado
TOM DAVIS, Virginia                  THOMAS M. BARRETT, Wisconsin
ED BRYANT, Tennessee                 BILL LUTHER, Minnesota
ROBERT L. EHRLICH, Jr., Maryland     LOIS CAPPS, California
STEVE BUYER, Indiana                 MICHAEL F. DOYLE, Pennsylvania
GEORGE RADANOVICH, California        CHRISTOPHER JOHN, Louisiana
CHARLES F. BASS, New Hampshire       JANE HARMAN, California
JOSEPH R. PITTS, Pennsylvania
MARY BONO, California
GREG WALDEN, Oregon
LEE TERRY, Nebraska
ERNIE FLETCHER, Kentucky

                  David V. Marventano, Staff Director

                   James D. Barnette, General Counsel

      Reid P.F. Stuntz, Minority Staff Director and Chief Counsel

                                 ______

                         Subcommittee on Health

                  MICHAEL BILIRAKIS, Florida, Chairman

JOE BARTON, Texas                    SHERROD BROWN, Ohio
FRED UPTON, Michigan                 HENRY A. WAXMAN, California
JAMES C. GREENWOOD, Pennsylvania     TED STRICKLAND, Ohio
NATHAN DEAL, Georgia                 THOMAS M. BARRETT, Wisconsin
RICHARD BURR, North Carolina         LOIS CAPPS, California
ED WHITFIELD, Kentucky               RALPH M. HALL, Texas
GREG GANSKE, Iowa                    EDOLPHUS TOWNS, New York
CHARLIE NORWOOD, Georgia             FRANK PALLONE, Jr., New Jersey
  Vice Chairman                      PETER DEUTSCH, Florida
BARBARA CUBIN, Wyoming               ANNA G. ESHOO, California
HEATHER WILSON, New Mexico           BART STUPAK, Michigan
JOHN B. SHADEGG, Arizona             ELIOT L. ENGEL, New York
CHARLES ``CHIP'' PICKERING,          ALBERT R. WYNN, Maryland
Mississippi                          GENE GREEN, Texas
ED BRYANT, Tennessee                 JOHN D. DINGELL, Michigan,
ROBERT L. EHRLICH, Jr., Maryland       (Ex Officio)
STEVE BUYER, Indiana
JOSEPH R. PITTS, Pennsylvania
W.J. ``BILLY'' TAUZIN, Louisiana
  (Ex Officio)

                                  (ii)









                            C O N T E N T S

                               __________
                                                                   Page

Testimony of:
    Heisler, John A., County Board, McHenry County, Illinois.....    53
    Jenkins, Renee S., on behalf of the American Academy of 
      Pediatrics.................................................    48
    Vosburgh, Karen..............................................    10
    Wardle, Lynn, Professor, J. Reuben Clark Law School, Brigham 
      Young University...........................................    22
    Weiss, Catherine, Director, ACLU Reproductive Freedom Project    13
    Wuchner, Addia, Northern Kentucky Independent Health District    43
Material submitted for the record by:
    McHenry County Citizens for Choice, prepared statement of....    71

                                 (iii)

  


  PROTECTING THE RIGHTS OF CONSCIENCE OF HEALTH CARE PROVIDERS AND A 
                         PARENT'S RIGHT TO KNOW

                              ----------                              


                        THURSDAY, JULY 11, 2002

                  House of Representatives,
                  Committee on Energy and Commerce,
                                    Subcommittee on Health,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 3 p.m., in 
room 2322, Rayburn House Office Building, Hon. Michael 
Bilirakis (chairman) presiding.
    Members present: Representatives Bilirakis, Burr, Norwood, 
Pitts, Tauzin (ex officio), Brown, Strickland, Capps, Towns, 
Deutsch, and Wynn.
    Staff present: Patrick Morrisey, deputy staff director; 
Cheryl Jaeger, majority professional staff; Steven Tilton, 
health policy coordinator; Eugenia Edwards, legislative clerk; 
John Ford, minority counsel; and Jessica McNiece, minority 
staff assistant.
    Mr. Bilirakis. I call this hearing to order and first would 
like to thank our witnesses for appearing before the 
subcommittee today. This subcommittee certainly values your 
expertise, and we are very grateful for your cooperation and 
attendance. And as you good people fall in, please, let us try 
to be orderly.
    Today's hearing will touch on two subjects that I know many 
members of the subcommittee, myself included, feel very 
strongly about. Because of the vastly divergent views and 
strong feelings invoked by the issues we will be discussing 
today, I believe it is important to have a hearing which will 
afford us the opportunity to listen to different viewpoints. 
And I think this open dialog and expert testimony will aid all 
members in making an informed decision about how best to 
legislate in this area.
    Our first panel will discuss an issue that we commonly 
refer to as the conscience clause. In 1996, the Congress 
passed, and President Clinton signed into law, provisions that 
provide protections to health care professionals and a, 
``health care entity'' from being forced to perform abortions 
if they have moral or religious objections to the procedure. 
However, court interpretations have called into question 
whether these sections of law apply to hospitals that object to 
offering elective abortions.
    In 1998, a number of senators attempted to clarify the 
record by stating that a health care entity was defined to 
include physicians and other which does not mean that it 
excludes hospitals. However, this clarification has not been 
sufficient and it has come to my attention that we need to 
amend the current statute to ensure that hospitals are covered 
by the conscience clause. Consequently, I have introduced H.R. 
4691, the Abortion Non-Discrimination Act, to guarantee that 
all health care entities are afforded the important protections 
provided by the original law, as I believe was intended.
    Our second panel will discuss the issue of whether parents 
have the right to know if their children receive contraceptive 
devices or drugs from title X family planning clinics. And, 
again, this is an issue where most of us have had some 
experience in the raising of our children. And I think it is 
safe to say that most parents have strong feelings about 
wanting to know what is going on with their children's health, 
and as a parent, I certainly can identify with this notion.
    Title X regulations specifically prohibit health care 
providers from informing parents of their child's actions to 
seek contraceptives. I am interested to hear from our witnesses 
today whether title X rules allow for appropriate flexibility 
and deference to the health care professionals that provide 
care in these clinics. Can a doctor use his or her best 
judgment about notifying a child's parents about health 
concerns when providing care to a minor? Question.
    Again, I know these are difficult issues, and I look 
forward to hearing from our witnesses so we can make informed 
decisions about how best to proceed, and I now recognize my 
good friend from Ohio, Mr. Brown, for his opening statement. 
Mr. Brown.
    Mr. Brown. Thank you, Mr. Chairman. This afternoon we will 
discuss the merits of a proposal to permit health care entities 
to refuse to comply with Federal, State and local laws 
pertaining to abortion services. We will discuss parental 
consent requirement for access to reproductive health services. 
I want to thank Ms. Weiss for joining us, Dr. Jenkins and the 
other distinguished panelists.
    The majority has labeled the first issue for debate a 
clarification of existing law. They will argue the legislation 
clarifies a provision of law known as the Coats Amendment, 
adopted, as the chairman said, in 1996 omnibus appropriations 
bill. The Coats Amendment allowed post-graduate physician 
training programs that chose not to provide or refer for 
training and abortion procedures to still qualify for Federal 
funding. This so-called clarification bill would dramatically, 
dramatically expand this narrow law.
    Let me be clear, this is not simply a technical amendment. 
It is a sweeping expansion to the law that would override 
Federal and State and local laws. This bill expands this scope 
of the law beyond graduate medical programs and permits any 
health care entity, including insurance companies and hospitals 
and HMOs to refuse to perform, to refuse to provide coverage 
of, to pay for or refer for abortions.
    In the interest of time, I want to mention just one example 
of how this bill is egregious and irresponsible, putting a 
political agenda, in my mind, above access to critical and 
human health care. The Federal Hyde Amendment ensures Medicaid 
patients access to abortion services in cases of rape, incest 
or where the pregnancy endangers the woman's life. The 
chairman's bill would override these standards of care. The 
bill would give the HMOs the legal standing to refuse to adhere 
to the Hyde Amendment. That is a major policy change with 
tremendous ethical implications.
    The chairman's bill also blurs the line between medicine 
and personal preference. How does this differ from a health 
care facility or an insurance company denying a critical 
procedure based on an ethnic bias or a racial bias? And I want 
to point out that once again the same Members of Congress who 
claim to be staunch champions of State and local sovereignty, 
who want to block grant Medicaid to gives States more 
flexibility, who want to privatize Medicare because it is a 
``one-size-fits-all,'' program, who constantly demonize the 
one-size-fits-all mentality of the Federal Government are now 
trying to impose a one-size-fits-all refusal clause at the 
State and the local level. Once you get into the realm of 
religion and ethics and morals, my conservative colleagues have 
no problem using the heavy hand of the Federal Government to 
stifle different perspectives at the State and local level.
    Second issue we will discuss this afternoon is parental 
consent. title X, the only Federal program dedicated 
exclusively to funding family planning and reproductive health 
care services has helped to prevent unintended pregnancies, 
reduce abortions, lower the rate of STDs, including HIV, and 
improve women's health overall. A study 4 years ago reported 
that teen pregnancy rates fell 17 percent sine the rate peaked 
in 1990, and 75 percent of this decline reflects improved 
contraceptive use among sexually active teens, 25 percent due 
to reduced sexual activity. That is a very impressive track 
record that an overwhelming majority of Americans support.
    What we are considering today would undermine the inherent 
value of a title X clinic, confidential access to family 
planning services, and require teens to get the consent of 
their parents before receiving contraceptives. While family 
planning clinics encourage minors to involve their parents in 
health care decisions, an admiral thing, as Chairman Bilirakis 
said, Congress cannot and should not write laws that will 
achieve communication between and adolescent and her or his 
parents where it simply doesn't exist.
    The American Academy of Pediatrics, the American College of 
Obstetricians and Gynecologists, the American Nurses 
Association, the American Public Health Association, the 
American Academy of Family Physicians, among many other 
respected members of the medical community, all oppose, all 
those groups that are so involved in this kind of medical care 
oppose mandatory parental consent or notification requirements 
for teens receiving services at a title X family planning 
clinic for obvious reasons, that children and parents, young 
teens and parents don't always communicate as well as we would 
like.
    This committee should respect the medical community's 
opinion as well as the success, the success that family 
planning clinics have achieved in reducing unintended teen 
pregnancies. Reducing unintended pregnancies is, after all, the 
key goal, it is a bipartisan goal, it should remain a 
bipartisan goal. I thank the chairman.
    Mr. Bilirakis. The Chair thanks the gentleman. The Chair 
recognizes the chairman of the full committee, Mr. Tauzin, for 
an opening statement.
    Chairman Tauzin. Thank you, Mr. Chairman. I want to thank 
you for holding this hearing today. I am pleased the committee 
is addressing two important ethical questions that impact 
health care in our country. Our committee spends a great deal 
of time exploring ways that we can improve access to health 
care for America's patients. But an equally important goal has 
always been that we ensure that ethical guidelines for our 
health care system are always maintained at the highest 
possible level. And this is true whether it involves issues 
pertaining to the rights of conscience of health providers or 
issues dealing with cloning or stem cells, which this committee 
wrestled with not too long ago. We still maintain a 
responsibility to ensure the ethics and morals that are indeed 
the foundation of much of our society are not trampled upon 
because of Federal policies. And today we address two of those 
timely issues.
    The first question we ask is should the Federal Government 
require health care providers to participate in procedures that 
violate their moral and religious beliefs? In my mind, the 
answer to that question is a clear no, although admittedly 
there are some differences of opinion here. Second, is the 
Federal Government, through some of our health care programs, 
undermining the critical role that parents play in guaranteeing 
the well being and the health of their children? That answer 
requires some analysis. More and more we are learning about 
instances where parents are currently being shut out of 
critical health care decisions regarding their children. I 
believe that is an unacceptable practice.
    On the first question, it is important to note that for 
over 30 years State and Federal Governments have passed 
conscience clause statutes intended to protect health care 
providers from being coerced into performing procedures that 
violate their moral and religiously held beliefs. I supported 
these laws in the past, and I hope we can all continue to do so 
in the future. A health care provider should never be forced to 
abandoned his or her moral values and religious beliefs and be 
required to perform a particular procedure.
    I would like to express my appreciation for the work of 
Chairman Bilirakis in raising awareness on this important 
issue. The chairman has offered the Abortion Non-Discrimination 
Act of this year, H.R. 4691, to clarify the intent of existing 
law so that it clearly prohibits the discrimination of health 
care entities who refuse to perform abortions. I strongly 
support this bill and encourage my colleagues to co-sponsor the 
bill if they have not already done so.
    On the second question we are addressing today, I am 
frankly very pleased we are beginning to take a closer look at 
whether or not parents should be denied information about 
whether a minor that they are legally responsible for is 
permitted access to contraceptives. And while there are 
substantial differences of opinion regarding the value and 
effectiveness of title X programs, current title X regulations 
do not permit health care providers to use their best judgment 
or even discuss sensitive health care issues with parents 
without the express consent of the minor. I think this turns 
things on its head.
    We learned, for example, at our welfare reform hearings 
last April, that when we were growing up, in the sixties, there 
were really two sexually transmitted diseases of great concern 
to be worried about. We were told today there are 25, and they 
include such diseases affecting young men and women in our 
society, very often women, as HPV, herpes and chlamydia. These 
are viral diseases; they cannot be cured, only managed. And 
when a title X clinic provides contraceptives and condoms to 
teens without the parent's consent or notification and there is 
no evidence that condoms reduce the sexual transmission of many 
of these infections, the health of these children, in many 
cases young women of our country, is put at risk without the 
parents even knowing that is occurring. That doesn't make sense 
to me.
    And when title X clinics allow a child to begin taking a 
prescription drug or to have access to contraceptives, that 
encourage a child to make a choice to engage in sexual 
activities, that put them at risk for diseases that can't be 
cured, in some cases are non-detectable, they don't even know 
they have them until they find out they have lost their ability 
to have children because the disease has destroyed the 
reproductive capacities. Or they have now incurred a disease 
that maybe a precursor to cancer because their parents didn't 
have the chance to tell them maybe this isn't such a good idea 
for you, maybe you ought to try abstinence, because the parents 
didn't know because the title X clinic couldn't talk to the 
parent about these kind of important decisions that parents and 
children should be making in their lives.
    Something has gone terribly wrong. If we only had these two 
diseases in the 1960's to worry about today, that would be one 
thing. Think about what young people are facing today, and 
think about the role that parents are being denied in caring 
for their own children and worrying about them, helping them 
make the right decisions. And I think you get a sense of why 
this is an important hearing today.
    So Mr. Bilirakis, I want to thank you for conducting it, 
and I want to thank the witnesses who are going to come share 
their thoughts with us today. I hope we learn a little bit 
today, and maybe we will quell politics with the issue and 
begin thinking about what really is best for the children of 
our country. Thank you, Mr. Chairman.
    Mr. Bilirakis. Thank you, Mr. Chairman, for your statement. 
The gentlelady from California, Ms. Capps.
    Ms. Capps. Thank you, Mr. Chairman. And I appreciate your 
holding this hearing, and I appreciate our expert witnesses for 
being with us today.
    Today, I am speaking and listening, not just as an elected 
representative but as a mother and a grandmother, a public 
health nurse and the former director of the Santa Barbara 
School District Teenage Pregnancy and Parenting Program, a 
program which provided, and does still provide, child care and 
development, child development services for school-age parents. 
I have first-hand real world experience with young men and 
women struggling with the difficult subject of sex. I have 
dealt with teenagers trying to cope with the ramifications of 
bad decisions, and I have worked with young women as they 
strive to make life-altering decisions. And I have seen the 
terrible results when we turn our back and deny them help. So 
today's subjects are of great personal interest to me, and I 
have significant concerns about them.
    First of all, I can tell you from my experience that 
parental consent requirements for title X services will result 
in higher teenage pregnancy rates, period. Like most of my 
colleagues, I think it is, when at all possible, the best 
option for a teen considering sexual activity to speak with and 
consult with his or her parents. Parental involvement in our 
children's lives is crucial especially for issues like these. 
And for anyone who works with young people, the interest in 
bridging that relationship between child and parent is 
paramount, but not all young people have that option for a 
variety of reasons. And requiring parental notification and 
consent will cause many teenagers to avoid seeking help from 
health clinics. If you have ever sat with someone who is the 
victim of incest, you will know what this subject means.
    These teens have unprotected sex, and they will struggle on 
their own to deal with the results. Many will seek unsafe 
abortions or will not get access to critical pre-natal care. No 
one wants that for our young people. Our best hope is to have a 
frank conversation with them and help them to understand the 
gravity of their choices. Parents need to have that role 
whenever possible. And then, as a last resort, we need to make 
sure that they have access to all needed services if their 
families fail them or are not there, literally not there for 
them.
    Our other topic, the so-called conscience clause, is 
equally difficult. For decades, women have had to fight to get 
access to the reproductive health services they uniquely need. 
Programs like title X and Medicaid have risen up around their 
efforts, and I consider myself to be a religious person. I am 
very respectful, as respectful as I know how to be, of the 
deep-seeded beliefs and feelings that many Americans have on 
the subject of reproductive health. I grant them their right to 
have positions and feelings that may differ from mine, but I do 
not accept that anyone should have the authority to compel 
others to assume these beliefs as well.
    Under current law, an individual who has a religious or 
moral objection to providing a service can refuse to offer it, 
but the law recognizes certain differences between an 
individual and an institution. Institutions do not have the 
same rights, nor should they. Health care facilities exist to 
provide services. It should be extremely rare when such a 
facility can deny anyone access to care. Even so, there are 
only minimal obligations on hospitals and other facilities. 
Under title X, they only have to tell someone what their 
choices are and where they can go to receive these services. 
And under Medicaid, hospitals and clinics will only be 
obligated to provide an abortion in cases of rape, incest or 
when the life of the mother is in danger. Enacting broader 
conscience clause for institutions will result in leaving women 
without the services that they have a constitutional right to.
    So, Mr. Chairman, I think the current law gives sufficient 
deference to moral objections, and that we need to protect 
access to critically important reproductive health care. And I 
yield back the balance of my time.
    Mr. Bilirakis. The Chair thanks the gentlelady. Mr. Pitts 
for an opening statement.
    Mr. Pitts. Thank you, Mr. Chairman. First, thank you for 
holding this important hearing today, and thank the witnesses 
for appearing today.
    Both the rights of conscience for health providers and a 
parent's right to know about prescription drugs for their minor 
children are a matter of basic ethics in health care. Mr. 
Chairman, I learned last year of the need for a comprehensive 
anti-discrimination protection for health care organizations 
that choose not to provide abortions. Shockingly, some of our 
fine private hospitals have recently threatened and even 
forced, compelled to provide abortions, a procedure to which 
they are opposed to providing.
    Currently, Federal law does provide conscience protection 
for individuals and providers who choose not to perform or 
refer for abortions. However, recent court cases have 
demonstrated that this law needs to be clarified to protect 
hospitals and health care organizations from abortion-related 
discrimination.
    Ms. Vosburgh, a witness before us today, represents Valley 
Hospital, located in Palmer, Alaska. Valley Hospital is a 
private, non-sectarian hospital that decided to have a policy 
against performing abortions. Valley Hospital had a right to 
have this policy since it, as I said, is a private hospital. 
Unfortunately, Valley Hospital was ordered to perform abortions 
against its will.
    Mr. Chairman, this is wrong. Abortion is elective surgery, 
it is not prenatal care, it is not basic health care, as some 
of our friends would like us to believe. Private hospitals 
should be able to decide what types of elective surgery they 
wish to offer. If they don't want to provide abortions, they 
shouldn't have to. For every one hospital that does not provide 
abortion, there are scores of hospitals that do provide them. I 
wonder what other elective surgeries we will begin forcing our 
hospitals to provide next.
    We are not talking about discrimination here, which would 
be offering a service to some patients and not others. We are 
talking about a private hospital board making a decision not to 
offer one type of elective surgery and making that decision 
apply to everyone who walks in the door, regardless of race, 
income, whatever.
    Mr. Chairman, I am proud to be a co-sponsor of your 
legislation, the Abortion Non-Discrimination Act. This 
legislation strengthens existing law by saying that health care 
providers may not be required to provide abortions. It is 
common sense, I think it is a technical change. The authors of 
the 1996 law admit that they intended for hospitals and health 
care providers to be included in the definition of health care 
entity. However, unfortunately, the courts have misconstrued 
this and thus the need for further clarification.
    The second issue before us today is even more disturbing. 
Mr. Chairman, in the State of Pennsylvania, a minor needs 
written parental or guardian consent to have his or her ears 
pierced, to get a driver's learning permit, to get married, to 
receive aspirin in school, to attend a field trip, to get a 
tattoo, to participate in athletic activity, to be absent from 
school, to ride a bus other than his own, the list goes on. We 
do not allow minors to attend R-rated movies, purchase tobacco 
products, consume alcohol. However, Federal regulations allow a 
minor to get contraceptives, including injected drugs, like 
Depo-Provera, and surgical implants, like Norplant, in health 
care clinics receiving title X funds without parental consent. 
In fact, it is against the law for medical staff to inform 
parents that their child is receiving prescription 
contraceptives.
    Mr. Chairman, it is deplorable that while a 14-year-old 
girl is required to have parental consent to get an aspirin in 
school or have her ears pierced, she can receive prescription 
contraceptive drugs and devices without the consent or 
knowledge of her parents. I am sure you agree with me that 
parents have a right to know what the government is doing to 
their children. Further, under current law, in most States, a 
minor receiving care in a physician's office must receive 
parental consent before receiving care. However, if that same 
minor were to enter a title X clinic, she could receive 
prescription contraceptives without parental consent or 
notification. Again, it is mandated under Federal regulations.
    The testimony we will hear today from Mr. Heisler will show 
the danger of this regulation. It is unconscionable that our 
government regulations prevented a 13-year-old parents--girl's 
parents from knowing that their daughter had been driven to a 
clinic by her teacher to receive contraceptives and then raped 
over a period of 18 months this went on. Another example, in 
1998, a 16-year-old in Walton County, Georgia, unbeknownst to 
her parents, went to receive a pelvic exam, an injection of the 
contraceptive drug, Depo-Provera, in a taxpayer-funded clinic, 
and as the girl was about to receive the injection she casually 
mentioned to the nurse that she had a heart murmur. The nurse 
told the girl she would need a doctor's note, so the clinic 
would be immune from a malpractice claim, and the family's 
doctor subsequently notified the mother that the chemical 
contraception, if it had been administered, there was a great 
probability that her child would have gone into cardiac arrest 
and possibly have died because of her heart condition.
    These horrific examples could have been prevented if our 
bill was passed. We don't expect the government to watch over 
every single teen out there to whom is given birth control. 
That is a parent's responsibility. However, by keeping them out 
of the loop, were are, in effect, removing parents from the 
equation. And so thank you, thank you to all the witnesses for 
taking time to come and testify. I look forward to hearing 
their testimony.
    Mr. Bilirakis. The Chair thanks the gentleman. Mr. Deutsch, 
for an opening statement.
    Mr. Deutsch. Thank you, Mr. Chairman. Just listening to 
opening statements, it is almost as if it is a tale of two 
cities or a tale of two countries. My good friend and colleague 
talked about an America which I wish it existed. I wish 
everyone in America could go to private physicians or go to 
clinics that are not affected by H.R. 4691, but that is not the 
case. This type of legislation, in fact, the facts are that it 
does discriminate. It does discriminate disproportionately of 
low-income women, people who don't have a choice, people in 
rural areas. And that would be the effect. I can turn the 
questions on its head that these are title X funded clinics 
that they don't have to participate. If they feel so 
objectionable of the requirements that go along with the 
funding, then they can choose not to participate; that is their 
choice.
    It is also--I mean, obviously, we have two separate parts 
of the hearing. It is also interesting, and the chairman well 
knows this coming from Florida, as I do, that the Florida 
Supreme Court has actually found a Florida constitutional right 
of non-notification. And it is interesting. I mean this is not 
a radical court by any stretch of the imagination. And it is 
also--again, I don't know what other States provide State 
constitutional protection that has been interpreted to provide 
this. But it is the follow-up of really this whole issue of a 
tale of two countries.
    I don't ever like to personalize statements as a member, 
but I have a daughter that I hope she never gets pregnant 
outside of marriage, but if she did, I would hope she would 
have the relationship with her mom and me to talk to us. But 
there are many children in America, unfortunately, and we are 
talking the tens of thousands, who unfortunately don't have 
those relationships with their parents and situations of abuse, 
potentially incest, potentially all sorts of other issues that 
exist. And there is a reason for the distinction that my 
colleague mentioned between going on a bus without permission 
and being able to receive contraception or for that matter 
abortion. There is a very real reason, and the experience of a 
16-year-old girl who might be far more experienced than maybe 
anyone in this room in this area defies the conditions that 
still exist in America, in many places, under many times and 
many circumstances.
    So I welcome this hearing, I welcome the testimony from 
different people, and I urge my colleagues who have not seen 
both sides of America to visit both sides of America. Thank 
you.
    Mr. Bilirakis. I thank the gentleman. Mr. Wynn, for an 
opening statement.
    Mr. Wynn. Thank you, Mr. Chairman. I appreciate your 
calling this hearing on a very, very important issue facing us 
today. I have very mixed feelings, but I think in listening to 
the testimony I will be focusing on, and I hope as a committee 
we focus on the welfare of the child from the standpoint of the 
child's health. In an era of AIDS and as well as rampant teen 
pregnancy, it seems to me that young people do have the need to 
have unfettered access to information about contraception as 
well as contraceptive devices. Having said that, I also 
acknowledge that there is a parental role, I just think that 
that parental role should not come into play once you reach the 
point of making these crucial decisions.
    I also would be interested, however, in hearing from people 
comment on the question of their interaction of contraceptives 
with other drugs that the child may be taking and how we can 
again look at the child's best--protect the child's welfare in 
those situations where there may be an adverse reaction if full 
information is not disclosed to the person making the 
contraceptive information or devices available.
    So there are a lot of complex issues before the committee. 
I also look forward to hearing from the witnesses, but I do 
believe we have to take the child's physical health, keep that 
in the forefront of this discussion. Again, I thank you for 
calling this hearing and look forward to the testimony. Thank 
you.
    Mr. Bilirakis. And the Chair thanks the gentleman. And we 
will go on to the panel now, but before we do I would like to 
say that Congressman Akin is here at his own time because he 
has an interest in this subject, and he is more than welcome to 
be sitting in during our deliberations.
    The first panel consists of Ms. Karen Vosburgh, from Palmer 
Alaska, a very beautiful community, I have been to it; Ms. 
Catherine Weiss, director of ACLU Reproductive Freedom Project 
out of New York City; and Professor Lynn Wardle, J. Reuben 
Clark Law School, Brigham Young University, Provo, Utah.
    Welcome. Your submitted testimony is a part of the record, 
and we would hope you would complement it. We will set the 
clock at 5 minutes and hopefully we will all do our best to 
adhere to that time limit. Ms. Vosburgh, please start off. 
Please, the mike, yes.

