TikTok, the wildly popular video sharing platform, has an algorithm that will occasionally push a video captioned “Pranking my kid!” or “Parenting hack!” No one watching the video will wonder if the kid(s) consented to filming and sharing their life to the Internet. However, people need to start considering the ways in which an influential online identity impacts a child’s mental health and social development.

Social media revolutionized global connection, information delivery, and creative expression. Many would argue that these sites and apps brought immense good to the world, but social media also introduced new problems. Some parents are profiting by turning their children into social media influencers, a practice that could be damaging to youth mental health. It is difficult to regulate any content, let alone content created by parents featuring their own children. However, it is possible to regulate the labor of monetized child influencers, and this is currently the most accessible approach to curbing harms brought by social media to youth mental health.

In May 2023, the U.S. Surgeon General released an Advisory on Social Media and Youth Mental Health. The Advisory compiled research and statistics on the matter and addressed the benefits of social media use among youths, like building positive community, sharing information, and creating space for self-expression. The rest of the Advisory studied the potential harms of social media use. Exposure to extreme, inappropriate, and harmful content can create risks of fatality, physical injury, body image issues, and low-self-esteem. In addition, excessive use of social media can create risks of insomnia, addiction, attention deficits, depression, and anxiety.

Next, the Advisory identified five groups—policymakers, social media companies, researchers, parents, and youths—and provided recommendations to each group on effectuating maximum benefits and minimal harms from social media, and “creat[ing] safer, healthier online environments for children.”

Recent lawsuits have claimed that the lack of safe, healthy online environments for children is a consequence of profit-motivated social media companies prioritizing engagement over safety. Social media companies have been condemned for the addictiveness of their platforms, including the constant, compulsive engagement of children which has led to negative effects on their physical and mental health. The goal of these lawsuits has been to hold these companies accountable for knowingly, intentionally, and deceptively designing algorithms that harmed youth mental health.

Social media companies certainly hold some of the blame for their part in this crisis, but they are hardly the sole perpetrators. Content creators—particularly parents who monetize videos or images of their children—must also be taken seriously for their role in harming youth mental health beyond the screen.

The U.S. Surgeon General’s Advisory recommends that parents mitigate the potential harms of social media by modeling responsible social media behavior to their kids. However, variation of social media use by parents, caretakers, and guardians makes it difficult to determine exactly what it looks like to “model responsible social media behavior” and protect children from harms.

In her 2017 article entitled Sharenting: Children’s Privacy in the Age of Social Media, law professor and children’s privacy expert Stacy Steinberg addresses the social media behaviors of parents who share content of their children online, using the term “sharenting” to describe this behavior. Sharenting serves as an outlet for parents to express their true feelings on the realities of raising children, particularly the hardships brought on by raising children with chronic mental health or developmental needs. By sharing these stories, parents build supportive communities of similarly situated parents and advocate for greater awareness and education around the raising of children with mental and developmental needs.

The dark side of sharenting lies in parental oversharing that invades a child’s privacy, agency, and safety. Some parents go viral for videos of them disciplining their children, for example, where a child is forced to stand in public with a sign describing his misbehavior. These parents are trying to effectuate behavior changes in their child through public shaming. Once shared, some in the online community approve of the disciplinary video, finding the post entertaining and authentic. However, others point out that this kind of online discipline is disrespectful and humiliating to a child. Unlike traditional offline forms of discipline, a viral video leaves a digital footprint beyond the child’s control.

Parents who share content of their kids with little regard for short-term and long-term repercussions may be just as harmful to youth mental health and development as the social media platforms. While litigation has the potential to protect children from the harms dealt by social media companies, it is a less viable option when the offender is a child’s own parents. Other methods must be used to protect children from their parents’ harmful use of social media.

Steinberg suggests a public health model of child protection. The public health model proved effective with the secondhand smoke campaign, where pediatricians warned parents of the dangers of secondhand smoke and encouraged parents to not smoke around children. When parents continued to do so, some state legislatures enacted laws to prohibit the discouraged behavior. The public health model prevails by identifying a crisis and disseminating appropriate warnings and education to the public, with state legislature available as a fallback measure.

Steinberg proposes a draft of the public health model for protection of youth mental health, organized by the best practices to be advised to the public. It mirrors the Advisory, listing educational points for parents like giving their child veto power over online posting, considering the effect that sharing has on the child’s current and future sense of well-being, and sharing anonymously.

For some parents engaged in sharenting, anonymous posting defeats the entire purpose of sharing because anonymity is counterproductive when the goal is to build a career as an influencer.

Melanie Fineman has discussed commercialized sharenting in her 2023 note Honey, I Monetized the Kids: Commercial Sharenting and Protecting the Rights of Consumers and the Internet’s Child Stars. She argues that commercial sharenting has negative effects on child influencers, or “kidfluencers,” and that more support for regulations of commercial sharenting might be earned by reframing the issue as “foster[ing] misleading content online” or “implicat[ing] child labor concerns.”

Sharenting fosters misleading content because parents often instruct their children to talk and react for the camera in ways that prioritize profit and engagement over authenticity. One mother told her Internet-famous twins to “say Oshkosh!” when asked about their favorite brand at an Oshkosh promotional event, though the twins later indicated they did not know what Oshkosh was. Followers on social media were influenced to support Oshkosh because of the twins’ uninformed endorsement, but the endorsement only occurred because Oshkosh incentivized their mother to do so.

Sharenting also implicates child labor concerns. A kidfluencer’s advertisements or sponsorships on social media could bring is so much money that running the account becomes a full-time job and income source for the parent. Content featuring the child becomes the key to the parent’s commercial success, increasing the risk of parents exploiting their children and harming their mental health.

An apt comparison might be child reality TV stars from shows like Toddlers and Tiaras or even Kendall and Kylie Jenner in their earliest years on Keeping up with the Kardashians. Children develop a different sense of self when they’re put in the public eye from a young age, lacking the agency to control their own image. Dissolving the boundary between portrayed character and personal self puts the child in a position to believe he or she is a commodity in the parents’ eyes, always expected to perform in a money-earning, content-worthy manner and creating pressure, stress, and negative mental health outcomes in the child.

