Revising Provider Refusal Laws to Make Health Care A Civil Right.

There's a recent post by Peter Wilson at conservative American Thinker that's making the "pro-life" internet rounds. It addresses the provision in the Patient Protection and Affordable Care Act (the health care bill), Section 1553, that "protects" doctors from participating in assisted suicide (or aid in dying, death with dignity, etc.). The full text of the section reads (second source here):

SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED SUICIDE.

(a) In General- The Federal Government, and any State or local government or health care provider that receives Federal financial assistance under this Act (or under an amendment made by this Act) or any health plan created under this Act (or under an amendment made by this Act), may not subject an individual or institutional health care entity to discrimination on the basis that the entity does not provide any health care item or service furnished for the purpose of causing, or for the purpose of assisting in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.

(b) Definition- In this section, the term `health care entity' includes an individual physician or other health care professional, 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.

(c) Construction and Treatment of Certain Services- Nothing in subsection (a) shall be construed to apply to, or to affect, any limitation relating to--

(1) the withholding or withdrawing of medical treatment or medical care;

(2) the withholding or withdrawing of nutrition or hydration;

(3) abortion; or

(4) the use of an item, good, benefit, or service furnished for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as such item, good, benefit, or service is not also furnished for the purpose of causing, or the purpose of assisting in causing, death, for any reason.

(d) Administration- The Office for Civil Rights of the Department of Health and Human Services is designated to receive complaints of discrimination based on this section.

The clause protects providers who refuse to participate in legal aid in dying -- a point that should make "pro-life"groups very happy. No doctor, if asked by a terminal patient to provide a fatal dose of drugs, is obligated to write the prescription. But Wilson, forgetting that many who observed the New Year's Eve Montana Supreme Court decision Baxter v. Montana that determined aid in dying was legal there clamored for a strong conscience clause to protect doctors from having to participate. This clause does so. (Death with Dignity laws in Oregon and Washington, the other two states where aid in dying is legal, already include clear provider refusals that protect doctors from participating.)

But Wilson is trying -- and failing -- to get at something much more subtle. "Pro-life" groups in their activism oppose aid in dying in all its forms as they define them, including removal from futile care, removal from nutrition and hydration (see Terri Schindler Schiavo Foundation) and even, among extreme groups and individuals, palliative sedation. This section of "Obamacare," as Wilson and conservative opponents of the bill call it, clearly defines what "assisted suicide" is.

Wilson asks Rita Marker, executive director of the International Task Force on Euthanasia and Assisted Suicide (and pal of ultra-conservative, pseudo-science proponent Wesley J. Smith) what she thinks of 1553. She calls it, "a 'bizarre conscience clause' for those who refuse to participate in assisted suicide." Fair enough, I guess, depending on what she means by bizarre.

Provider refusal clauses -- so-called "conscience clauses" are a bit of a mess right now, as Wilson points out. The history of provider refusal clauses is rather brief -- and marks the point when technology began to overtake conservative ideas of women's roles in society and medical imposition to God's provenance -- and began as a reaction to the legalization of abortion in 1973. What were once "protection" of doctors from performing medical services they morally or religiously objected to morphed into "protection" of entire institutions, like the Catholic church which is the second largest provider of health care in the U.S.

Backlash to Roe v. Wade has expanded these federal laws (as noted below, states have their own blanket of provider refusals) to include increased rights of doctors at the detriment of rights for patients. Some do not require referrals -- a doctor is not required to give a woman, gay or elder patient a meaningful referral for services -- or informed consent -- a doctor is not required to tell a woman, gay, or elder patient all of their medical options. Some are renewed annually because they are attached to federal funding (hence the phrase "no federal funding for abortion," which is not factual: the clause only applies to Medicaid funds but exemplifies the slow creep of these laws).

I note women, gays and elders because these are the groups most often targeted by provider refusals. Here's a brief history of the federal laws that are currently on the books:

In 1976 the Hyde Amendment established that no federal monies allocated to Medicaid could be used to pay for abortions. Hyde, renewed each year, has been challenged in the courts numerous times and upheld (see Maher v. Roe.) The language has become more limiting over the years and during the health care debate, feminists had to admit that their historical acceptance of this law allowed it to morph into blatant discrimination against the poor. They have renewed their calls for overturning Hyde.

The first of the provider refusals, or so-called “conscience clauses,” the 1973 Church Amendment, named for Frank Church (D-ID), protects health care “entities” or individuals who accept Medicaid from discrimination for their choice to perform or not perform abortions. States enacted their own subsequent laws and today, according to the Guttmacher Institute, 46 states allow providers to refuse abortion services. Forty-three allow institutions to do so.