 STATEMENTS OF KAREN VOSBURGH; CATHERINE WEISS, DIRECTOR, ACLU 
 REPRODUCTIVE FREEDOM PROJECT; AND LYNN WARDLE, PROFESSOR, J. 
       REUBEN CLARK LAW SCHOOL, BRIGHAM YOUNG UNIVERSITY

    Ms. Vosburgh. Good afternoon, Mr. Chairman, and thank you 
for bringing this up to the forefront. I do thank you for that. 
And also other members of the committee. Thank you for 
providing me this opportunity to testify and to express my 
support for protecting health care providers from forced 
involvement in abortion.
    I serve as a director of the Association Board of Valley 
Hospital, which is a nonprofit, nonsectarian community-based 
hospital. This hospital lies in an amazingly beautiful valley, 
as you said, Mr. Chairman. It is surrounded on three sides by 
these incredible mountains and beautiful rivers. I mean it is 
just a very pristine area. It is Palmer, Alaska, and it is 
located about 50 miles east of Anchorage. There is also another 
town, Wasilla, that is 10 miles from Palmer. And these two 
towns and the outlying areas make up a place we call the 
Valley. There is about 50,000 people there.
    It is a place of faith. There are 70 churches in this 
valley, and we are a very God-based community, and we believe 
that abortion--we know that abortion is killing a human being.
    Valley Hospital is truly a community hospital in that it is 
governed by the members of the community. Membership in the 
hospital is open to all residents of our community without 
regard to citizenship, race, sex or religious preference. The 
members elect the association board on which I serve. The 
association board is responsible for raising funds, acquiring 
land, property and equipment for the hospital and for selecting 
the members of the hospital's operating board. This board sets 
the policy of the hospital. And because the members of the 
operating board are ultimately selected from our community, the 
board truly represents the community. Among the operating 
board's current members, for example, are a pastor, a realtor, 
an attorney, a teacher and a physician.
    The community both serves and is served by the hospital. 
The mission of the hospital is to enhance the health of those 
we serve, guided by the values of honoring the dignity of all 
people, representing the interests of the community and 
providing the highest level of care within the bounds of 
ethics.
    Our small town has an OB/GYN who performs elective 
abortions. She uses Valley Hospital for her later-term, second 
trimester elective abortions. For the most part, our community 
wants abortion to stop at Valley Hospital. So, in the early 
1990's, the members elected people to the association board who 
believe in respect for human life and who hold the philosophy 
that hospitals are for healing and not for killing. The 
association board selected the operating board, which passed a 
resolution reflecting this policy. The resolution ended 
abortion at Valley Hospital except in the cases of rape, incest 
and danger to the life of the mother, which is exactly the same 
policy that the Federal Government has had in Medicaid and its 
other health programs for many years. In fact, every year, our 
operating board continues to update this policy. This is the 
latest one, and it states that, ``A policy has been adopted 
that elective abortions shall not be performed at Valley 
Hospital. The exceptions to this policy include documentation 
by one or more physicians that the fetus has a condition that 
is incompatible with life, a life-threatening condition exists 
for the patient or the pregnancy is a result of rape or 
incest.''
    When the abortionist was told she could no longer perform 
abortions at Valley Hospital, she was overheard complaining 
that abortions were a good portion of her income. She sued. The 
trial judge, Judge Dana Fabe, ruled in her favor, stating that 
because Valley Hospital received some Federal and State money 
from Medicaid and Medicare, that it was a quasi-public entity 
and therefore has to provide abortions. The judge's reasoning 
was strange, to say the least. How can our receipt of Federal 
funds be used to forbid us to have the same abortion policy 
that the Federal Government requires in all its own health 
facilities?
    I believe, however, that this particular Judge Fabe's 
opinion was colored by her personal views on abortion. In 1993, 
she made the statement in a newspaper there that, ``If a high 
school student in this State has a fundamental right to choose 
his or her hairstyle, an Alaskan woman must certainly have a 
fundamental right to choose whether or not to terminate a 
pregnancy.'' That is her reasoning.
    Of course, Valley Hospital challenged this decision, and it 
went before the Alaska Supreme Court. The five-member court is 
one of a handful of State supreme courts to rule that State 
funds must be used for elective abortions despite the contrary 
decision of the State legislature. One member, Justice Bryner--
I was there when he said this, and I just about fell on the 
floor--he said during oral arguments for the State funding 
issue, he declared that pregnancy is a disease. It was no 
surprise that this court upheld Judge Fabe's original decision. 
The Alaska Supreme Court held that Valley Hospital was quasi-
public because of its receipt of public monies.
    In addition, the court struck down a State law protecting 
hospitals that refuse to participate in abortions, denying the 
right of our board to exercise its rights of moral conscience. 
The court even suggested that it would not respect the 
religious beliefs of those who decline involvement in abortion, 
saying, ``recognizing such a policy as compelling could violate 
the Establishment Clause of the First Amendment.'' And you will 
find that in Valley Hospital Association v. Mat-Su Coalition 
for Choice.
    In response, the legislature sought to reverse the decision 
by constitutional amendment, which requires a two-thirds vote 
of our legislators. Sadly, the amendment failed to garner the 
two-thirds majority by just one vote, and I am sure many of you 
understand that here.
    Mr. Bilirakis. Please summarize, Ms. Vosburgh.
    Ms. Vosburgh. Will do. This court decision potentially 
places all hospitals in our State in a Catch-22 situation. If 
you are a non-religious hospital, you have no First Amendment 
claim of religious freedom, so you must provide abortions. If 
you are a religious hospital with a free exercise claim, 
respect for your right of conscience may be seen as showing 
favoritism to religion, so you may still have to provide 
abortions.
    I like this quote, this is from Bernard Nathanson who is a 
former abortionist. He said, ``It is clear that permissive 
abortion is purposeful destruction of what is undeniably human 
life. It is an impermissible act of deadly violence.'' For 
those of us who share this view, that abortion is a form of 
violence, not a form of health care, being required to provide 
and support it is a grave injustice.
    I ask for myself, my community and for any other hospital 
or health care provider that does not want to be forced to be 
involved in killing innocent human life, please pass 
Congressman Bilirakis' bill, the Abortion Non-Discrimination 
Act. We, too, have a right to choose--to choose not to be 
involved in destroying innocent human life. Thank you.
    [The prepared statement of Karen Vosburgh follows:]
                  Prepared Statement of Karen Vosburgh
    Good afternoon, Mr. Chairman and members of the committee. Thank 
you for providing me this opportunity to testify and express my support 
for protecting health care providers from forced involvement in 
abortion.
    I serve as a director of the association board of Valley Hospital, 
a nonprofit nonsectarian community-based hospital. The hospital lies in 
an amazingly beautifully valley, surrounded on three sides by majestic 
mountains, with rivers and streams of crystalline blue in Palmer, 
Alaska. Palmer is located about 50 miles east of Anchorage. There's 
another town, Wasilla, that's 10 miles from Palmer. These two towns and 
the outlying areas are known as ``the valley.''
    Valley Hospital is truly a community hospital in that it is 
governed by the members of the community. Membership in the hospital is 
open to all residents of our community without regard to citizenship, 
race, sex or religious preference. The members elect the association 
board on which I serve. The association board is responsible for 
raising funds, acquiring land, property and equipment for the hospital 
and for selecting the members of the hospital's operating board. This 
board sets the policy of the hospital. And because the members of the 
operating board are ultimately selected from our community, the board 
truly represents the community. Among the operating board's current 
members, for example, are a pastor, a realtor, an attorney, a teacher, 
and a physician.
    The community both serves and is served by the hospital. The 
mission of the hospital is ``to enhance the health of those we serve'' 
guided by the values of honoring the dignity of all people, 
representing the interests of the community, and providing the highest 
level of care within the bounds of ethics.
    Our small town has an OB/GYN who performs elective abortions. She 
uses Valley Hospital for her later-term, second trimester abortions. 
For the most part, our community wants abortion to stop at Valley 
Hospital. So, in the early 1990's the members elected people to the 
association board who believe in respect for human life and who hold 
the philosophy that hospitals are for healing, and not killing. The 
association board selected the operating board, which passed a 
resolution reflecting this policy. The resolution ended abortion at 
Valley Hospital except in the cases of rape, incest and danger to the 
life of the mother--exactly the same policy the federal government has 
had in Medicaid and its other health programs for many years.
    When the abortionist was told she could no longer perform abortions 
at Valley Hospital, she was overheard complaining that abortions were a 
good portion of her income. She sued. The trial judge, Judge Dana Fabe, 
ruled in her favor, stating that because Valley Hospital received some 
federal and state money, it was a quasi-public entity, and therefore 
has to provide abortions. The judge's reasoning was strange, to say the 
least. How can our receipt of federal funds be used to forbid us to 
have the same abortion policy that the federal government requires in 
all its own health facilities? I believe, however, that Judge Fabe's 
opinion was colored by her personal views on abortion. In 1993 she made 
the statement that ``if a high school student in this state has a 
fundamental right to choose his or her hairstyle, an Alaskan woman must 
certainly have a fundamental right to choose whether or not to 
terminate a pregnancy.''
    Of course, Valley Hospital challenged the decision, and it went 
before the Alaska Supreme Court. This five member court is one of a 
handful of state supreme courts to rule that state funds must be used 
for elective abortions despite the contrary decision of the state 
legislature. One member, Justice Bryner, declared that ``pregnancy is a 
disease'' during oral arguments on the funding issue. It was no 
surprise that the court upheld Judge Fabe's original decision. The 
Alaska Supreme Court held that Valley Hospital was ``quasi-public'' 
because of its receipt of public monies. In addition, the court struck 
down a state law protecting hospitals that refuse to participate in 
abortions, denying the right of our board to exercise its rights of 
moral conscience. The court even suggested that it would not respect 
the religious beliefs of those who decline involvement in abortion, 
saying, ``recognizing such a policy as `compelling' could violate the 
Establishment Clause of the First Amendment.'' Valley Hospital Ass'n. 
v. Mat-Su Coalition for Choice, 948 P.2d 963 (Alaska 1997).
    In response, the legislature sought to reverse the decision by 
constitutional amendment, which requires a two-thirds vote of our 
legislators. Sadly, the amendment failed to garner that two-thirds 
majority by just one vote.
    This court decision potentially places all hospitals in our state 
in a ``Catch-22'' situation. If you are a non-religious hospital you 
have no First Amendment claim of religious freedom, so you must provide 
abortions. If you are a religious hospital with a ``free exercise'' 
claim, respect for your right of conscience may be seen as showing 
favoritism to religion, so you may still have to provide abortions.
    At a time when he was not a member of any religion, former 
abortionist Bernard Nathanson once said: ``It is clear that permissive 
abortion is purposeful destruction of what is undeniably human life. It 
is an impermissible act of deadly violence.'' For those of us who share 
this view--that abortion is a form of violence, not a form of health 
care--being required to provide and support it is a grave injustice.
    I ask for myself and my community, and for any other hospital or 
health care provider that does not want to be forced to be involved in 
killing innocent human life. Please pass Congressman Bilirakis's bill, 
the Abortion Non-Discrimination Act (H.R. 4691). We, too, have a right 
to choose--a right to choose not to be involved in destroying life.
    Thank you for considering my views.

    Mr. Bilirakis. Thank you, Ms. Vosburgh.
    Ms. Weiss, please proceed. Make sure that mike is on.

                  STATEMENT OF CATHERINE WEISS

    Ms. Weiss. Mr. Chairman and members of the subcommittee, 
good afternoon and thank you for inviting me to testify today. 
I am here, as you know, on behalf of the American Civil 
Liberties Union. Because of its dual long-term commitments to 
religious liberty and reproductive freedom, the ACLU has a 
profound interest in the ongoing debate about religious 
exemptions in the reproductive health context. I am going to 
begin by telling you about the case that brought the ACLU into 
this debate, then I will outline the framework we use for 
analyzing these exemptions. And I will end with a brief 
discussion of H.R. 4691.
    First the story. In 1994, I got a call from a very 
distraught doctor in Nebraska. He told me that a 19-year-old 
woman had been admitted through the emergency room of the 
hospital where he practiced. She had a blood clot in her lung. 
Tests revealed that she was 10 weeks pregnant. The clotting 
disorder was a rare complication of the pregnancy. Her treating 
physicians told her that she had two alternatives. She could 
stay in the hospital for the remaining 6\1/2\ months of her 
pregnancy, taking medications and undergoing surgery to reduce 
her risk of death or she could have first trimester abortion. 
She wanted to go home to her toddler so she decided to have an 
abortion. Four doctors certified that it was a life-saving 
procedure for her. On the morning surgery was scheduled, 
however, the hospital's lawyer appeared in the operating room 
brandishing a State law that said that no hospital could be 
required to permit an abortion on its premises. The procedure 
was canceled. Ten days of dangerous delay followed. Although 
moving the patient greatly increased her medical risks, she was 
ultimately transferred 20 miles by ambulance to the office of 
her physician. He performed the abortion safely. Although his 
patient had survived the unconscionable risks to which she had 
been suggested, the doctor wanted to know whether what the 
hospital had done was legal. That is one of the questions 
presented here today.
    I move now to the framework the ACLU has developed for 
analyzing religious exemptions. This framework is meant to 
balance protection for religious liberty with protection for 
other critical personal rights. We have identified two main 
factors. First, would refusal harm the health or other critical 
personal interests of people who do not share the beliefs that 
motivate the refusal? The more such burdens fall on third 
parties, the less acceptable any claimed right to refuse. 
Second, is the objector sectarian institution engaged in 
religious practices or is instead an entity, whether 
religiously affiliated or not, operating in a public, secular 
setting? The more public and secular the setting, the less 
acceptable an institution's claimed right to refuse.
    H.R. 4691 fails this test. The burdens imposed by the bill 
would fall primarily on patients of all faiths and no faith 
seeking health care in public and secular settings. Consider, 
for example, the hypothetical case of a low-income woman in 
Washington State who has just been raped. The police take her 
to a local emergency room in a large, urban catholic hospital. 
State law in Washington requires hospitals to offer all rape 
victims emergency contraception so that they can prevent a 
pregnancy resulting from the assault. The hospital, however, 
believes that emergency contraception is an abortifacient, so 
relying on H.R. 4691 the hospital refuses to provide or even 
inform the patient about emergency contraception. She leaves 
not knowing that this drug exists.
    Three weeks later, the woman's pregnancy test comes back 
positive. She is devastated and decides to have an abortion. 
She calls her Medicaid managed care organization. As you know, 
State and Federal law entitle rape victims to Medicaid coverage 
for abortion. Relying on H.R. 4691, however, the managed care 
organization tells the patient that it does not provide 
abortions and refuses to give her any further information on 
the subject. She assumes that her abortion isn't covered and 
starts the race against time of trying to raise the money on 
her own as the pregnancy advances.
    This account provides just one example of how H.R. 4691 
could allow hospitals, health plans and other institutions to 
shirk critical legal obligations to patients, even patients in 
publicly funded health care programs. But surely health care 
institutions that employ the general public and serve the 
general public and even receive public funds should comply with 
public health laws. The ACLU urges the subcommittee to reject 
this dangerous bill. Thank you.
    [The prepared statement of Catherine Weiss follows:]
    Prepared Statement of Catherine Weiss, Director, American Civil 
             Liberties Union, Reproductive Freedom Project
    Chairman Bilirakis, Ranking Member Brown, and members of the 
Subcommittee: My name is Catherine Weiss and I am the Director of the 
American Civil Liberties Union's Reproductive Freedom Project. I am 
pleased to testify today on behalf of the ACLU about refusal clauses in 
the reproductive health context. The ACLU is a nationwide, nonpartisan, 
nonprofit organization of approximately 300,000 members dedicated to 
protecting the principles of freedom and equality set forth in the 
Constitution and in our nation's civil rights laws.
    Today, I will explain the practical impact of refusal clauses 
(sometimes also called religious exemptions or ``conscience clauses'') 
that permit entities and individuals to refuse to provide or cover 
health services to which they object on religious or moral grounds. I 
will provide a brief overview of federal refusal clauses. And I will 
offer an analytic framework for evaluating refusal clauses that 
balances protection for religious liberty with protection for the 
public health. Finally, I will explain that the public overwhelmingly 
rejects the principles that underlie overly broad refusal clauses, and 
I will urge you to oppose H.R. 4691 because it would impose 
unacceptable burdens on women of all faiths and no faith seeking 
reproductive health care in public, secular settings.
    The ACLU has a long, proud history of vigorously defending 
religious liberty. In Congress and in the courts, we have supported 
legislation providing stronger protection for religious exercise--even 
against neutral, generally applicable laws. For nearly a decade, the 
ACLU fought to preserve or restore the highest level of constitutional 
protection for claims of religious exercise. We were founding members 
of the coalition that supported the Religious Freedom Restoration Act 
in 1993, and we were instrumental in urging Congress to enact the 
Religious Land Use and Institutionalized Persons Act of 2000. We have 
also represented persons challenging burdens on the exercise of their 
religious beliefs. For example, we have sued to protect the right of 
Jewish students to wear a Star of David pendant at school; we have sued 
to defend the right of conservative Christian activists to broadcast on 
public access television; and we have filed a brief in support of two 
women who were fired for refusing to work at a Greyhound racetrack on 
Christmas day. We even offered to back the Rev. Jerry Falwell in his 
2001 challenge to Virginia laws restricting ownership of church 
property.
    We have been equally vigilant in our advocacy of reproductive 
rights. The ACLU fought long and hard to persuade Congress to pass the 
Freedom of Access to Clinic Entrances Act to protect reproductive 
health clinics, patients, and professionals from deadly violence. We 
are currently key supporters of the Equity in Prescription Insurance 
and Contraceptive Coverage Act to ensure more widespread access to 
contraception for working women. We have participated in nearly every 
critical Supreme Court case protecting reproductive freedom, from Roe 
v. Wade to Planned Parenthood v. Casey to Stenberg v. Carhart. This 
history makes the ACLU well-positioned to assist the Subcommittee in 
its consideration of refusal clauses, which, as is illustrated below, 
can have a dramatic effect on the health of women.
                            a case in point
    In the Spring of 1994, a nineteen-year-old Nebraska woman, Sophie 
Smith,1 was admitted to the emergency room at a religiously 
affiliated hospital with a blood clot in her lung. Tests revealed that 
Smith was approximately ten weeks pregnant, and that the clotting 
problem resulted from a rare and life-threatening condition exacerbated 
by the pregnancy. The hospital immediately put Smith on intravenous 
blood-thinners to eliminate the existing blood clot and to help prevent 
the formation of more clots that could kill Smith instantly if they 
lodged in her lungs, heart, or brain.
    Smith's doctors told her that she had two alternatives. She could 
stay in the hospital on intravenous blood-thinners for the remaining 
six-and-a-half months of her pregnancy. She would also need a procedure 
in which doctors would insert an umbrella-like device into one of her 
veins designed to catch blood clots before they reached a vital organ. 
Or she could have a first-trimester abortion, switch to oral blood 
thinners, and be released from the hospital. Smith decided to have the 
abortion. She wanted to go home to care for her two-year-old child.
    On the morning Smith was scheduled to have the abortion, the 
hospital lawyer appeared in the operating room. He announced that the 
hospital would not permit an abortion on its premises--even though four 
doctors had certified that an abortion was necessary to save Smith's 
life. The lawyer was armed with a state refusal law that stated, ``No 
hospital, clinic, institution, or other facility shall be . . . 
required to allow the performance of an abortion therein.'' 
2 The procedure was canceled and ten days of dangerous delay 
followed.
    Smith wanted to be transferred to a facility that would perform the 
abortion, but moving her increased the risk that a blood clot would 
kill her. Because the blood-thinners she was taking made her prone to 
excessive bleeding, Smith's doctors felt that she should be treated in 
a hospital. But the hospital refused to reconsider its decision not to 
allow the abortion on its premises. Notwithstanding the risks to her 
health, Smith was ultimately transferred by ambulance to her doctor's 
office. He performed the abortion and sent her back to the hospital.
    Smith was lucky in the end. She survived the risks she faced when 
this hospital refused to treat her. But the risk itself was 
unacceptable.
              a brief overview of federal refusal clauses
    Refusal clauses pertaining to certain reproductive health services 
swept the nation in the years following the Supreme Court's 1973 
decision legalizing abortion in Roe v. Wade.3 Congress 
started the trend that same year when it passed legislation (sponsored 
by Senator Frank Church and known as the ``Church Amendment'') in 
reaction to a 1972 court order that had required a Catholic hospital to 
allow a sterilization procedure to be performed on its 
premises.4 The Church Amendment established that an 
individual's or entity's receipt of federal funds under certain public 
health programs is not a basis for requiring recipients with moral or 
religious objections to perform or assist in sterilization or abortion 
procedures, or to make facilities or personnel available for the 
performance of such procedures.5 The legislation also 
prohibits certain federally funded institutions from discriminating in 
employment, or in the extension of staff or other privileges, against 
any health care professional because the professional refuses to 
perform or assist in an abortion or sterilization procedure based on a 
religious or moral objection; because the professional does perform or 
assist in abortion or sterilization procedures in a separate setting; 
or because of the professional's religious or moral beliefs concerning 
these procedures.6
    In 1996, Congress adopted the Coats Amendment.7 The 
amendment prohibits the government from ``discriminating'' against 
medical residency programs or other entities that lose accreditation 
because they fail to provide or require training in abortion services. 
The amendment was passed after the Accreditation Council for Graduate 
Medical Education adopted a professional standard requiring residency 
programs in obstetrics and gynecology to provide abortion training. 
Under the standard applicable at that time, residency programs or 
physicians with religious or moral objections could opt out of the 
required abortion training, although programs remained responsible for 
insuring that willing residents received abortion training at another 
institution. The Coats Amendment established that the government could 
not ``discriminate'' against a medical residency program solely on the 
basis of the program's refusal to train new doctors in abortion 
practice or to refer them elsewhere for such training, even when a 
residency program lost its accreditation because of its failure to 
offer training.
    In 1997, Congress adopted new statutory requirements for the 
Medicaid program that, among other things, mandated that states inform 
patients about how to obtain covered services--including family 
planning services--that their Medicaid managed care organization did 
not provide.8 Congress made clear, however, that the new 
provisions did not require a Medicaid managed care organization to 
provide, reimburse, or cover any counseling or referral service to 
which the organization objects on moral or religious 
grounds.9
    In 1998, Congress passed a hard-fought provision that required 
health plans participating in the Federal Employees Health Benefits 
Program (``FEHBP'')--which provides health insurance for federal 
employees--to cover prescription contraceptive drugs and 
devices.10 Federal employees can generally choose from a 
wide variety of participating plans. Congress explicitly exempted from 
the requirement five religiously affiliated health plans that were then 
FEHBP participants. It also created an exemption for ``any existing or 
future plan, if the plan objects to such coverage on the basis of 
religious beliefs.'' (In the years since, no additional plan has 
requested a religious exemption.) And, in 1999, the House voted against 
an amendment offered by Representative Chris Smith that would have 
broadened the exemption to plans that object to contraceptive coverage 
on the basis of ``moral beliefs.''
                       striking the right balance
    The framework we propose below for analyzing refusal clauses 
balances protection for the public health in general, reproductive 
health in particular, patient autonomy, and gender equality with 
protection for individual religious belief and institutional religious 
worship. We reject the imposition of religious doctrines on those who 
do not share them, especially at the expense of the public health. At 
the same time, we seek the maximum possible accommodation of an 
individual's religious or conscientious objections, so long as 
patients' rights are not compromised as a result. We also seek to 
insulate pervasively sectarian institutions from having to comply with 
laws that interfere with their religious practices.
    To strike the proper balance, policymakers and advocates must 
consider each proposed refusal clause carefully, tailoring it to its 
context. Concrete examples may be clearer than general principles: 
every rape survivor ought to be offered emergency contraception to 
protect herself from getting pregnant as a result of the assault, no 
matter where she is treated; an administrative assistant working at a 
Catholic university should not have to pay out-of-pocket for birth 
control pills because her employer believes contraception is a sin; but 
a church should not have to purchase contraceptive coverage for its 
ministers and other clerics; and a doctor, nurse, or pharmacist who 
cannot in good conscience participate in abortions or contraceptive 
services should be allowed to opt out, so long as the patient is 
ensured safe, timely, and financially feasible alternative access to 
treatment. The factors we identify for evaluating refusal clauses 
should lead to these kinds of fair results.
               a framework for analyzing refusal clauses
    Constitutional principles neither require nor forbid most refusal 
clauses.11 Nevertheless, legal principles are useful in 
constructing a framework for analyzing when an exemption is called for 
and what it should look like. Based in part on our study of the case 
law, the ACLU has identified two measures for evaluating refusal 
clauses. We consider first whether granting an exemption would impose 
burdens on people who do not share and should not bear the brunt of the 
objector's religious beliefs. Exemptions that impose little or no 
burden on others are more acceptable; exemptions that impose 
substantial burdens are less so. By ``burdens,'' we mean to include 
obstacles to health care and other critical personal interests, but we 
do not mean to include the mere exposure of third parties to religious 
practices or the tax or other financial burdens that may result from 
permitting certain exemptions. We consider next whether the exemption 
protects the religious practices of pervasively sectarian institutions 
or instead protects institutions operating in the public sphere. 
Exemptions that insulate core religious functions are more acceptable 
than those that spill over into the secular world.
    These measures are not part of any currently accepted legal test. 
But they reflect concerns that have been an undercurrent in many 
relevant cases without necessarily determining the outcome of those 
cases. Although each measure has independent importance, there is some 
overlap between the two: the imposition of particular religious beliefs 
on those who do not share them is less likely within a pervasively 
sectarian institution performing religious functions than in a more 
secular setting.
Avoiding Burdens on Others
    In the reproductive health context, the risk of imposition on those 
who do not share the objector's beliefs is especially great when an 
employer, hospital, health plan, pharmacy, or other corporate entity 
seeks an exemption. The refusal of such institutions to abide by 
reproductive health mandates directly affects employees, patients, 
enrollees, and customers of diverse backgrounds and faiths. The law 
should not permit an institution's religious strictures to interfere 
with the public's access to reproductive health care.
    The courts have repeatedly shown themselves wary of the imposition 
of an institution's religious beliefs on others. In Catholic Charities 
v. Superior Court,12 for example, the California Court of 
Appeal explained at length why the state was justified in adopting a 
narrow refusal clause that permitted only pervasively sectarian 
organizations--such as churches, religious orders, and some parochial 
schools--to refuse to include contraceptive coverage in health plans 
for their employees. A broader exemption, granting a right to refuse to 
Catholic Charities and other church-affiliated organizations that 
employ diverse workforces, would have meant ``imposing the employers' 
religious beliefs on employees who did not share those beliefs.'' An 
expansion of the refusal clause would also have ``undermine[ed] the 
anti-discrimination and public welfare goals of the prescription 
contraceptive coverage statutes.'' 13
    Another court expressed similar concerns in St. Agnes Hospital v. 
Riddick.14 There, a board that oversees graduate medical 
education had withdrawn accreditation from a Catholic hospital's ob/gyn 
residency program because of several deficiencies, including the 
hospital's refusal to provide or otherwise allow its medical residents 
to obtain clinical training in contraception, sterilization, or 
abortion procedures. The hospital claimed that the withdrawal of its 
accreditation amounted to religious discrimination. The court rejected 
this claim, concluding that the state had more than sufficient reason 
to insist on comprehensive medical education despite the hospital's 
religious objection. These reasons included the public's 
``overwhelmingly compelling interest in . . . competently trained 
physicians'' and the importance of preventing the hospital from 
``impos[ing] its Catholic philosophy on its residents, many of whom are 
not Catholic.'' 15
    The threat of imposition on others is significantly reduced when 
the law protects individual--as opposed to institutional--decisions 
about whether to provide certain health services. The federal Church 
Amendment contains antidiscrimination provisions that shield the 
conscientious decisions of doctors, nurses, and other practitioners. 
These provisions serve as a useful model in that they protect both 
those who refuse to participate in and those who provide abortion or 
sterilization procedures.16
    Laws that protect individual religious refusals offer important 
protections for health care professionals but may compromise the rights 
of patients unless adequate safeguards are included. There should be 
limits even to an individual health care provider's right to refuse. 
For example, whatever their religious or moral scruples, health 
professionals should give complete and accurate information and make 
appropriate referrals. Both legal and ethical principles of informed 
consent require doctors to tell patients about all treatment options, 
``including those [the doctor] does not provide or favor, so long as 
they are supported by respectable medical opinion.'' Doctors who refuse 
to treat should also ``refer the patient to a physician who does offer 
or favor the alternative treatment.'' 17 Nor can a health 
care provider's religious or moral convictions ever justify endangering 
a patient's safety. Courts have been appropriately intolerant of lapses 
in medical professionalism, even when they are religiously motivated. 
For example, a federal appeals court held that a New Jersey hospital 
was not liable for religious discrimination in firing a labor and 
delivery nurse who twice refused on religious grounds to scrub for 
emergency obstetrical procedures. She refused, although in both cases 
the pregnant women's lives were threatened, and the hospital claimed 
her refusal in the second case dangerously delayed treatment for a 
hemorrhaging patient.18
Insulating the Religious Functions of Pervasively Sectarian 
        Institutions
    The second measure we use to evaluate refusal clauses focuses on 
the nature of the institution and activity exempted. Churches, temples, 
mosques, seminaries, and other pervasively sectarian institutions 
engaged in religious practices ought generally to be free of the 
requirements of laws repugnant to their beliefs. Among health care 
institutions, privately funded Christian Science sanatoria may 
exemplify those that should qualify for a religious exemption. Such 
sanatoria are staffed by Christian Science healers, and they attend 
only to those seeking to be healed exclusively through prayer.
    When, however, religiously affiliated organizations move into 
secular pursuits--such as providing medical care or social services to 
the public or running a business--they should no longer be insulated 
from secular laws that apply to these secular pursuits. In the public 
world, they should play by public rules. The vast majority of health 
care institutions--including those with religious affiliations--serve 
the general public. They employ a diverse workforce. And they depend on 
government funds. A recent study found that Medicare and Medicaid 
accounted for 46% of total revenues to religiously affiliated hospitals 
in California in 1998, while unrestricted contributions, including 
charitable donations from church members, accounted for only .0015% (or 
$15 in every $10,000) of total revenues.19 These 
institutions ought to abide by the same standards of care and 
reproductive health mandates as apply to other health care 
institutions.
    Again, in deciding Free Exercise claims, the courts have recognized 
the importance of distinguishing the religious from the secular 
context. In refusing to allow employment discrimination claims by 
ministers and other clerics against their churches, for example, the 
courts have concluded that the state should not intrude into matters of 
church governance and administration because a church's autonomy in 
these areas is central to its religious mission.20 The 
courts have also noted that the employees of churches and comparable 
religious institutions may be assumed, ``based on the religious nature 
of the employment, [to] agree with or willingly defer their personal 
choices to the religious tenets espoused by their employer.'' 
21 On the other hand, the courts have acknowledged the 
appropriateness of preventing entities engaged in secular endeavors 
from foisting their religious principles on members of the general 
public.22
                        where the public stands
    The ACLU recently conducted public opinion research--including 
focus groups and a nationwide telephone survey--on religious objections 
to providing reproductive health services. This qualitative and 
quantitative research shows that Americans overwhelmingly oppose laws 
that protect religious objectors at the expense of the patient's rights 
and the public health.
    The public opposes refusal clauses that threaten access to health 
care.
 89% oppose ``allowing insurance companies to refuse to pay for 
        medical services they object to on religious grounds.''
 88% oppose ``allowing pharmacies to refuse to fill 
        prescriptions they object to on religious grounds.''
 86% oppose ``allowing employers to refuse to provide their 
        employees with health insurance coverage for medical services 
        the employer objects to on religious grounds.''
 76% oppose ``allowing [hospitals] to refuse to provide medical 
        services they object to on religious grounds.''
    The public's insistence on access reflects its view that religious 
refusals jeopardize women's health and lives. Seven in ten Americans 
are concerned, for example, that if ``religiously affiliated hospitals 
are allowed to limit access to medical services, the health and lives 
of many women will be threatened.''
    The public believes that individuals must be allowed to make health 
care decisions for themselves. While proponents of refusal clauses 
often cast the issue as one in which religious liberty is pitted 
against reproductive rights, the public sees this dichotomy as false.
 72% agree with the following statement: ``Religious liberty is 
        not threatened by requiring hospitals to provide basic medical 
        care. We are not talking about limiting a person's ability to 
        worship, but access to basic health care.''
    Even when the issue is presented as a choice between the religious 
interests of institutions and the health care decisions of individuals, 
however, the public backs the patient.
 79% believe that it is ``more important to respect the 
        personal conscience of individuals making difficult health care 
        decisions'' than to ``respect the conscience of a religious 
        hospital.''
 69% believe that it is ``more important to protect the 
        reproductive freedom of women'' than to ``protect the religious 
        freedom of religious hospitals.''
    Moreover, the public believes that the government's first 
responsibility is to protect the public health.
 72% are more concerned that the government hold ``all 
        hospitals--whether religiously affiliated or not--to the same 
        standards'' than they are about keeping ``the government from 
        forcing religious hospitals to violate their beliefs.''
 83% believe that ``if a hospital receives government funds, it 
        should be required to provide basic, legal medical services, 
        regardless of the hospital's religious objections.''
    Overall, our public opinion research shows that Americans are 
deeply troubled by the idea that religious interests could come between 
them and their health care needs.
            h.r. 4691--a broad and dangerous refusal clause
    Based on the framework outlined above, the ACLU opposes H.R. 4691, 
a bill sponsored by Chairman Michael Bilirakis (R-FL), Majority Leader 
Dick Armey (R-TX), and Representative Joseph Pitts (R-PA). H.R. 4691 
would allow a broad range of health care entities to refuse to comply 
with a wide array of federal, state, and local requirements to provide 
reproductive health services. As noted above, the United States 
Constitution does not require any exemption--let alone such a broad 
exemption--from compliance with public health laws. Moreover, H.R. 4691 
fails the test set forth in the ACLU's framework because its burdens 
would fall primarily on those who do not share the beliefs that 
motivate the refusal and because it protects institutions engaged in 
the public and secular provision of health care.
    H.R. 4691 would build upon the Coats Amendment, an existing federal 
refusal clause described above. If enacted, the newly expanded language 
would provide (amendments in italics):
        The Federal Government, and any State or local government that 
        receives Federal financial assistance, may not subject any 
        health care entity to discrimination on the basis that--
                (1) the entity refuses to undergo training in the 
                performance of induced abortions, to require or provide 
                such training, to perform, provide coverage of, or pay 
                for induced abortions, or to provide referrals for such 
                training or such abortions;
                                .  .  .
        (c) Definitions:
        For purposes of this section:
                                .  .  .
                (2) The term ``health care entity'' includes an 
                individual physician or other health professional, a 
                postgraduate physician training program, a participant 
                in a program of training in the health professions, 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.
Practical Effects of the Proposal
    The main effect of H.R. 4691 is to prohibit a governmental entity 
from ``discriminating''--that is, treating a health care entity 
differently--on the basis of the entity's refusal to perform, refer, 
train, cover, or pay for abortions. But what constitutes 
``discrimination'' would no doubt be the subject of debate and 
potential litigation.
    H.R. 4691 could have the following effects, among others:

 It would compromise the ability of Title X clients to obtain 
        information critical to their health. Title X, which provides 
        federal funds for contraceptive services for low-income 
        individuals, requires that grantees provide a referral to a 
        qualified abortion provider upon request as part of non-
        directive options counseling for pregnant women. H.R. 4691 
        would prohibit the federal government from enforcing this 
        regulation if it were deemed ``discriminatory'' to deny Title X 
        grants to providers that refuse to make abortion referrals. The 
        bill could thus undermine federal standards and compromise the 
        health of low-income pregnant women by denying them critical 
        information.
 It would interfere with the delivery of abortion services to 
        poor women in dire emergencies. H.R. 4691 would impede a 
        state's ability to comply with the federal Hyde Amendment, 
        which mandates coverage of abortions for women in the Medicaid 
        program in cases of rape, incest, or where the pregnancy 
        endangers a woman's life. Requiring Medicaid managed care 
        organizations that participate in the program to provide such 
        coverage could constitute ``discrimination'' against those that 
        refuse to provide or refer patients elsewhere for these 
        services.
 It would interfere with states' ability to enforce their own 
        laws on abortion. H.R. 4691 could prevent those states that 
        cover medically necessary abortions beyond those mandated by 
        the Hyde Amendment (whether as a result of state constitutional 
        rulings or by virtue of state laws) from effectuating that 
        coverage by contracting only with Medicaid managed care 
        organizations that agree to provide or refer for abortion 
        services. Currently, more than fifteen states require such 
        coverage. H.R. 4691 would interfere with these states' ability 
        to enforce their own laws and constitutional decisions and to 
        manage and ensure delivery of mandated services within their 
        own Medicaid programs.
 It would disrupt the enforcement of state health care 
        regulations. H.R. 4691 would thwart the enforcement of state 
        and local laws that require entities certified or licensed by 
        the state to address the full range of health care needs in the 
        communities they serve. A state might be prevented, for 
        example, from denying a ``certificate of need'' (a state-issued 
        document that is similar to a permit and that is often required 
        before two hospitals can merge) to a newly merged hospital that 
        refused to provide even lifesaving abortions and thus left 
        pregnant women in the community without help in medical 
        emergencies. (Mergers between a religiously affiliated hospital 
        and a secular hospital often raise this issue because some 
        religiously affiliated hospitals insist that the newly merged 
        entity apply religious doctrine in the provision of health 
        services.)
 It could immunize a health care entity's refusal to provide 
        emergency contraception, even to victims of rape. Because it 
        does not define the term ``abortion,'' H.R. 4691 could permit 
        health care entities to refuse to provide emergency 
        contraception, even to victims of rape. Although emergency 
        contraception is merely a high dose of ordinary birth control 
        pills and does not interrupt an established pregnancy, some 
        religiously affiliated providers define emergency contraception 
        as an ``abortifacient.'' Health care entities that subscribe to 
        this view could use this bill to attempt to shield themselves 
        from repercussions for refusing to comply with state laws that 
        require hospitals to provide emergency contraception (or 
        referrals for emergency contraception) to rape survivors who 
        present in their emergency rooms.
                               conclusion
    Even interpreting it conservatively, H.R. 4691 is a potentially 
sweeping federal exemption from current legal and regulatory 
requirements that govern access to health services. In fact, it amounts 
to a broad non-compliance permit for religiously affiliated entities 
that serve the general public and receive public funds, but 
nevertheless want exemptions from the general laws that govern other 
health care entities. The ACLU therefore opposes this dangerous measure 
and respectfully urges this Subcommittee to reject it.