Exploiting a child’s presence on social media for the parents’ financial gain is a difficult issue to address due to legal protection of parental rights. A parent’s right to control and shape their child’s life historically outweighs the child’s rights to privacy or autonomy. Thus, the law is unlikely to compel parents to stop sharenting and grant children autonomous control over their own digital footprints. Limitations also exist in regulating what is posted, rather than who is posting. Steinberg notes that a parent’s social media posts may be considered free speech protected by the First Amendment, and therefore, insulated from state regulation. However, states are permitted to regulate the monetization of a child on social media and mitigate damages of commercial sharenting by approaching the matter as a labor issue.

Fineman describes California’s Coogan Law, which ensures that a portion of money earned by child actors be put in a trust until the child turns eighteen. The intent is to protect children from exploitative employment, where earnings are spent by parents and not the child. It returns a degree of control to the child, diminishing the risk of the child believing he or she is a commodity in the parents’ eyes. Coogan’s Law has since been mimicked in other states like New York, New Mexico, Louisiana, and Illinois.

Illinois is the first state in the nation to pass legislation amending its Child Labor Law to include protections for child influencers on social media. The amended act defines vlogs, family, and online platforms, and mandates that profits from online content featuring a child’s name, image, or likeness must be directed to a trust fund account for the child. Children will have the right to sue their parents for failing to direct profits to the trust fund in violation of the amended Child Labor Law.

The amended Illinois act goes into effect on July 1, 2024, so it remains to be seen whether it successfully mitigates the harms to child influencers posed by commercial sharenting. In the meantime, the public health model could serve as a means of protecting the mental health of child influencers by disseminating education to parents and raising awareness of the privacy, health, and safety risks of sharenting.

Višegrad is a town in eastern Bosnia and Herzegovina (Bosnia). As a child, I would frequently visit this town. Višegrad is struggling with protecting its natural aesthetic and the health and well-being of its inhabitants. The Drina River flows through Višegrad, renowned for its emerald color and historical significance. It symbolizes the struggles of the Bosnian war and underscores urgent environmental and public health challenges requiring immediate intervention.

Before delving into the challenges facing Višegrad today, I would be remiss to not mention and acknowledge the struggles of Bosnia that continue to affect many war-torn families today. Bosnia as a whole has been the victim of unspeakable atrocities and genocide. In 1992, Muslims of Višegrad faced a siege; they were deliberately attacked, tortured, and murdered by Serbs. Serbs, individuals from Serbia, inhabit both Serbia and Bosnia. In Serbia, they operated under the direction of Slobodan Milošević, and in Bosnia, they were led by Radovan Karadžić. They actively promoted Serbian nationalism and pursued the creation of a “…Greater Serbia.” Their goal encompassed the “…disappearance of Bosniaks [Bosnians].” They executed this agenda by ordering Serb forces to “…ethnically purify the territory…” of Bosnian Muslims. The International Criminal Tribunal for the Former Yugoslavia investigated some of the crimes that took place in Višegrad, but many attacks and murders remain unprosecuted. They are unlikely to ever be prosecuted, resulting in zero closure for many families of Višegrad.

As aforementioned, the Drina River flows through Višegrad. The town boasts the  Mehmed Paša Sokolović (Sokollu Mehmed Pasha) bridge, designed and built by the Ottoman architect, Mimar Sinan, in the sixteenth century. It spans 179.5 meters in length. Despite being regarded as a historical treasure and even being added to the UNESCO World Heritage List, victims were taken to the bridge and murdered. In 1992, a Višegrad local reported, “They [Serb militiamen] took them [Muslim men] from the trucks and to the railing of the bridges,” and “…they would shoot them,” and throw “…them all into the river.” The war in Bosnia lasted until 1995 when the Dayton Accords were signed. If earlier action had been taken, the staggering loss of 250,000 lives and displacement of over 2 million Bosnians could have been prevented.

You may be asking yourself: How did the war cause the environmental degradation that is still evident today? Is Bosnia taking any action to rebuild its environment? If these questions are on the forefront of your mind, let me pose a simple one: If you witnessed murder and genocide, would rebuilding the green landscape be your top priority? Since scars of the war persist in the region, they have resulted in environmental degradation and even a potential public health crisis.

The Drina River begins at the confluence of the Tara and Piva rivers, flowing for 215 miles until it runs into the Sava river. The Drina serves as a boundary between western Bosnia and eastern Serbia, originating in the northwestern part of Montenegro. Over twenty years ago, individuals built a hydro-power plant with old oil drums to protect the dam from debris that flowed with the river. However, today, after heavy rain and snow, you can nearly find everything under the sun in the Drina. There are reports of finding dead animals, car parts, medical waste, and plastic bottles. The waste can accumulate to around 5,000 cubic meters since garbage flows into Višegrad at least twice a year. The waste piles up behind the barrier that was installed by the hydro-power plant. Consequently, a floating landfill has formed in what was once a picturesque emerald river.

The waste is not generated by the locals of Višegrad, but they are forced to deal with its consequences. The floating landfill results from waste originating in the towns surrounding Višegrad; waste from these surrounding towns flow upstream through the Drina, and accumulate in Višegrad. Despite attempts by workers at the hydro-power plant to clear the waste, Višegrad struggles with an ongoing cycle. Even though they remove and burn 10,000 cubic meters of waste each year in the town’s landfill, the effort has not proven to be highly effective. Fears are materializing not only regarding the river’s ecosystem, but also what the impact will be on locals when the waste is burnt. Burning waste releases toxic chemicals that pollute the air; it is inhaled by both humans and animals, and can also make its way into soil and plants. Ultimately, the toxic chemicals can make its way into the human food chain through crops and livestock.

Fears surrounding the effects on the Drina’s ecosystem are also well-founded. With plastic water bottles being the primary type of waste found in the Drina, many species mistake the waste for food and ingest it; once ingested, it can lead to starvation and/or death. Further, it is no secret that plastic is not fully biodegradable. In fact, the waste can generate even more bacteria and spread disease.

The piled-up waste has drastically harmed the tourism of Višegrad since many tourists make their way to the town to visit the Mehmed Paša Sokolović bridge. It is difficult to market a town that is engulfed with waste that can negatively affect the health of individuals. Since the town heavily relies on outdoor tourism, owners of hotels and restaurants have become devastated and are actively suffering from the sight of the waste.