Republicans gained majority in the House in the 1994 elections for the first time since 1954, initiating a new wave of abortion restrictions. The 1996 Coats Amendment was a reaction to the requirement made by the accrediting body for OB/GYNs that students must receive abortion training. Congress stepped in to preempt the requirement.

In 2005, the annual Weldon Amendment was first attached to the appropriations measure that funds the Labor, Health and Human Services and Education departments. It stipulates that neither individuals nor “health care entities,” can be discriminated against for refusing to pay for, cover, or refer for abortion services.

And in December of 2008, what’s been called a “parting gift” from the Bush administration, the greatest expansion of refusal laws was enacted with support from the U.S. Conference of Catholic Bishops (USCCB) and the Catholic Health Association. In essence, it sold patients down the river and gave religious providers (individuals and institutions) not only the right to deny services but information about or referrals for them.

Since the Obama administration addressed the “conscience clause” last year the Catholic Church has mounted a campaign to retain it. Without such protections, the Church would lose the ability to dictate the services its providers perform and its more than 100 million annual patients receive.

Wilson's truncated history of provider refusals only hints at their 30 year creep and authoritarian nature. Once written to protect the conscience of individual doctors, a noble intent, they now allow institutions, most egregiously, the Vatican via the United States Conference of Catholic Bishops, to determine not only what care is provided to millions of patients but what available, legal care those patients can be informed of and referred to.

Rita Marker, without such intention, most clearly noted this creep in a recent article, also for American Thinker:

Some years ago, I was speaking to a Nebraska state senator after testifying on a pending bill. I had explained that I wasn't saying that the bill would be interpreted in a certain way, only that it could be. Then he said something I've never forgotten. "Be assured that if a law can be interpreted in a certain way, it will be -- by someone. And it will all be perfectly legal."

Unfortunately, the greatest resources and organization reside in the hands of institutions, churches, and other organizations determined to limit the use of medical technology based on denominational, theological or authoritarian principles. Not to that lone woman who is pregnant, shamed, in a traumatic situation; not to the dying elder who is suffering and no longer wants to be fed through a PEG tube in his belly, not to the rape victim; not to the doctor employed by a Catholic hospital but prevented from telling a troubled teen how to avoid getting HIV.

And here is another lesson for us about our form of Democracy. Majority rule defies the rights of minorities by supplanting individual conscience with the loudest and most funded voices in the country. If it is indeed the intention that counts, these laws are no longer intended to protect an individual doctor's conscience. They are used as tools by those who wish to make abortion, aid in dying and other patients' rights illegal -- or more importantly, legal but completely unaffordable and inaccessible.

And here is Wilson's objection to section 1533 of the health care bill: "it reframes the debate as one of civil rights, and brings assisted suicide more into the mainstream." The debate about patients' rights is already about civil rights; and it is already mainstream.

President Enforces Rights for Patients.

From fabulous Pam Spaulding at Pam's House Blend:

The President, in an extremely positive development for LGBT families, has directed the Secretary of Health and Human Services (HHS) to ensure that hospitals participating in Medicaid or Medicare will allow patients to designate who may visit them as well as name their primary caretaker and decision maker. Countless tragedies have occurred because of denial of access or ability to decide on the health of a loved one because the hospital would only recognize the rights of a blood relative.

I'm happy to report that my state, North Carolina, recently put this into place on its own, as you'll see in the memo.

According to the White House, these measures could require substantive changes to the visitation policies of hospitals in at least twenty-five states whose laws do not currently require the extension of visitation rights, and will hold hospitals participating in Medicaid or Medicare to the highest care standards nationwide.

The changes in this official memorandum also benefits widows and widowers without children, members of religious orders, and others whom otherwise may not have been able to receive visits from good friends and loved ones who are not immediate relatives, or select them to make decisions on their behalf in case of incapacitation. Full text of the memo below; the PDF can be downloaded by clicking the image.

C&C Reports on the Status of Aid in Dying in Montana.

You can read the article here.

An aside: I'm delighted to see Compassion and Choices announcing itself under the rubric of patients' rights. I've consistently advocated for various patients' rights groups - women's rights, elder rights, disability rights, medical marijuana rights, LGBT rights - to come together to reform our health care system and end discrimination against minorities. I hope other groups take note and follow in the stand for patients' rights from inequality and discrimination.

This Man Is An Elected Official in Virginia?!