                                ENDNOTES

    1 Ms. Smith's name has been changed to protect her 
identity.
    2 Neb. Rev. Stat. Sec. 28-237.
    3 410 U.S. 113 (1973).
    4 See Taylor v. St. Vincent's Hosp., 523 F.2d 75, 76 
(9th Cir. 1975).
    5 42 U.S.C. Sec. 300a-7.
    6 Id. Sec. 300a-7(c), (d), (e).
    7 42 U.S.C. Sec. 238n.
    8 42 U.S.C. Sec. 1396u-2(a)(5)(D).
    9 42 U.S.C. Sec. 1396u-2(b)(3).
    10 Omnibus Consolidated and Emergency Supplemental 
Appropriations Act, Pub. L. No. 105-277, Sec. 656, 112 Stat. 2681 
(1998).
    11 Employment Div. v. Smith, 494 U.S. 872 (1990) 
(holding that the Free Exercise Clause does not entitle religious 
objectors to exemptions from neutral, generally applicable laws); Corp. 
of the Presiding Bishop v. Amos, 483 U.S. 327 (1987) (holding that the 
Establishment Clause does not prohibit an exemption from Title VII of 
the Civil Rights Act that permits religious organizations to 
discriminate on the basis of religion in employment decisions.).
    12 109 Cal. Rptr. 2d 176 (Ct. App.), petition for review 
granted, 31 P.3d 1271 (Cal. 2001).
    13 Id. at 183.
    14 748 F. Supp. 319 (D. Md. 1990).
    15 Id. at 330. The Accreditation Council for Graduate 
Medical Education (ACGME) has since made clear that ob/gyn residency 
programs must offer clinical training in contraception and 
sterilization. In addition, the current standards require clinical 
training in abortion, unless a residency program has a ``religious, 
moral, or legal restriction,'' in which case the program must 
nevertheless (1) ensure that residents receive training in how to 
manage abortion complications; (2) permit residents to receive abortion 
training elsewhere; and (3) publicize the restriction to all residency 
applicants. Program Requirements for Residency Education in Obstetrics 
& Gynecology Sec. V.A.2.d., e. (ACGME, effective Sept. 1999), http://
www.acgme.org/req/220pr999.asp. As discussed above, however, the Coats 
Amendment requires that residency programs be treated as accredited--
for licensing, funding, and other governmental purposes--
notwithstanding any refusal to offer, refer for, or arrange for 
abortion training. 42 U.S.C. Sec. 238n.
    16 42 U.S.C. Sec. 300a-7(c), (d), (e).
    17 President's Commission for the Study of Ethical 
Problems in Medicine and Biomedical and Behavioral Research, Making 
Health Care Decisions: A Report on the Ethical and Legal Implications 
of Informed Consent in the Patient-Practitioner Relationship 76 (1982); 
see also Principles of Medical Ethics of the American Medical 
Association, Policy E-8.08 Informed Consent (issued 1981), available at 
http:// www.ama-assn.org (using policy finder); American College of 
Obstetricians & Gynecologists Committee Opinion No. 108, Ethical 
Dimensions of Informed Consent 7-8 (1992).
    18 Shelton v. Univ. of Med. & Dentistry, 223 F.3d 220 
(3d Cir. 2000).
    19 Lois Uttley & Ronnie Pawelko, MergerWatch Project, 
Educ. Fund of Family Planning Advocates of N.Y.S., No Strings Attached: 
Public Funding of Religiously-Sponsored Hospitals in the United States 
15 (2002).
    20 See, e.g., Gellington v. Christian Methodist 
Episcopal Church, 203 F.3d 1299 (11th Cir. 2000).
    21 Catholic Charities, 109 Cal. Rptr. 2d at 189.
    22 Riddick, 748 F. Supp. at 330; Catholic Charities, 109 
Cal. Rptr. 2d at 189.

    Mr. Bilirakis. Mr. Wardle, please proceed, sir.
    Thank you, Ms. Weiss.