In March, the Eko Centar Višegrad started taking water samples. However, the problem is long-term, and finding a solution will not be easy nor cheap. It has been proposed that towns upstream of the Drina should implement their own waste collection to prevent the waste from ultimately accumulating in one town, Višegrad.

Although the locals of Višegrad are not currently pursuing any legal actions, it may be worth considering. Whether actions are directed against the government as a whole for failing to implement more effective interventions, or against the surrounding towns that ultimately contribute to the floating landfill, legal action could serve as an effective tool in revitalizing the Drina in Višegrad. However, as Bosnia continues to heal its wounds from the war, it may not be surprising if locals encounter opposition when they express their desire to revitalize a river.

Despite the wounds of the war and the public health challenges that face Bosnia, it continues to strive for healing and renewal. Although locals of Višegrad continue to confront the tragedies of the war whilst facing public health challenges, they take it upon themselves to do it with a commitment of resilience and remembrance. I dream of the moment I can visit an emerald-colored Drina again, but ultimately, a nation whose wounds of the war are healed is something every Bosnian yearns for. Together, we envision a future where peace and prosperity flourish through our green landscape and the Drina River.

Women’s reproductive rights have always been topics of contentious political and legal debates in the United States. And in the wake of the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Org.—which held that the federal Constitution does not confer a constitutional right to abortion—reproductive rights will continue to have polarizing political salience for years to come. But there is an inescapable scientific and public health fact that lies at the heart of this debate, one which has no political allegiance: the alarming rates of maternal morbidity and mortality. To alleviate this disturbing issue, a new maternal health care model has been announced. The model has been dubbed the “Transforming Maternal Health Model,” or TMaH Model for short.

Data from the U.S. Centers for Disease Control and Prevention (CDC) speak to the sad state of affairs regarding maternal health in the United States. In 2018, the maternal mortality rate was 17.4 deaths per 100,000 live births. However, as of 2021, the rate had climbed to a shocking 32.9 deaths per 100,000 live births. Compared to other wealthy nations, the United States ranks last when it comes to maternal mortality; a perplexing acknowledgment given the cost and sophistication of the U.S. health care system. Many of these deaths were preventable, of course. According to data from Maternal Mortality Review Committees—”multidisciplinary committees that convene at the state or local level to comprehensively review deaths that occur during or within a year of pregnancy (pregnancy-associated deaths)”—an estimated 80% of pregnancy-related deaths in the United States between 2017 and 2019 were preventable. Disparities between racial and ethnic groups are especially worrisome. For example, based on 2021 data, non-Hispanic Black women had 2.6 times the rate of pregnancy-associated deaths than non-Hispanic White women. Nevertheless, amidst all these horrendous trends and statistics, not all hope is lost.

On December 15, 2023, the U.S. Department for Health and Human Services (HHS), through the Centers for Medicare and Medicaid Services (CMS), introduced the new model for maternal health care. The goal is to combat the maternal health crisis for those enrolled in Medicaid and Children’s Health Insurance Programs. CMS announced that the Biden Administration is focusing on maternal health disparities as well as the improvement in the postpartum health outcomes of mothers and the infants. This model could be a promising start to addressing maternal morbidity and mortality in the United States, however, many issues will require careful attention.

A CMS overview of the Model explains the ten-year plan to address the high rate of negative pregnancy results. The first three years of that plan will be dedicated to pre-implementation, and the remaining seven are dedicated to implementation and proper execution. The complete Model addresses three main pillars: access, quality improvement, and delivery.

Pillar I – Access to care, infrastructure, and workforce capacity: Many mothers do not have proper access to health care, both pre- and postpartum. Proper access for these mothers may include regular visits to doctors, prenatal care (such as prescribing of prenatal vitamins), and postpartum check-ups. In considering the previously discussed statistics, Pillar I displays the proposing parties’ hope that the rate of complications will decrease with the introduction of the proper access to maternal health care, and it may be likened to a gateway to the success of the overall Model.

Pillar II – Quality Improvement and Safety: The TMaH Model will be state-based. Participating State Medicaid Agencies will be collaborating with their local hospitals and health systems to implement the goal-based protocols, which will be “evidence-informed”. In reviewing the quality and safety protocols, which have been labeled “patient safety bundles,” it appears that the key to Pillar II is consistency.

Pillar III – Whole-person care delivery: Pillar III aims to provide customization and specialized care based on the mother and child. Each pregnancy is unique in nature and Pillar III aims to ensure that complications do not occur due to the failure of the health care system.

Data from 2019 provided by the National Library of Medicine offers that 98.4% of women in the United States gave birth in a hospital. Given that a vast majority of births occur in this setting, it makes sense that the procedures may be standardized. However, the mother and child would be at a disservice if these procedures were not tailored to the patients undergoing them.

The TMaH Model seems to show an understanding that a case-by-case approach may not be practical. However, it also demonstrates the desire by federal and state health authorities to utilize the data obtained to address the systemic failures at hand, while providing the specialized care needed for each patient.

Adjusting the procedures to each mother’s unique needs provides them the best possible chance at survival without complication. For example, one birth may require closer attention postpartum due to mother’s hypertension or history of substance use than another. This “closer attention” may take the form of increased postpartum check-ups or more careful prescription of medications for a mother that has known substance abuse issues.

The TMaH Model should be praised for its holistic approach to each pregnancy, keeping firmly in mind the “physical, social, and mental health needs” of the patients. In a time where women are losing control over whether they should be mothers, it is encouraging to see the health system try to provide those that are expecting with accessibility to proper care. One may argue that this overall goal is far-fetched given the increasing rate of complications. While this is a lofty goal, it is far from unattainable. The proposed pillars, timeline, and overall Model are all feasible if they are combined with the proper funding.

Funding opportunities for the TMaH model will be announced to state Medicaid agencies beginning Spring of 2024 and which hopefully provide the Model with the means to enact change.

The recent LePage v. Center for Reproductive Medicine decision by the Supreme Court of Alabama has brought the legal status of embryos to the forefront. The opinion has fueled a renewed interest about the future of in vitro fertilization (IVF). Within days after the ruling, a slew of press detailed the far-reaching implications of this decision for IVF treatment and the future of reproductive autonomy, fetal personhood, and access to care.