You may not yet have heard about Eugene Delgaudio, an elected official on the board of supervisors in Louden County, Virginia. But the gay community has had to listen to his hideous hatred for more than a decade. He won reelection as recently as 2007. I'm on the GOPUSA mailing list and the nastiness below came by my inbox today. Beware. It's a hideous mass that I post for one reason: only awareness can kill discrimination and hatred this deep.

Some extra reading for you, if like me, you're in shock that someone with this resume can hold elected office:

Kyle at RightWingWatch, 2010.

Dana Milbank at the Washington Post, 2005.

The Corner, National Review Online, 2005.

Michael Laris, Washington Post, 2002.

You see, the Radical Homosexuals are storming through Washington demanding passage of their agenda.

And with the passage of Thought Control last year, they say NOW is the time to push their perverse "life-style" on every man, women and child in America.

And they insist YOU actually support them.

The Homosexual Lobby played a major role in electing Obamaand the majorities he enjoys in both houses of Congress.

I can only begin to imagine all the damage the Radical Homosexuals will do with their allies controlling the House of Representatives, the Senate and the White House.

As the President of Public Advocate of the U.S., I've devoted twenty-seven years to battling the radical homosexuals in Washingtone.

Backed by Hollywood celebrities, the media and millions of your tax dollars, the Radical Homosexuals have many Congressmen quivering with fear -- and they have a Radical Homosexual-friendly majority in control of Congress.

That is why pro-family Senators and Congressmen are counting on me to find out if you really support the Gay Bill of Special Rights and homosexual marriage as the radical homosexuals claim.

Frankly if you really do support the radical Homosexual Agenda -- or if you just no longer care enough to stand up for the family -- insiders in Congress say the entire Homosexual Agenda could pass in a matter of months.

*** Special job rights for homosexuals and lesbians. Businesses may have to adopt hiring quotas to protect themselves from lawsuits. Every homosexual fired or not hired becomes a potential federal civil rights lawsuit.

Radical homosexuals will terrorize day care centers, hospitals, churches and private schools. Traditional moral values will be shattered by federal law.

*** Same-sex marriages and adoptions. Wedding-gown clad men smooching before some left-wing clergy or state official is just the beginning.

You'll see men hand-in-hand skipping down to adoption centers to "pick out" a little boy for themselves.

*** Homosexual advocacy in schools. Your children or grandchildren will be taught homosexuality is moral, natural and good. High school children will learn perverted sex acts as part of "safe sex" education.

With condoms already handed out in many schools, Radical Homosexuals will have little trouble adopting today's "if it feels good do it" sex-ed curriculum to their agenda.

And to add insult to injury, lobbyists for the Homosexual Agenda are paid off with your tax dollars!

That's right, radical homosexual groups like the Gay-Lesbian Task Fo! rce and ACT-UP receive millions from the government.

Hundreds of millions of dollars flow from taxpayers to homosexual activists through funding for homosexual "art," so-called AIDS-awareness programs, and research grants.

And yet, Public Advocate receives absolutely no taxpayer assistance. My small office of volunteers and low-paid staffers are making quite a sacrifice to defend America's morals and values.

But hard work is not enough. Items like mail, stamps, and even this email cost money.

That is why I ask you to make a generous donation after youcomplete the American Morality survey today.

Anti-Gay Rant Video from CPAC

Catch this anti-gay rant from yesterday's CPAC events. The hatred, intolerance and fear are shocking.

From the conservative (and misguided) PA Watercooler.

UPDATE: from TalkingPointsMemo, apparently Ryan Sorba is into beating women too. What a stud!

AIDS and Aid in Dying.

Newsweek's Sarah Kliff has a new article up that looks at how the AIDS epidemic focused the gay community on end of life and assisted suicide issues (and, one could argue, on the need for same-sex marriage).

The lede of the article is BBC commentator Ray Gosling's recent arrest after admitting on a documentary that years ago he smothered his suffering lover with a pillow, and Gosling's subsequent arrest for questioning. Kliff writes:

Gosling's admission and his ensuing arrest was certainly shocking. But it also confirmed what assisted-suicide experts already knew: legal issues of hastening death have long plagued AIDS patients and their doctors. "Certainly, we know it's a community where this type of bootleg assisted suicide occurred throughout the 1990s," says Ian Dowbiggin, the author of A Concise History of Euthanasia and an expert on the right-to-die movement. "This specific example of assisted suicide, I don't know how common it is, but it is likely more common in this particular community than elsewhere."