                    STATEMENT OF LYNN WARDLE

    Mr. Wardle. Thank you. Mr. Chairman and distinguished 
members of this subcommittee, I am honored to be invited to 
present testimony today. I have studied and written about 
abortion for over two decades, and I have seen the 
transformation of the debate. Initially, advocates of 
permissive abortion desired to give women the private choice to 
select abortion. They asserted that they did not intend to 
force anyone to do anything, but they just sought to repeal 
laws that prohibited one option available to them that they 
thought should be available. However, once that goal was 
achieved by judicial decree, it was not long before they 
demanded that public funds be available to pay for those 
abortions and that public hospitals should be forced to perform 
abortions. Fortunately, although the ACLU and other 
organizations instigated and provoked years of litigation to 
try to force, through interpretation of the Constitution, that 
public facilities be made available, the Supreme Court rejected 
those claims.
    But they didn't stop there. They have now attempted to 
enact regulation for accrediting medical schools and teaching 
hospitals. Where was the ACLU when that conscience debate was 
fought? Those who claim to stand for the rights of conscience 
ought to have a record that supports that claim.
    When the ACGME regulation was proposed and the battle was 
fought for the Coats Amendment, Congress had to step forward to 
pass an amendment to prevent coercion to protect the rights of 
conscience of medical students and doctors and hospitals. 
Recently, there has been a series of attempts to compel 
hospitals and health care groups and other health care 
organizations to provide abortion services or to give up 
licenses or be denied the permission to continue to provide 
medical health services. Also there have been attempts to force 
health care insurers and private employers to provide abortion 
coverage and of abortion payment. This isn't free choice, this 
isn't privacy, this isn't equality, this is bald coercion.
    The Supreme Court decisions on abortion funding are very 
clear, that the Constitution does not require, in spite of the 
efforts of those who claim to be speaking for choice, to force 
others to engage in practices that are against their 
conscience. Let me give you a few examples, incidents that have 
occurred, just the tip of the iceberg. There was a 1980's study 
of nurses in America that revealed that 5 percent of those 
studied, which extrapolated would be 50,000 nurses in America, 
perceived that their assignment or promotion opportunities had 
been limited by their moral and religious beliefs about 
abortion. They identified over 100 incidents in which that had 
occurred just in the sample. We can give incidents of--these 
are from the Protection of Conscience web site. Nurses refused 
employment, forced to resign, workers fired for refusing 
payment for illegal abortion, worker fired for--hospital aide 
fired for refusing to clean abortion instruments, K-Mart 
pharmacist fired for refusing to dispense abortifacient, 
student pressured to participate in abortion, hospital forces 
nurses to participate in genetic terminations, more D.C. 
medics, referring to District of Columbia, say they were forced 
to have abortions, and now of course Mayor Bloomberg's new 
policy in New York requiring, mandating all city hospitals to 
provide abortion training. This is the media mogul who once 
reportedly told an employee who said she was pregnant, ``Kill 
it, kill it.''
    Rights of conscience are so fundamental to our country I 
just want to--the policy decision that is at issue here was 
made over 30 years ago when the Church Amendment was enacted. 
It was enacted to protect a hospital with a religious 
affiliation from having to perform abortions. It passed 
handily, but it has had to be amended in light of repeated new 
tactics designed to coerce the denial of and to bar the 
exercise of rights of conscience.
    One of the speakers earlier referred to this as a major 
expansion, this proposed bill. I would respectfully disagree. 
This is not a major expansion but it is an effort to close a 
loophole that is undergoing--seen a major expansion in tactics 
to circumvent the policy and purpose of the law. When we talk 
about respect for rights of religion and religious conscience, 
we have to put action behind our words. We can't be like 
Cromwell. Wasn't it Cromwell who said he would respect the 
religious liberty, but if anyone tried to celebrate the mass, 
he would burn them at the stake? We see echoes of that in some 
of the statements by people who are trying to force others to 
perform abortions against their conscience: ``Oh, I respect 
your right of conscience, but you had better perform an 
abortion or if not, you will be fired or you will lose your 
license, you will lose your certificate of authority.''
    It is ironic that this bill comes at this time before this 
committee, because I believe this committee has been recently 
testimony about scandals that resulted when conscience was 
anesthetized in business practices. And we have seen a call by 
our President for a revival and renewal of conscience. And yet 
at the same time, witnesses are asking this committee to not 
pass a law to protect the rights of conscience in the health 
care field? I think that it is extremely ironic and would be a 
tragedy.
    Mr. Bilirakis. Please summarize, sir.
    Mr. Wardle. I urge this committee to enact the Abortion 
Non-Discrimination Act. Thank you.
    [The prepared statement of Lynn Wardle follows:]
 Prepared Statement of Lynn D. Wardle,1 J. Reuben Clark Law 
                    School, Brigham Young University
---------------------------------------------------------------------------
    \1\ Professor of Law, J. Reuben Clark Law School. I engaged in 
scholarly research and writing about these issues for over two decades, 
and teach a law school Seminar on Biomedical Ethics and Law. See Lynn 
D. Wardle, The Quandary of Pro-life Free Speech: A Lesson from the 
Abolitionists, 62 Albany L. Rev. 853-966 (1999); Lynn D. Wardle, 
Protecting the Rights of Conscience of Health Care Providers, 14 J. 
Legal Medicine 177-230 (1993); Lynn D. Wardle, A Matter of Conscience: 
Legal Protection for the Rights of Conscience of Health Care Providers, 
2 Cambridge Q of Health Care Ethics 529-42 (1993). I express 
appreciation to my research assistant, William J. Perkins, especially 
for updating the summary of state laws protecting conscience, and to 
Maureen Kramlich, for their assistance in providing material that 
helped in preparing this Statement. Of course, the opinions expressed 
herein are my own professional opinions and I do not speak for or 
represent any other person or organization.
---------------------------------------------------------------------------
                            i. introduction
    Today a growing number of health care practices, procedures, and 
medications present serious moral concerns for many health care 
providers. Recent medical and pharmacological developments increasingly 
put health care entities at the vortex of some of society's most 
controversial moral dilemmas. These include issues relating to 
providing, performing, participating in or facilitating as abortion 
(both by traditional surgical methods and also by chemical methods such 
as the ``Morning After Pill''), human cloning, embryonic stem cell 
techniques, genetic engineering including sex preselection, DNA 
screening for genetic disorders, sterilization, contraception, sex-
change, euthanasia, assisted suicide, and capital punishment by lethal 
injection, to name just a few medically-related practices with profound 
moral implications. Increasingly there is pressure upon health care 
providers, both individuals and organizations (such as clinics, 
hospitals, practice groups, and insurers) to put aside personal moral 
beliefs in order to facilitate convenient access to new drugs, 
procedures, and technologies.
    In the ordinary course of professional life, without any additional 
pressures, these dilemmas arise often enough to create crises for tens 
of thousands of health care entities. However, in addition to these 
dilemmas there is increasing pressures upon health care participants to 
facilitate or provide products or services which violate their own 
consciences. Advocates of particular procedures and programs, 
particularly major providers of promoters of abortion are 
systematically singling out health care providers and entities to 
squeeze and compel them to abandon their moral values as the price to 
pay to remain in the profession and market.
      ii. overview of the development of the crisis of conscience
    I have closely studied abortion law and policy in the United States 
for thirty years, and have seen the transformation. Initially, 
advocates of permissive abortion argued that they merely desired to 
give women the private choice to select abortion. They asserted that 
they did not intend to force anyone to do anything, but only sought to 
repeal laws that prohibited one option--abortion--that they believed 
should be available to pregnant women.
    However, after that goal was achieved by judicial 
decree,2 it was not long before they demanded that public 
funds be available, that public hospitals should be forced to provide 
the service which they considered so desirable. In a series of cases, 
they repeatedly tried to get the Supreme Court to interpret the 
Constitution so as to invalidate laws that restricted public funding 
and provision of abortion in public hospitals.3 Fortunately, 
the U.S. Supreme Court turned them down every time. Sadly, a number of 
state courts have not been so fair, and have accepted these zealots' 
demands that the state constitutions be interpreted to judicially 
mandate public funding of abortion.4
---------------------------------------------------------------------------
    \2\ Roe v. Wade, 410 U.S. 113 (1973).
    \3\ See Maher v. Roe, 432 U.S. 464 (1977); Beal v. Doe, 432 U.S. 
438 (1977); Poelker v. Doe, 432 U.S. 519 (1977); Harris v. McRae, 448 
U.S. 297 (1980); Williams v. Zbaraz, 448 U.S. 358 (1980); Rust v. 
Sullivan, 500 U.S. 173 (1991).
    \4\ See, e.g., Alaska v. Planned Parenthood, 28 P.3d 904 (Alaska 
2001); New Mexico Right to Choose/NARAL v. Johnson, 975 P.2d 841 (N.M. 
1998); Women of Minn. v. Gomez, 542 N.W.2d 17 (Minn. 1995); Moe v. 
Sec'y of Admin. & Fin., 417 N.E.2d 387 (Mass. 1981); Comm. to Defend 
Reprod. Rights v. Myers, 625 P.2d 779 (Cal. 1981).
---------------------------------------------------------------------------
    Then they tried to stop citizens who wished to exercise their right 
to peacefully assemble in opposition to abortion, and to punish 
individuals who tried to offer free, peaceful ``sidewalk counseling'' 
to pregnant women to advise them about alternatives to abortion. While 
the Supreme Court has invalidated many (but not all) of such laws and 
decrees,5 the effort to suppress pro-life free speech 
continues, led ironically by the same organizations that championed 
``the right to choose.'' 6
---------------------------------------------------------------------------
    \5\ See, e.g, Frisby v. Schultz, 487 U.S. 474 (1988); Bray v. 
Alexandria Women's Health Clinic, 508 U.S. 263 (1993); National 
Organization for Women, Inc. v. Scheidler, 510 U.S. 249 (1994); Madsen 
v. Women's Health Center, Inc., 512 U.S. 753 (1994); Schenck v. Pro-
Choice Network of Western New York, 519 U.S. 357 (1997); Hill v. 
Colorado, 120 S.Ct. 2480 (June 28, 2000).
    \6\ Lynn D. Wardle, The Quandary of Pro-life Free Speech: A Lesson 
from the Abolitionists, 62 Albany L. Rev. 853-966 (1999).
---------------------------------------------------------------------------
    Just a few years ago, they attempted to enact regulations for 
accrediting medical schools and teaching hospitals to force medical 
students and young doctors to be trained to perform abortions. Congress 
had to step forward and pass a law to prevent that coercion and to 
protect the rights of conscience of medical students, doctors and 
hospitals.7
---------------------------------------------------------------------------
    \7\ 42 U.S.C. Sec. 238n.
---------------------------------------------------------------------------
    Recently, there have been a series of attempts to compel hospitals, 
health care groups, and other hare care organizations to either provide 
abortion services or to be denied the license, permission or 
opportunity to engage in the health care service.8 Also, 
there have been attempts to mandate that health care insurers and 
private employers provide coverage and pay for abortion services.
---------------------------------------------------------------------------
    \8\ See generally Valley Hosp. Ass'n v. Mat-su Coalition for 
Choice, 948 P.2d 963, 965 (Alaska 1997); See also Doe v. Bridgeton Me'l 
Hosp. Ass'n, 366 A.2d 641 (N.J. 1976).
---------------------------------------------------------------------------
    The Supreme Court has declared that the Constitution protects 
private choice of abortion against state prohibition.9 The 
Court has emphasized that it does not compel public assistance, support 
or facilitation of abortion.10 The decisions can be read as 
neutrality decisions--the state must not use its power to coerce a 
decision one way or another regarding childbirth or abortion. The 
government may prefer, persuade, encourage, and promote one way or the 
other, but it may not compel.
---------------------------------------------------------------------------
    \9\ See Roe v. Wade, 410 U.S. 113 (1973); Planned Parenthood v. 
Casey, 505 U.S. 833 (1992); see also Maher v. Roe, 432 U.S. 464 (1977); 
Beal v. Doe, 432 U.S. 438 (1977); Poelker v. Doe, 432 U.S. 519 (1977).
    \10\ See supra, note 6.
---------------------------------------------------------------------------
    The private choice to decline to participate in abortion deserves 
no less protection than the choice to participate in abortion.
    Yet zealous abortion activists continue to try to use the powers of 
government to compel participation in and payment for and coverage of 
abortion. Specifically, they try to compel hospitals, clinics, provider 
groups, and health care insurers to provide facilities for, personnel 
for, and funding for abortion.
            iii. examples of abuses of rights of conscience
    In repeated cases, pro-abortion extremists are trying (successfully 
in many cases) to assert the position that a health care entity who 
will not perform abortions must be denied access to the public market. 
For instance, currently there is a battle in New Jersey in which pro-
abortion zealots are trying to stop the merger of a secular hospital 
with a religious hospital group because that will result in the 
hospital not performing abortions.11 Rather than helping 
some abortion clinic in the area to expand or operate more actively in 
the area, the pro-abortion zealots are taking the position that a 
hospital who does not perform abortion must be disqualified from 
participating in the health care profession.
---------------------------------------------------------------------------
    \11\  Beth E. Fand, Hospital focus of reproductive rights battle, 
The Burlington County Times (NJ), July 9, 2002,  (viewed July 9, 2002).
---------------------------------------------------------------------------
    In recent years, there have been a number of incidents involving 
apparent violations of the rights of conscience of health care workers 
in the United States. Well known is the attempt by the ACGME to require 
all Ob/Gyn residents in all Ob/Gyn programs be trained to perform 
abortions.12 During the 1999 California legislative session, 
a bill was introduced that would have, among other things, disallowed 
hospitals that decline to participate in abortion from receiving public 
financing or state-funded health care contracts.13 In 
Connecticut, after abortion rights activists learned that an outpatient 
surgical center proposed by four hospitals would not perform abortion 
and sterilizations, they formed a coalition to defeat the proposed 
center and intervened in Certificate of Need proceedings and the 
Connecticut Office of Health Care Access refused to issue a 
certificate.14 Incidents in which hospital mergers to help 
struggling hospitals survive have occurred in New Hampshire, Florida, 
and New York, as well.15 I cite just a few headlines from 
the Protection of Conscience website: ``Nurse Refused Employment, 
Forced to Resign'' (she refused to participate in abortions); ``Worker 
fired for refusing payment for illegal abortion (refused to sign for 
welfare payment for abortion); ``Hospital Aide Fired for Refusing to 
Clean Abortion Instruments''; ``Kmart Pharmacist Fired for Refusing to 
Dispense Abortifacient'' (other workers had done it for her); ``Student 
pressured to participate in abortion'' (in Saskatchewan, Canada, 1999); 
``Foothills Hospital Now Forces Nurses To Participate In Genetic 
Terminations'' (nurses angry about being forced to participate in 
abortion of imperfect and late term babies); and ``More DC Medics Say 
They Were Forced to Have Abortions.'' 16 Michael Bloomberg, 
the new Mayor of New York, now compels abortion training as an 
``additional required component to OB/GYN residency programs in all New 
York City city-owned hospitals. The training is outlined in Michael 
Bloomberg's Blueprint for Public Health along with a proposal requiring 
victims of sexual assault to be given emergency contraception when 
taken to emergency rooms. Previously, only 2 out of the 11 public 
hospitals include abortion as part of their training. The training will 
teach OB/GYNs how to perform abortions and provide counseling.'' 
17 News reports say that Bloomberg's plan ``allows residents 
who object to abortion on moral grounds to forego the training.'' 
18 But what pro-abortion politicians consider an appropriate 
exemption for rights of conscience often turns out to be mere eye wash, 
narrow, ineffective and cynical. ``[T]he media mogul . . . reportedly 
once told a pregnant employee to ``Kill it! Kill it!'' (The comment, 
which Bloomberg has denied making, was cited in the legal papers of 
Sekiko Sakai Garrison, a former Bloomberg News staffer who brought one 
of three publicized sex-harassment cases against him or his company.)'' 
19
---------------------------------------------------------------------------
    \12\ AAPLOG website, .
    \13\ A.B. 525, 1999-2000 Leg., Reg. Sess. (Ca. 1999).
    \14\ State of Connecticut Office of Health Care Access Applicants: 
Roy D. Bebe, M.D., Harford Hospital, John Dempsey Hospital, New Britain 
General Hospital, Saint Francis Hospital and Medical Center, ASC 
Network Corporation Docket Number 96-547 (``Establish and Operate a 
Freestanding Ambulatory Surgery Center in Avon'') and Applicant Saint 
Francis Hospital and Medical Center Docket Number 96-537 (``Establish 
and Operate a Freestanding Ambulatory Care Center in Avon'') letters 
denying applications dated September 29, 1997, signed by Raymond J. 
Gorman, Commissioner.
    \15\ N.H. Att'y. Gen. Rep. on Optima Health, March 10, 1998. City 
of St. Petersburg v. Bayfront Medical Center, Inc., Bayfront Health 
System, Inc. and Baycare Health System, Inc. Case No. 8:00-CV-623-27A ( 
M.D. Fla.)--Middle District of Florida Tampa Division Proposed Final 
Order--approved by City Council on April 10, 2001S. 333, 2001-2002 Reg. 
Sess. (Ny. 2001) (requiring insurance coverage for ``certain women's 
reproductive health services,'' by hmos, including abortion); A. 2674, 
2001-2002 Reg. Sess. (Ny. 2001) (requires review of changes in hospital 
mission statement); A. 4397, 2001-2002 Reg. Sess. (Ny. 2001) (public 
health council to find that ``health care needs'' will continue to be 
met after a merger ).
    \16\ Protection of Conscience Project, http://
www.consciencelaws.rg/Repression-Conscience.
html> (7 Nov. 2001).
    \17\ Nikki Katz, Bloomberg Requiring Additional Abortion Training, 
About Women's Issues  (seen 29 Jan 2002); NYC Mayor to Mandate Abortion 
Training for Docs, Village Voice, Jan. 8, 2002.
    \18\ Id.
    \19\ Id.; Cybercase News Service, Jan. 9, 2002.
---------------------------------------------------------------------------
    These examples reveal only the tip of the iceberg. A landmark 
empirical study of, inter alia, nurses attitudes about and difficulties 
encountered because of personal objection to abortion and other medical 
procedures in the 1980s revealed that approximately 5% of the nurses 
sampled (which extrapolated out would amount to approximately 50,000 
nurses in the United States) perceived that their assignment and 
promotion opportunities may be limited by their moral and religious 
beliefs about abortion.20 The nurses in this sample 
``identified a total of 103 definite cases in which nurses had either 
been dismissed or had their opportunities limited because of moral 
beliefs . . . [F]ifty-seven cases were identified in which the nurses 
beliefs about abortion had cost them opportunities for promotion or 
sustained employment.'' 21 Moreover,
---------------------------------------------------------------------------
    \20\ Durham, Wood & Condie, supra note____, at 257, 287.
    \21\ Id. at 287.
---------------------------------------------------------------------------
        [a]pproximately 7% of Catholic nurses, 4% of Protestant nurses, 
        and 6% of those belonging to `other' religions indicated they 
        knew at least one other person whose opportunities with 
        hospitals had been limited by personal beliefs . . . Thirty-six 
        nurses [in the national sample] identified a total of 118 of 
        their colleagues who had been limited as a result of their 
        moral and religious beliefs.22
---------------------------------------------------------------------------
    \22\ Id. at 258. Again, extrapolated over the entire nursing 
profession this would represent approximately tens of thousands of 
nurses who have been the victim of employment discrimination because of 
their religious or moral beliefs. Id. at 258.
---------------------------------------------------------------------------
             iv. existing conscience clause protection laws
    These incidents attempt to circumvent existing laws enacted by 
Congress and 49 states enacted to provide some protection for the 
rights of conscience of health care workers in at least some 
situations.23 The laws, called ``conscience clauses'' 
generally are drafted to protect the right of health care professional 
to refuse to participate in providing a service or procedure to which 
they have religious or other moral objections. Conscience clauses have 
been enacted by both federal and state law makers. Sadly, many of these 
laws are outdate, addressing concerns that are nearly 30 years old, but 
not address the more recent threats to rights of conscience. Conscience 
clauses can be traced to a specific judicial decision that provoked a 
firestorm of controversy. In November 1972 a United States District 
Court in Billings, Montana issued an injunction forbidding a Catholic 
hospital to deny the use of its facilities to a physician who wanted to 
perform a sterilization on a patient there.24 The suit to 
enjoin the hospital was brought under 42 U.S.C. Sec. 1983 and 28 U.S.C. 
Sec. 1343, which provide redress for deprivation of civil rights under 
color of state law. The district court ruled that the fact that the 
hospital had received public funds under the federal Hill-Burton Act 
was alone sufficient to make the hospital a ``state actor'' for 
purposes of those civil rights statutes. The next year, in direct 
response to that ruling, and just months after the Supreme Court's 
decision in Roe v. Wade,25 Congress passed the Church 
Amendment, the original federal conscience clause, 42 U.S.C. Sec. 300a-
7, which was designed to prohibit a court or a public official from 
using receipt of federal grants or assistance under three specific 
acts,26 as a basis for requiring any individual or 
institution to perform or assist in performing abortions or 
sterilizations, if such would be contrary to religious or moral 
beliefs.27 Because of the Supreme Court decision in Roe 
effectively required all states to legalize nontherapeutic abortion on 
demand, the conscience clause movement became immediately relevant, and 
most states enacted conscience clauses to protect the right of at least 
some health care providers to refuse to perform or participate in 
abortions.
---------------------------------------------------------------------------
    \23\ There is some inconsistency in the reports on the number of 
states with some conscience clause protection. Seven years ago, I 
identified 44 states with such laws and six without any. Americans 
United for Life, which does very reliable work, that 46 states now have 
conscience clauses. See further Katherine A. White, Note, Crisis of 
Conscience: Reconciling Religious Health Care Providers' Beliefs and 
Patients' Rights, 51 Stan. L. Rev. 17031707 n. 18 (1999), citing Rachel 
Benson Gold, Special Analysis: Provider `Conscience' Questions Re-
emerge in Wake of Managed Care's Expansion, in State Reproductive 
Health Monitor 18 (1997). AUL identifies the four states without any 
protection of rights of conscience as Alabama, Mississippi, New 
Hampshire and Vermont. With the aid of a very good research assistant, 
Brittany Howick, however, I have found that Mississippi and New 
Hampshire each have a law protecting the rights of conscience in the 
context of living wills or end of life directives made for a patient by 
another. Thus, it appeals that all states except Alabama and Vermont 
have some statutory protection for some rights of conscience of some 
health care providers in at least some cases.
    \24\ See Taylor v. St. Vincent's Hospital, 369 F.Supp. 948, 950 
(D.C.Mont., 1973) (quoting H.R. No. 93-227; 1973 U.S.Code Cong. & 
Admin.News p. 1553), aff'd 523 F.2d 75 (9th Cir. 1975).
    \25\ 410 U.S. 113 (1973).
    \26\ The three acts are: The Public Health Service Act, the 
Community Mental Health Centers Act, and the Developmental Disabilities 
Services and Facilities Construction Act.
    \27\ 1973 U.S. Code Cong. & Admin. News 1473, 1553.
---------------------------------------------------------------------------
    The Church Amendment is still the main federal protection for the 
rights of conscience of health care providers. Additionally, Title VII 
of the Civil Rights Act requires employers generally to accommodate the 
religious beliefs of their employees that do not cause undue 
hardship.28
---------------------------------------------------------------------------
    \28\ 42 U.S.C. Sec. 2000.
---------------------------------------------------------------------------
    Also, in 1997 Congressional ``amendments extend[ed] conscience 
protections to cover Medicaid and Medicare managed care plans, which 
may now refuse to `provide, reimburse for, or provide coverage of a 
counseling or referral service if the . . . organization offering the 
plan . . . objects to the provision of such service on moral or 
religious grounds . . .' '' 29
---------------------------------------------------------------------------
    \29\ Katherine A. White, Note, Crisis of Conscience: Reconciling 
Religious Health Care Providers' Beliefs and Patients' Rights, 51 Stan. 
L. Rev. 1703, 1708 (1999), citing Balanced Budget Act of 1997, Pub. L. 
No. 105-33, tit. IV, Sec. 1852(j)(3)(B), 111 Stat. 251, 295.
---------------------------------------------------------------------------
    Forty-nine states provide at least some protection for rights of 
conscience of some health care providers in some 
circumstances.30 (Only Vermont has no statutory protection 
for rights of conscience whatever.) However, only one state, Illinois, 
has a comprehensive conscience protection law that covers all health 
care providers, institutions, and payers and applies to all health care 
services. One other state, Washington, protects the right of conscience 
to refuse to participate in any health care services and covers all 
individuals but only religiously-affiliated institutions.
---------------------------------------------------------------------------
    \30\ Current State Statutes, January 2002, in Americans United for 
Life, Health Care Rights of Conscience Act, Model Legislation and 
Policy Guide, January 2002 (herein ``AUL Rights of Conscience Act'').
---------------------------------------------------------------------------
    Abortion is the focus of most conscience clauses. Forty-five states 
allow some health care workers to refuse to participate in abortions. 
Twenty-five states' conscience clauses cover only abortion. Ten states 
allow health care workers to exercise their right of conscience to not 
participate in abortion only if working for individuals or private 
institutions. Two states conscience protection laws cover abortion but 
apply only when the health care provider is an individual, and one 
other state has a similar restriction covering sterilization also. Four 
states cover specifically abortion and contraception. One state covers 
health care providers regarding abortion, sterilization and artificial 
insemination, and another covers only abortion, abortifacients, and 
sterilization. At least three states (California, Mississippi and New 
Hampshire, and I suspect more but have not done the research) protect a 
right of health workers to decline to participate in some end-of-life 
decision implementations in limited circumstances. Two states cover 
counselors and social workers in some contexts. One state protects the 
right of pharmacists to not participate in abortion, assisted suicide 
and euthanasia. Eleven states protect the rights of conscience of 
medical and nursing students in some situations. Only nine of the 
sixteen states that mandate health insurance plans to include 
contraceptive drugs or devices if prescription drugs are covered 
contain any conscience clause provisions (usually limited to religious 
employers).
    Existing conscience clause laws are inadequate as drafted for at 
least five major reasons. First, most are very narrow in terms of the 
practices, procedures or contexts in which they apply--most were 
drafted with abortion and sterilization in mind and go no further. 
Second, many of them are very narrow and restrictive, covering only a 
small group of health care providers, not workers in the health care 
industry generally. Third, the scope of protection (the discrimination 
forbidden) is limited. Fourth, the remedies and procedures for 
vindicating the rights are undeveloped and restricted. Fifth, most of 
the laws are outdated, having been written before many of the medical 
developments occurred that have created some of the most difficult 
moral dilemmas.
                       v. hostile interpretations
    In addition to the deficiencies of drafting, there are problems of 
interpretation. Judicial interpretation of these statutes has been very 
grudging, even hostile. In contrast to how civil rights laws in general 
have been construed during the past thirty years, conscience clauses 
have received very cold, unsympathetic, unsupportive reception by state 
and federal judges. Judges have given narrow, hostile interpretation 
regarding procedures covered, persons covered, protections provided, 
and have casually circumvented the laws by invoking other laws.
    In the limited time available to me, I cannot adequately convey the 
hostile tenor of most of the cases interpreting conscience clauses. Let 
me just give you a few selected examples. For example, in Browhfield v. 
Daniel Freeman Marina Hospital.31 In that case, a rape 
victim asked an emergency room worker at a Catholic hospital about the 
availability of the ``morning after'' pill. The worker declined to give 
any information because of her religious beliefs. The patient brought 
suit against the hospital, and the hospital raised the California 
conscience clause in defense. That statute provided that ``no nonprofit 
hospital or clinic which is organized or operated by a religious 
corporation . . . or its administrative officers, employees, agents or 
. . . governing board shall be liable . . . for failure or refusal to 
perform or to permit the performance of an abortion in such facility or 
clinic or to provide abortion services.'' 32
---------------------------------------------------------------------------
    \31\ 256 Cal. Rptr. 240 (Cal. App. 2989).
    \32\ Cal. Health & Safety Code Sec. 25955k. Six years ago, this 
statute was revised and recodified Cal. Health & Safety Code 123420 
(2001) without substantive change.
---------------------------------------------------------------------------
    Thus, the case turned on whether the morning after pill produced 
abortion. Finding no definition of ``abortion'' in the statute, the 
court made no effort to discern legislative intent (specifically, 
regarding the morning after pill, or generally, regarding protecting 
conscience rights of health care providers), and made no effort to 
interpret the statute in light of the policy underlying the statute or 
to achieve integrity within the structure of the provision, or to 
determine as a matter of judicial notice whether the morning after pill 
was understood by the medical community or the Catholic medical 
community to cause abortion.33 Instead, citing dicta in 
another case suggesting that at least one federal court did not 
consider the morning after pill to be an abortifacient,34 
the California court summarily concluded that the hospital's refusal 
was not protected because the morning after pill did not cause 
abortion.35
---------------------------------------------------------------------------
    \33\ While the conclusion of the court that the morning after pill 
does not cause abortion is medically inaccurate (in at least some 
cases), the method of statutory construction is even more disturbing. 
The question the court had was one for which a resort to random dicta 
in other cases giving unsupported judicial ruminations in the context 
of interpreting entirely different statutes enacted by a different 
government is not an intelligent approach to legislative 
interpretation.
    \34\ McRae v. Matthews, 421 F. Supp. 533 (ED. N.Y.1976), rev'd on 
other grounds, Harris v. McRae, 448 U.S. 297 (1980). The court also 
cited dicta from another case.
    \35\ Brownfield, 256 Cal.Rptr. at 245.
---------------------------------------------------------------------------
    While the conclusion of the court that the morning after pill does 
not cause abortion in at least some cases is probably inaccurate, the 
method of statutory construction is even more disturbing. The question 
the court had was one for which a resort to random dicta in other cases 
giving unsupported judicial ruminations in the context of interpreting 
entirely different statutes enacted by a different government is not an 
intelligent approach to legislative interpretation. The Brownfield case 
is an example of how judges can manipulate the interpretation of a 
statute to reach the outcome they prefer for personal or ideological 
reasons. Thus, it illustrates an unfortunate but very real risk for 
those who try to rely upon the current generation of conscience 
clauses.
    In Spellacy v. Tri-County Hospital,36 Pennsylvania 
courts held that a part-time admissions clerk who claimed that she was 
fired by the hospital as a result of her refusal to participate in the 
admission procedures of abortion patients was not protected by the 
state's conscience clause because her position was one of mere 
``ancillary'' or ``clerical'' assistance.37
---------------------------------------------------------------------------
    \36\ 18 Empl. Prac. Dec. (CCH) para. 8871 (Pa. C.P. De. Cty.), 
aff'd, 395 A.2d 998 (1978).
    \37\ Id. at 5605 (relying on administrative regulations 
interpreting the conscience clause). Alternatively, the court found 
that the hospital had met its duty to accommodate because it had 
offered her four others jobs, all of which she had declined. ``There 
came a time in the Spellacy situation when the plaintiff had simply 
rejected one too many reasonable accommodation offers, and her employer 
could not be expected to continue generating new ones.'' Durham, Wood & 
Condie, supra note____, at 318-319.
---------------------------------------------------------------------------
    Likewise, in Erzinger v. Regents of University of California, the 
California Appellate court noted: ``The proscription only applies when 
the applicant must participate in acts related to the actual 
performance of abortions or sterilizations. Indirect or remote 
connection with abortions or sterilizations are not within the terms of 
the statute.'' 38
---------------------------------------------------------------------------
    \38\ Erzinger v. Regents of University of California, 137 Cal. App. 
3d 389, 394, 187 Cal. Rptr. 164, 168 (1982). The court held that 42 
U.S.C. Sec. 300a-7 did not apply to prevent a university from requiring 
students to participate in a comprehensive health insurance program 
which included benefits for persons desiring abortions or 
sterilizations.
---------------------------------------------------------------------------
    The same bias is reflected in the dissenting opinion of two Montana 
Supreme Court justices in Swanson v. St. John's Lutheran 
Hospital.39 That case involved a wrongful discharge action 
brought by a nurse-anesthetist who had worked at a hospital for eight 
years. She had performed more than two dozen sterilizations, but after 
participating in one particularly shocking and gruesome abortion, she 
informed her supervisor that she would not participate in any more 
sterilizations. The hospital administrator tried to change her mind, 
referred her to her priest, and called the priest to ask him to counsel 
her to change her mind. She remained fixed in her decision, and the 
next day was fired by the hospital administrator. She brought suit 
under Montana's conscience clause, which protects the rights of 
individuals to refuse on moral or religious grounds to perform 
sterilizations, and prohibits employment discrimination based on such 
refusals. After a harrowing encounter with a hostile Montana trial 
court, she ultimately prevailed in the Montana Supreme 
Court.40 However, two of the Montana Supreme Court justices 
would have denied her claim on the ground, inter alia, that her reasons 
for refusing to participate in any more sterilizations were emotional 
rather than moral.41
---------------------------------------------------------------------------
    \39\ 597 P.2d 702 (1979).
    \40\ See infra, notes ____ through ____ and accompanying text. See 
also Swanson v. St. Johns Lutheran Hospital, 615 P.2d 882 (Mont. 1980) 
(affirming award of $11,950.86 to Nurse Swanson, and affirming 
rejection of her claim for punitive or future damages for lack of 
evidence).
    \41\ 597 P.2d at 714. The hospital administrator himself obviously 
perceived her denial to be based on religious/moral grounds, and 
treated it as such, contacting the nurse's priest in an effort to have 
him influence her to drop her objections. The dissenters failed to 
explain the distinction between ``emotional'' and ``moral'' grounds. 
Are they really mutually exclusive categories? Their bias against 
conscience clause rights is evident.
    By contrast, in a case interpreting a conscience clause that 
protects the right of physicians from employment discrimination because 
they have performed abortions or sterilizations, a pair of federal 
courts did not require any evidence about the moral or religious basis 
for a doctor's practice or sterilizations. See Watkins v. Mercy Medical 
Center, 364 F. Supp. 799 (D. Ida. 1973), aff'd, 520 F.2d 894 (9th Cir. 
1975). There appears to be at least a hint of anti-Catholic, anti-
prolife bias in the way the conscience clauses have been interpreted. 
See also In Re Raquena, 517 A.2d 886,891 (N.J. Super. 1986) (lecturing 
Medical Center that unwillingness to participate in withdrawal of life-
support food/hydration systems was not ``pro-life'', and requiring the 
hospital to participate in the withdrawal over its and staff's moral 
objections). See further infra notes ____ through ____ and accompanying 
text.
---------------------------------------------------------------------------
    In Catholic Charities of Sacramento, Inc. v. Superior 
Court,42 a Catholic charitable organization was held not to 
qualify for the ``religious employer'' exemption from a California 
statute requiring employer to provide prescription contraceptives in 
benefits package, and was also denied constitutional protection from 
that requirement which violated basic Roman Catholic doctrine. .
---------------------------------------------------------------------------
    \42\ 109 Cal.Rptr.2d 176 (3d D.Cal.App. 2001).
---------------------------------------------------------------------------
    In Valley Hosp. Ass'n, Inc. v. Mat-Su Coalition for 
Choice,43 the Alaska Supreme Court held that that state's 
conscience clause was unconstitutional to the extent it applied to 
allow a private nonprofit hospital that was the sole hospital in the 
Mat-Su valley to refuse to provide abortions because it was a de facto 
quasi-public institutions.
---------------------------------------------------------------------------
    \43\ 948 P.2d 963 (Alaska 1997).
---------------------------------------------------------------------------
    In Larson v. Albany Medical Center,44 a New York state 
appellate court held that employees fired in alleged retaliation for 
exercising rights protected under the state conscience clause had not 
no private right of action.
---------------------------------------------------------------------------
    \44\ 676 N.Y.S.2d 293 (3d App. Div. 1998).
---------------------------------------------------------------------------
         vi. the history of protection of conscience in america
    The history of protection of conscience in America is directly 
relevant to the protection of rights of conscience of health care 
providers in three ways. First, protection for rights of conscience 
underlie and historically preceded the First Amendment.45 In 
June, 1776, even before the Declaration of Independence, the Virginia 
Declaration of Rights provided, inter alia, that ``all men are equally 
entitled to the free exercise of religion, according to the dictates of 
conscience . . .'' 46 After centuries of government support 
for the state church in Virginia, the Baptists led a petition campaign 
demanding that ``every tax upon conscience . . . be abolished.'' 
47 In 1779, Thomas Jefferson introduced his Bill for 
Establishing Religious Freedom in the Virginia Legislature (House of 
Burgesses). It declared that ``to compel a man to furnish contributions 
of money for the propagation of opinions which he disbelieves, is 
sinful and tyrannical.'' (If Jefferson thought that about merely 
funding things against ones will, one can imagine what he would say 
about being compelled to perform acts or services like abortion or the 
MAP against one's conscience.) Jefferson's Bill did not pass for over 
six years, but in December, 1785, while Jefferson was Minister to 
France, James Madison engineered passage of Jefferson's Bill. As 
finally enacted it declared that ``no man shall be . . . molested or 
burdened in his body or his good, nor shall otherwise suffer on account 
of his religious opinions or belief . . . and that the same shall in no 
wise diminish, enlarge or effect their civil capacity.'' So proud was 
Jefferson of his role in securing protection for rights of conscience 
that he asked that his gravestone be inscribed: ``Thomas Jefferson, 
Author of the Declaration of Independence, of the Statute of Virginia 
for Religious Freedom, and Father of the University of Virginia.'' 
48
---------------------------------------------------------------------------
    \45\ Joseph L. Hassan, Freedom of Conscience in Early Virginia: A 
Precursor to the Religion Clauses of the First Amendment, Paper 
submitted for Origins of the Constitution, Apr. 17, 1998.
    \46\ Kermit Hall, et al, American Legal History: Cases and 
Materials 70 (1996).
    \47\ Hassan, supra, at 12.
    \48\ Hassan, supra, at 17.
---------------------------------------------------------------------------
    Second, it is critical to understand that in America in the 1770s 
and 1780s two different views about matters of conscience and religion 
were competing.49 One view, with a high and honorable 
heritage traceable to John Locke's famous essay, A Letter Concerning 
Toleration, viewed accommodation of religious variety and differences 
to be a matter of utilitarian toleration or accommodation. In some of 
his early writing, at least, Thomas Jefferson advocated this approach. 
Respect matters of conscience and religion as simply a matter of 
toleration--sound public policy, good neighborliness and good Polistes. 
On the other hand, the Virginia Baptists and most famously, James 
Madison, spoke of matters of conscience and religion not merely as 
toleration but as fundamental, natural rights. It makes a big 
difference whether respect for another's moral convictions is given 
simply as a matter of convenience and tolerance (to be suspended when 
outweighed by other political considerations, for example, in time of 
emergency), or whether that is a matter of your neighbor's basic civil 
rights. Fortunately, the Founders ultimately concluded that protection 
for conscience was a matter of fundamental right. Early colonial 
charters and state constitutions spoke of it as a right, and during the 
frightening emergency of the War of Independence, rather than suspend 
respect for divergent moral views, many states granted exemptions from 
conscription to persons with religious scruples against war, such as 
Quakers and Mennonites. In 1775, the Continental Congress granted a 
general exemption from military conscription to religious groups. The 
Virginia Declaration of Rights was initially drafted too guarantee 
``fullest toleration'' of religion; but Madison amended it and when it 
passed, it protected the rights of religion: ``all men are entitled to 
the full and free exercise of it according to the dictates of 
conscience.'' Madison's Memorial and Remonstrance expressed the 
language of rights, not toleration (``The equal right of every citizen 
to the free exercise of his Religion according to the dictates of 
conscience is held by the same tenure with all our other rights.'' 
50 Of course, the best example is the protection of 
conscience as a right is inclusion of the right to free exercise of 
religion in the First Amendment of the Bill of Rights. (James Madison, 
of course, was the Father of the Bill of Rights.) Ironically, some 
courts and most commentators today have slipped into using the language 
of toleration and accommodation. It is time for us to reassert 
emphatically the language of rights.
---------------------------------------------------------------------------
    \49\ Dawn Hendrickson Steadman, The Free Exercise Clause and 
Original Intent: A View Toward Exemptions, for Origins of the 
Constitution, Winter Semester 2000.
    \50\ Steadman, supra, at 24.
---------------------------------------------------------------------------
    Third, when an effort to revive the religion tax in Virginia was 
made after the War of Independence, James Madison drafted his famous 
Memorial and Remonstrance declaring that certain things like religious 
duties ``must be left to the conviction and conscience of every man; 
and it is the right of every man to exercise it as these may dictate.'' 
51 He explained why:
---------------------------------------------------------------------------
    \51\ Id.
---------------------------------------------------------------------------
        Before any man can be considered as a member of Civil Society, 
        he must be considered as a subject of the Governor of the 
        Universe: And if a member of a Civil Society, who enters into 
        any subordinate Association, must always do it with reservation 
        of his duty to the general authority; much more must every man 
        who becomes a member of any particular Civil Society, do it 
        with a saving of his allegiance to the Universal 
        Sovereign.52
---------------------------------------------------------------------------
    \52\ James Madison, Memorial and Remonstrance cited in Hussan at 
15.
---------------------------------------------------------------------------
    Madison clearly understood that if men are not loyal to themselves, 
to their conscience, to their God and their moral duty as they see it, 
it is utterly irrational folly to expect them to be loyal to less 
compelling moral obligations of legal rules, statutes, judicial orders, 
or the claims of citizenship and civic virtue, much less professional 
duties. If you demand that a man betray his conscience, you have 
eliminated the only moral basis for his fidelity to the rule of law, 
and have destroyed the foundation for all civic virtue.
    Finally, the loss of virtue that results from requiring men to 
violate and disregard their conscience undermines the basis for self-
government. The founders of the American Constitution really believed 
that virtue in the citizenry was absolutely essential, indispensable 
for this system of government to function and survive. I have brought 
just a few quotes from the Founders to make this point.
    Thomas Jefferson: ``[O]ur rules can have authority over such 
natural rights only as we have submitted to them. The rights of 
conscience we never submitted, we could not submit. We are answerable 
for them to our God.'' 53
---------------------------------------------------------------------------
    \53\ Thomas Jefferson (1743-1826)
---------------------------------------------------------------------------
    George Washington: ``Tis substantially true, that virtue or 
morality is a necessary spring of popular government. The rule indeed 
extends with more or less force to every species of Free Government. 
Who then is a sincere friend to it, can look with indifference upon 
attempts to shake the foundation of the fabric? . . .'' 54
---------------------------------------------------------------------------
    \54\ George Washington, Washington's Farewell Address from Saul 
Padover,The Washington Papers (searched Sept. 9, 1999).
---------------------------------------------------------------------------
    Samuel Adams agreed that ``neither the wisest constitution nor the 
wisest laws will secure the liberty and happiness of a people whose 
manners are universally corrupt.'' 55
---------------------------------------------------------------------------
    \55\ Id.
---------------------------------------------------------------------------
    James Madison told delegates to Virginia's ratifying convention: 
``To suppose that any form of government will secure liberty or 
happiness without any virtue in the people, is a chimerical idea.'' 
56 He also wrote in Federalist No. 57: ``The aim of every 
political Constitution is or ought to be first to obtain for rules men 
who possess most wisdom to discern, and most virtue to pursue, the 
common good of society; and in the next place, to take the most 
effectual precautions for keeping them virtuous whilst they continue to 
hold their public trust.''
---------------------------------------------------------------------------
    \56\ Id.
---------------------------------------------------------------------------
    John Adams clearly warned: ``Out constitution was made only for a 
moral and religious people. It is wholly inadequate to the government 
of any other.'' 57 He also said: ``Liberty can no more exist 
without virtue and independence than the body can live and move without 
a soul.'' 58
---------------------------------------------------------------------------
    \57\ J. Howe, The Changing Political Thought of John Adams 165 
(1966).
    \58\ 10 The Works of John Adams 284.
---------------------------------------------------------------------------
    Thus, protection of conscience has been crucial to the foundation 
of this nation.
                            vii. conclusion
    This Energy and Commerce Committee has recently be involved in 
hearing testimony about enormous scandals caused because businessmen 
and accountants and other professional have anesthetized their 
consciences in the pursuit of wealth. The consequences have been seedy, 
shady, and disastrous for the companies and for the economy of the 
country.
    In this context, it is more than a little ironic to hear abortion 
zealots plead that Congress must look the other way while they continue 
to coerce health care professionals and entities to ignore their 
consciences. The results of not protecting and encouraging the exercise 
of conscience in the health care profession will be just as disastrous 
as it has been for Enron and Worldcom and perhaps for Martha Stewart.
    Currently pending in Congress is the Abortion Non-Discrimination 
Act. It is a very small, but very important step in the right 
direction. It simply protects conscience by requiring modest 
accommodation for entities that cover and pay for and provide medical 
services. It merely prohibits use of state power to coerce abandonment 
of conscience and moral principles. It is a true neutrality provision, 
guaranteeing each health care participant the right to choose for 
himself or herself or itself to follow the values and moral precepts 
they espouse.
    I urge this Committee to act promptly to enact the Abortion Non-
Discrimination Act and other acts which will address the crisis of 
conscience and begin to eliminate the intolerance, coercion and 
discrimination against health care participants who do not believe in 
participating in the provision of abortion and other morally 
controversial procedures.
                               Attachment

   Summary of State Laws Protecting Rights of Conscience--July 8, 2002
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Alabama...................................  Code of Ala. Sec.  22-8A-8
                                             (2001) No nurse, physician
                                             or healthcare provider is
                                             required to withdraw life-
                                             sustaining treatment.
                                             Health care provider will
                                             attempt to transfer patient
                                             to other provider.
Alaska....................................  Alaska Stat. Sec.  18.16.010
                                             (b) ``Nothing in this
                                             section requires a hospital
                                             or person to participate in
                                             an abortion, nor is a
                                             hospital or person liable
                                             for refusing to participate
                                             in an abortion under this
                                             section.''
Arizona...................................  A.R.S. Sec.  36-2151
                                             Hospital, physician or
                                             other medical personnel may
                                             refuse to perform an
                                             abortion for moral or
                                             religious reasons.
Arkansas..................................  A.C.A. Sec.  20-16-304, 601
                                             (2001) No person or
                                             hospital has to participate
                                             in an abortion. Medical
                                             personnel may refuse to
                                             give contraceptives or
                                             information about such
                                             things if it is against
                                             their religious beliefs.
California................................  Cal. Health & Safety Code
                                             123420 A physician, nurse
                                             or other hospital employee
                                             may refuse to participate
                                             in an abortion for moral or
                                             religious reasons.
                                             Admission to a school may
                                             not be denied due to
                                             applicant's unwillingness
                                             to participate in an
                                             abortion. Non-profit
                                             facility or religious
                                             hospitals do not have to
                                             perform abortions.
Colorado..................................  C.R.S. 18-6-104 (2001)
                                             Hospital does not have to
                                             admit a person for the
                                             purpose of performing an
                                             abortion. A person who is
                                             an employee at a hospital
                                             does not have to perform an
                                             abortion if it is against
                                             his morals or religious
                                             principles.
                                            C.R.S. 25-6-102, 207 (2001)
                                             No private institution or
                                             physician is required to
                                             give out contraceptive. A
                                             county or city employee may
                                             refuse the duty to supply
                                             contraceptives.
Connecticut...............................  Conn. Gen. Stat. Sec.  19a-
                                             580a (2001) Any physician
                                             who does not wish to comply
                                             with a living will must
                                             transfer the patient.
Delaware..................................  24 Del. Code Ann. 1791 No
                                             person is required to
                                             participate in an abortion.
                                             No hospital has to
                                             participate.
Florida...................................  Fla. Stat. Sec.  390.0111
                                             (2001) Hospital and person
                                             do not have to participate
                                             in abortion if it against
                                             moral or religious
                                             principles.
                                            Fla. Stat. Sec.  381.0051
                                             (2001) Physician or other
                                             person may refuse to give
                                             contraceptives for medical
                                             or religious purposes.
Georgia...................................  O.C.G.A. Sec.  16-12-142
                                             (2001) No person or
                                             hospital shall be required
                                             to perform an abortion when
                                             it is against his moral or
                                             religious principles.
                                            O.C.G.A. Sec.  49-7-6 (2001)
                                             Any employee can refuse to
                                             provide family planning
                                             services if it is contrary
                                             to his religious beliefs
Hawaii....................................  H.R.S. Sec.  453-16 Nothing
                                             in this section shall
                                             require any hospital or any
                                             person to participate in
                                             such abortion nor shall any
                                             hospital or any person be
                                             liable for such refusal.
Idaho.....................................  Idaho Code Sec.  18-612
                                             (2002) No hospital or
                                             person shall be required to
                                             perform an abortion if it
                                             is objected to for moral
                                             reasons.
Illinois..................................  745 ILCS 70--Rights of
                                             Conscience are protected
                                             for all procedures. Sec.
                                             11.2--Health Care Payers
                                             are not liable. Sec. 12--
                                             Right to recover treble
                                             damages, may not be less
                                             than $2,500.
Indiana...................................  Ind. Stat. 16-34-1-3 to 5.
                                             No hospital shall be
                                             required to perform an
                                             abortion. No person shall
                                             have to do so if it against
                                             his moral or religious
                                             principles and one cannot
                                             be required to participate
                                             in an abortion as a
                                             condition of training or
                                             employment.
Iowa......................................  Iowa Code Sec.  146.1&2
                                             (2002) No person shall be
                                             required to perform an
                                             abortion if it against his
                                             moral or religious
                                             convictions. No hospital
                                             that is not maintained by
                                             public authority must
                                             perform an abortion.
Kansas....................................  K.S.A. Sec.  65-443, 444
                                             (2001) No person or
                                             hospital is required to
                                             perform an abortion.
                                             Refusal to do so is not
                                             grounds for civil liability
                                             against any person.
Kentucky..................................  KRS Sec.  311.800 (2001) No
                                             public funds shall be used
                                             to perform an abortion. No
                                             private hospital or person
                                             shall be required to
                                             perform an abortion.
Louisiana.................................  La. R.S. 40:1299.31 to .32
                                             (2002) No person in the
                                             medical field can be liable
                                             for refusing to participate
                                             in abortion. No social
                                             service worker is liable
                                             for refusing to recommend
                                             abortions. No hospital
                                             shall be required to
                                             perform an abortion.
Maine.....................................  22 M.R.S. Sec.  1591-2
                                             (2001) no person or
                                             hospital is required to
                                             perform an abortion. No
                                             hospital, firm, or
                                             education institution can
                                             discriminate for a person's
                                             refusal to perform an
                                             abortion.
                                            22 M.R.S. Sec.  1903 (2001)
                                             A private institution or
                                             physician or their agent
                                             may refuse to provide
                                             family planning services if
                                             it is against their
                                             religious or moral beliefs.
Maryland..................................  Md. Health-General Code Ann.
                                             Sec.  20-214 No person or
                                             hospital has to participate
                                             in an abortion, artificial
                                             insemination, or
                                             sterilization. There is no
                                             immunity if a person's
                                             referring the patient to a
                                             source of pregnancy
                                             termination would have
                                             prevented death or long
                                             lasting injury.
Massachusetts.............................  Mass. Ann. Laws ch. 112,
                                             Sec.  12I (2002) Any person
                                             who objects to abortion or
                                             sterilization will not be
                                             required to participate.
                                             Such an objection will not
                                             be used against a person to
                                             keep him out of medical
                                             school, social work, etc.
Michigan..................................  MCLS Sec.  333.20181, 20182
                                             (2002) No hospital,
                                             teaching institution or
                                             person connected with such
                                             a facility is required to
                                             perform an abortion if
                                             objected to on
                                             professional, moral, or
                                             religious grounds.
Minnesota.................................  Minn. Stat. Ann. 145.414,
                                             145.42 No hospital or
                                             person is liable if they
                                             refuse to participate in an
                                             abortion. No health Plan
                                             company will be held liable
                                             for not providing
                                             abortions.
Mississippi...............................  Miss. Code Ann. Sec.  41-41-
                                             215 ``A health-care
                                             provider may decline to
                                             comply with an individual
                                             instruction or health-care
                                             decision for reasons of
                                             conscience.''
Missouri..................................  Sec.  197.032 R.S.Mo.No
                                             person or public or private
                                             hospital shall be required
                                             to treat a person for
                                             abortion.
                                            Sec.  188.110 R.S. Mo.
                                             (2001) No employer can
                                             discriminate against
                                             employees for their refusal
                                             to participate in an
                                             abortion.
                                            Sec.  188.110 R.S.Mo. (2001)
                                             No school can deny
                                             admittance for a person's
                                             refusal to participate in
                                             an abortion
Montana...................................  Mont. Code Anno., Sec.  50-
                                             20-111 (2001) No private
                                             hospital need provide
                                             abortion. All persons have
                                             the right to refuse or
                                             participate in an abortion.
                                             Person can mean individual
                                             or corporations.
                                            Mont. Code Anno. Sec.  50-5-
                                             502 to 505 No hospital or
                                             medical facility or persons
                                             shall have to perform
                                             sterilization. Person has
                                             the right to injunctive
                                             relief or monetary damages.
                                             Hospital or medical
                                             facility shall not loose
                                             any privileges or
                                             immunities.
Nebraska..................................  Neb. Rev. Stat. ' 28-337 No
                                             hospital in the state,
                                             public or private, must
                                             perform an abortion, but it
                                             must inform the patient of
                                             this policy.
Nevada....................................  Nev. Rev. Stat. 632.475--
                                             Nurse or somebody providing
                                             direct assistance to a
                                             patient does not have to
                                             assist in an abortion if it
                                             is against her morals
New Hampshire.............................  RSA 137-H:6 (2002) A
                                             physician who, for
                                             conscience sake, cannot
                                             comply with a living will
                                             shall without delay
                                             transfer the patient to
                                             another physician.
New Jersey................................  N.J. Stat. Sec.  2A:65A-1
                                             ``No person shall be
                                             required to perform or
                                             assist in the performance
                                             of an abortion or
                                             sterilization.''
                                            N.J. Stat. Sec.  2A:65A-2
                                             ``No hospital or other
                                             health care facility shall
                                             be required to provide
                                             abortion or sterilization
                                             services or procedures.
                                            N.J. Stat. Sec.  2A:65A-2 No
                                             civil liability for those
                                             who refuse to perform
                                             abortion or sterilization.
New Mexico................................  N.M. Stat. Ann. Sec.  30-5-2
                                             (2001) No person or
                                             hospital has to participate
                                             in abortion for moral or
                                             religious reasons
                                            N.M. Stat. Ann. Sec.  24-8-6
                                             (2001) No hospital is
                                             required to admit a patient
                                             for sterilization if done
                                             so on religious grounds.
New York..................................  NY CLS Civ R Sec.  79-i
                                             (2002) No person shall be
                                             required to perform an
                                             abortion if it is against
                                             his conscience or religious
                                             beliefs.
North Carolina............................  N.C. Gen. Stat. Sec.  14-
                                             45.1 Physician or nurse do
                                             not have to perform
                                             abortion if it is against
                                             their religious principles.
                                             A hospital or healthcare
                                             institution does not have
                                             to offer abortions.
North Dakota..............................  N.D. Cent. Code, Sec.  23-16-
                                             14 (2002) NO hospital or
                                             person shall be required to
                                             perform an abortion.
                                            N.D. Cent Code 14-02.4-15.1
                                             (1997) Government may not
                                             discriminate against health
                                             care institute or private
                                             agency for refusal to
                                             participate in any health
                                             care service that is
                                             against written religious
                                             and moral policies.
Ohio......................................  ORC Ann. 4731.91 (Anderson
                                             2002) No public or private
                                             hospital or person has to
                                             participate in an abortion.
Oklahoma..................................  63 Okl. St. Sec.  1-741 No
                                             Private hospital or person
                                             has to participate in an
                                             abortion.
Oregon....................................  Or. Rev. Stat. ' 435.485
                                             (2001) No physician must
                                             give advice to a patient
                                             concerning abortion, but he
                                             must advise the patient. No
                                             hospital employee is
                                             required to participate in
                                             an abortion.
                                            Or. Rev. Stat. Sec.  435.225
                                             (2001) ``Any employee of
                                             the Department of Human
                                             Services may refuse to
                                             accept the duty of offering
                                             family planning and birth
                                             control services'' if it
                                             conflicts with religious
                                             principles.
Pennsylvania..............................  18 Pa. C. S. Sec.  3202
                                             (2002) Right of Conscience
                                             is protected for all person
                                             who desires to not provide
                                             an abortion.
                                            18 Pa. C.S. Sec.  3213.
                                             Except for a facility
                                             devoted to abortions, no
                                             facility is required to
                                             perform abortions, and no
                                             medical personnel, employee
                                             or student is required to
                                             participate in an abortion.
                                             Civil Liability may reach
                                             $5,000.
                                            43 P.S. Sec.  955.2 (2002)
                                             No hospital or person is
                                             required to perform an
                                             abortion or sterilization.
                                             No school can deny
                                             admission due to a person's
                                             refusal to participate in
                                             abortion or sterilization.
Rhode Island..............................  R.I. Gen. Laws Sec.  23-17-
                                             11 (2001) No person shall
                                             be required to participate
                                             in an abortion or
                                             sterilization if such are
                                             objected to on moral or
                                             religious grounds.
South Carolina............................  S.C. Code Ann. Sec.  44-41-
                                             40 (2001) No private
                                             institution is required to
                                             perform an abortion.
South Dakota..............................  S.D. Codified Laws Sec.  34-
                                             23A-12 (2001) No person who
                                             refuses to perform an
                                             abortion shall be held
                                             liable.
Tennessee.................................  Tenn. Code Ann. Sec.  39-15-
                                             204, 205 (2001) No hospital
                                             or person need provide an
                                             abortion.
                                            Tenn. Code Ann. Sec.  68-34-
                                             104 No private institution
                                             or physician is required to
                                             provide contraceptive
                                             procedures or supplies if
                                             refusal is based on
                                             conscientious or religious
                                             objections.
Texas.....................................  Tex. Occ. Code Sec.
                                             103.001, 002 (2002) No
                                             physician, nurse or
                                             employee of a hospital
                                             maybe required to
                                             participate in an abortion.
                                            Tex. Occ. Code Sec.  103.003
                                             (2002) A person whose
                                             rights are violated may sue
                                             the hospital, medical
                                             facility or educational
                                             institution for an
                                             injunction plus affirmative
                                             relief, including
                                             reinstatement, backpay plus
                                             10%
                                            Tex. Occ. Code Sec.  103.004
                                             Hospital need not provide
                                             abortions.
                                            Tex. Ins. Code Ann. art.
                                             20A.09(m)--No, HMO,
                                             physician, or provider is
                                             required to recommend or
                                             provide services that
                                             violate religious
                                             convictions.
Utah......................................  Utah Code Ann. Sec.  76-7-
                                             306 (2001) No person shall
                                             be required to perform an
                                             abortion if it is against
                                             his moral or religious
                                             beliefs. No private or
                                             denominational hospital
                                             shall be required to
                                             perform abortions.
Virginia..................................  Va. St. Sec.  18.2-75 A
                                             hospital, medical facility
                                             or physician do not have to
                                             perform abortion.
Washington................................  Wash. Rev. Code Ann.
                                             70.47.160 (2002) No HMO
                                             need provide or pay for
                                             services that are
                                             religiously objectionable.
                                            Wash. Rev. Code Ann. Sec.
                                             70.122.060 (2002). No
                                             nurse, physician, or other
                                             health care practitioner
                                             may be required by law or
                                             contract in any
                                             circumstances to
                                             participate in the
                                             withholding or withdrawal
                                             of life-sustaining
                                             treatment if such person
                                             objects to so doing
West Virginia.............................  W. Va. Code Sec.  16-2F-7
                                             (2001)--No person need
                                             participate in and abortion
                                             if they refuse for medical
                                             reasons or any others.
                                            W. Va. Code Sec.  16-2B-4
                                             (2001) Any employee of the
                                             state may refuse the duty
                                             of providing family
                                             planning services.
                                            W. Va. Code Sec.  16-30-12 A
                                             health care facility does
                                             not need to change it
                                             policies that are grounded
                                             in sincerely held religious
                                             convictions or moral
                                             principles.
                                            A health care provider need
                                             not provide service that is
                                             contrary to its religious
                                             beliefs. (Living Wills
                                             etc.)
Wisconsin.................................  Wis. Stat. Sec.  253.09
                                             (2001) No hospital or
                                             person is required to
                                             participate in abortion or
                                             sterilization.
Wyoming...................................  Wyo. Stat. Sec.  35-6-105,
                                             106 (2001) No private
                                             hospital or institution or
                                             person need provide or
                                             participate in abortions.
                                             (Also mentions Euthanasia,
                                             but appears to be in
                                             context of abortion.)
                                            Wyo. Stat. Sec.  42-5-101
                                             (2001) Any person may
                                             refuse the duty of
                                             providing family planning
                                             or birth control services
                                             if done so for religious or
                                             personal beliefs.
------------------------------------------------------------------------