The Science:

IVF is a complex and expensive fertility treatment aimed at addressing infertility and preventing the transmission of genetic diseases. The process involves collecting mature eggs, fertilizing them with sperm in a lab, and placing the resulting embryos in the uterus to facilitate pregnancy. Some embryos are cryogenically frozen to preserve these fertilized eggs for future usage. But this is also not a medical procedure and process without risks. According to Mayo Clinic, there is a high risk as some embryo may be destroyed during the freezing process.

The Case:

In December of 2020, a hospital patient at the Mobile Infirmary Medical Center wandered into the Center for Reproductive Medicine in Mobile, Alabama. Having found his way into the reproductive health center via an unsecured door, the patient entered the Center’s cryogenic storage facility and removed several embryos. However, because of the subzero temperatures at which the embryos were stored, the patient’s hands were burned, causing him to drop the embryos on the floor, destroying them. The owners of the destroyed embryos filed suit against the Center and its governing hospital, asserting claims under Alabama’s Wrongful Death of a Minor Act, and, in the alternative, common law negligence claims seeking damages for mental anguish and emotional distress. According to the Alabama Wrongful Death of a Minor Act, the “death of a minor child is caused by the wrongful act, omission, or negligence of any person, persons, or corporation.” The trial court dismissed these claims, in part, finding that “in vitro embryos . . . do not fit within the definition of a ‘person’ or ‘child.’” On appeal, the Supreme Court of Alabama reversed the dismissal and defined the cryogenically stored embryos as children. In LePage v. Center for Reproductive Medicine, the Supreme Court of Alabama ruled that under the state’s Wrongful Death of a Minor Act, the definition of a “child” included the unborn, irrespective of their location (inside or outside a biological uterus).

Implications for IVF:

The decision by the Alabama Supreme Court has not only shaken many in the legal community, with some seeing in it the anti-abortion perspectives given credence in the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, but it has also taken the health care industry by surprise. The implications of this decision are far reaching, both medically and economically.

Since the decision was handed down in February 2024, several IVF treatment centers have postponed performing IVF procedures because they fear that not doing so will place them in legal jeopardy as lawmakers—both in Alabama and elsewhere—scramble to make sense of the ruling.

This ruling by the court is wrong, however. The legal recognition of embryos as children from the time of conception raises concerns regarding the legal status and protection of early pregnancies. This can potentially influence reproductive liberty by limiting medical procedures such as IVF and, more ominously, criminalizing natural processes.

Embryonic development is a complicated process that begins within twenty-four hours of conception, with rapidly proliferating cells that eventually mature into a fetus by the eighth week. At this stage, the zygote/embryo lacks any traits that can be associated with a child. The choice to equate embryos with children simplifies the complexities of early pregnancy. The fetal phase, which begins nine weeks after conception, indicates the stage of uterine expansion (after implantation). Identifying embryos as children weakens this critical difference, raising questions about the legal repercussions for pregnancies in their earliest and most fragile stages.

The ruling’s impact is particularly worrying when considering the frequency of miscarriages and early pregnancy losses. The Cleveland Clinic states that “[b]etween 10% and 20% of all known pregnancies end in miscarriage. Most miscarriages (80%) happen within the first three months of pregnancy (up to 13 weeks of pregnancy).”

In a recent opinion piece by Dr. Gavin E. Jarvis of Cambridge University, he argues that “Complex biologic processes do not work perfectly all of the time, including human reproduction. A recent re-analysis has concluded that pre-implantation embryo loss is approximately 10–40% and that total loss from fertilization to birth is approximately 40–60%.” If the public accepts the LePage decision, would that imply that approximately 40 to 60% of women who experience miscarriages, a natural and common occurrence in early pregnancy, could potentially be considered to have committed wrongful death of a minor? This point raises critical questions about where the legal responsibility would be drawn – would it extend to the doctor performing the IVF or even the mother in the early stages of pregnancy, creating potential liabilities for these parties in cases of pregnancy loss?

Advocating for reproductive rights involves a sophisticated understanding of the early stages of pregnancy as well as a rejection of the idea that embryos are equivalent to infants. Individuals’ rights to make informed decisions about their bodies and fertility require a legal framework that recognizes the intricacies of reproductive biology. If sustained, the LePage decision may violate human liberty and interfere with medical treatments, underscoring the need for a more educated and nuanced approach.

In addition, this decision will also have a significant influence on the economy. The potential economic consequences of a state losing IVF services are noteworthy. According to Forbes, the average cost for an IVF treatment in 2024 is $15,000 to $20,000. If such legal and political impediments to IVF procedures continue, the result could be reduced business activity and downstream impacts on a state’s economy. There’s a concern that in states without criminal penalties for IVF, the average cost might increase significantly, possibly reaching $50,000. There is also the possibility of aggregation principle, affecting interstate commerce.

The potential loss of IVF services by a state because of legal challenges has the potential to cause substantial disruptions to both interstate commerce and the overall national economy. The implementation of such limitations may result in a decrease in commercial operations for healthcare providers, motivating individuals to pursue IVF treatments in alternative states where services are more readily available. This would lead to increased healthcare expenditures outside of the state, which would have a good influence on the economies of those states and a negative impact on the economy of the state that does not provide IVF. Moreover, the escalated expenses associated with IVF might potentially burden insurance systems and government healthcare programs. Healthcare companies may reassess their investments and operations in IVF unfriendly states, resulting in employment cuts, less tax income, and lower economic activity. The combined impact of these elements has the potential to initiate government action or regulation in order to rectify economic disparities and guarantee widespread availability of vital healthcare services across the country.

The LePage decision presents a substantial threat to reproductive rights. The ramifications extend well beyond the courtroom affecting the lives of millions of people navigating the complexities of pregnancy as well as the health care industry.

For several decades, medical aid-in dying (better known as physician-assisted suicide (PAS)), has been at the core of a controversial debate in bioethics between federal and state legislatures. While the United States Supreme Court has deliberated over a patient’s right to refuse life-sustaining treatment against the state’s interest in preserving life, it has also rejected PAS as a substantive right protected under the Constitution. Despite this, several states have taken steps to ensure their citizens, specifically those suffering from terminal illnesses, have the right to die on their own terms. Currently, in the United States, ten states and the District of Columbia have legalized PAS for terminally ill patients. This has primarily been accomplished via state policy reform and implementation of “Death with Dignity” statutes. These state laws provide terminally ill residents with the legal right to obtain prescriptions that will allow them to end their lives. The question that remains, however, why are the federal government and non-death with dignity states reluctant to extend this decisional autonomy to the rest of the country? Given that the Constitution prevents the federal government from intruding into our personal and often private decisions, should we not be allowed to decide our means of death?