Much of it has to do with the nature of the disease, which began to disproportionately affect gay men in the 1980s and early 1990s. AIDS patients were ravaged by tumors, seizures, and paralysis, and doctors had little to offer by way of a cure. Early treatments often merely prolonged this suffering. "People who suffered from AIDS were naturally interested in assisted suicide, whether it was legal or not," says Dowbiggin. As Gosling explained on the BBC of his own partner's disease, "Doctors said, 'There's nothing we can do'; he was in terrible pain." Legally, there was nothing his doctors likely could have done: in the United Kingdom, as in the United States (except for Washington and Oregon), physicians are barred from assisting a patient's suicide.

I just finished reading Dowbiggin's book not too long ago and recommend it for a good overview of the assisted suicide movement (though from the writing I would suppose he's not the most dynamic dinner guest). He opens the book with a look at how AIDS played a role in the re-energizing of the aid in dying movement then combs through ideas and practices of assisted suicide throughout history.

It's a wonder to me that gay rights have shown their most traction in same-sex marriage until I consider that in the early days of the AIDS epidemic, men were dying as their lovers waited outside the hospital, unable to obtain visiting rights, unable to exercise power of attorney, and removed from the legal and medical process by a shaming society.

As we watch the same-sex movement gain ground, it's good to remind ourselves of all the benefits, legal and social, that marriage delivers. And as we watch the movement for patient's rights form alliances, before thought unnecessary or unproductive, it's good to remember who in society is most effected by discriminatory health care delivery and laws.

Jill Stanek and Not Dead Yet Shake Their Fingers At Me, I Respond.

I don't take the same glory from having my "opponents" shout me down that Jill Stanek does - don't we have too many social issues to solve to fan distracting flames? - but I am intrigued to find that two prominent "pro-life" voices have recently maligned me for as benign and obvious a point as:

Culture wars focus public attention on one prominent, contentious, emotional issue (like assisted suicide or abortion) to the detriment of other very important health issues like women's health care and elder care. This is the gist of an article I wrote at AlterNet this week. You can read it here.

Yesterday, Stanek herself took the time to blog her poke at me:

Pro-abort Ann Neumann at Alternet is tying the fight to legalize euthanasia and assisted suicide in the UK to the fight to advance abortion rights in the US. Of course. The common denominator: Death, death, death.

My God is My Credential.

The common denominator is, of course, not "death, death, death" but the highly publicized efforts of folks like Stanek to focus not only on diminishing and discrediting women's rights but also those of elders. Pro-life groups have for the past few years worked hard to raise "euthanasia" on their platform. Terri Schiavo's brother, Bobby Schindler, spoke at the "pro-life" march a few weeks ago. "Right to life" groups are supporting elder rights-infringing legislation all over the country. The Catholic Church and Fundamentalists jointly have gone after women's and elder's health care autonomy. Stanek's own site regularly attacks end of life care choice. That the "pro-life" movement is working to determine the rights of the vulnerable and dying as their own domain is no secret, certainly not one that I'm exposing.

That anyone who believes in women's rights or elders' rights is pro-death is ludicrous, a line of irrational thinking that requires precisely the closed arguments that I say culture wars require. But that doesn't stop "pro-life" groups from trying to paint as pure evil those who don't abide by their fundamentalist attempts to impose denominational health care on the rest of the country. They've framed the debate for so long that they've begun to sound silly if you step back and look with any shred of critical thought at the issues.

That a woman loses her rights (to the state, or to the fetus, or, well, to Jill Stanek) when she becomes pregnant is religious idealization of a potentiality - a future human being. It is the same kind of religious ideology that is behind the "personhood" bills across the country that work to further limit women's access to medically-sound, legal health care. And the same imposition that allows these groups to damage the rights of patients at the end of their life. You know, "cradle to grave," "whole cloth," "sanctity of life" stuff that gives the self-righteous license to meddle in your health care decisions.

I am far from pure evil; I just happen to think that women and elders, not Jill Stanek, should make their own health care decisions. But Stanek's easy to write off as absurd and fanatical. Women's rights advocates and rational Americans have been doing it for years. But luck with those "credentials" Jill.

Don't Go Near Disability Rights.

The comment from yesterday that caught my interest the most came from the "anti-euthanasia" disability group with the catchiest name ever, Not Dead Yet. They write at their site:

Anyway, if you're here and you're reading this - it's obvious who she left out. Disability advocates and activists - in the US and the UK - oppose legalization of euthanasia and assisted suicide. The "practical" issues she and Beresford refer to are exactly the economic, social and support factors that disability advocates constantly bring up as being central to any discussion of assisted suicide and euthanasia.

And Neumann already knows this - or she should. She found her way to Bill Peace's Bad Cripple blog last month, but shied away from engaging from the critique of her initial attacks on what she termed "slippery slope" arguments on the blog. Not long after that, she announced the news of the Disability and Health Journal Issue on Assisted Suicide on her own blog.