    Mr. Bilirakis. Thank you, Mr. Wardle. I felt compelled to 
introduce the legislation that we are discussing today, because 
the intent of the legislature has always meant an awful lot to 
me. And in trying to determine what was intended, I reach to 
these additional views signed by Senators Bill Frist, 
McConnell, Gregg, Hutchinson, Coats and DeWine, where they 
said, ``We believe that the term `health care entity,' ''--and 
I don't know how anyone can, in my opinion, look at it 
logically and come to the conclusion that a health care entity 
could exclude a hospital. But we believe that the term, 
``health care entity,'' was intended to be read in the 
straightforward manner of including not only the specific 
entities mentioned but also those which are routinely seen as 
health care entities in common usage and other Federal laws, 
such as a hospital, provider-sponsored entity, health 
maintenance organization, health plan, et cetera, et cetera. So 
that is why I felt compelled to do this, because, as Mr. Wardle 
said, there is a gap there--I am not sure if you used that 
exact word--and we have got to try to fill that gap.
    Ms. Vosburgh----
    Ms. Vosburgh. Yes.
    Mr. Bilirakis. [continuing] You have indicated that, if I 
understood you correctly, there is a provider across the street 
from the hospital----
    Ms. Vosburgh. Yes.
    Mr. Bilirakis. [continuing] who performs----
    Ms. Vosburgh. Yes, that is abortions.
    Mr. Bilirakis. [continuing] elective abortions.
    Ms. Vosburgh. Abortionist lamage, yes.
    Mr. Bilirakis. So if Valley Hospital were afforded 
conscience protection, then it is likely that women would still 
have access to elective abortions, correct?
    Ms. Vosburgh. Yes, they would. In fact, she does her first 
term trimester abortions in her own clinic.
    Mr. Bilirakis. In her own clinic.
    Ms. Vosburgh. She uses the hospital for second trimester 
abortions.
    Mr. Bilirakis. Well, could she perform the second trimester 
abortions in her own clinic?
    Ms. Vosburgh. No.
    Mr. Bilirakis. She could not.
    Ms. Vosburgh. No. It is a State law; she has to use the 
hospital.
    Mr. Bilirakis. Okay.
    Ms. Vosburgh. But, you know, why should we be forced to----
    Mr. Bilirakis. How many--I don't know the answer to this, 
and I guess it is always dangerous to ask a question you don't 
know the answer to--but how many hospitals are there in the 
valley?
    Ms. Vosburgh. Just one.
    Mr. Bilirakis. Just one.
    Ms. Vosburgh. Anchorage is about 50 miles away.
    Mr. Bilirakis. About 50 miles away. Are there hospitals 
there where there may not be a problem regarding their 
conscience in terms of performing abortions?
    Ms. Vosburgh. Providence is a Catholic hospital; it will 
not allow abortions there either. But there is always a 
regional--there is the Vets Hospital, so I am not sure if she 
would do her second trimester abortions there. My suggestion 
would be to her to build her own facility if she wants to do 
second trimester abortions.
    Mr. Bilirakis. Okay. Do you feel then that your experience 
in Alaska--you obviously feel very strongly about this point, 
but do you feel that that experience presents a compelling 
argument for clarifying Congress' original intent in providing 
Federal conscience protections?
    Ms. Vosburgh. Yes. I believe if this had been in place 
solidly, that this probably would not have happened.
    Mr. Bilirakis. Yes. It is just unfortunate. Sometimes you 
can't see the forest for the trees up here, and you are just so 
overloaded with so many things on your plate that the intent of 
the Congress at the time was not played out accurately in terms 
of what was meant by ``health care entity.''
    Ms. Vosburgh. One thing I did want to mention is the cases 
that I brought up here are hard cases--the rape, incest and 
life of the mother--which are--you know, those are the ones 
that are tear-wrenching and things. But the fact of the matter 
is even Planned Parenthood admits that 95 percent and more--
some people say only 1 percent--are for life, incest and rape. 
So 95, 96, 97 percent of all abortions are for nearly birth 
control purposes. Why should we----
    Mr. Bilirakis. Well, let us not--yes. I don't disagree with 
you. Let us not go into that.
    Ms. Vosburgh. All right.
    Mr. Bilirakis. Mr. Weiss, you mention in your testimony 
that you oppose extending conscience clause protections to 
other health care entities because, using your words, ``Its 
burdens fall primarily on those who do not share the beliefs 
that motivate the refusal.'' Would you agree that forcing a 
Catholic hospital, which is based on a faith that finds 
abortion objectionable, and I think you would agree with that, 
to perform abortions would also place a burden on that entity 
based on a belief that this institution does not share if we 
are talking about placing a burden?
    Ms. Weiss. Chairman, it is a matter of balancing the rights 
involved. The question there is what kind of institution is it? 
Let us just take for a minute Valley Hospital as against an 
institution that I think would be entitled in many cases to 
exemptions from the public health laws, which would be a 
privately funded Christian Science Sanitorium. Valley Hospital, 
just by way of example, was held to be a quasi-public entity by 
the Alaska Supreme Court for three reasons. First, because it 
was built on public land, 5 acres donated by the city, with 
over $10 million in public funds. It operated on very 
significant public funds. It had been granted a certificate of 
need by the State through a regulatory process which gave it a 
health care monopoly in the valley, in return for which it 
promised to meet the health care needs of the valley. It is the 
only hospital in the valley in which second trimester 
procedures can be performed.
    Mr. Bilirakis. Well, how would you feel about it if it were 
a Catholic hospital?
    Ms. Weiss. Well, then it would depend for me on whether the 
Catholic hospital met these same kinds of criteria. Is it a 
hospital that was built with or on public land? Is it operated 
significantly with public dollars? Does it treat the general 
public? Does it employ the general public? If so, then I submit 
it should abide by public health laws. If not, as is the case, 
for example, with the Christian Science Sanitorium, built with 
private funds, operated with private funds, it employs 
Christian scientists, it serves Christian scientists, it heals 
exclusively through prayer, that kind of pervasively sectarian 
health care institution ought, in general, to be out from under 
public health laws that are repugnant to its beliefs, because 
it is serving a population of believers.
    Mr. Bilirakis. Thank you, Ms. Weiss. My time has expired. 
Ms. Capps?
    Ms. Capps. Thank you very much, Mr. Chairman. And, Ms. 
Weiss, I will give you a chance to continue. I want to start 
with the premise that I understand from colleagues who have 
proposed this legislation that H.R. 4691 is a small technical 
change in the law and give you an opportunity to agree or 
disagree and then expand on that.
    Ms. Weiss. I think that really it is clear from the 
comparison of the Coats Amendment with the comparison of the 
chairman's bill that it is by no means a small technical change 
in the law. The Coats Amendment defines the term, ``health care 
entity,'' in this way. The term, ``health care entity,'' 
includes an individual physician, a post-graduate physician 
training program or a participant in a program of training in 
the health professions. The Coats Amendment was passed to 
address what this body, Congress, viewed as a problem with 
mandatory--with a professional standard that the Accreditation 
Council for Graduate Medical Education had issued to require 
residency programs either to offer or to arrange abortion 
training for residents.
    Just to correct the record here, that professional standard 
at all times, when it was first promulgated and now, has 
provided an opt-out for any individual resident or physician 
who does not want to participate in abortions. It has never, by 
its terms, forced any doctor who had an objection personally to 
perform any abortion.
    So this body responded to address the problem in residency 
programs. This new bill, as I think you know, applies not 
simply to fit individual physicians and residency programs but 
to hospitals, health plans, HMOs, insurance companies or any 
other kind of health care facility, organization or plan. In 
other words, it applies to everybody. And instead of applying 
merely to the provision of abortions or referral for abortions 
or training in those things, it applies also to providing 
coverage of abortions or paying for them. So it vastly expands 
the kinds of entities that can have exemptions and the 
exemptions they can claim. That is why, for example, in the 
example I gave, a Medicaid managed care organization, an HMO, 
that participates in the Medicaid Program, could simply refuse 
to discuss abortion, even abortion that a woman was entitled to 
under Federal law.
    Ms. Capps. And at this point, I would appreciate just a 
brief answer from the other three. I want to really get at the 
distinction between the conscience clause for an individual 
provider and what it means to be offering a service. And do you 
think taxpayer dollars should provide that service, such as a 
hospital, a clinic or an HMO? And maybe each of you have a 
chance--I would like to ask if, in your mind, you see no 
corporate responsibility--you, for example, Ms. Vosburgh, being 
on the board of a hospital--no corporate responsibility to 
provide the services that the taxpayers have funded you with?
    Ms. Vosburgh. It is an elective--the abortions that are 
done there are elective, and, no, I don't see anything. The 
bill that is trying to be passed here would give a conscience 
clause out, not only to the doctors and nurses, which are 
already provided----
    Ms. Capps. Yes.
    Ms. Vosburgh. [continuing] but for the entities themselves.
    Ms. Capps. But let us get at, and I will ask, Mr. Wardle, 
you too to answer here, if there are further distinctions that 
can be made. Do you believe also that an institution is the 
same as an individual in terms of the conscience clause? And 
that we who fund here take very seriously our responsibility to 
use taxpayer dollars wisely, that when we set out to fund the 
Medicaid and the various provisions that are authorized under 
the Constitution of this United States, that an institution has 
the right to opt-out of that responsibility?
    Mr. Wardle. Well, thank you, Ms. Capps, Representative 
Capps. I would like to respond in two ways--three ways. First, 
you have used the term, ``corporate responsibility.'' That is a 
wonderful term, and it ought to be on our mind, and the purpose 
of this bill is to protect corporate responsibility, 
responsibility meaning conscience, ethics, principles. Second, 
look at the history of the protection, the conscience clause 
laws in this country. The very first one that was passed was 
passed by Congress. It was the Church Amendment passed almost 
exactly 30 years ago, and it was designed to protect the rights 
of institutions to not have to perform abortions.
    And, third, is there a difference between individuals and 
corporations? Yes, there is, but with respect to protecting 
rights of conscience, where will you draw the line? Are you 
going to say you, as an individual, have the right to free 
speech, but, oh, no, corporations cannot engage in free speech, 
newspapers, radio companies, television----
    Ms. Capps. I am going to interrupt just because--Mr. 
Chairman, may I have 1 extra minute so that Ms. Weiss can also 
answer this question. I would like to get a survey from all.
    Mr. Bilirakis. Without objection, but your 27 seconds over 
already. Without objection, it is----
    Ms. Capps. Thirty seconds more.
    Ms. Weiss. Of course there is a critical difference between 
institutions and individuals in this matter, and that is 
because when institutions claim rights of conscience they are 
very likely to be imposing their religious tenets on people who 
do not share them. That is to say there are conscientious 
rights on both--rights of conscience on both sides of the 
ledger. When an individual patient makes a decision not to have 
any more children, she is making a decision in which she is 
standing on moral ground. It is a decision about what is best 
for her and her family and her children. And that means that 
she has rights that need to be protected on that side of the 
ledger.
    Ms. Capps. Thank you. Thank you, Mr. Chairman.
    Mr. Bilirakis. I thank the gentlelady. Mr. Pitts?
    Mr. Pitts. Thank you. Ms. Weiss, you mentioned in your 
testimony about Sophie Smith. Would you, for the record, 
provide more information to the committee on this case that you 
mention in your testimony, the blood clot?
    Ms. Weiss. Yes, Representative. What information would you 
like?
    Mr. Pitts. Well, just anything you have on it: The name of 
the hospital that you are talking about.
    Ms. Weiss. The hospital was a sectarian hospital in 
Nebraska, and I have not mentioned its name in testimony 
because the physician in question, the one who called me, is 
fearful of violence and does not want to be revealed and 
continues to practice there. So I have not provided identifying 
information for that reason.
    Mr. Pitts. Okay.
    Ms. Weiss. I apologize. That is often a problem in 
providing identifying details in this field because of the 
ongoing problem of violence.
    Mr. Pitts. In your line of reasoning, as I was seeking to 
follow it, you seem to say that any entity that takes public 
money can't have a conscience. A couple of days ago, an article 
appeared in the Burlington County Times about the purchase of a 
hospital in Burlington County by Our Lady of Lordes Health Care 
Services. And the article indicated that the ACLU in New Jersey 
had been challenging the purchase. The articles says that the 
ACLU is insisting that our Lady of Lordes, ``add a separate 
building on the Rancocas Hospital campus where women could go 
for abortions.'' Is it the position of the ACLU that Catholic 
hospitals, that our Lady of Lordes, should be required by law 
to build a separate clinic for abortions upon their property?
    Ms. Weiss. Well, that is a very interesting case, 
Representative Pitts. That is a case in which a Catholic 
facility is acquiring or merging with a formally secular 
facility and trying to ensure that the new merged entity lives 
by the ethical and religious directives for Catholic health 
care services that govern Catholic facilities, thereby 
preventing abortions, sterilization, contraception, fertility 
treatments, a wide array of reproductive health care.
    But the facility that it is buying was itself created by a 
charitable trust, and in that charitable trust there was--the 
intent of the donor was expressed to provide a wide array of 
health services to the low-income community in the relevant 
city in New Jersey. Now, the question in that case was does the 
conscience, the moral stance of the original donor to the 
secular institution have also rights or is it only that the 
Catholic facility has rights of conscience? And the answer is 
of course that is not the case. Both facilities were created by 
charitable trusts, both facilities have consciences, and the 
question is how do we--can they merge, is there a way that they 
can affiliate and recognize the conscientious rights of both 
facilities? That is what is at issue in that case, that is why 
there is an ongoing debate about how to preserve the intent of 
the founders of the formally secular facility. That is why you 
are seeing that in the newspaper, sir.
    Mr. Pitts. Thank you. I wish I could continue with you. 
Maybe we will have a second round, I don't know.
    Professor Wardle, do you understand this bill to cover 
cases of emergency contraception that some providers may see as 
abortifacient? Does it expand or change the current legal 
definition of abortion anyway?
    Mr. Wardle. I don't think it changes the current definition 
of abortion in any way. But let me point out two things here. 
The critical issue is who decides what my rights of conscience 
are? Is it going to be for the ACLU to dictate the boundaries 
of my conscience? And if my definition of what is conscience 
and what is moral disagrees with them, can they force me to do 
their will? Can they deny me the opportunity to practice, if I 
were a doctor, practice medicine; if I were a health care 
administrator, to administer medicine? The question is who 
defines conscience? I am pleased to let Ms. Weiss define her 
own conscience but not to impose that on me. Likewise, if 
patients want to have medical services that I would not perform 
as a doctor, let Ms. Weiss direct them in the direction where 
they can get those services.
    You see her definition of abortion is as an entitlement, a 
definition that has been repudiated at least five times by the 
United States Supreme Court, but she and the ACLU don't accept 
it. They believe that abortion is not just a right of private 
choice but it is an entitlement that has to be facilitated and 
you have to facilitate it. The distinction between public and 
private is specious in our economy that is so wholly 
publicized. The government takes my money then gives it back to 
me in manner of a student loan. Does that now make me as a 
student a public actor? Gives it back to me in the form of a 
license to practice medicine or a certificate of need to 
perform medical services. Does that make me a public actor? The 
public/private distinction is a specious distinction.
    Mr. Pitts. I see that I am out of time.
    Mr. Bilirakis. Your time is expired. Would you gentlemen 
like to have an additional minute?
    Mr. Pitts. Yes, sir, Mr. Chairman, if you don't mind.
    Mr. Bilirakis. Without objection----
    Mr. Pitts. I will ask Professor Wardle, based on your 
research, do you recognize a concerted movement or an effort to 
require all hospitals to provide abortions? You made some 
reference to that. I would like you to expand.
    Mr. Wardle. Thank you, Mr. Pitts. Yes, and that is how the 
issue has changed. I have seen a dramatic change in 30 years. I 
have studied this for 30 years and written about it for nearly 
a quarter of a century, and you have seen a dramatic change in 
the dialog and the expectation from privacy. Just let us be 
able to choose this. We are not asking to force anybody to do 
anything. Just let us be able to choose to. Now, you have to 
facilitate, you have to perform, you have to pay.
    Essentially, the position that has been articulated by Ms. 
Weiss this morning is that no Catholic hospital, and I would 
say not just Catholic but other religious affiliated hospitals 
and not just religious affiliated hospitals. We have here a 
witness from a sectarian hospital that asserted by democratic 
process a set of principles, right of conscience, forcing them 
to take a position. The position that is taken today is if you 
are a hospital that would decline to perform abortions, you 
cannot expand, you cannot merge, you cannot acquire, you cannot 
grow unless you are willing to do abortion.
    Mr. Bilirakis. The gentleman's time has expired. Mr. 
Strickland to inquire.
    Mr. Strickland. Thank you, Mr. Chairman. Mr. Wardle, I have 
a question in regard to your most recent comment that you have 
observed something over a 20- or 25-year period, and people 
have gone from just wanting to be able to make the choice to 
have that as some kind of right that could be imposed upon 
others. But I am just curious, do you agree with the first part 
of that? Do you believe that the person should be able to make 
a personal choice?
    Mr. Wardle. I believe that in some cases that is absolutely 
right. I think the Supreme Court could have reached the 
decision it did in Roe v. Wade without the absurd toddering 
doctrine that it put underneath it. In the case of rape, 
certainly, in the incest, in the case of life or a health 
threat.
    Mr. Strickland. You know, this really puzzles me because 
when we talk about the morality of abortion, when we talk about 
the taking of an innocent human life, then to say in case of 
rape, in case of incest. It seems to me that there is an 
inconsistency. If it is an innocent human life, then the child 
conceived as a result of rape or incest is also an innocent 
human life. Now, I believe in the right of a woman to choose, 
but I am just pointing out what I think is a glaring 
inconsistency among those who make these moral distinctions and 
still question the validity of a conscience of an individual 
who may have a different point of view.
    Mr. Wardle. Mr. Representative, I believe the question is, 
though, and I respect your point of view and the point you make 
is a very thoughtful and thought-provoking one, but is it for 
you to tell me what my conscience is or to tell Ms. Vosburgh 
what her conscience is or to tell Ms. Weiss?
    Mr. Strickland. No, it isn't, and that is why--this causes 
conflict within me, because I think what we are talking about 
here is an area that for thoughtful people results in internal 
conflict.
    You said something about the mayor of New York. Would you, 
for my sake, repeat what you said that his comment was when 
someone was found to be pregnant?
    Mr. Wardle. I am quoting from news reports. ``These media 
mogul reportedly once told a pregnant employee to, `kill it, 
kill it.' '' I would add, as I do in my written testimony, 
Bloomberg has denied making the comment, but it was cited in 
legal papers of Sekiko Sakai Garrison, a former Bloomberg news 
staffer, who brought one of three publicized sex harassment 
cases----
    Mr. Strickland. Yes, sir.
    Mr. Wardle. [continuing] against him or his company.
    Mr. Strickland. I just think it would have been more fair 
of you to have relayed his denial at the time when you relayed 
what supposedly was his comment. I don't know Mr. Bloomberg, 
have no affiliation or any particular sympathy for him, but I 
think to put out such a statement without also giving us his 
denial was a little unfair to him.
    Mr. Wardle. Well, I did give it to you in writing, and I 
just read it to complete the record, sir.
    Mr. Strickland. Well, thank you for that. Ms. Vosburgh, 
this may have been discussed when I wasn't here, and if it is, 
I apologize. But does your hospital believe that it should 
perform an abortion under any circumstances?
    Ms. Vosburgh. Yes, rape, incest, life of the mother. It is 
in the policy that they every year rewrite, which lines up with 
Federal law too, with title X.
    Mr. Strickland. I was just unsure because I was not here.
    Ms. Vosburgh. Yes. And while I am on here, I would like to 
answer Mrs. Capps. She said since we are a hospital, I am on 
the board--Okay, sorry.
    Mr. Strickland. Yes. I am sorry, we only have 5 minutes. I 
think Ms. Capps may have--I hope the chairman will give us a 
second round here.
    Mr. Bilirakis. I am not contemplating doing that. We have 
another panel to go yet.
    Mr. Strickland. Okay. Well, I am----
    Ms. Vosburgh. I would have been finished by now anyway. 
Well, the thing is we are elected----
    Mr. Strickland. Well, I will respect your right to----
    Ms. Vosburgh. Okay. Well, we are elected. We are elected 
from the community, from our community. We are elected, and we 
elect people onto the operating board which make that decision, 
and the community, the body of the community does not want--
they do not want abortions there. Abortions to the majority of 
the community there, it is an abhorrent thing. It is the taking 
of human life. Very tiny, yes, but it is human life. That is 
what fetus means, little one. And it is killing them.
    Mr. Strickland. Can I interrupt here?
    Ms. Vosburgh. Yes.
    Mr. Strickland. Because are you expressing a religious 
belief----
    Ms. Vosburgh. No.
    Mr. Strickland. [continuing] when you say that or are you 
expressing a scientific belief? And if it is a scientific 
belief, then it is not a matter of conscience, it is a matter 
of judgment, it seems to me.
    Ms. Vosburgh. It is a matter of humanity. I mean we need to 
protect all of us.
    Mr. Strickland. I do think the Constitution does grant 
legitimate exceptions for a lot of things based on religious 
belief. It troubles me that someone could just--some group of 
individuals could just decide that this is a moral issue devoid 
of religious theological context and then claim the kind of 
protections that I think are only available to those who use a 
religious test for their particular beliefs.
    Mr. Bilirakis. Without objection, the gentleman is granted 
an additional minute.
    Mr. Strickland. You are very kind.
    Mr. Bilirakis. Took you by surprise.
    Mr. Strickland. You are very kind, Mr. Chairman. I will not 
accept that gracious invitation. Thank you so much.
    Mr. Bilirakis. Mr. Akin, did you have maybe a quick 
question you might raise to this panel? You are not a member of 
the committee, but I know the other members would not mind if 
you raised a particular question.
    Mr. Akin. I appreciate the offer.
    Mr. Bilirakis. All right. Well, we customarily--first of 
all, thank you. We customarily present questions in writing to 
the panelists and we will ask you to respond to those in a 
timely fashion. What is timely? Well, anyhow, 2 or 3 weeks we 
would hope at the most. So I hope you won't mind receiving 
those questions and will respond. And we can only thank you. 
Ms. Weiss came from New York, Mr. Wardle----
    Ms. Capps. Mr. Chairman?
    Mr. Bilirakis. [continuing] from Utah and Ms. Vosburgh from 
Alaska, so you have come quite a long distance, particularly 
two of you. Yes, ma'am?
    Ms. Capps. May I suggest that we offer a second round or 
request that you consider it?
    Mr. Bilirakis. I would rather not because we have a second 
panel who is just sitting here, and it is the prerogative of 
the Chair, as I understand it, and I hope you don't mind, but I 
would rather not do that. All right. You are excused. Thank you 
so very much.
    Panel II consists of Ms. Addia--is that correct?
    Ms. Wuchner. Addia Wuchner, yes.
    Mr. Bilirakis. Addia, yes, I am sorry. Ms. Wuchner, Dr. 
Renee Jenkins, on behalf of the American Academy of Pediatrics, 
and Mr. John Heisler who is going to be better introduced by I 
suppose it is his congressman, Mr. Manzullo who has asked--Mr. 
Manzullo asked for the right to introduce Mr. Heisler. Please 
proceed, Don.
    Mr. Manzullo. Thank you, Mr. Chairman. I have to 
introduce--it is my pleasure to introduce my constituent and 
then I have to run to catch an airplane. Thank you for giving 
me the opportunity to introduce my constituent, John Heisler. 
Mr. Heisler is a member of the McHenry County Board. He spent 
the past several years as the county board's liaison to the 
Board of Health. Our paths crossed in 1997 when one of the 
communities in McHenry County, Crystal Lake, was devastated by 
the news that a 13-year-old girl had been repeatedly sexually 
assaulted by her 37-year-old junior high school teacher. The 
teacher eventually was sentenced to 10 years in prison.
    But the following the arrest was even more shocking, the 
teacher had used the title X Federal Family Planning Program at 
the McHenry County Health Department to shield his crime, and 
taxpayers were footing the bill. Tired of using condoms, the 
teacher brought the young girl to a place where he knew she 
could get birth control drugs without anybody finding out, the 
federally funded county health department. The teacher knew 
that title X rules prohibited clinics from notifying parents 
when issuing birth control drugs to young girls.
    When the girl arrived, a clinic worker injected her with a 
powerful birth control drug, Depo-Provera, a hormonal drug that 
possesses severe side effects, including excessive bleeding and 
bone loss. Eighteen months later into the crime, the little 
girl broke down, told her parents, she underwent intensive 
therapy and battled anorexia.
    The whole argument for providing young girls birth control 
drugs behind their parents' back is cloaked in the double 
standards, which Mr. Heisler will bring out. But as a result of 
what happened in McHenry County, we, in 1998, approved my 
parental notification bill. The Senate never acted on the 
provision, however, and it died. But we did get legislation 
that passed, that became law, that title X clinics are not 
following, and that is that whenever they have reason to 
believe that a minor is under the age of consent, these title X 
agencies have the statutory duty to follow local State laws 
requiring notification to authorities that a child is indeed 
being raped. That was the two-part prong of the bill that we 
got passed. It is quite a story that Mr. Heisler has to tell. 
Again, I appreciate the opportunity to introduce him and I 
would ask to be excused.
    Mr. Bilirakis. Thank you.
    Mr. Akin. Thank you.
    Mr. Bilirakis. The Chair excuses the gentleman.
    Ms. Wuchner?