The core issue of PAS boils down to whether an individual right to end one’s life is guaranteed under the Constitution. In Washington v. Glucksberg, the Supreme Court was asked to decide whether Washington State’s prohibition on “causing” or “aiding” suicide went against the Fourteenth Amendment’s  due process liberty interest. Looking to the nation’s history and traditions around the treatment of suicide, the Supreme Court found that no such right to die existed, and that, in fact, it was quite distinct from the right to refuse life-sustaining medical treatment. The court used an originalist approach in its decision and concluded that the legalization of PAS would violate traditional notions of the Fourteenth Amendment’s Due Process Clause. However, they held that PAS legalization was a substantive issue for the states to decide.

States that allow for PAS often enact requirements that follow the regulations and requirements first established under Oregon’s 1997 “Death with Dignity” Act. Statutes like Oregon’s allow qualifying terminal patients the right to end their lives with a prescribed lethal medication approved by their physician. The law requires an extensive patient/physician request process. This ensures a physician provides the correct treatment option to their patient and that the patient is fully consenting and aware of the requested procedure and its outcome. States with “Death with Dignity” statutes will also require the patient be a legal adult, capable of deciding and voicing their own healthcare choices, have a diagnosis of a terminal illness that will result in death within six months, and a resident of the state but this requirement has become loosened in some PAS states. Additionally, the patient must submit various oral and written requests to their physician and may even be required to undergo a physiological evaluation. This decision is only that of the patient and at the discretion of their physician. By states introducing such statutes, they are creating an effective procedural process that, on a state level, would allow their citizens affected by terminal illness to have guaranteed substantive rights even if the federal Constitution does not encompass them.

Although states like Oregon and California have shown the benefits of enacting PAS statutes, there is still significant opposition from various coalitions representing medical professionals, religious groups, and disability rights groups that have made legislative progress towards expanding PAS availability quite tricky. This objection is often rooted in a divide between moral/ethical ideologies and the potential risk of harm to the medical field. There is no doubt that there is a divide between pro-life and pro-choice organizations, reformists, and legislatures who have contradicting views of the practice. Pro-life advocates find legislative initiatives in favor of PAS to defile the sanctity of life by putting a vulnerable population at greater risk of improper treatment and diminishing their rights. On the other end of the spectrum, PAS advocates, such as the organization known as Compassion & Choices, argue that PAS can empower a terminally ill patient to have complete control of the remainder of their life, while also calling for a “patient-directed system” that prioritizes a patient’s wishes while also reforming end-of-life care policy.

Aside from political influences, there is a concern that a wider acceptance of PAS may tarnish the medical field, including potentially increasing the risk for medical abuse. Many have pointed to the fact that a physician taking part in a PAS procedure is in direct contradiction to their role as a healer and violating their ethical duties to preserve life and do no harm. While this is true from a traditional perspective, more modern iterations of the Hippocratic Oath do not prohibit nor make physicians promise not to participate in certain practices. The development of the oath has recognized the necessity of modern medical interventions and shown an awareness of novel health care issues while maintaining a commitment to individuals receiving sufficient care and treatment. Thus, under the modern Hippocratic Oath, PAS could be deemed an acceptable form of care among physicians who choose to participate in the practice.

While a state can legalize the practice of PAS, no law requires or forces physicians to take part in the treatment if they object to its practice on social, political, religious, or ethical grounds. There is also a concern about PAS becoming a sanctioned form of medical abuse were it to take some of the place of current end-of-life care. While this would be an extreme implication, such slippery slope arguments are not without merit given the history of medical abuses that have been targeted towards vulnerable communities. Based on this hypothetical, there is the concern that physicians could push PAS onto patients who cannot afford other treatment options, restrict hospital resources for terminal patients, or even coerce patients towards PAS because it could eliminate the “unnecessary” burdens related to long term care.

A federal right to PAS is unlikely, given the Supreme Court’s focus on only recognizing those rights deeply rooted in the nation’s history and traditions. Other avenues for future legalization, such as through congressional legislation, would be unlikely given Congress’s longstanding opposition to PAS, including a ban enacted by the 105th Congress that prohibits the use of federal funds for PAS programs. However, I envision other progressive states slowly moving towards implementing the pro-PAS legislature. Currently, state legislatures in Maryland, Massachusetts, and Michigan, to name a few, are optimistic about the potential that PAS-related bills will be introduced and voted on throughout 2024, given the uptick in public and legislative support.

The future success of PAS lies in limiting it to a genuine last-resort option. This would require the patient to undergo other treatment(s); if there is no success, then a physician can identify PAS to their patient. From there, the patient must follow the required PAS procedures to be considered a proper candidate for the treatment. Additional safety nets could also be established, such as third-party mediation between patient and physician interactions regarding the treatment and recording the number of patients who have undergone treatment at a particular facility or physician.

PAS is a remarkable treatment option for those who genuinely have exhausted all other options and are confronted with an end to their lives that lacks the dignity and control they’ve exuded throughout the rest of their lives. It allows the individual to have complete autonomy over themselves at a point of extreme vulnerability where they may feel powerless. While controversial, I believe PAS has widespread use within the medical field but must be under stringent regulation and only applicable to the most severe instances. However, we still have to work towards a future in which policymakers and the general public can feel confident in this treatment and change their views of PAS to one centered around the benefits of autonomy and preventing unnecessary suffering.

The term “Rural America” invokes certain ideals and feelings on what it means to be American. The classic image that often springs to mind is that of American Gothic, which perfectly encapsulates what it is that so many in this country are nostalgic for. Family, arduous work, agrarianism, and even the woman being placed behind the man because she knows her place in that world: a perfect picture of an imperfect society. Yet, the yearning and desire to return to this simpler, more banal lifestyle is already taking a toll on its most vulnerable members: mothers and expectant mothers.

The current outlook for maternal health post-Dobbs v. Jackson has trended toward the negative. Maternal mortality rates have continued to rise in the U.S. without any sign of abatement and it is even worse for women specifically located in rural America. OBGYNs across the United States see worsened impacts on racial and ethnic inequities, management of pregnancy-related medical emergencies, mortality, and even attracting new OBGYNs to the field post-Dobbs.