So she knows that disability activists and advocates are out there, talking about the "practical" things. The trouble is, we think legalization of assisted suicide and euthanasia is bad policy.

In other words, she's fostering and promoting the very polarization that she bemoans. Maybe it's because she really isn't sorry that assisted suicide is seen as a "culture wars" issue after all.

Minus the dismissive, snarky tone, NDY is right. I have been aware of their "anti-euthanasia" efforts for some time. And they are absolutely right that I have avoided them, to some extent. But I'll get to the reasons in a minute. As to the "polarization" I am fostering, I suspect they mean my disclusion of disability rights groups from the patients' rights alliance (that doesn't really exist but that I fantasize about often).

Nothing can be farther from the truth. But I hope to have a new article out in a few days that dispel that accusation. I just don't think that NDY represents and speaks for all disabled persons and I know that not all disabled persons are anti-aid in dying (or anti-patients' rights or anti-women's rights). And as to my joy in any assisted suicide culture war? I'll let my readers discern how engaged I am with hospice and palliative care, health care reform, and elders' rights.

As to the provision of rights to one group infringing on the rights of another, that's just bad thinking too. Giving a mentally-sound, terminal patient with less than six the right to a lethal prescription that they may or may not choose to take when death approaches has nothing to do with the disabled community. Again, I sympathize with the fear and vulnerability the disabled community feels toward the medical industry, the state, and society. But conflating two separate issues is just bad advocacy. With a little (understandable) paranoia thrown in.

NDY continues:

She's wrong about that DMZ - we live in it. And neither the pro-euthanasia activists nor the highly political "pro-life" organizations want to acknowledge our place in the debate, because we'd distract from their Culture War. Neither side really sees people with disabilities as having a place in their respective cultures, so it's easy to marginalize us - and both sides do it with abandon and ease.

In some ways, this paragraph is also true. We don't have a patients' bill of rights in the U.S. because the various, disparate groups concerned have failed to build a coalition that is strong enough to rival that of the Religious Right. I have written that were women's rights, elders' rights, gay rights, medical marijuana rights, and disability rights activists to get together, they could resoundingly oppose denominational health care delivery in this country, the religious laws that are daily pushed in our state and federal legislatures, the biased court decisions that limit time and again a patients' rights.

However, Not Dead Yet isn't working for patients' rights, though the try to claim that mantle. They're working to prevent others from making their own health care decisions at the end of life. Yet they try to present themselves as free of political motivations. Incredibly disingenuous.

Founded in the 90's after Jack Kevorkian was acquitted, the group has worked to support the Schindler family in their fight to keep Terri Schiavo on artificial nutrition and hydration and to oppose aid in dying legislation everywhere.

Their argument can be summed up thusly: assisted suicide (or "euthanasia"), when legalized, forces already-marginalized people with disabilities to be coerced into ending their lives prematurely. By matter of their inherent vulnerability, the disabled are the first in society to be offered up by the state, the medical profession or society as not worthy of full protection. Making aid in dying legal devalues the disabled in society and jeopardizes their rights.

While also an argument dispelled with fact and statistics, it is never an easy position for a liberal rights proponent like myself to go against "the disabled." And to be perfectly clear, my position on patients's rights in no way infringes on the rights of the disabled. In any way.

Because of the way Not Dead Yet and other "disability rights" groups have positioned themselves, if you disagree with them by, say, supporting legalized aid in dying (as legislated as Death with Dignity in Oregon and Washing, like I do), you're out to kill the disabled. It's the same "with us or against us" stuff that pushes politicians into bad legislation and media commenters into squirming discomfort. Come out against a position taken by a disability rights group? No way, no thank you. To explain one's position against an "anti-euthanasia" disability group takes more than a glib sound-bite. And who has time for nuance in politics these days?

Rhetorically, Not Dead Yet and other such "anti-euthanasia" groups have sprung their argument like a trap. Because they are the most vulnerable, they've taken up the mantle for speaking for us all. And because all of us will be disabled at some point in life, either from frailty in old age or other health situations that impair what we consider our current "normal" functionality, we can anticipate oncoming disability. But we can't know what it's going to be like. I accept and acknowledge that as much as I do the fact that as a white woman I don't know what racial discrimination feels like. But that can't stop me from working to abolish racism.

I too accept that disabled persons have fear of the medical profession and of society's disdain for their physical and mental challenges. And I resoundingly admit that these fears have historical and contemporary relevancy. But I refuse to accept that my advocacy for patients' rights and end of life choice in any way diminishes the rights of the disabled.

