I’m a professional wedding officiant and longtime L.G.B.T.Q. rights advocate. While I recognize that some officiants and other vendors may have ethical or religious objections to same-sex unions, I rejoice that marriage equality is the law of the land.
Many wedding expos, websites, registries, professional organizations and social media groups have nondiscrimination policies requiring all vendors to serve same-sex couples. I know several officiants who participate in these and who will not marry L.G.B.T.Q. couples. I’m wrestling with whether to “out” them to the gatekeepers.
These other officiants aren’t costing me business. If anything, their exclusiveness may cause some couples to seek me out. But it’s a matter of principle — those who serve the public should not be allowed to discriminate, and same-sex couples should be spared a jolting refusal as they plan their special day.
Do I have a duty to report these noncompliant officiants? Should I remind them of the nondiscrimination policies? Or should I mind my own business and let an aggrieved couple report them? Name Withheld
Our law wisely respects religious conscience within very broad limits, and you correctly recognize that religious conscience, not just unthinking bigotry, might guide people who object to same-sex unions. That doesn’t mean every conscientious religious decision is exempt from moral criticism. As the English moral philosopher Elizabeth Anscombe once put it, “A man’s conscience may tell him to do the vilest things.”
So it’s perfectly legitimate, even admirable, for private groups to adopt policies of nondiscrimination that go beyond legal requirements. It’s perfectly legitimate, even admirable, for members or participants to help enforce these policies. (Reminding the noncompliant of their obligations is one way of doing so.) But are you dutybound to police the policy?
Whether you’re required to report a transgression generally depends both upon its moral gravity and upon whether, as an observer, you’re especially well positioned to do so. Suppose you see someone committing a minor parking violation that nobody else is in a position to have seen. That passes the test of observer privilege but fails the test of magnitude. Hence: no duty to report. Suppose you see a brawl in a crowded club, but so has everyone else present. That passes the test of magnitude but fails the test of observer privilege: again, no duty to report.
Failing to abide by a group’s L.G.B.T.Q. nondiscrimination clause is bad, but not bodily-injury bad, and there’s no reason to think that you’re uniquely well positioned to turn in these rule breakers. “Duty” is a high bar. You have every right to report them, but you shouldn’t beat yourself up if you leave it to others.
I’m a doctor in an urban emergency room in California, and I’m struggling with two classes of patients who are becoming more common in our E.R: patients experiencing homelessness, and patients with chronic pain requiring opiate therapy.
By law, E.R.s are required to medically screen and stabilize all patients. What this means is that any person can come to the emergency room with any medical complaint and be given a warm place to stay until said medical complaint is evaluated. While this law is being used appropriately by the vast majority of patients, a small subset of patients (often the most vulnerable) take advantage of it. They know that if they present to the E.R. with a medical complaint — real or imagined — they will be guaranteed a bed for a few hours and a meal (per California law). We will often see the same handful of people once or twice a day. We know that they often have no other access to food or shelter, and we want to be helpful. The problem is that the E.R. is not meant for shelter and food. First, it is a very costly use of resources. Second, these patients often divert scant resources such as ambulances and beds from others who have acute medical needs. We often have to weigh whether to provide the desired food, shelter or clothing or deny those resources in hopes that the patients are helped elsewhere.
Similarly, we have seen an uptick in chronic-pain patients abandoned by primary-care clinics that no longer administer opiates due to the unclear crackdown on opiate prescribing, even legitimate opiate prescribing. Patients often come in desperate because of their ongoing pain, or because of the withdrawal from medicines taken safely for years. Some will even threaten to start using heroin if we don’t prescribe opiates, which we know is a real possibility. And again, while we want to help, we cannot have the E.R. become the default place for people to get pain medicine when others won’t help.
I struggle with these questions daily. The reality is that it is costing the health care system $200-$300 to provide a patient with a cold turkey sandwich. How do I, as a physician, proceed? Name Withheld
Given the situation you describe, you have to go on doing what you’re doing. If people show up with a medical complaint, even one you have doubts about, you have to treat them appropriately and, apparently, under the law that means they get a meal; it also means dispensing painkillers, including opiates, when (but only when) that’s medically indicated.
The solution isn’t for you to change what you’re doing in the hospital. It’s for the state of California to make sensible provisions for its citizens, without unduly burdening particular institutions. And you can best help with that by working to get a shelter opened near your hospital, say, or joining together with your medical colleagues to put pressure on elected officials, including state legislators, and drawing public attention to your concerns. We need effective policies to deal with the food, shelter and health care needs of our least fortunate fellow citizens.
That’s not just on you; it’s on all of us. The private and nonprofit sectors can also help, in partnership with the public — as with the Commonwealth Care Alliance, in Massachusetts. The Center for Medicare and Medicaid Innovation, established by the Affordable Care Act, has been tracking promising pilot programs that deploy social services and primary care to keep “high users” out of the E.R. But at the moment, you have good reason to complain: That we still haven’t addressed these problems adequately makes it harder for people like you to do your job.