This is just the general state of maternal health across the United States. In states that have enacted abortion bans the situation is becoming worse. In Idaho, there are fewer applications for OBGYNs seeking residency, in Texas more than half of its counties lack obstetrician-gynecologists, and in West Virginia, less than a third of its counties have hospital birthing centers. Among those states, the women who have access to reproductive care are often in the urban areas, whereas rural residents had a 9% greater chance to suffer maternal morbidity compared to urban residents, and the risks of preterm births (associated with issues such as intellectual disabilities, asthma, etc.) are higher without access to obstetrician care which rural women have less access to.

What’s more, the closure of rural maternity wards has continued to grow in a cyclical feedback relationship, with OBGYNs either not seeking employment in those communities or moving elsewhere due to conflicts with restrictive abortion bans which results in maternity wards closing.

As more maternal medical personnel leave a certain area, they create something called a maternity care desert. A maternity care desert forms when a county has no obstetric hospitals or birth centers and no obstetric providers. These maternity care deserts are going to continue growing and disproportionately impact rural women in the South and Midwest particularly. Further studies show that nearly two-thirds of the maternal deaths that occur are preventable had the expectant mother had access to a maternity ward. If the trend of rural maternity wards closing continues, then the number of dying mothers will also continue to grow even though their deaths are entirely preventable.

It is not enough that rural women already face poorer health outcomes and have less access to health care compared to urban women, but many live in states that have enacted the strictest bans on reproductive health while also providing the lowest support for maternal health. It would rise to the level of comedy if this issue were not impacting some of the most vulnerable citizens in the country. One counterargument to this is to point out that women and mothers can choose how to manage their health best, but that relies on the presumption that women have choices they can pursue in these situations.

Expectant mothers in rural America are often faced with a dichotomic choice: finance themselves by moving to a nearby urban area to safely give birth under the care of OBGYNs or attempt a homebirth with all the associated risks that come from the decision. This choice presumes that hopeful mothers can finance their way to give birth, but the issue is compounded when taking into account that rural areas in general have less financial support. This poverty, coupled with the fact that states that deny access to reproductive health care are condemning women and their children to deeper poverty, shows the powerlessness for many mothers in rural America from lack of financial support.

Without the financial backing that is consistent with higher education and careers that accompany women with access to reproductive health care, it will only continue to make women in rural America more likely to become mothers without being ready to care for a child. This leads to them to become less financially stable, undereducated, and reliant on marital ties to make ends meet.

With such a bleak picture presented, the natural inclination is to ask what can be done. For example, Idaho has led the way in a new heterodoxic approach by simply discontinuing its maternal mortality review committee, becoming the only state without one.  While novel, it is not the approach that helps mothers if we elect to stop reporting their deaths.

The most straightforward solution is to legalize access to reproductive health care via abortion and contraceptives. There is endless evidence that when women are able to control their own reproductive health, it improves economic and healthcare outcomes. Since abortion continues to find itself as one of the seeming controversies of this century, there are alternatives.

One solution is to approve out-of-state healthcare providers as state Medicaid providers. This would allow the state to reimburse expectant mothers who need to travel across state lines to access obstetrician care and leave more money in their pockets to provide for their families. The current situation of Medicaid across the U.S. is heavily dependent on which state you are residing in, but if women in Coeur d’Alene, Idaho could go across the border to Washington for obstetrician care without incurring large amounts of debt, then they could receive much needed maternal support and prevent being one of the two-thirds of maternal deaths that were preventable.

Another solution is for the state to provide housing for expectant mothers who live far from maternity wards akin to Ronald McDonald House Charities. Maternity housing is usually run by anti-choice crisis pregnancy centers and these maternity houses are usually in states that have the highest rates of maternal mortality and poverty. If states were to step in and provide government-sanctioned housing before, during, and after birth, then they would be able to remove these predatory institutions that seem to thrive on using vulnerable women who often have no other place to go. The mother would have their room and board provided for by the state while staying and then, after delivery and subsequent evaluations, would be able to return to their rural communities without incurring monolithic amounts of debt and save the mothers from predatory pregnancy centers.

One last solution would be to expand telemedicine and clinic networks to facilitate access to maternal medicine consultation services. In Idaho again, telemedicine has been at the forefront of bringing much-needed medical access to rural communities in a cost-effective manner that was even able to weather the COVID-19 pandemic. If telemedicine is possible for deeply rural communities, then it is not much of a stretch to add on obstetrician care as an addendum. This issue is now gaining more traction as maternal telehealth becomes more in need for women who require contraceptives in states that have banned access to reproductive services and are looking for alternatives.

Ultimately, the patchwork of abortion laws that has sprung up post-Dobbs has resulted in increased maternal mortality rates that disproportionately affect rural women. If this new American Gothic is to continue, then instead of the woman being behind the man it would have to leave women out of the painting entirely, since rural mothers are the ones impacted most and have the least say in decisions over their reproductive health. If this continues, and rural America keeps leaving its women behind, how can the nostalgia for the rural parts of the nation continue when they only support half of their population?

For a brief moment, imagine that you are a mother of three loving children whom you take care of to the best of your ability, despite living in a one-bedroom rental space. Unfortunately, one of your children has scabies, a rash that is an infestation of mites on the top layer of skin where they burrow and lay eggs; it is spread from person-to-person by direct exposure with an individual who has the disease, such as household members. To take the best precautionary steps, you take your three children to a pediatric doctor in hopes of treating the entire family before the scabies further spreads. However, your doctor only prescribes medicine for two of your children, the two that do not have scabies – yet. Your third child, with the scabies, cannot receive a prescription since their account has been locked due to unpaid bills surrounding their health issues. This is just one of many examples of a wealthy nonprofit health system taking advantage of its patients.

Allina Health System (Allina Health) is a large nonprofit system throughout Minnesota and Wisconsin where it manages more than 100 hospitals. Allina Health details on its homepage that, “Health care can be complicated but it doesn’t have to be.” However, do Allina Health’s words mean anything?