So yes. Not Dead Yet is right that I don't often pursue disability rights issues. I write about end of life care and religion. But as I continue to press for a patients' rights coalition that will push back draconian and discriminatory care, I will have to better articulate disability rights activists into this alliance. I just don't think of Not Dead Yet as a disability rights group interested in patients' rights.

Separate Church and 8.

Calling for enforcement of the Establishment clause in the Proposition 8 trial - that legislated religious opposition to same-sex marriage is unconstitutional - demonstrators in Utah chanted "separate church and 8" outside the building where a new documentary about the Mormon Church's participation in the California Proposition 8 bill that outlaws gay rights to marriage.

From Park Record:

The film, called "8: The Mormon Proposition," had been expected to be among the most controversial to screen during the Sundance Film Festival this year, and a demonstration had seemed likely for some time. It was unclear until Sunday, though, whether another group in support of the California ballot measure would also make an appearance outside the Racquet Club during the premier.

The demonstrators on Sunday chanted the slogan "Separate church and 8," a play on the phrase "separation of church and state." They held signs with the same slogan. The demonstrators were in earshot of the people heading to the film. There did not appear to be anybody from Park City or surrounding Summit County standing with the demonstrators, who seemed to be primarily from the Salt Lake Valley or elsewhere in Utah.

Rick Bickmore, who is gay and from Salt Lake City, said he would like to be married someday and he was disappointed when the ballot measure passed in 2008, even as he said his sister, a Californian, voted for the proposition.

"Our idea here is to be here with dignity," Bickmore said.

Uganda and Homosexuality.

Two new stories about Uganda and the anti-homosexuality bill there that originally proposed killing gays but now favors, after US pressure, lifetime imprisonment and "curative" procedures.

At RHRealityCheck, Edwin Ocong'o asks why Ugandans have so willingly accepted the Religious Right's anti-homosexuality ideas.

At The Nation, Peter Rothberg asks Americans to raise their voices against the discriminatory and draconian proposals in Uganda.

And a new article from Voice of America on how Ugandan officials are reacting to the increasing pressure form non-religious American voices.

Discrimination by State.

If you're gay, you're better off in the Northeast, if you're terminally ill, you're better off in the Northwest. Or so the country stands now where predominantly Northeastern states allow same-sex marriage and Northwestern ones allow aid in dying.

That's the point John Crisp makes at ScrippsNews today:

A good friend is in the middle of a challenging battle with cancer. She reports lying in bed the other night after the lights were out and musing about whether, if she decided to leave her home state of Texas, she would choose a state that permits physician-assisted suicide or one that would allow her finally to marry her long-time, same-sex partner.

Unfortunately, no state in America allows both. For some reason, the states with progressive laws on physician-assisted suicide are in the northwest: Washington, Oregon, Montana. And the states that permit same-sex marriage are mostly in the northeast, like Massachusetts, New Hampshire, and Vermont. Texas isn't likely to permit either one anytime soon.

These two issues may not appear to have much in common, but both have an equally difficult time getting much traction in our country. Some states -- California and Maine, for example -- have made tentative moves toward permitting same-sex marriage and then pulled back, contributing to the frustration that gays and lesbians must feel as they try to gain a completely equal footing with heterosexuals in our culture.

Equality and laws that prevent discrimination against the dying or homosexuals seem to have a regional prevalence. But the issue is more complicated than regional flavor.

Because of Federalism, the autonomy afforded states to make their own laws by the US government, laws have often lingered in places with strong cultural prejudice toward minority groups. The most obvious example is the South and slavery. But other factors are at play with same-sex marriage and aid in dying.

Some state constitutions are more open to personal autonomy, like Montana's which the Supreme Court there ruled on New Years Eve did not prevent aid in dying.

Some states have a stronger religious foothold where everything from education to women's reproductive rights are kept in the last century to appease the powerful church organizations there.

Homosexuality is clearly more tolerated in urban areas, like the Northeast, where gays have gravitated from their rural homes or where living openly doesn't mean risking a lynching.

And a concentration of advocates can make a state more tolerant of their rights, like San Francisco.

While federalism works wonderfully for state-based issues like, say - and this is a stretch but the only two examples I can come up with - protecting local industries or tackling local environmental issues, it's a disaster for protecting minorities and the rights of those discriminated against.

The federal government can legislate laws that override state laws but the bill must specifically tackles such inequalities. Not all federal laws trump state laws. And the US Supreme Court can make case decisions that translate to compliance for all states but, as we've seen with abortion, states then can, under the influence of discriminatory groups there, work to mitigate such laws by limiting access.