   STATEMENTS OF ADDIA WUCHNER, NORTHERN KENTUCKY INDEPENDENT 
 HEALTH DISTRICT; RENEE S. JENKINS, ON BEHALF OF THE AMERICAN 
   ACADEMY OF PEDIATRICS; AND JOHN A. HEISLER, COUNTY BOARD, 
                    McHENRY COUNTY, ILLINOIS

    Ms. Wuchner. Thank you. Mr. Chairman and members of the 
Committee, I appreciate this opportunity to be here today to 
discuss with you the issue of a parent's right to know, 
especially as it pertains to medical treatment of minor 
children without their parents' knowledge or notification.
    I am a mother of three, a registered nurse, with a 
background in women's health. I currently serve on the board of 
directors for the Northern Kentucky Independent District Health 
Department and Chair the Community on Human Sexuality 
Education.
    Most parents would be shocked to learn that their teenage 
daughters may walk into one any of the title X federally funded 
clinics and obtain free birth control, including injectables 
such as Depo-Provera, emergency contraceptives, the morning 
after pill, without the knowledge or notification of their 
parents. They would be shocked because, for centuries, all 
sorts of rights flowing from the parent-child relationship have 
been acknowledged and protected by law, among them decisions 
concerning custody, the education and the medical treatment of 
their children. Yet today, when it comes to sex and the 
prevention and treatment of pregnancy and the prevention and 
treatment of sexually transmitted diseases, is seems neither 
mother nor father are trusted to know what is best.
    The Northern Kentucky Board recently passed a motion to 
gather community input and review title X and Family Planning 
Services. This review led them to a vote. But the review led to 
much more. It led to the highlight of the many strings attached 
to title X which we will discuss today. For example, Section 
8.7 states, ``Title X projects many not require the written 
consent of parents or guardians for provisions of services to 
minors, nor can the project notify parents or guardians before 
or after a minor has requested and received title X-funded 
family planning services.''
    Section 8.6 states, ``Title X projects must offer women and 
minors with a diagnosis of pregnancy, counseling, which is to 
include pregnancy termination along with information on 
prenatal care delivery, infant care and foster care.''
    We found title X policies contradicted our health board's 
commitment in 2000 to under title V funding to fund a model of 
character-based abstinence education that included the 
importance of parental communication. It was apparent to most 
of us on the board that title X was problematic and would 
remain so, as it currently exists, because it erodes the 
parent's right and the parental/child relationship, and it 
blocks their right to monitor their children's health. It was 
resolved by the majority of board members that on a local level 
this may not be the place to deal with this issue of parental 
notification, but rather it should be addressed at State and at 
national legislative levels.
    Mr. Chairman, committee members, one-third of approximately 
5 million women served by the title X programs are U.S. 
teenagers. In Northern Kentucky, females under the age of 18 
represent 24 percent of those came in with parental knowledge, 
but 75 percent of the young women seen in our clinics are seen 
without parental notification. The clinics see and treat girls 
as young as 12 years old. I would like to share with you the 
day-to-day realities of title X.
    Just this year, in one of our Northern Kentucky clinics, a 
14-year-old girl came in with her boyfriend's mother. Upon the 
initial interview, she denied being sexually active, but it was 
important to her that her boyfriend and his mother like her. 
The boyfriend's mother wanted the girl to be put on the birth 
control so that she would not become pregnant when her son had 
sex with her. Please keep in mind the girl was 14 years old. 
The adult who brought her into the clinic was not her mother. 
Following title X guidelines, the 14-year-old's mother could 
not be notified.
    Or what about the 12-year-old who had sex last Thanksgiving 
holiday and stated she didn't know why she did, she wanted the 
boy to like her and not get mad. What about her parents? She is 
only 12 years old. Is putting her on the pill the Government's 
solution? Perhaps we can prevent her from becoming pregnant, 
but she will also need to use a condom, and that will only 
prevent some of the sexually transmitted diseases that she will 
be exposed to. She is 12 and routinely forgets her homework 
assignments. A 14-year-old girl, recently seen in a local 
emergency room with a sexually transmitted infection, gave a 
medical history of already having five different sexual 
partners.
    Title X specifies that a minor must be treated as an adult 
when seeking family planning services, yet these are really 
children at risk, children in engaging in adult behaviors. 
These high-risk behaviors do not need the cloak of government-
funded clinics providing a pill to replace behavioral 
interventions but rather a true model of health would provide 
interventions when necessary that assists parents in building a 
bridge rather than a wedge in the parental and child 
relationship.
    It is in the context of the parent/child relationship that 
the norms and values of the family are transmitted. A minor 
cannot legally sign a document or a contract. The school nurse 
cannot give her an aspirin. She cannot have her ears pierced at 
the mall without her parents' okay. Yet title X allows this 
minor to decide and receive family planning services and 
medications without her parents' knowledge. This means that 
your daughter, your granddaughters or any minor female can be 
put on hormonal medications or given an emergency birth control 
without notification of her parents or guardians, those most 
knowledgeable of her health and family health history.
    Mr. Bilirakis. Please summarize.
    Ms. Wuchner. It is irresponsible to move in this direction. 
Mr. Chairman and members of the committee, a common sense 
wisdom and sound medical practice would agree that parents have 
the right to monitor their child's health care and well being. 
As Government and as a Nation, we must support the first 
building blocks of our society, the family, by restoring a 
parent's right to know and monitor their child's health and 
their well being. Thank you.
    [The prepared statement of Addia Wuchner follows:]
   Prepared Statement of Addia Wuchner, Board of Directors, Northern 
                  Kentucky Independent Health District
    Mr. Chairman and Members of the Committee: I appreciate the 
opportunity to be here today to discuss the issues of a ``parent's 
right to know'', especially where it pertains to medications or medical 
treatment and care, in this case, adolescent reproductive health and 
the distribution of hormonal birth control agents and devices to minors 
without parental knowledge or notification.
    I am a registered nurse with a background in women's health. I 
currently serve on the Board of Directors of the Northern Kentucky 
Independent District Health Department and Chair the Human Sexual 
Education Committee. I was appointed to the Board and serve as the 
designee of Judge Executive Gary Moore of Boone County, Kentucky. The 
Health District provides services for a four county region.
    Most parents would be shocked to learn that their teenage daughter 
may walk into lkone of these federally funded clinics and obtain free 
contraceptives, including injectables such as Depo-Provera, and 
emergency contraceptives (the morning after pill) without their 
knowledge or notification.
    They would be shocked because, for centuries, all sorts of rights 
flowing from the parent-child relationship have been acknowledged and 
protected by law, among them decisions concerning custody, education 
and medical care. Yet today, when it comes to sex, the prevention and 
``treatment'' of pregnancy, and the prevention and treatment of 
sexually transmitted diseases, the federal government tells us that 
neither Mother nor Father knows best.
    The rights of parents to address and provide for their children's 
medical care has been undermined by controversial guidelines 
transforming parent's right to know into a privacy issue.
    Children need two decades, more or less, of love, education, 
training, discipline and experience to be able to function 
independently of parents and make sound decisions concerning their 
lives. Throughout this formative period, parents have the right and 
duty to guide their children well. This last proposition should hardly 
be controversial. Ask any mother and father who've had to provide a 
school nurse with written permission just to see that their child gets 
a midday dose of Tylenol .
Background on Recent Title X Federal Funding Issues and Northern 
        Kentucky Independent District Health Department:
    Earlier this year the Board passed a motion to gather community 
input and review the policies of Title X funded Family Planning 
Services and the medical and scientific information available on all 
FDA approved contraceptives and birth control methods currently 
provided under the Family Planning Services.
    A public caucus was held on the issues of the ``Impact of Title X'' 
on May 9, 2002, and on June 19, 2002 the Board met to vote on whether 
we would continue to accept or reject the Federal Title X funding of 
Family Planning Services.
    As the issues were manipulated under the microscope of the press, 
political, religious, ethical and moral debates, and at great length, 
they became emotionally charged with accusations that some Board 
members do not care about poor women. The actual facts of why the Board 
was taking a look at Title X funded Family Planning and the birth 
control medications and devices that are dispensed through the program 
became, at times, publicly clouded. Our responsibility to the Northern 
Kentucky community impelled us to ask several questions: What is Title 
X's impact on health of women and adolescent females? What are the 
ramifications of Title X funding? What benefits could be attained by 
discontinuing the status quo and promoting women's health, absent of 
Title X?
    While researching the medical and scientific information on birth 
control methods and devices, our Title X review also highlighted the 
many ``strings'' attached to accepting Title X funding from the federal 
government. These requirements (strings) are laid out in the Program 
Guidelines for Project Grants for Family Planning Services set forth by 
the United States Department of Health and Human Services, Office of 
Public Health and Population Control.
    The Program guide begins by defining the wording of the document 
and just what is meant when the words ``must'' and ``may'' are used. 
Section 1.1 Definitions states, ``Throughout this document the word 
``must'' indicates mandatory program policy''.
    For example:

 Title X projects may not require the written consent of 
        parents or guardians for provision of services to minors. Nor 
        can the project notify parents or guardians before or after a 
        minor has requested or received Title X funded family planning 
        services. (reference Section 8.7 Program Guidelines for Project 
        Grants for Family Planning Services)
 Title X projects must offer women and minors with a pregnancy 
        diagnosis, counseling which is to include pregnancy termination 
        along with information on prenatal care and delivery, infant 
        care, foster care . . . (Reference Section 8.6 Program 
        Guidelines for Project Grants for Family Planning Services)
                             board actions.
Title X Blocks parents' right and responsibility to monitor their 
        children's health
    In 2000, the Northern Kentucky Independent District Health Board 
took a fresh look at the efficacy and coherence of its adolescent 
sexuality programs and chose to support Character Based Abstinence 
Education. The Board was farsighted in recognizing both the power of an 
abstinence focus and that the 20th-century model of contraceptive 
education was ineffective. However, Title X remains a product of its 
times, and its requirement to provide contraceptive services to 
adolescents without parental notification contradicted our Health 
Board's year 2000 stated intention to focus on character based 
abstinence education, including parental communication.
    The fact is that Title X blocks parents' rights and 
responsibilities to monitor their children's health. When minors seek 
contraceptive information, they must be informed about all birth 
control methods, treated for medical conditions and sexually 
transmitted infections and have medication prescribed and dispensed to 
them with out their parents' knowledge or consent. This became an issue 
that greatly disturbed Board Members and the community.
    Board members researched, studied, pondered, and sought public 
input. We found ourselves constrained by the fact that you could not 
reject part of Title X and still receive funding for services. We were 
bound to the structure and guidelines set forth by the Programs 
Guidelines of the Project. On June 19, the twenty-seven members present 
at the Board meeting voted 14 to 13, with the Chair casting a tie 
breaking vote, to reject a motion that would have discontinued the 
Department's acceptance of close to $220,000 in Title X and related 
funding.
    Two issues/concerns were prevalent in discussions with Board 
members. First, there was concern that if we rejected the funding there 
would not be another service in place at this time to adequately 
provide family planning services to low income women. Second, and of 
most concern to the majority of the Board members, was the treatment of 
children and adolescents without parental knowledge.
    The Judge Executive, Steve Pendery from Campbell County, resolved 
that the local level may not be the place to deal with the issue of 
parental notification but, rather, it should be addressed at a State 
and National Legislative level. While Judge Pendery felt he needed to 
vote to retain the Title X funding for practical reasons, in the press 
the next morning Judge Pendery concluded that the Board is not as 
divided as it seems; ``We're a lot closer on this issue than the vote 
makes it sound.''
    I voted with the support of my Judge Executive, Gary Moore, to 
discontinue the Health Department's collaboration with Title X funding 
and to look for other sources of funding to support a model of Family 
Planning Services not restricted by the constraints of Title X. On June 
20, Judge Pendery's designee sent a letter to Board members requesting 
that we move forward with letters to all legislators in Kentucky asking 
for their help in changing the Title X requirements regarding girls 
under the age of 18 receiving birth control without their parents' 
knowledge.
    It was apparent to most of us on the Board working on this issue 
that Title X would remain problematic as it currently exists because it 
erodes parental rights and the parent-child relationship.
Title X and Parent's Right to Know
    Mr. Chairman and Members, I know you are well aware that Title X of 
the Public Health Service Act was established as a federal program in 
1970. For many years it has offered low-income women certain 
``reproductive health'' services, including family planning as well as 
``non-directive'' pregnancy counseling and referrals on all 
``options,'' including termination of pregnancy.
    One-third of the approximately five million women served by the 
program are teenagers. Unmarried teens may qualify for free services 
regardless of their parents' income, knowledge of or consent to care. 
Currently, a teenager may walk into any Title X clinic and receive free 
prescription contraceptives, including injectables, i.e., Depo-Provera, 
or emergency contraceptives (the morning after pill) without her 
parents' knowledge or consent. Congressmen, one of these young girls 
may easily be your daughter or granddaughter.
    To date, our Northern Kentucky clinics' statistics show that of the 
clients seen and treated this year, looking at numbers for females 
under the age of 18, only 24% came in with parental knowledge or 
consent. Approximately 75% of the young women seen in our clinics are 
seen without parental notification. The clinics have seen and treated 
girls as young as 12 years old.
Example Case:
    Just this year, in one of our Northern Kentucky clinics, a 14-year-
old girl came in with her boyfriend's mother. Upon initial interview, 
she denied being sexually active at that time, but it was important to 
her that her boyfriend and his mother like her. The boyfriend's mother 
wanted the girl put on some form of birth control so she would not 
become pregnant when her son had sex with her. Please keep in mind the 
girl was 14 years old. The adult who brought her in to the clinic was 
not her mother. The 14-year-olds' mother was not notified. This is the 
reality of the strings attached to Title X.
    Under the auspices of Title X, providers of women's and adolescent 
health services have fallen into disaster control mode, leaving 
proactive mediation and behavioral interventions on the back burner. We 
abet unhealthy practices by offering birth control to sexually active 
teens, especially young women who are the population at the greatest 
risk for Human Papillomavirus (HPV) and other STDs. These behaviors of 
young people need parental awareness, so that they may support and give 
guidance and dialog that respects the norms and values of the family. A 
true health model would then provide intervention when necessary that 
assists parents in parenting, building a bridge rather than a wedge in 
the parent-child relationship. These high risk behaviors do not need 
the cloak of government funded clinics providing a ``pill'' to replace 
behavior interventions, rather the situation calls for more support for 
parental communication.
    Title X specifies that a minor must be treated as an adult when 
seeking family planning services, yet these are really children 
engaging in adult behaviors.
    The issue remains that a minor cannot legally sign a contract; the 
school nurse cannot give her an aspirin; she cannot have her ears 
pierced in the mall without her parent's OK; yet Title X allows a minor 
to decide and receive family planning services and FDA approved methods 
of birth control without a parent's knowledge. Title X is anti-parental 
rights.
                               conclusion
    Title X means your daughter, your granddaughter, or any minor 
female, can be put on hormonal medications or be given an emergency 
contraceptive (morning after pill), without those most knowledgeable--
her parents or guardians--of her health and family health history being 
able to advise her regarding known risk factors that, in combination 
with contraindications or adverse effects, could lead to serious future 
health complications. While the clinician must ask her if she knows her 
own medical and family medical history (mandatory), it is irresponsible 
and dangerous to assume that a 13 or 15-year old would have a complete 
knowledge of such information. Most children are unaware of their 
family risk factors. It is also unethical for a medical professional to 
treat a patient and prescribe or dispense medication without a 
completed personal and family medical history.
    Overall, lack of parental notification in the Title X program are 
affronts to parents' rightful role as the primary educators of their 
children. Government agencies and counselors cannot replace and should 
not interfere with the rights and responsibilities of parents, 
particularly in sensitive matters dealing with human sexuality. 
Government should protect the role of loving and supportive parents, 
yet make it possible to terminate the rights of parents who abuse the 
trust and privilege of being a parent.
    Parents must be trusted to monitor their minor children's health 
and to protect them from the consequences of promiscuous behavior.
    Mr. Chairman and Members of the Committee, common sense, wisdom, 
and sound medical practice would agree that parents have the right to 
monitor and care for the health and welfare of their children. I 
implore you to take the necessary steps to reverse the erosion of 
parental rights and lift the blanket of confidentiality currently 
mandated under Title X. This completes my prepared statement. Thank you 
again for this opportunity to testify on the issue of a Parent's Right 
to Know. I would be happy to respond to any questions you may have at 
this time.

    Mr. Bilirakis. Thank you very much.
    Dr. Jenkins?

                  STATEMENT OF RENEE S. JENKINS

    Ms. Jenkins. Good afternoon, Mr. Chairman, members of the 
committee. I am Dr. Renee Jenkins--is this on? Okay. Start 
again. Good afternoon. Mr. Chairman, members of the committee. 
I am Dr. Renee Jenkins here in Washington who has taken care of 
adolescents for more than 20 years. I am also professor and 
Chair of the Department of Pediatrics and Child Health at 
Howard University College of Medicine. I am speaking today on 
behalf of the American Academy of Pediatrics. My statement also 
is endorsed and supported by the American College of 
Obstetricians and Gynecologists, the American Academy of Family 
Physicians and the Society for Adolescent Medicine.
    Most importantly, I too am a parent who shares the same 
worries about my daughter's health as other parents. My 
testimony today will cover three key points: One, the 
importance of parental involvement; two, the importance of 
confidentiality and access to health care; and, three, concerns 
about H.R. 4783, the States and Parental Rights Improvement Act 
of 2002.
    Under parental involvement, as clinicians we firmly believe 
that parents should be involved in and responsible for assuring 
medical care for our children. Family communication about 
health care decisions is the desired goal and the health care 
professions are able to assist in this effort. We strongly 
encourage and hope that adolescents communicate with and 
involve their parents and other trusts adults in important 
health care decisions. These health care decisions include 
issues of substance abuse, mental health and reproductive 
health.
    Providing confidential health care services does not 
preclude working toward the goal of family communication and 
involvement of parents, as is sometimes inferred. To the 
contrary, research has shown that adolescents often voluntarily 
share information with their parents. Clinical experience 
confirms that this often occurs after they consult privately 
with their health care provider. My role as a pediatrician is 
to support, encourage, strengthen and enhance parental 
communication and involvement in adolescent decisions without 
compromising the ethics and integrity of my relationship with 
adolescent patients.
    While there may be circumstances when it is necessary and 
appropriate for the health care provider to inform parents or 
guardians of certain health problems facing a minor, for 
example, when there is a risk of imminent harm, there is a 
critical need to ensure that an adolescent's health information 
is protected. Concern about confidentiality is one of the 
primary reasons that young people delay seeking health care, 
including health care for sensitive health issues. While 
parental involvement is both very desirable and should be 
encouraged, it may not be feasible.
    Legislated mandatory parental consent or notification will 
certainly reduce the likelihood that young people will seek 
timely treatment for sensitive health issues. Adolescents will 
rarely admit to the use of the alcohol and drugs in front of 
their parent. The confidential interview gives them an 
opportunity to speak to a professional that can help them early 
and detect underlying depression when it is present and avoid 
the risk of suicide, for example, and other negative outcomes. 
When young people have symptoms of sexually transmitted 
diseases, they often delay going for treatment so long that 
complications that would normally be avoided occur, sometimes 
requiring hospitalization.
    Having access to confidential care also provides an access 
point for adolescents to receive other health care services. 
These include things like cholesterol screening, immunizations, 
blood pressure monitoring or pelvic exams, services that are 
critical to the adolescent's health but could be overlooked if 
the adolescent had not visited a doctor. Ensuring the 
confidentiality in the delivery of health care services 
provides a necessary gateway that allows adolescents to simply 
get in the door so that we as health care professionals can 
help guide them in appropriate directions that includes 
parental involvement. Without confidentiality, early care and 
treatment is too often preempted.
    Concerns about H.R. 4783, for reasons outlined in greater 
detail in our testimony, we oppose this legislation. We believe 
that this legislation will undermine the Federal guarantee of 
confidentiality for health care services under the title X 
program and other child and adolescent health programs. H.R. 
4783 would create barriers to health care, especially for low-
income young people who need to obtain affordable prescription 
drugs, including prescriptive contraceptives through federally 
supported health clinics. The barrier would also impact health 
care services outside the scope of reproductive health.
    In conclusion, as a physician, a teacher and most of all as 
a parent who is concerned about the quality and safety of 
health care for my daughter as well as for the quality and 
safety of health care for all adolescents in this country, I 
urge you to reject attempts to restrict adolescents' access to 
confidential health care services, including prescription drugs 
or devices. Mr. Chairman, thank you for the opportunity to 
testify before this committee today, and I will be happy when 
the time comes to take any questions. Thank you.
    [The prepared statement of Renee S. Jenkins follows:]
Prepared Statement of Renee Jenkins, Professor and Chair, Department of 
 Pediatrics and Child Health, Howard University College of Medicine on 
              behalf of the American Academy of Pediatrics
    Good afternoon. Mr. Chairman, members of the Committee, I am Dr. 
Renee Jenkins, a practicing pediatrician who has taken care of 
adolescents for more than 20 years. I am also professor and chairman, 
Department of Pediatrics and Child Health, at Howard University College 
of Medicine. I am speaking today on behalf of the American Academy of 
Pediatrics (AAP), an organization representing 57,000 pediatricians 
throughout the nation. In addition, my comments are endorsed and 
supported by the American College of Obstetricians and Gynecologists, 
the American Academy of Family Physicians and the Society for 
Adolescent Medicine.
    Each of the organizations supportive of this testimony is fully 
committed to the health and well-being of adolescents. Specifically, 
the American College of Obstetricians and Gynecologists is an 
organization representing 44,000 obstetricians-gynecologists dedicated 
to health for women of all ages; the American Academy of Family 
Physicians is one of the largest national medical organizations, 
representing more than 93,500 family physicians, family practice 
residents and medical students; and the Society for Adolescent Medicine 
includes more than 1,400 physicians, nurses, psychologists, social 
workers, nutritionists and others involved in service delivery, 
teaching or research on the health and welfare of adolescents. In 
total, we represent more than 196,000 medical professionals.
    It is from these perspectives, and perhaps most importantly as a 
parent, that I am here today to express our views concerning the issue 
of parental consent or notification for minors seeking health care 
services, including prescription drugs or devices. My comments today 
will also address H.R. 4783, the ``State's and Parental Rights 
Improvement Act of 2002,'' which we believe would undermine 
confidential health care services for adolescents. I would like to 
thank the Committee for this opportunity to present this statement as 
Congress continues to debate this issue of significance to adolescent 
health care.
                                overview
    The American Academy of Pediatrics and the endorsing organizations 
firmly believe that parents should be involved in and responsible for 
assuring medical care for our children. Moreover, we would agree that 
as parents we ordinarily act in the best interests of our children and 
that minors benefit from our advice and the emotional support we 
provide as parents. We strongly encourage and hope that adolescents 
communicate with and involve their parents and/or other trusted adults 
in important health care decisions affecting their lives. These 
discussions include such issues as substance abuse, mental health and 
pregnancy and pregnancy termination. We know and research confirms that 
most adolescents do so voluntarily. This is predicated not by laws but 
on the quality of their relationships. By its very nature family 
communication is a family responsibility. Adolescents who live in warm, 
loving, caring environments, who feel supported by their parents, will 
in most instances communicate with their parents in a crisis including 
the disclosure of a pregnancy or other urgent health concerns. However, 
even adolescents reared in the best of household environments will at 
times be unwilling to make full disclosure of their behaviors because 
they do not wish to disappoint and hurt loving and caring parents.
    Family communication about health care decisions is the desired 
goal, and health care professionals are able to assist in this effort. 
Allowing confidentiality of care for adolescents does not preclude the 
involvement of parents, as it is sometimes presumed. To the contrary, 
research has shown that adolescents often voluntarily share information 
with their parents and clinical experience confirms that this often 
occurs after they consult privately with their health care provider.
    Ensuring confidential care is about striking an important balance 
among parents, providers and the adolescent patient. While there may be 
circumstances when it is necessary and appropriate for the health care 
provider to inform parents or guardians of certain health problems 
facing a minor (e.g., life-threatening emergency) there is a critical 
need to ensure that an adolescent's health information is protected. 
Providing confidential care does not preclude working toward the goal 
of family communication.
    Pediatricians, parents and policy makers know well the number of 
adolescents that are beginning to use illicit drugs, alcohol and become 
sexually active. What may start as experimentation with friends often 
leads to long term dependencies, accidents, injuries, sexually 
transmitted disease and a myriad of other physical and behavioral 
issues. In the infrequent cases where communication between adolescents 
and their parents can not be facilitated, many of these negative 
outcomes can be avoided if the adolescent has access to confidential 
health care.
    My role as a pediatrician is to support, encourage, strengthen and 
enhance parental communication and involvement in adolescent decisions 
without compromising the ethics and integrity of my relationship with 
adolescent patients. Health professionals have an obligation to provide 
the best possible care to respond to the needs of their adolescent 
patients. This care should, at a minimum, include mental health, 
substance abuse, and services for other psychosocial problems including 
therapy, crisis management, day treatment, and residential care; 
comprehensive reproductive health services, such as sexuality 
education, counseling, mental health assessment; diagnosis and 
treatment regarding pubertal development; access to the full range of 
family planning services; pregnancy-related care; prenatal and delivery 
care; diagnosis and treatment of sexually transmitted diseases and 
referrals for other health and social services.
    We understand that pending legislation, the ``State's and Parental 
Rights Improvement Act of 2002'' (H.R. 4783), is, in part, the basis 
for this discussion today. This legislation would allow states to 
require parental consent or notification for the purpose of dispensing 
prescription drugs or devices to minors under federal health care 
programs, such as the Title X Family Planning program and the Title V 
Maternal and Child Health Block Grant.
    For reasons outlined below, we believe that this legislation would 
undermine the federal guarantee of confidentiality for health care 
services under the Title X program and other child and adolescent 
health programs, and is inconsistent with the policies of the endorsing 
organizations. In addition, this legislation could have a chilling 
effect on state programs that may opt to follow the federal 
recommendation.
    The stated intent of those who support mandatory parental consent 
or notification legislation, of the type that H.R. 4783 would allow 
states to adopt, is that it enhances family communication as well as 
parental involvement and responsibility. However, the evidence does not 
support that these laws have that desired effect. To the contrary, 
there is evidence that these laws may have an adverse impact on some 
families and that it increases the risk of medical and psychological 
harm to adolescents. According to the AAP, ``[i]nvoluntary parental 
notification can precipitate a family crisis characterized by severe 
parental anger and rejection of the minor and her partner. One third of 
minors who do not inform parents already have experienced family 
violence and fear it will recur. Research on abusive and dysfunctional 
families shows that violence is at its worse during a family member's 
pregnancy and during the adolescence of the family's children.'' It is 
for these and other reasons that the American Academy of Pediatrics and 
other organizations represented today oppose H.R. 4783 and any other 
legislation that will undermine federal guarantees of confidentiality 
for adolescents receiving health care services.
    Since the involvement of a concerned adult can contribute to the 
health and success of an adolescent, policies in health care settings 
should encourage and facilitate communication between a minor and her 
parent(s), when appropriate. However, concerns about confidentiality, 
as well as economic considerations, can be significant barriers to 
healthcare for some adolescents. For example, the potential health 
risks to adolescents if they are unable to obtain reproductive health 
services are so compelling that legal barriers and deference to 
parental involvement should not stand in the way of needed health care 
for patients who request confidentiality.
                        confidentiality of care
    I would like to turn my attention to the issue of confidentiality--
whether adolescents can access health care services, including 
prescription drugs and devices, without parental consent. The American 
Academy of Pediatrics and other medical organizations that I am 
representing today firmly believe that young people must have access to 
confidential health care services. Every one of our states' laws also 
provides confidential access to some services for young people, whether 
for sexually transmitted diseases (STDs), drug addiction or 
reproductive health care. Concern about confidentiality is one of the 
primary reasons young people delay seeking health services for 
sensitive issues, whether for substance use, an unintended pregnancy or 
for other reasons. While parental involvement is very desirable, and 
should be encouraged, it may not always be feasible and it should not 
be legislated. Young people must be able to receive accurate diagnosis 
and appropriate treatment expeditiously and confidentially.
    Let me share a few general examples that underscore the importance 
of confidentiality of care:

 Reproductive health: Chlamydia is the number one bacterial 
        sexually transmitted disease (STD) in the United States today. 
        Every state allows a minor to give his or her consent for STD 
        services. However, if a young woman comes into the clinic to 
        receive a confidential consultation because she suspects she 
        has chlamydia, or some other STD, it is critical that she not 
        only receive the diagnosis in confidence but also the treatment 
        to address the medical issue. Untreated, this type of problem 
        can lead to serious consequences, including pelvic inflammatory 
        disease or hospitalization.
 Eating disorder: Given the societal pressures and images 
        portraying the glamour of being thin, young adolescent women 
        face a range of eating disorders, including bulimia and 
        anorexia nervosa. In the case of bulimia, it may be difficult 
        for a parent to detect this illness and a child may not be 
        forthcoming with a parent for fear of disappointing them. 
        Having access to confidential health care services may be one 
        of the few avenues that an adolescent is able to pursue to 
        address his/her needs.
 Mental Health: Unfortunately, as we all know, mental health 
        issues continue to be associated with a stigma, as well as 
        often linked with substance abuse. For adolescents this stigma 
        can be even more amplified for many reasons. However, we find 
        that a teen may see a physician in confidence for a short 
        period of time to address the feelings of fear or depression or 
        drug use and then, through these consultations, build 
        confidence in being able to talk a parent. Some teens are 
        surprised to learn that their parents are very supportive and 
        will not punish them for their behaviors or illness. Having a 
        buffer of confidentiality is critical to facilitating a 
        positive outcome.
    Most adolescents will seek medical care with their parent or 
parents' knowledge. Making services contingent on mandatory parental 
involvement (either parental consent or notification) however, may 
drastically affect adolescent decision-making. Mandatory parental 
consent or notification reduces the likelihood that young people will 
seek timely treatment for sensitive health issues. In a regional survey 
of suburban adolescents, only 45 percent said they would seek medical 
care for sexually transmitted diseases, drug abuse or birth control if 
they were forced to notify their parents.
    A teen struggling with concerns over his or her substance use, 
emotional well-being or sexual health may be reluctant to share these 
concerns with a parent for fear of embarrassment, disapproval, or 
possible violence. A parent or relative may even be the cause or focus 
of the teen's emotional or physical problems. The guarantee of 
confidentiality and the adolescent' s awareness of this guarantee are 
both essential in helping adolescents to seek health care.
    For these reasons, physicians strongly support adolescents' ability 
to access confidential health care. A national survey conducted by the 
American Medical Association (AMA) found that physicians favor 
confidentiality for adolescents. A regional survey of pediatricians 
showed strong backing of confidential health services for adolescents. 
Of the physicians surveyed, 75 percent favored confidential treatment 
for adolescents. Pediatricians describe confidentiality as 
``essential'' in ensuring that patients share necessary and factual 
information with their health care provider. This is especially 
important if we are to reduce the incidence of adolescent suicide and 
other mental health concerns, substance abuse, sexually transmitted 
diseases, unintended pregnancies and other preventable risky behaviors.
    Many influential health care organizations support the provision of 
confidential health services for adolescents; here is what they say:
    The American Academy of Pediatrics. ``A general policy guaranteeing 
confidentiality for the teenager, except in life-threatening 
situations, should be clearly stated to the parent and the adolescent 
at the initiation of the professional relationship, either verbally or 
in writing.''
    American College of Obstetricians and Gynecologists. ``Parents and 
adolescents should be informed, both separately and together, that they 
each have a private and privileged relationship with the provider. 
Additionally, they should be informed of any restrictions on the 
confidential nature of that relationship.''
    The American Academy of Family Physicians. ``The American Academy 
of Family Physicians supports the appropriateness of parental 
involvement in medical decision-making for adolescents, especially when 
they are engaging in precarious or adult behaviors. Whenever possible, 
family physicians make an effort to facilitate parental contact to help 
bridge any communication challenges that may arise between parent and 
child.''
    The Society for Adolescent Medicine. ``The most practical reason 
for clinicians to grant confidentiality to adolescent patients is to 
facilitate accurate diagnosis and appropriate treatment . . . If an 
assurance of confidentiality is not extended, this may create an 
obstacle to care since that adolescent may withhold information, delay 
entry into care, or refuse care.''
    The American Medical Association. ``The AMA reaffirms that 
confidential care for adolescents is critical to improving their 
health. The AMA encourages physicians to involve parents in the medical 
care of the adolescent patient, when it would be in the best interest 
of the adolescent. When in the opinion of the physician parental 
involvement would not be beneficial, parental consent or notification 
should not be a barrier to care.''
    American College of Physicians-American Society of Internal 
Medicine. ``Physicians should be knowledgeable about state laws 
governing the rights of adolescent patients to confidentiality and the 
adolescent's legal right to consent to treatment. The physician must 
not release information without the patient's consent unless required 
by the law or if there is a duty to warn another.''
    The American Public Health Association. APHA ``urges that . . . 
confidential health services (be) tailored to the needs of adolescents, 
including sexually active adolescents, adolescents considering sexual 
intercourse, and those seeking information, counseling, or services 
related to preventing, continuing or terminating a pregnancy.''
                               conclusion
    In conclusion, as a physician, a teacher, and most of all, as a 
parent, who is concerned about the quality and safety of health care 
for my daughter as well as for the quality and safety of health care 
for all adolescents in this country, I urge you to reject attempts to 
restrict adolescents' access to confidential health care services, 
including prescription drugs or devices.
    Thank-you. I would be happy to answer any questions you may have.

    Mr. Bilirakis. Thank you very much, Dr. Jenkins.
    Mr. Heisler.

                  STATEMENT OF JOHN A. HEISLER

    Mr. Heisler. Mr. Chairman and members of the committee, I 
want to thank you for the opportunity to come before you and 
explain why McHenry County, Illinois refuses to take Federal 
funding that requires us to provide contraceptive services to 
minor without parental notification.
    Our county was forced to deal with an issue of parental 
notification when we found out that a 12-year-old junior high 
student was getting chemical contraceptive shots because her 
37-year-old teacher was raping her. The McHenry County Board of 
Health administers a $4 million budget and generally--should I 
continue?
    Mr. Bilirakis. Yes, please continue. That is a message to 
us regarding what is happening on the floor.
    Mr. Heisler. The Department of Health has three divisions: 
Animal Control, Environmental and Nursing. About 75 percent of 
the revenues of the health department are derived from grants. 
In the past, grants were sought out and applied for by senior 
staff within the department. Grant applications are formally 
submitted to State and Federal Government over the signature of 
the health department administrator. Since my county's 
rejection of the title X grant, all new grant applications and 
all grant renewals in excess of $50,000 are submitted to the 
county board for approval prior to being submitted to the 
grantor.
    The McHenry County Board of Health was created by 
resolution of the county board, not by referendum. While State 
statute in Illinois does extend a great deal of authority to 
the board of health, the ultimate authority comes from the 
county board who approves its budget and appoints its members.
    The title X debate in McHenry County began in January 1997 
when it was learned that a 12- or 13-year-old school girl had 
been driven to the county health department clinic on several 
occasions by her 37-year-old Crystal Lake Middle School teacher 
who had been having sexual relations with her for some 18 
months to receive injections of the contraceptive drug, Depo-
Provera. Unfortunately, Federal title X regulations prevented 
her parents from being informed.
    Her teacher, William Saturday, pleaded guilty to criminal 
sexual assault charges in September 1997 and was sentenced to 
10 years in prison. According to public record, Mr. Saturday 
was released in February of this year after serving less than 
half of his sentence. He is currently on parole and living in 
McHenry County as a registered sex offender.
    This teacher could not take or send a 12-year-old girl to 
his school nurse. He could not take her to a private doctor or 
physician. He could only take her to a title X program facility 
where no parental consent was allowed. The title X grant aided 
him in his crime. In Illinois we protect our children under 
various State statutes. A minor cannot buy a pack of 
cigarettes, a drink or even get a tattoo in Illinois because of 
the potential danger. Furthermore, the school code of the State 
of Illinois prohibits the administration of any drug or medical 
attention without parental consent. It is shocking to think 
that a Federal grant program can circumvent our State code.
    As a member of the board of health, the Health Department 
Oversight Committee and the county board, I began to inquire 
about the no-parental notification clause of title X. I was not 
made apparent of the executive review and the executive review 
of the grant. Hearing no acceptable answers, I asked the health 
department administrator to check with the Federal Government, 
and he was told that there would be no exceptions and further 
that we had to accept the title X grant with the no-parental 
notification provision or reject it in its entirety. I would 
like to repeat that. The Federal agency that administers title 
X essentially gave the parents in McHenry County two options: 
Take the title X money and be kept in the dark about your kids 
or reject the money. Ultimately McHenry County did, in fact, 
reject title X funding.
    At the regular county board meeting of October 1997, I made 
the motion to remove the approximately $47,800 in title X funds 
from the county budget. In addition, as finance chairman, I 
restored the gynecological services to poor adult women to the 
budget from local tax dollars. The message was sent back to 
Washington, ``We cannot be bought. We will not accept your 
money if it affects our children. We feel it is the parents' 
right to determine if any child needs medical services. A child 
in McHenry County cannot be given even an aspirin from the 
school nurse without parental consent. The board of health in 
McHenry County will not circumvent the basic rights of parents 
by accepting Federal title X funds.''
    McHenry County has not applied for title X funds since this 
time. We do not provide contraceptive services to minors 
without parental consent. We have allocated tax dollars for 
pre-natal care and all other related gynecological services to 
that segment of our population that cannot afford medical 
services or insurance. As with all of our nursing services, we 
target recipients who do not qualify for Medicaid or have 
sufficient income to afford medical insurance.
    The debate over the title X grant in McHenry County was 
stifled by a gag order due to the lawsuits brought against the 
county by the girl's parents. Elected officials, board members 
and employees were asked not to discuss the issue as it might 
have had a detrimental effect on the defense of the county's 
position.
    Mr. Bilirakis. Please summarize, Mr. Heisler.
    Mr. Heisler. I have lived in Crystal Lake all my life. My 
entire family still lives in Crystal Lake, and I think I 
represent the values of the majority in McHenry County. Unlike 
other political issues, there was no room for compromise with 
the Federal title X funds. I believe, at least in this 
instance, the moral majority did prevail. If the Federal 
Government continues to mandate that we keep parents in the 
dark, we will be happy to provide for our own without help from 
title X funding. Thank you.
    [The prepared statement of John A. Heisler follows:]
                 Prepared Statement of John A. Heisler
    Mr. Chairman and Members of the Committee, I want to thank you for 
the opportunity to come before you and explain why McHenry County, 
Illinois refuses to take federal funding that requires us to provide 
contraceptive services to minors without parental notification. Our 
County was forced to deal with the issue of parental notification when 
we found out that a 12-year-old junior high school student was getting 
chemical contraceptive shots because her 37-year-old teacher was raping 
her.
Background:
    McHenry County is about 50 miles northwest of Chicago, Illinois. 
Population is approximately 280,000. McHenry County is the fastest 
growing county in the State of Illinois.
    The County Board is a 24-member board, made up of four elected 
representatives from each of the six districts within the County.
    I have been a member of the County Board since August 1994. I am a 
member of the Public Health Committee, the Valley Hi Nursing Home 
Committee and Chairman of the County's Finance Committee. McHenry 
County has an annual budget of about $130 million and has approximately 
1,200 employees including a sheriff's department of 300 officers.
    Throughout the County, we have several organizations that are 
supported by the County budget. These organizations have their own 
Boards whose members are appointed by the County Board, and each has a 
``Liaison'' member from the County Board with voting privileges. These 
``Liaison'' members are on these Boards to give some fiscal guidance 
and to promote the general philosophy of the full County Board.
    In the fall of 1994, I was appointed Liaison Member of the McHenry 
County's Board of Health. The McHenry County Board of Health had eight 
members (now nine) consisting of two physicians, a dentist, a civil 
engineer, a nurse, two citizens from the County and the County Board 
Liaison.
    The McHenry County Board of Health administers a $4 million budget 
and generally sets the policies and standards of conduct for a staff of 
100. The Department of Health has three divisions: animal control, 
environmental, and nursing. About 75% of the revenues of the Health 
Department are derived from grants. In the past, grants were sought out 
and applied for by senior staff within the Department. Grant 
applications are formally submitted to the State or Federal Government 
over the signature of the Health Department Administrator. Since the 
County's rejection of the Title X grant, all new grant applications, 
and all grant renewals in excess of $50,000 are submitted to the County 
Board for approval prior to being submitted to the grantor.
    The McHenry County Board of Health was created by Resolution of the 
County Board, not by referendum. While State Statute does extend a 
great deal of authority to the Board of Health, the ultimate authority 
comes from the County Board who approves its budget and appoints its 
members.
Title X:
    The Title X debate in McHenry County began in January 1997, when it 
was learned that a 12-year-old grade school girl had been driven to the 
County Health Department Clinic on several occasions by a 37-year-old 
Crystal Lake Middle School teacher who had been having sexual relations 
with her for 18 months, to receive injections of the contraceptive drug 
Depo-Provera. Unfortunately, federal Title X 
regulations prevented her parents from being informed.
    Her teacher, William Saturday, pleaded guilty to criminal sexual 
assault charges in September 1997, and was sentenced to 10 years in 
prison. According to public records, William Saturday was released in 
February of this year--after serving less than half of his sentence--
and he is currently on parole and living in McHenry County as a 
registered sex offender.
    This teacher could not take or send the 12-year-old girl to the 
school nurse. He could not take her to a private doctor or physician. 
He could only take her to a Title X program facility where no parental 
consent was allowed. The Title X grant aided him in his crime.
    In Illinois we protect our children under various state statutes. A 
minor cannot by law buy a cigarette, a drink, or even get a tattoo in 
Illinois because of the potential danger.
    Furthermore, the school code of the state of Illinois prohibits the 
administration of any drug or medical attention without parental 
consent. It is shocking to think that a federal grant program can 
circumvent our state code.
    As a member of the Board of Health, the Health Department Oversight 
Committee (Public Health Committee) and the County Board, I began to 
inquire as to why the ``no-parental notification clause'' of Title X 
was not made apparent in the executive review of the grant. Hearing no 
acceptable answer, I asked the County Health Department Administrator 
to check with the Federal Government, and he was told that there would 
be no exceptions and further that we had to accept the Title X grant 
with the ``no-parental notification'' provision, or reject it in its 
entirety.
    I'd like to repeat that: The federal agency that administers Title 
X essentially gave the parents in McHenry County two options: 1) take 
Title X money and be kept in the dark about your kids or 2) reject the 
money.
    Ultimately, McHenry County did, in fact, reject Title X funding. At 
the regular County Board meeting of October 1997, I made the motion to 
remove the approximately $47,800 in Title X funds from the County's 
Budget. In addition, as Finance Chairman, I restored all gynecological 
services to poor adult women to the budget from local tax dollars. The 
message sent back to Washington was: We can't be bought. We will not 
accept your money if it affects our children. We feel it is the 
parents' right to determine if any child needs medical services. A 
child in McHenry County cannot be given even an aspirin from the school 
nurse without parental consent. The Board of Health in McHenry County 
will not circumvent the basic rights of parents by accepting federal 
Title X funds.
    McHenry County has not applied for Title X funds since this time. 
We do not provide contraceptive services to minors without parental 
consent. We have allocated tax dollars for pre-natal care and all other 
related gynecological services to that segment of our population that 
cannot afford medical services or insurance. As with all of our nursing 
services, we target recipients who do not qualify for Medicaid or have 
sufficient income to afford medical insurance.
The Debate:
    The debate over the Title X grant in McHenry County was stifled by 
a gag order due to the lawsuits brought against the County by the 
girl's parents. Elected officials, Board Members, and employees were 
asked not to discuss the issue as it might have had a detrimental 
effect on the defense of the County's position. The vocal minority in 
the community was not under any such restriction. As a result, the 
public debate was very one sided. Proponents of Title X organized into 
a group called ``Friends of Public Health'' and attacked me at home, at 
work, at church and at Board meetings. Under the gag order, I was not 
permitted to reply or respond.
    I have lived in Crystal Lake all my life. My entire family still 
lives in Crystal Lake, and I think I represent the values of the 
majority in McHenry County. Unlike other political issues, there was no 
room for compromise with the federal Title X funds. I believe, at least 
in this instance, the moral majority did prevail.
    If the federal government continues to mandate that we keep parents 
in the dark, we will be happy to provide for our own without help from 
Title X funding.
    Thank you.

    Mr. Bilirakis. Thank you, Mr. Heisler. Ms. Wuchner, last 
April, this subcommittee had a hearing on abstinence education. 
I was pleased to read in your testimony that Northern Kentucky 
Independent District Health Board stated an intention to focus 
on what we call character-based abstinence education, including 
parental communication. So I wonder if you can take maybe a 
couple minutes, give us an update on the status of such 
education in Northern Kentucky and what do you think of it? In 
other words, your opinion, how would you grade it?
    Ms. Wuchner. That change came about last year because of 
research into title V funding, just like we were doing this 
year in title X. And it revealed that some of the programs that 
we were currently providing for the schools did not meet the 
wise guidelines that Congress set forth in title V funding. And 
so we had a set up a screening tool to screen programs that 
would meet the guidelines and be appropriate for the values and 
the conditions of our community. One of the things I want to 
add is that when a public opinion poll was taken in Northern 
Kentucky by the press, it was three to one in favor of 
abstinence education. This is the voice of parents in our 
community. That led to then a lot of hard work to discover 
programs that would meet the factors in the screening tool, 
meet the guidelines, and we began doing that and chose a 
particular program that would now be available for this coming 
school year.
    I would like to say that for quite some time the health 
department was not the most popular place to come for your ex 
education for your schools. There were public schools that used 
the programs but many that didn't. We just had a meeting and 
the report was that we need to add some staff. We may have more 
people than we ever anticipated, more schools signing up for 
programs this fall that support character-based abstinence 
education and a continuum and also the parents' communication 
and parents have been put into the program. So thank you.
    Mr. Bilirakis. Thank you. Thank you very much. And the 
Chair now yields the balance of his time to Mr. Pitts.
    Mr. Pitts. Thank you, Mr. Chairman. Mr. Chairman, I would 
like to submit for the record a letter to you from the 
Honorable Steven Ogden, a State Representative from Texas who 
wrote a parental consent law that was invalidated by the title 
X regulations.
    Mr. Bilirakis. Without objection, that will be the case.
    [The letter referred to follows:]

                                                      July 11, 2002
The Honorable Michael Bilirakis
Chair, Subcommittee on Health
Committee on Energy and Commerce
U.S. House of Representatives
2125 Rayburn House Office Building
Washington, DC 20515
    Dear Chairman Bilirakis: Over the past several sessions of the 
Texas Legislature, I have attempted to strengthen state law and 
practice to ensure parents and guardians are involved in their 
children's health care decisions.
    Currently, Title X of the Public Health Services Act and Title XIX 
of the Social Security Act hamper my state's desire to preserve the 
traditional role of parents in raising their children.
    In the state's appropriations bill for FY 2000-2001, I included a 
rider directing the Texas Department of Health (TDH) to distribute 
funds for medical, dental, psychological or surgical treatment provided 
to a minor only if consent to treatment were obtained according to 
Texas law (Chapter 32 of the Family Code). The rider was permitted to 
be waived if federal funds would be lost.
    In an exchange of letters between TDH and the regional office of 
the U.S. Department of Health and Human Services in 1999, it was 
determined that Texas would lose federal funds if the rider were 
implemented. Nevertheless, I included a similar rider in the FY 2002-
2003 appropriations bill.
    I seek your assistance in amending current federal law and 
regulations to permit Texas to accept federal funds under Title X and 
Title XIX without having to ignore its sovereign laws.
            Sincerely,
                                                   Stephen E. Ogden
Attachments
cc: The Honorable Joe Barton
   Mr. Ed Perez, Texas Office of State and Federal Relations