An investigative New York Times article discovered that Allina Health had not allowed patients to seek or receive care if they have unpaid medical bills. Not only that, but for patients to finally receive the care they truly need, their entire bill must be paid off. This policy was suspended in March 2020, but started back up in April 2021. Staff were instructed to withhold care, and even cancel appointments if a patient is in at least $4,500 of debt.

Since Allina Health is a nonprofit hospital system, it didn’t have to pay $266 million in taxes. However, in exchange of its nonprofit status, the Internal Revenue Service (IRS) requires Allina Health to help its community which requires providing free and/or cheaper care to individuals with low incomes. The IRS did not set a minimum low-income amount that Allina Health could use as a guide which resulted in Allina Health spending less than half of one percent of its assets on its deal with the IRS.

The issue at hand only involves patients who required treatment from specialists and clinics, not the hospitals. Per federal law, hospitals are required to treat those who come into its emergency room, notwithstanding whether or not the patient will be able to pay the bill at the end of their care. However, the Emergency Medical Treatment and Labor Act does not explain how patients should be treated when they are receiving other kinds of care.

It should be of no shock that many individuals nationwide are in debt, especially medical debt. In Minnesota, where the majority of Allina Health hospitals are, 109,000 individuals in the state are in medical debt, totaling to $148 million. For a moment, recall the deal that Allina Health had with the IRS. Allina Health’s annual revenue is around $4 billion, and it could have wiped out the entire medical debt of Minnesota if they had upheld the end of their deal. Instead, the nonprofit did not have to pay taxes and it did not benefit their community, rather it served as a detriment.

Although money plays a large role in this issue, the immeasurable impact that this had, and continues to have, on families in the Midwest is detrimental and could be life-altering. Physicians of Allina Health have even come out and spoken against the nonprofit’s predatory practice. One doctor said that, “Nobody wins when patients can’t get preventive care.” Other employees of Allina Health have also shared their own experiences; a receptionist detailed that the computer system itself would not let her schedule appointments for patients in debt even if she wanted. Adding on, if an employee cancels an appointment, but the patient later pays off the bill, the canceled appointment is not restored. One Allina Health patient, JoLynda Anderson, had her appointment canceled due to her debt, and was enrolled into monthly payment plans. Even with the payment plans ready to go, Anderson could not attend the appointment since all her debt had not yet been paid off; she had been waiting for this appointment for nearly four months. Allina Health says that prior to taking away a patient’s care, its employees will call and send many letters about the patient’s debt before they reach the debt threshold. However, just because they notify the patient does not mean that it is a measure put into place for the patient’s best interest.

Minnesota Attorney General Keith Ellison is actively looking into the situation and urges those affected by Allina Health’s “aggressive billing practices” to contact his office to further understand whether any laws or agreements have been breached. Allina Health hospitals have a zero tolerance policy for abusive, harassing, oppressive, false, deceptive or misleading language when looking at medical debt. Keith Ellison is working hard to create a conversation and ask the hard questions that Allina Health does not want to hear.

Personally, I believe that as a nonprofit organization, Allina Health should not be taking advantage of patients who are vulnerable due to both their low-income status and health issues. What could possibly be the solution? Unfortunately, I do not see a definitive “fix” for this issue. There cannot be one solution since patients in the past have been subject to this predatory practice and nothing will change what they went through. Liz Reyer, a Democratic representative of Minnesota said it best: “[T]hey’re [patients] not buying nice new clothes or a nice new car; they’re taking care of their health.” Money cannot fix the problems of the past. However, money continues to be the most important factor for Allina Health.

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It sure seems as if Allina Health should update their home page. It cannot say that, “[Y]our [patients’] health is our top priority” if they refuse patient care the moment money is brought into the equation.

The quick-paced nature of the healthcare field is at play with this topic. In the midst of writing this blog post, the New York Times published an article entitled “Nonprofit Health System Pauses Policy of Cutting Off Care for Patients in Debt.” On June 9th, 2023, Allina Health announced that it would stop withholding patient care from those in debt as it takes a closer look at its policy. This is a large triumph; however, there is still one major fault. Although Allina Health is temporarily halting its predatory practice, it will not restore the care that has been withheld from patients in the past.

Matt Hoffman, an Allina Health physician, said that the stoppage of withholding care has given him hope that Allina Health will make the requisite changes that are needed. He hopes that Allina Health does the right thing and reinstates patients who have been affected.

I hope that Allina Health’s new policy change is not a scheme of false hope. After all, Allina Health stopped this particular practice when COVID-19 started to pick up. However, it was later put into practice again. I have low expectations for Allina Health, and it is only a matter of time before it upsets individuals once more if it continues its predatory practice.

As of 2023, a whopping 26 states lacked legal safeguards to prevent discrimination by private healthcare insurance companies against LGBTQ+ individuals. States like Tennessee and Mississippi have recently passed legislation permitting medical discrimination against LGBTQ individuals, specifically the transgender community. Tennessee Senate Bill 0001 and Mississippi House Bill 1125 fully ban gender-affirming healthcare for transgender minors. These states are only two of many whose legislators have lobbied for restrictions on gender affirming related healthcare access or passed legislation to effectuate such restrictions.

Generally, gender-affirming healthcare is a supportive form of healthcare that consists of an array of medical, mental health, and non-medical services for transgender and nonbinary people. Gender-affirming healthcare for minors can consist of treatments such as hormone therapies, puberty blockers, and, on the rare occasion, surgeries. Typically, this care has been covered by insurance. However, recently, some states have either begun to put restrictions in place regarding a minor’s ability to receive this kind of care or have allowed for private insurance companies to refuse to cover such care all together.

Critics of legislation prohibiting gender affirming care and insurance safeguards worry that misinformation about gender-affirming healthcare invited tighter restrictions on obtaining gender-affirming healthcare. For example, Vanderbilt Medical Center had to deny rumors that surgeons performed genital surgeries on minors because misinformation was being spread as an attempt to criticize them for providing gender-affirming care. In fact, Vanderbilt has only ever performed limited chest surgeries for minors, which is still a procedure which requires the patient be at least sixteen years old and obtain full parental consent. In other words, just because a minor has access to gender-affirming care this does not mean that child is able to get any significant surgery or treatment at the drop of a hat, without parental consent, as critics suggest.