Our constitution may claim that equality is guaranteed but cultural forces work tirelessly to maintain discriminatory practice in states where religious bias is strong and powerful. Changing the culture is no easy task but doing so is perhaps the only way to prevent federal court decisions from creating a backlash locally, as abortion did in the 70s and 80s all over the country, or civil rights legislation did in the South.

Would you move to a new state if it provided you more freedoms than the one you're in? Well, I'm in New York City these days and it's a city/state I chose because of tolerance and diversity. As our population becomes more mobile, less tied to home and family, and more urban, values migrate and discriminatory practices are ameliorated. I'd be a fool to suggest that the gutting of rural America is caused by a desire for greater tolerance of "non-traditional" lifestyles but that's certainly a factor in state cultures.

But that kind of movement is a privilege. Not everyone has the resources to pick up and go to a new place. If you're gay in rural Texas, best to keep your head down or get out. And that is the fallacy of US equality. Some states or regions are more equal than others.

Sharlet on Maddow.

The gays are murderers like the Nazis and perpetrators of Rwanda's genocide. The kill the gays bill in Uganda is now the "imprison and counsel the gays" bill. The Family trying to cover up their foreign policy influence and discredit those exposing them. Yup. It's all in there:

Visit msnbc.com for breaking news, world news, and news about the economy

Marriage Equality Defeated in New Jersey.

Yesterday New Jersey voted to prevent equality for all citizens in marriage:

The Jersey City resident was upset and surprised that the state Senate defeated the Freedom of Religion and Equality in Civil Marriage Actin a 20-14 vote today.

Hecht and Beth Achenbach, her partner of eight years, said they don’t know that they can continue to call New Jersey home with states like Connecticut and Washington D.C. close to passing gay marriage laws.

“It’s not that far to move to get equal rights,” Hecht said. “I basically feel like the state of New Jersey doesn’t need my money then.”

She added, “I should probably go to a state that will appreciate everything I have to offer and will take my tax money and will give back fair and equal rights.”

The Fight for Patients' Rights.

Why does the US still not have a bill of patients' rights that guarantees equal, affordable access to scientifically-proven, effective medical services?

Because patients' rights advocates fall into a number of devoted, diligent but uncoordinated and underfunded groups:

Disability rights

LGBT rights

Medical Marijuana rights

Women's reproductive rights

End of life/Elder rights

Minority rights

And because they are fighting resource-rich, organized, powerful opponents which, despite their disparagement of "elitists" or "intellectuals," inhabit and influence the halls of government in an unprecedented way:

The medical industry has strongly fought any patients' rights bill introduced in legislation. Over the past dozen years, more than 5 bills have been defeated. They have spent vast amounts of money to prevent government protection of individual and group rights; they oppose regulation at all levels.

The church, both the Catholic and Fundamentalist/Evangelical Right has spent the years since Roe v. Wade (when they allied around the common goal of imposing "traditional values" on our pluralistic society) building their unified "pro-life" effort. Pro-life means everything the ideological right is against, from women's reproductive services to aid in dying, from marijuana rights to gay equality. These organizations enjoy tax-exempt status, have been brought into government to provide social services, and are not required to register as lobbyists when they work to influence legislation.

The state has refused to look at patients' rights as an Establishment Clause issue, preferring to, when it does protect rights, use the rights to privacy. Even the Supreme Courts rulings on Establishment clause grounds (predominantly in the area of schools and public property) have been unpredictable.

Until opposition to patients' rights by industry and the church are recognized for what they are - unregulated capitalism and discrimination - corporations, medical associations and religious ideology will continue to shape how medicine is delivered.

Catholic Charities: San Francisco v. the Christians.

From Bread on the Water, a (hilarious and amazingly "sheltered") article about the challenge in San Francisco to Catholic Charities, which refuses to allow gay couples to adopt from its agency.

The article is worthwhile because of how it perpetuates a number of conservative and fundamental myths: the Church is under attack; gays have sex by fisting; exaggerating crowd sizes is a legitimate way to inflate public support of the church; children need a mother and a father to have "normal" lives; only a godly household is conducive to parenting; the separation of church and state means the state can't regulate the church; religious freedom means churches are free to impose their discriminatory doctrine via social services on a diverse society.

I say the article is hilarious because it is all emotional - fear and hatred, specifically - and has little regarding the facts of the case or any studies showing how children fare in gay households. In other words, it is indicative of the anti-intellectualizing that is rampant in media: go for the outrageous; justice, truth, science, rational thought be damned. As though any member in society is justified in making up their mind about a legal case based on an unprovable idea (gays are perverse) and not on the facts (children fare as well in secular and even gay households as they do in Christian households, perhaps better if you consider education a good thing.) And then there's the photo used to represent those hideous gays!