    Mr. Pitts. Thank you. Ms. Wuchner, if a doctor in your 
State's title X program decided that it was in the best of a 
girl, both physically and emotionally, to notify her parents 
that their daughter was receiving chemical contraception shots, 
was depressed, was sick with a venereal disease, what penalty 
would be levied against the title X clinic? Would your program 
lose Federal funding?
    Ms. Wuchner. I think it is the perception of the clinicians 
that they would lose the funding. Now, there has always been 
discussion to this point, but at this point no one ever 
exercises that right if there is a right to do that because of 
the fear of losing the funding of the program. When the board 
grappled with this decision on title X funding this year, it 
was the consensus that it was problematic, that clinicians 
could not make that decision, that they were bound by the 
structure of title X funding to provide services to minors 
without parent notification.
    Mr. Pitts. Thank you. Dr. Jenkins, does the American 
Academy of Pediatrics support any laws requiring parental 
notification or parental consent before prescribing medications 
or performing surgeries?
    Ms. Jenkins. Let me say that the American Academy of 
Pediatrics recognizes the right for adolescents to receive 
confidential care and the acknowledgment that under State 
statutes are what governs most of us in terms of what we can do 
in a practice situation. Again, the concept here seems to be 
prohibiting physicians from notifying parents, and I don't 
think that is the stand that most of us are engaged in at all. 
I think most of us in fact involve parents when we can with 
adolescents once they come and present issues of a sensitive 
nature, including issues related to reproductive health. And so 
this particular stand that we would support laws that prohibit 
physicians I don't think our interpretation of the laws are 
that physicians are prohibited from giving parents--engaging 
parents in the health care with their adolescents. I think the 
picture is that it is not in the adolescent's best interest to 
think that they will come in the office, they will see you, 
they will present an issue to you and then you will call their 
out of the context of their engagement in that visit. And I 
think those are the kinds of situations that in many of the 
bills about this communication is what people are trying to 
protect against. And that is the fear that you, out of the 
context of the relationship within the care, that you would 
then pick up the phone or do something else to notify a parent 
and not really work with the young person to help them share 
this information.
    Mr. Pitts. Well, Dr. Jenkins, if I may interrupt, and my 
time has expired, does the academy support any laws requiring 
parental notification or parental consent? I mean you have 
indicated----
    Ms. Jenkins. You mean any laws related to what? To----
    Mr. Pitts. Before prescribing medications or performing 
surgeries?
    Ms. Jenkins. I don't performing surgeries is part of that. 
I think the academy does not support laws that require parental 
consent for contraceptive care, for example, that require 
parental consent. But I think part of what your question was 
expands pretty far beyond that limitation.
    Mr. Pitts. Well, I am not sure----
    Mr. Bilirakis. The title X regs say that they must not be 
disclosed, that receiving services must be held confidential 
and must not be disclosed. That is what it says.
    Ms. Jenkins. But when they are saying, ``must not,'' are 
they saying under what kind of provision that that occurs? It 
seems to me that if in some of the pictures that have been--
kind of cases that have been discussed here, that it does not 
preclude the physician from counseling the adolescent about 
involving their parents, okay?
    Mr. Bilirakis. That is correct.
    Ms. Jenkins. What it does is it says don't pick up the 
phone and call somebody. It seems to me that would be my 
interpretation under that situation. It does not say that you 
cannot work with the adolescent and engage them in a situation 
in which they would involve their parents.
    Mr. Bilirakis. My time has long expired. Mrs. Capps.
    Ms. Capps. Thank you. I will allow you, Dr. Jenkins, in a 
moment to return to this. But, first, Mr. Heisler, you gave an 
eloquent testimony to the case study, if you will, of your 
country and your involvement in it. And your reason for being 
here is because you say that you did not want to accept, as a 
county, Federal money when it had all the strings attached to 
it that it did. And you have refused title X funding which 
implements mandatory parental notification laws for your health 
care facilities within your jurisdiction there. But I wonder if 
you have noticed that two statistics have changed in that time. 
Apparently 25 percent more teenage births have occurred in your 
county and that the rate of chlamydia for people 20 years and 
younger has doubled whereas the surrounding counties these 
numbers have continued to go down.
    Dr. Jenkins, I want to thank you for being here on behalf 
of the academy. The American Academy of Pediatrics has been 
really on the forefront of engaging, I believe, our families to 
become stronger, because it is through this kind of 
communication skill that you help to instill in adolescents 
that gives them the confidence to talk with their parents in 
sensitive areas that sometimes teenagers are shy or hesitant to 
do. I am thinking of my own experience as a mother and also 
working with teen parents to watch and bring my own kids into 
their pediatrician as kids and sat in the office with them, and 
then at a certain point to have the child be able to walk into 
the doctor's office alone and the kind of increased confidence 
that gave my own children to begin to formulate the questions 
that they could deal with directly with you and that I had the 
confidence of trusting you and your profession.
    You are kind of here today representing all of these people 
within clinics and settings around the country who work with 
teenagers, not the easiest group necessarily to work with, 
particularly in the area of sexuality and especially perhaps in 
this country where we have many conflicting standards that 
impede upon a young person's mind and also recognizing, as the 
academy does, the variety of family, that there is not a word 
``family'' that is uniform in this country today that you 
presume upon that as you see a patient come into see you within 
the context of their home life, which can be very, very varied. 
And so I want--I would like you to use this time to further get 
at for us what this confidential relationship is, why is it so 
scary to some of us, and how can we come to see it as something 
that can be positive and assist our young as they make very 
important and life-changing decisions?
    Ms. Jenkins. Right. First of all, let me say it sounds like 
you had a wonderful pediatrician.
    Ms. Capps. Yes, I did.
    Ms. Jenkins. Okay.
    Ms. Capps. I felt very fortunate to--more than one, 
actually, over the life long.
    Ms. Jenkins. Is that right? Okay. Well, I think what you 
have painted as a parent is that developmental context, and 
that is just so important. I think very often when people deal 
with their teenagers evolving through adolescence and into 
adulthood, they don't understand that it is a process and that 
in that process there has to be a bit of letting go, a pulling 
back over time. And so what helps the adolescent really manage 
themselves more effectively as older adolescents and young 
adults is having the opportunity to work with their primary 
care giver around these issues or to go to other health 
professions and express these issues. So I think our role is to 
really work with them to do that. And I think many of us also 
do this outside of even our own practices. I work with a 
project in the District now that works with fifth graders and 
their parents around some of these issues, trying to improve 
parental communication but also help the young people be 
supported by their families and work with families about how to 
support young people through their adolescence. So, certainly, 
pediatricians are in their training programs taught these types 
of skills and practice them and believe in them very firmly.
    Ms. Capps. Could we focus again for the remaining time on 
title X and the rare, I would hope rare, times when teenagers 
present themselves to you, to our clinics in the various 
communities without, with an absence, with a dysfunctional 
family, if you will, or a non-existent family, an incestuous 
family, whatever the--and it is not that rare. How then does 
the pediatrician respond?
    Ms. Jenkins. I think the pediatrician very often will look 
for other adult support individuals. I think sometimes there is 
not support within the family, and we have talked about 
situations in which external people are engaged in some sexual 
abuse with adolescents, but the incest is not uncommon and 
situations in which someone in the household is having an 
inappropriate relationship with the child is not uncommon. And 
so many agencies also have a relationship in which they are 
able to get help for these young people in addition to just 
providing family planning services. I think sort of the sense 
that we have this isolated sort of take this pill, take this 
shot is really not the way people operate, and I think that we 
understand the context in which some of this occurs, and we do 
seek intervention for these young people, and we certainly 
report incidents according to State and local statutes.
    Ms. Capps. Thank you very much.
    Mr. Bilirakis. Thank you. Mr. Pitts for his own time.
    Mr. Pitts. Thank you, Mr. Chairman. Mr. Heisler, your 
testimony was quite compelling. You said that the parents of 
the young girl who was raped sued the county. What happened in 
that lawsuit? Do you know if anyone besides the perpetrator was 
held liable for keeping the parents in the dark after this 
awful victimization had gone on for 18 months? And also you 
said the Title X Office said essentially, ``Keep the parents in 
the dark or don't take the title X money?'' Did you ever hear 
from the office again when you made national news for rejecting 
title X money? Did anyone from the Title X Office call and say, 
``Hey, let us work something out''?
    Mr. Heisler. Thank you, Congressman. Frankly, with regard 
to the suit that the parents brought against the county, I do 
know that the county was dismissed out of the suit. I believe 
the principal at the grade school where this teacher taught was 
dismissed out of the suit. Beyond that I don't know what 
happened with it. Now, with respect to any further contact from 
the Title X people, we have had none.
    Mr. Pitts. Do you think that other concerned citizens 
should ask their counties to follow your lead in breaking away 
or do you think the Federal agency that runs title X should 
reexamine the regulations that they have?
    Mr. Heisler. Oh, absolutely. I mean I might respond to that 
by saying I don't know the reason why Congresswoman Capps made 
that comment to me regarding the increase in teen pregnancy in 
McHenry County, but I can tell her that we have had a 100 
percent decrease in teachers raping kids in McHenry County. It 
doesn't happen anymore. Parents know about it.
    Mr. Pitts. Thank you. Dr. Jenkins, studies have reported 
that children are reaching puberty at very early ages, even as 
early as 9 years old. In your professional opinion, should a 
title X clinic be handing our or injecting a 9-year-old girl 
with prescription contraceptive drugs? Do you think a 9-year-
old should be making medical decisions without her parents' 
input?
    Ms. Jenkins. I know you don't think I am going to say yes. 
First of all, I think when people talk about the studies you 
are talking about with puberty, they mean appearance of breast 
buds, which is the onset of puberty. They do not mean, for 
example, full reproductive maturity. So I think we should be 
clear about we are talking about when we read those studies 
about early puberal maturation.
    It is my opinion that most responsible health professionals 
recognize that adolescents of a certain chronologic age who 
have behaviors that perhaps are in the adult range do not 
necessarily have decisionmaking skills that are in that range, 
and take the appropriate stances in terms of intervention of 
some sort, either to try to understand what is the context of 
that relationship and to seek intervention for a young person.
    For example, I work in the inner city here in the District, 
and the anecdotal evidence is that approximately mid-teens is a 
time when you get adolescents who are reporting sometimes 
certain sexual behaviors. But when you have young people who 
are below those ages who come to you with any evidence and very 
often they are not reporting it, it is what you find on 
examination that suggests, for example, that something is 
occurring, that you take the appropriate intervention. And most 
often that is to engage a social service individual into 
investigating what the situation is for that young person. But 
I don't think----
    Mr. Pitts. But you are aware that the title X regs say that 
services without regard to age, you know, religion, race, 
color, national origin, age have to be provided.
    Ms. Jenkins. If services are provided, I don't think it 
probably says specifically that you have to inject or give 
someone a contraceptive if you think that is inappropriate for 
what has happened to that young person.
    Mr. Pitts. Well, suppose a 12-year-old girl walks into the 
title X clinic, don't you think someone should be calling the 
authorities or her parents? Isn't having sexual relations with 
a 12-year-old statutory rape, as we heard in this case, 12-, 
13-year-old? But do you agree that to comply with Federal law, 
title X clinics should be reporting the fact that these minors 
are coming in for contraception?
    Ms. Jenkins. I think, as far as I am aware, that the 
reporting of statutory rape is determined by the jurisdiction, 
and in the District, for example, there are guidelines around 
the age for reporting statutory rape and also child abuse. As 
far as I am aware, those statutes do not necessarily say that 
the first step is to call a parent up for notification. The 
first step is to engage the appropriate authorities.
    Mr. Pitts. Would you limit the number of times per month, 
for instance, that a minor girl could get drugs? For instance, 
there is no limit now for a teenager going in for the ``morning 
after'' pill.
    Mr. Bilirakis. Just a very brief answer to that, please, if 
you can.
    Ms. Jenkins. I think that is a question sort of taken out 
of context, and so I----
    Mr. Bilirakis. Do you want an answer to your question. The 
doctor seems to feel it is taken out of context.
    Mr. Pitts. Go ahead. You may proceed.
    Mr. Bilirakis. Go ahead.
    Ms. Jenkins. Okay. My answer would be I would need to--I 
would have to know more about a case situation than to say 
arbitrarily, ``You can only come here three times.'' I think we 
clearly have to understand in some of the instances what we are 
talking about these young people getting contraception. The 
alternative in not getting contraception is pregnancy, and many 
of the issues are certainly not resolved by a young person 
becoming pregnant in a situation like that or being faced with 
the alternative we heard about earlier, which is an abortion.
    So I think when we are giving contraceptive services, we 
generally are talking about a young person, for the most 
instances, who is not at the ages that you are talking about 
but who is an older young person. As the high school studies 
show, that 50 percent or more of young people have had some 
sort of sexual encounter, and so you are really not doing--
giving a drug or not giving a drug based on there being no 
alternative or no other risk that presents itself.
    So I think when you manage young people you look at what 
the risks are for the total situation in terms of what is being 
done. And very often for the young people that come to title X 
the alternative is, ``Well, if I can't get contraception, I am 
not going to have sex anymore.'' That generally is not what the 
interpretation is. And very often these young people end up in 
a situation where they either acquire an STD or they become 
pregnant unintentionally. So I think we are working in a 
battleground situation that is not as cut and dry as you want 
to present it in the situation, let me tell you. They are very 
complicated, and very often you make decisions in the context 
of the total picture for the young person, but you 
appropriately engage agencies when it presents to you a 
situation that requires that.
    Mr. Bilirakis. Thank you, Doctor. Mr. Strickland.
    Mr. Strickland. Thank you. I am sitting here thinking of a 
school librarian in my district that was called to the 
gymnasium of one of my local schools. The girl was sick, the 
coach said, ``See what you can find out.'' They went into this 
broom closet. The librarian said to this young girl, ``Could 
you be pregnant?'' She said, ``Oh, no, I have never done it.'' 
And then she started screaming, ``It is coming out,'' and this 
librarian said, ``I pulled down her blue jeans and a baby was 
born in that broom closet.'' That is the situation that we 
face. Then the girl started saying, ``My mother will kill me. 
My mother will kill me.'' I wish every family in this country 
was an Ozzy and Harriet kind of family. It is not.
    Now, I just want to make something clear. Title X requires 
that providers comply with State laws on reporting incest, rape 
and molestation. Is that not true? Can someone answer that?
    Ms. Jenkins. Yes.
    Mr. Strickland. So what are we talking about? If a 12-year-
old comes into your clinic and is pregnant, that child has been 
molested, the report is made to the authorities, is it not?
    Ms. Jenkins. Should be, yes.
    Mr. Strickland. Absolutely. I think we ought to clear that 
up, because I think there has been an implication here that 
these clinics cover up crime, and I don't think there is any 
evidence that that is in fact the case.
    Dr. Jenkins, just for the record, I want to make sure that 
from your point of view this is the bottom line. In your 
professional opinion, H.R. 4783, the Brady Consental Parent 
Bill, do you believe that bill, if passed in its present form, 
would be bad for the health of children?
    Ms. Jenkins. Yes, I do. I think it would be bad for the 
health of adolescents who need or who will not be able to 
access care and prescriptions that would be relevant to their 
care, yes.
    Mr. Strickland. Okay. And a question to Ms.--and if I am 
mispronouncing the name, I apologize--is it Wuchner?
    Ms. Wuchner. That is correct. Thank you.
    Mr. Strickland. Ms. Wuchner, do you believe that women who 
use birth control pills are committing abortion or abortions 
result from the use of birth control pills?
    Ms. Wuchner. Well, first of all, the question is 
irrelevant, because we are talking about minor children and 
medications given to minor children.
    Mr. Strickland. But I would like to know your opinion about 
an adult woman who uses a birth control pill. Do you believe--
--
    Ms. Wuchner. Do I believe she is committing an abortion?
    Mr. Strickland. Yes.
    Ms. Wuchner. No. I think the pill operates by three 
mechanisms and that is scientific fact. Do I believe she is 
committing an abortion? No, at this point. Do you understand 
what I mean by that? The pill has three mechanisms of action, 
which is listed in the PDR. One is to prevent ovulation, the 
other is to affect the viscosity of the mucous and the other 
would prevent egg implantation which is a fertilized embryo if 
that should occur from implanting. It would render the lining 
unacceptable to that. But we are talking about minor children 
and prescriptions being given to minor children and treatment 
being given to minor children without their parents' knowledge, 
parents who are entrusted to care for these children by just 
the human nature----
    Mr. Strickland. I understand.
    Ms. Wuchner. [continuing] puts children in the care of 
their parent.
    Mr. Strickland. And I am sympathetic. I think in nearly all 
cases certainly parents ought to be involved. What would you 
say to those circumstances, and they occur and the occur much 
more frequently than most of us would like to admit, where 
there is a father, an uncle, some other relative, do you 
believe there should at least some provision for not involving 
the parents when a child may have been subjected to an abusive 
situation within the home itself?
    Ms. Wuchner. The law at that point provides a provision, 
and that is the requirement that that would be reportable. That 
is a reportable case to the authorities. It takes it out now of 
the context of parental consent and now puts it into a legal or 
an illegal situation that has occurred with a minor child.
    Mr. Strickland. But isn't it----
    Ms. Wuchner. You see what I am saying, that is separate.
    Mr. Strickland. But isn't----
    Ms. Wuchner. And that is not calling the parents to report 
them if they are the perpetrators of the child. Whoever 
perpetrates the child that needs to be reported. That is 
problematic. We are talking about medical care and treatment of 
minors, and that is different. We are not talking about an 
abusive situation. It could be an abusive situation, which 
means that it is reportable.
    Mr. Strickland. When a young child is being sexually 
involved, that is an abusive situation.
    Ms. Wuchner. That is correct. When she is being sexually 
abused by someone in the family, the authorities are reported 
and an investigation ensues which would mean parental 
notification. And if that parent is violating or a member of 
that family or community is violating that child, then the 
legal action and the appropriate action is going to take place 
whether--there is going to be natural notification.
    Mr. Strickland. Could I just follow up very quickly?
    Mr. Bilirakis. Very quickly.
    Mr. Strickland. Would you be satisfied if the law required 
under circumstances that are difficult like this that the 
authorities be notified rather than the parents?
    Ms. Wuchner. The law does require under the circumstances 
that authorities be notified.
    Mr. Strickland. But are the parents also required to be 
involved under those circumstances, as the law is written?
    Ms. Wuchner. Now, we are talking about circumstances, and 
we are talking about general medical care that does not involve 
parents. Under the law, the authorities are notified and 
parents would immediately become involved because what would 
take place is the authorities would then go to begin an 
investigation. See that is a separate issue. We are talking 
about a child that has been now violated in some range. So that 
means that there would have been authority notified, and then 
what happens is it is not the clinician who is treating the 
child that has notified the parents, because, again, as Mr. 
Pitts mentioned, adolescents must be assured of their 
confidentiality, and the musts that are mentioned or the 
guidelines in title X, those musts are mandatory. You can't 
breach from those. So the only way around that must is to go to 
the legal authorities and report it. The clinicians' hands are 
tied.
    Mr. Strickland. My time is up. Thank you.
    Mr. Bilirakis. Mr. Towns, to inquire.
    Mr. Towns. Thank you very much, Mr. Chairman. Let me begin, 
Mr. Heisler, by making sure that I understood you. You said 
that the majority--are you saying the majority of the health 
care professionals support your position or are you saying the 
majority of the people in McHenry County support your position?
    Mr. Heisler. No, I said the majority of the people in 
McHenry County.
    Mr. Towns. Well, is it true then that before McHenry County 
Health Board was able to successfully reject title X funding, 
they first voted not to reject title X funds? Is that true? Yes 
or no.
    Mr. Heisler. The board itself, the health board itself, we 
had several votes. It came down to a 4 to 4 at the health 
depart-ment----
    Mr. Towns. Four to 4 is not a majority.
    Mr. Heisler. No, I know. The health board did not initially 
reject title X. The county board rejected the title X funding. 
The county board appoints the health board and approves their 
budget.
    Mr. Towns. Let me make certain I understand. There is a 
representative by the name of Cal Skinner who changed the 
numbers on the board in order to break a tie, and then you went 
out shopping for someone who committed themselves, and 
indicated the fact that they would vote to reject the funds. 
You had to campaign to get somebody to do that.
    Mr. Heisler. No, that is not right.
    Mr. Towns. After you got that person to do that----
    Mr. Heisler. Not at all.
    Mr. Towns. [continuing] then you ended up having a 5 to 4 
vote. Now, how do you arrive at this great majority that you 
keep talking about here?
    Mr. Heisler. You are misinformed, Congressman. That is not 
at all what happened. The change in the number of members in 
the board of health, which is a subboard of the county board, 
went from five to four, eight to nine, so we could have that 5 
to 4 well after this whole title X thing was over with. We 
didn't want to have that happen again.
    Mr. Towns. If it was 4 to 4, how did you get that? I mean 
somewhere in here I am losing a step.
    Mr. Heisler. Well, let me explain it. The board of health--
--
    Mr. Towns. Four to 4 is a tie.
    Mr. Heisler. Four to 4 it fails, you are right. Four to 4 
it fails. The board of health did not reject it. The county 
board removed the funding, removed the title X funding. The 
county board funds the board of health activities.
    Mr. Towns. Well, let me ask you this then, isn't it true 
that the majority of the health care professionals in McHenry 
County spoke out adamantly in favor of continuing title X 
funding?
    Mr. Heisler. I wouldn't say that that is true at all.
    Mr. Towns. Well, I have a letter from 23 doctors and nurses 
in McHenry County, as well as a number of organizations, such 
as the Illinois Caucus of Adolescence Health, who disagree with 
your opinion on this issue. Isn't it also true that only one 
physician came out in support of ending title X funding?
    Mr. Heisler. You seem to have the statistics there, sir. I 
don't know who that one physician might be. I can tell you----
    Mr. Towns. I don't want to meet him either. I don't want to 
meet him. Go ahead.
    Mr. Heisler. I can only tell you what happened. And what 
happened, McHenry County appoints the board of health. The 
county board appoints the board of health. The county board 
created the board of health. The board of health, through some 
decision that it might make that perhaps adverse to the 
philosophy of the elected officials of McHenry County, can in 
fact dissolve the board of health. The ultimate authority at 
McHenry County relative to these title X grants comes with the 
elected officials of the county board. We rejected it 15 to 6.
    Mr. Towns. Let me say this: Is it safe to say that you do 
not represent the values of the majority of the medical 
profession in McHenry County? Is it safe to say that?
    Mr. Heisler. You can say that. I am not a medical 
professional, I didn't take a poll of the medical profession of 
McHenry County. I speak for the people. I am an elected 
official of McHenry County. I speak for 250,000 people that 
live there. I have lived in McHenry County for 58 years.
    Mr. Towns. You didn't take a poll of the people either.
    Mr. Heisler. Let me explain that. My grandfather started a 
shoe store 100 years ago on the corner of Crystal Lake, 
Illinois, and there is more people that walk into that shoe 
store and tell me about their philosophy of life than walk into 
your home office I will bet you because we know what is going 
on. My brother is on the county board. We know how the people 
feel in McHenry County about this issue. That is why it failed.
    Mr. Towns. I seriously doubt that, because I come from a 
county that represents 2.5 million people, so I seriously doubt 
that.
    Mr. Heisler. Well----
    Mr. Bilirakis. The gentleman's time has expired. Now, is 
this something you want to continue on for another few seconds?
    Mr. Towns. Well, no more than the fact that I think that 
his testimony is very misleading. He indicated that the 
majority of the people, and it would seem to me he had taken a 
poll of the people of McHenry County. I mean and then all of a 
sudden he is talking about somebody walking in a shoe store.
    Mr. Bilirakis. Well, I am not going to speak on behalf of 
Mr. Heisler, but he is an elected official just as we are. We 
are representing the people, and I think what his point is that 
he represents the people in that area, and if he wasn't 
representing them adequately as far as this issue or any other 
issues are concerned, he would no longer be an elected official 
when his elections take place.
    Mr. Towns. Well, maybe the next election will take care of 
that.
    Mr. Bilirakis. So anyhow, the time is expired. Mr. Akin, 
would you like a couple of minutes to inquire? You have been 
very patient, you have sat here throughout this entire thing. 
You obviously have an interest in it.
    Mr. Akin. Yes. Thank you, Mr. Chairman. I appreciate that 
opportunity. I did have a question or two. I just wanted to 
clarify a couple things.
    Mr. Bilirakis. All right. Let us do it. Let us do it.
    Mr. Akinn. Thank you. I guess any of the three of you might 
be able to answer this, but, Dr. Jenkins, perhaps maybe you 
could. Let me just give you a hypothetical because there has 
been a little bit of confusion about exactly, at least from 
listening to testimony, where we are in this. Let us say that 
you are in a title X clinic, a child comes into you, let us 
just assume it is a minor child. And the child says, basically, 
``I want some contraceptive shots'' or whatever it is, and they 
are a minor. And they say, ``My mom and dad would shoot me if 
they knew I were here. But I know that I can come here and 
trust you, and so therefore I want this--I am a minor and I 
want this medication.'' Can you, according to the law, call 
that child's parents and tell them what is going on? I am not 
talking about what you want to do, I am just saying legally 
could you do that the way the law is set up now?
    Ms. Jenkins. Under title X?
    Mr. Akin. Yes.
    Ms. Jenkins. What has been discussed here is that 
apparently to pick up the phone and call the parent at that 
point would be not allowed under title X.
    Mr. Akin. So it would be illegal for you to do that.
    Ms. Jenkins. As far as I understand title X. I don't know 
if you are trying to set me up.
    Mr. Akin. No. I am just trying to get the facts as to how 
this works. I am not trying to get you thrown in jail.
    Ms. Jenkins. Okay. I don't have it in front of me, but 
based on what we have talked about, that is what the guidelines 
say, okay?
    Mr. Akin. Ms. Wuchner, is that your understanding that that 
would be----
    Ms. Wuchner. Yes, Mr. Akin, that is correct.
    Mr. Akin. So it would be illegal for people----
    Ms. Wuchner. I am looking at the regs, exactly. It would be 
illegal----
    Mr. Akin. Okay. So they could not do that.
    Ms. Wuchner. It would be in violation of the guidelines 
that are mandated in title X, yes.
    Mr. Akin. Okay. Now, Dr. Jenkins, you have mentioned that 
you deal with a lot of different kinds of situations, and some 
of them are just kind of dicey; they are not the sort of things 
that are--I understand that. But also there are some families 
that are functional out there. What this law says to me is that 
de facto we are giving the minor the right to choose their 
parents, effectively, in this situation. And they are saying as 
a minor, ``Well, you know, my parents, I don't really want to 
accept what they are saying is right and wrong or what they 
think I should be doing, and so I am going to end run their 
authority and come to you.'' Does it make you feel 
uncomfortable when the parents know nothing about it, let alone 
consent to it, that in a sense you usurp their role as an agent 
of the State in cases where maybe there is a very functional 
family?
    Ms. Jenkins. My experience has been that a lot of times 
young people overestimate the reaction of their parents, okay? 
And what in my position I very often do is to try to work with 
them around getting a better communication with their parents 
about it. I don't just say, ``Okay, you don't want to tell your 
parents. Okay. There is no discussion about that.'' Because I 
have found that over time when there is a functional family 
that most parents would rather their kids get some help and not 
be at risk for adverse and negative outcomes. One of my very 
first experiences of health----
    Mr. Akin. Well, I think you answered my question, and 
actually it seems like a very common sense answer, what you 
said. You know, what you are saying is is that you try to work 
with the particular situation, try and bring some 
reconciliation and maybe steer the child back toward their 
parents. I mean I think that is a real common sense answer.
    I guess the concern I have is the way the law is set up 
right now. What you are telling me is that you are prohibited 
from having the alternative of talking to the parent at all in 
this situation.
    Ms. Jenkins. I don't think that is true. I think what it 
says----
    Mr. Akin. Unless the kid acquiesces.
    Ms. Jenkins. Yes.
    Mr. Akin. So in every one of these situations we are 
basically giving the government the de facto right to usurp or 
to take over the role of parents without the parents' knowledge 
or consent when the child is a minor. That is the way it is set 
up now. I think most of us believe that, yes, if you can, you 
work with the parents, but it seems like the law is actually 
contrary to that situation, and it seems like to me you talk 
about making decisions, the first natural line of defense for 
the child is the parents. And who is making the decisions? 
Doesn't it seem logical to at least give the parents a chance 
to be parents? I understand there are dysfunctional families, I 
understand there are parents who don't want to make the 
decisions, don't care about their children. But there are some 
who do.
    Mr. Bilirakis. Well, the gentleman's time has expired. Ms. 
Capps, for 30 seconds to finish this up.
    Ms. Capps. I was going to ask my colleague to yield and 
just to give Dr. Jenkins an opportunity. You are assuming that 
it is a mechanical situation where a child comes in, demands a 
prescription and it is automatically written. And I don't think 
that is the kind of relationship that I heard Dr. Jenkins 
talking about. The optimum relationship is one where you have 
known this adolescent over years, if possible. Now, that is not 
always that way, but there certainly isn't anything in this 
law, as I understand it, that requires that the State usurps 
the role of the parent. It does give one protection really for 
abnormal, abusive relationships in which a child is a victim. 
And there is no adult other than this provider who is a 
professional, who should be trusted to both report and also 
work with. Now, that is why I think it is difficult to answer 
the question because it is not one that I would assume that you 
find yourself in.
    Mr. Bilirakis. Well, the gentlelady's time is long expired. 
Ms. Wuchner, as long as everybody is taking liberties----
    Ms. Wuchner. Yes, sir.
    Mr. Bilirakis. [continuing] do you feel that there should 
be more flexibility in title X? I mean, you know, we have 
discussed all of these problems, and we know that there are all 
sorts of different and often very difficult situations, and I 
think it is very easy to put ourselves in the shoes of Dr. 
Jenkins and some of the patients that she sees. But from the 
standpoint of flexibility, do you have a comment, very briefly? 
I don't want to--you know, we have been at this for 2\1/2\ 
hours now.
    Ms. Wuchner. Okay. Basically, I think there has been a lot 
of confusion. It is not the long-term relationship that happens 
in a public health clinic, it is short term. Usually the 
patient, there are two visits, and clinicians would love to 
encourage young people to notify their parents, but that 
doesn't take place, and I told you in 75 percent of the times 
it doesn't.
    Mr. Bilirakis. And they can't do that without the approval 
of the child; is that right?
    Ms. Wuchner. Without the approval of the child. It is the 
mandates of title X, they are restricted by that. So there is 
not an opportunity to bring that child and that parent together 
in dialog without the permission--even when the clinician know 
it is in the best interest of that child and they are fearful.
    Mr. Bilirakis. Even if Dr. Jenkins, who seems to----
    Ms. Wuchner. In a title X clinic.
    Mr. Bilirakis. [continuing] I mean not seems to, who cares 
about children, if Dr. Jenkins feels that she should do it in 
certain instances, unless she gets the approval of the child, 
she can't do it.
    Ms. Wuchner. I am a nurse and I have worked with doctors 
for many years as a nurse, and we use nurses in our clinics 
because that is what required by the State. And there is not 
one clinician that wants to come there that day and give bad 
care, but the law ties the hands of the clinician, it ties the 
hands of the board. We could not make our decision, and this is 
the point that we came to where it was an agreement almost on 
the majority of the board that title X was problematic in this 
area.
    Mr. Bilirakis. All right.
    Ms. Wuchner. I hope I answered your question.
    Mr. Bilirakis. You did, you did. All right, listen. The 
record remains open obviously for opening statements on the 
part of the members of the committee, and also remains open 
regarding the opportunity to submit questions to you three good 
people where hopefully you will respond to those in a timely 
fashion. You know, we appreciate it very much. We can just go 
on and on and on. This is a very significant topic, obviously. 
Yes, ma'am?
    Ms. Capps. May I just make one question to you, Mr. 
Chairman.
    Mr. Bilirakis. Lois, very quickly.
    Ms. Capps. Twenty-five States have laws guaranteeing access 
to contraception to minors, and 50 States for STD treatment. So 
this law, if it is enacted by Congress, will usurp a lot of 
States' rights; am I correct?
    Mr. Bilirakis. You are telling me, don't ask me. Well, I 
don't know what the future of this legislation is, but 
obviously it would have an opportunity for debate in all of 
these technical points, and the answer to your question would 
all come out. But these good people are here to help us make 
those decisions.
    Ms. Capps. And I just--since Ms. Wuchner has worked in a 
lot of these clinics, doctors don't have to prescribe. I mean 
the question that came from my colleague very to the point of 
saying that the minor comes in and you can't notify the parent. 
But you also don't have to prescribe.
    Ms. Wuchner. First of all, I will just clarify, I have 
never worked in the clinic. My area is women's health, but I am 
on the board of the directors of the health department.
    Ms. Capps. Well, I guess it would be Dr. Jenkins. I mean 
you don't automatically write a prescription for a 12-year-old.
    Ms. Jenkins. No. There are lots of reasons why you wouldn't 
do that.
    Ms. Capps. Where you would not do that, it would not be in 
the child's best interest.
    Ms. Jenkins. Right.
    Mr. Bilirakis. Okay. All right.
    Ms. Capps. I promise not to ask anymore.
    Mr. Bilirakis. The hearing is over. Thank you very much.
    [Whereupon, at 5:35 p.m., the subcommittee was adjourned.]
    [Additional material submitted for the record follows:]
        Prepared Statement of McHenry County Citizens for Choice
    McHenry County Citizens for Choice (MCCC) is a local non-partisan 
grassroots organization dedicated to education about women's 
reproductive rights. We represent the full spectrum of McHenry County 
voters. Our activists include a cross section of moderate Republicans 
and concerned Democrats who are also members of such diverse groups as 
the League of Women Voters, The Women's Leadership Council, The 
American Association of University Women, and The Religious Coalition 
for Reproductive Choice. Supporters also belong to professional groups 
such as the American Academy of Pediatrics, the American Medical 
Association, and the American Association of Public Health.
    MCCC represents thousands of citizens in McHenry County who have 
been diametrically opposed to the past and present attempts of 
Congressman Donald Manzullo (R-16) to deny minors confidential access 
to the Title X program through the imposition of federal parental 
consent restrictions.
    In McHenry County, during the 1997-1998 period under discussion, 
there were hundreds of post cards and letters sent to the county board 
in support of Title X funding. In addition, more than twenty local 
medical doctors, including pediatricians, signed a common letter of 
support. None of these documents were ever publicly or privately 
acknowledged. Other medical professionals, public health 
administrators, advocates for adolescent health and private citizens 
wrote letters to the editor of the local paper and came forward at 
regularly scheduled meetings of the Board of Health and the full County 
Board to speak in favor of retaining Title X funds and it is noteworthy 
that the two medical doctors on the Board of Health supported Title X. 
Congressman Manzullo has continually failed to address the concerns of 
his constituency regarding this matter in his attempts to make this a 
national issue.
    The major travesty however, was the way in which opponents of Title 
X repeatedly attempted to link a local criminal case involving 
predatory sexual abuse with the teen confidentiality requirement in 
Title X. That action confused the issue and distracted local elected 
officials whose concern should have been focused on the public health 
issue under their jurisdiction.
    The case in question began in 1997 and involved a multimillion-
dollar lawsuit alleging sexual abuse of a minor, which was brought 
against a teacher, his employer--Crystal Lake School District 47, and 
the County Health Department. In a subsequent civil suit against the 
local Church of Jesus Christ of Latter Day Saints, the girl divulged 
that the teacher, who was also a youth minister at the church, 
originally befriended her during a church outing to Six Flags Great 
America. According to court records the abuse began in the spring of 
1995. Nine months later the abuser took the girl to the Health 
Department where she told nurses and a doctor that she needed birth 
control. The records indicate that she had been sexually active for 
nine months before her visit to the Health Department.
    Nevertheless, Congressman Manzullo misrepresented the true 
situation when he was quoted in an interview with the local newspaper, 
``It simply brings into focus what happens when a 14-year-old receives 
birth control shots from a health department without the knowledge or 
consent of the parents.''
    To complicate matters, the law suit brought by the parents of the 
victim against the County Health Department and the school district 
effectively curtailed any public discussion at the county level. At one 
point the County Board was also involved peripherally in the legal 
entanglement. It provided a large window of opportunity for only one 
side of the issue to be aired since the litigation forced the Health 
Department professionals, the Board of Health and eventually the County 
Board, to remain silent under direction of their attorneys. The 
hundreds of cards, letters, and petitions signed and submitted by 
ministers, teachers, healthcare workers and local residents received no 
response or public recognition.
    The local newspaper filled its pages for months with articles about 
the ``sex scandal.'' It repeatedly cited the use of Title X services, 
thereby craftily relaying a subliminal message about the evils of 
contraceptive availability. There were two other cases of sexual 
misconduct with minors involving teachers in McHenry County during this 
same period; one teacher convicted in 1997 and another facing charges 
that same year. However, apparently because contraception was not an 
issue, both received only a perfunctory reference in the last paragraph 
of a front page article on this case.
    Was there really a concern for the well-being of a teen victim or 
was it an opportunity to take the focus away from Title X as a public 
health issue and replace it with personal religious ideology shrouded 
in the cloak of ``parental control?'' ``Parental control'' has long 
been a wedge issue for ultra-conservatives and to engender fear is an 
effective tool when in reality your position has no substance. 
Religious political manipulation can have tragic consequences in the 
lives of real people especially when it is substituted for sound 
professional consideration on issues of public health.
    Teenage sex is a serious issue with two aspects: (1) moral, and (2) 
public health. The morality of the issue must be handled by the 
teenagers, their parents, and their clergy or other professionals they 
wish to involve. The public health side is appropriately handled by the 
civic agencies such as the Health Department which is charged with 
maintaining the health and safety of the citizenry. It is yet another 
example of the importance of keeping issues properly categorized. It 
was when the Health Department abandoned its civic mission and became 
an arbiter of morality due to extreme political pressure that the issue 
became so muddled that everyone sustained a loss; the teens, the 
community, the taxpayers and the integrity of our local government.
    The ideal concept of parents communicating and guiding their 
adolescents through the difficult years to adulthood is one on which we 
can all agree. The problem is, we are not in an ideal world. We are in 
a world of advertising which sells products by promising better sexual 
opportunities. A world where there are less than ideal homes, where 
little or no information is given, where parenting skills are lacking 
and in some where real abuse exists.
    The confidentiality of Title X is no threat to parental 
involvement. Parents can and should talk to their children and educate 
them on these issues every day of their lives. With accurate 
information, open communication and the opportunity to discuss good and 
bad choices along with consequences and responsibilities . . . many of 
society's problems could be solved.
    The concept of parental involvement is right. But laws are not the 
answer. More realistically, in our community, as in many, we need to 
build the societal infrastructure to ensure reasonable success for our 
teen population in navigating the difficult adolescent years. By that 
we mean comprehensive sexuality education and parenting classes for 
both parents and teens, a coordinated community effort sponsored by 
hospitals, schools, churches, local agencies and the media.
    What happened in McHenry County was not about parent's rights. It 
was about closing access to information, professional counseling and 
reproductive care. It was about changing the focus from all the 
positive elements of Title X and furthering a child rearing philosophy 
based on withholding contraceptive information. It was about punishing 
teens who have disobeyed their parent's by forcing them to bear the 
consequences of an unwanted pregnancy or sexually transmitted disease 
to teach them a lesson. It was also about some parents, unsure of their 
own ability to communicate effectively with their teens, trying to 
block out any source of information that might be available in the 
community. Something like burning books.
    If there was any doubt that right-wing politics and personal 
religiosity had a stranglehold on this issue from the beginning, it 
should be noted that it was the wife of the chairman of the health 
board who raised the level of rhetoric against Title X (with the 
backing of a local right-wing state representative). This person 
organized a demonstration outside the county building before a health 
board meeting where the only non-print medium represented was a 
religious television station.
    Locking the door of Health Departments by requiring parental 
consent will not keep teens from having sex. We know that 85% (Planned 
Parenthood ) are already sexually active for nearly a year before they 
access those services. When they do, it is because they fear they may 
be pregnant.
    If contraceptive availability is not why teens have sex then what 
is? Many teens find solace in sexual relationships when love, attention 
and self esteem are missing in their lives. They want someone who will 
love them unconditionally and not leave. We fail to acknowledge that 
teenagers have sex for the same reasons adults do. We lose credibility 
when we deny that our children are sexual beings. But they must be made 
aware that having sex carries with it all sorts of responsibilities. 
They must feel a responsibility for the physical and emotional well-
being of the other person and be prepared for all the possibilities and 
decisions that being sexually active may present to them such as 
disease and unintended pregnancy. For those reasons and others, it is 
both desirable and rational to be abstinent until physically, 
emotionally and financially able to enter a committed long term 
relationship.
    The professionals at health clinics can address the emotional and 
physical needs of their patients in a straightforward non-judgmental 
way. They can encourage better parent/teen communication to seek 
solutions for the reasons the teen feels the need for a sexual 
relationship. It can be the intervention that prevents that teen from 
becoming another abortion statistic or entering the welfare rolls as a 
single parent. This type of counsel is, in fact, required under the 
provisions of Title X.
    The issue should not be viewed as a matter of parental rights or a 
political battle to be won. It is simply the most compassionate and 
financially effective way of addressing real and pressing problems of 
preventative health care in our community. People of good will 
recognize that while everyone is free to guide their own children, we 
cannot close the door to a healthful and productive life to teens who, 
for whatever reason, are not receiving that guidance. A caring 
community should not abandon teens who are most at risk, those who are 
already disadvantaged by all the conditions associated with poverty, 
and dysfunctional or broken families. Those teens must also have access 
to good counseling and education from professionals they trust, who can 
help them learn how to make responsible decisions in their lives.