In addition to the challenges to accessing care stemming from misinformation campaigns, proponents of LGBTQ rights have continuously emphasized that access to gender-affirming healthcare saves lives. This is critically important when transgender individuals suffer from high rates of suicide. Research shows that gender-affirming healthcare improves the overall mental health and well-being of gender diverse adolescents. In particular, transgender minors are subject to significant health disparities compared to their cisgender peers. Therefore, legislation banning such care is likely to enhance such disparities since transgender minors are being restricted access to healthcare that can be truly lifesaving.

As a society that, in recent decades, has made leaps and bounds in promoting LGBTQ rights, we should be grateful for the progress made thus far. However, at the same time we should still be aware that these recent restrictions could begin to substantially erode that hard won progress. We still have work to do. Until all states provide LGBTQ individuals with inclusive insurance protections, both through private insurers and state employee insurance benefits, the fight for such rights is far from over.

Jim Sheldon-Dean has worked in HIPAA, health information privacy, and security regulatory compliance for 23 years. He speaks about HIPAA at conferences, conventions, and private educational sessions. I attended his webinar which discussed HIPAA, texting, and email.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal statute that prohibits the disclosure of patient health information (PHI) without the patient’s consent or knowledge. HIPAA seeks to prevent healthcare fraud by securing PHI and restricting access to health data. It mandates that all HIPAA-covered entities implement safeguards to secure sensitive personal and health information. (Why is HIPPA Important, The HIPAA Journal). HIPAA contains three rules: the privacy rule, the security rule, and the breach notification rule. The privacy rule governs uses and disclosures. The security rule applies to electronic PHI and employs a risk analysis to identify and plan the mitigation of security risks. The breach notification rule mandates that violations of PHI be reported to Health and Human Services (HHS) and the affected individuals.

The HIPAA Breach Notification Rule defines a breach as “an impermissible use or disclosure . . . that compromises the security or privacy of the protected health information.” In the event of a breach, entities must notify the affected individuals and HHS. Privacy breaches have detrimental effects on individuals and organizations. Noncompliant organizations incur penalties and fees, suffer reputational harm, and be subject to potential lawsuits. The exposure of the affected individuals name, address, credit card information, social security number, and medical conditions results in a loss of privacy and the potential for identity theft.

Patients and providers in healthcare are increasingly communicating through email and text messaging. Many patients prefer email or text messaging because it is a quick and convenient way for managing appointments, receiving test results, and asking healthcare related questions. Providers also prefer email and text messaging to access patient information, communicate with hospital staff, and maintain an appointment calendar.

While texting may be convenient in healthcare, it also has many shortcomings. Most importantly, there is an increased risk of violating HIPAA. Email and text messaging are insecure forms of communication that may be accessed or exposed by unknown third parties. Furthermore, there is no straightforward method for physicians to document the email or texting encounter. Finally, the inability to prioritize incoming text messages, may result in a crucial test result sitting in the patient’s inbox for more than 24 hours.

To reduce the risk of breach, organizations and providers must remain flexible. Organizations should provide and promote the use of secure communication solutions. Hospitals should educate staff on the dangers associated with plain email and explain what should not be sent through email or text message. There are also secure private emails and secure text messaging applications that can be used to safeguard communications of PHI. Cortext by Imprivata, TigerText, DocHalo are some secure text messaging and email options physicians can use. Lastly, it is essential for organizations to implement policies and procedures governing the use of email and text messaging. These policies should include a risk analysis, a process for approving and monitoring uses, guidelines for acceptable email and text messaging interactions, and the identification of secure services.

Overall, organizations should facilitate and try to comply with patient requests as much as possible. Patients have the right to choose their preferred mode of communication, even if it is an insecure method. However, providers should explain the risks associated with insecure communication methods, obtain the patient’s consent, and notify those with whom the patient communicates of their preference. Having policies in place will enable physicians to document and manage these requests appropriately.

In conclusion, email and text messaging are inherently insecure forms of communication. Even if individuals have a right to use insecure means of communication, they must be informed of the potential for security breaches. Recognizing the inevitability of these communications, healthcare organizations should implement policies addressing email and texting, and ensure these modes of communication are HIPAA compliant.

In the months since Dobbs v. Jackson Women’s Health, access to birth control has become a contentious topic. Whether individuals have access to hormonal birth control is becoming a fear for people who rely on it for health reasons including regulating hormones and improving acne. Allowing pharmacists to prescribe and dispense hormonal birth control would help mitigate barriers and expand access to contraception.

Since 2020, more than ten states have expanded or strengthened pharmacists’ prescriptive power to include contraceptives. That means there are now twenty-four states and Washington DC that permit pharmacists to prescribe this important medication. There are many benefits to allowing pharmacists to prescribe and dispense hormonal birth control. Pharmacies are more accessible than a clinic or hospitals in many communities, they generally have more accessible hours, and do not always require appointments. These benefits allow more people to have convenient access to hormonal birth control.

Additionally, research has demonstrated that patients are in favor of increasing prescription power because of convenience and accessibility. A study in California found that seventy-four percent of survey respondents chose to visit a pharmacist for contraception because it would be quicker than getting a doctor’s appointment. Real-world applications of this have already taken place in states like Oregon. Two years after Oregon implemented its pharmacist-prescribed contraception protocol, it prevented an estimated 51 unintended pregnancies and saved the state $1.6 million.

Even with all the benefits, expanding pharmacists’ roles creates some challenges. To begin these programs, states must implement sufficient billing infrastructure, find ways to pay pharmacists for their extra services, comply with privacy and confidentiality standards, and make sure pharmacists are adequately trained in prescribing hormonal birth control to ensure patient safety.

There are multiple legal and regulatory processes that must be put into place to allow pharmacists to expand prescribing power. One potential process is giving pharmacists outright prescriptive authority, which allows pharmacists independent power to prescribe hormonal birth control. This framework specifies certain conditions where pharmacists are authorized to prescribe certain medications. Pharmacists are given specific procedures from a state board of pharmacy, and they are required to follow the instructions given when prescribing birth control to patients. Another option is implementing a collaborative practice agreement. In this framework, pharmacists and pharmacies are in partnership with other healthcare providers, and the pharmacists are authorized by physicians to select, initiate, monitor, continue, and adjust medication regimens for patients.

By implementing these programs, individuals will be able to get birth control in a more convenient way. This is especially important for women and individuals needing birth control in a post-Dobbs world where access to contraceptives is being challenged throughout the courts.