But the writer is wise in some ways. By painting religious discrimination as just and decrying the persecution of religious, traditional, patriarchal beliefs, the Christian right is able to rally it's core believers. Their brand of faith teaches them to find glory in condemnation, to fight on against their (contrived) enemies, that opposition and challenge makes them more Christ-like and holy.

This view of others as opposition is entrenching, sustaining. As fundamental beliefs have shaped our laws over the past 50 years as activists for minority groups have risen up in search of their own rights, fundamentalists have declared that any reclaiming of personal rights by these groups is encroachment (see abortion). The church has moved so far beyond its proper boundaries in society that pushing it back out of social services (funded by federal funds which, of course, can't be used for necessary women's health care but are necessary for the spread of religious ideology), out of bedrooms and private lives, out of medical care and marriage is looked at as aggression by the church and even by non-religious, conservative by-standers. If you're not gay or don't know much about the gay community you could easily see this kind of issue as perhaps unimportant. Why would perverts want to raise children? So what if those facilitating adoption deem the gay community unworthy?

But as a member of a pluralistic, diverse society, as a voter and a citizen who's duty it is to demand and enforce the rights of minority groups, we are responsible for your own ignorance and wrong assumptions, particularly when they perpetuate the kind of hilarious drivel below for the sake of continued hatred, ignorance and discrimination. Being passive in the face of the church, or even reverential, as is society's general approach, is allowing such ignorance, stereotyping and discrimination to continue.

Religious freedom doesn't mean much to many people who don't practice a religion, but it cannot be denied that defending freedom of religion, at the very least, defends one's ability to choose one's own values and then act on them, provided that those actions don't deprive others of the same ability.

The City of San Francisco is presently governed by a body of legislators who have chosen to believe that same-sex couples are entitled to all the benefits of heterosexual couples, including parenting children.

As in all things, Nature has something to say about that. To parent children, same-sex couples must introduce a member of the opposite sex into the equation at some point. For some same-sex couples, the answer is adoption. However, Catholic Charities in San Francisco has refused to place children in their care into same-sex households.

Scandalized, the San Francisco Board of Supervisors in early 2006 passed a resolution (Resolution 168-06,click here) condemning the Catholic Church's refusal to offer children for adoption by gay couples. A week later, the Board officially condemned a rally of 25,000 Christian teenagers gathered to oppose a popular culture that glamourizes violence and sex, including abortion and homosexuality.

San Francisco's Board of Supervisors labeled the Catholic Church's refusal to require parentless children to be raised by homosexuals as "hateful," "discriminatory," "insulting," "callous," and "showing a level of insensitivity and ignorance which has seldom been encountered by this Board of Supervisors."

As opposed to (one cannot help observing) the tact, sensitivity, and enlightenment displayed by San Francisco's answer to the traditional religious community, namely, the Sisters of Perpetual Indulgence (shown) whose motto is, "Go and sin some more." (I am not making this up.) It should be noted that San Francisco's Catholic churches do not prevent the Sisters of Perpetual Indulgence from participating in Catholic religious services. But the Church is not putting little babies into their hands.

Catholic doctrine teaches, for example, that allowing children to be adopted by homosexuals would actually mean doing violence to these children, in the sense that their condition of dependency would be used to place them in an environment that is not conducive to their full human development," the center explained. "Such policies are gravely immoral and Catholic organizations must not place children for adoption in homosexual households."

And what did San Francisco's elected legislature think of that rally of 25,000 Christian evangelical teenagers eager to follow that antique guideline known as the Ten Commandments? The Board of Supervisors called their rally a "fascist mega-pep rally" of "virtue terrorism." Got that? San Francisco feels "terrorized" when faced with non-fisting adolescents.

At present, the 9th Circuit Court is considering a challenge to San Francisco's resolution condemning the Catholic Church for its moral teachings. The challenge was brought by the Thomas More Law Center, which presented oral arguments to the Court on December 17, 2009.

The Establishment Clause of the U.S. Constitution does not permit government hostility toward religion. Robert Muise, who argued the case before the eleven-judge panel, said, "If the full court allows this government attack on Catholics to stand, it will likely further embolden anti-Christian attacks by government." Bill Donohue, speaking for the Catholic League, pointed out that Board of Supervisors' "invective and bigoted comments" tell "what will be happening under the 'hate crime law' recently signed by President Obama."

On the other hand, according to Muise, "Should the full court ultimately render a decision in our favor, this case will establish much needed precedent for claims alleging government hostility toward religion."