August 30, 2018

The Honorable Secretary Alex Azar
U.S. Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue S.W.
Washington, D.C. 2020

Dear Secretary Azar,

As organizations representing more than 4.4 million health care providers and providers in training across the United States, we write to express our opposition to the Trump Administration’s proposed changes to Title X, the nation’s only family planning program dedicated to providing affordable birth control and reproductive health care, such as testing and treatment for sexually transmitted infections, and lifesaving cancer screenings. In support of the millions of people who would be most harmed by this damaging policy, as well as the health care providers who serve them, we express our strong opposition to the proposed rule because it would: inject government interference into the patient-provider relationship; require providers to withhold information from their patients about all health care options, violate bedrock principles of health care professional ethics; and limit access to basic, preventive reproductive health care by restricting reproductive health providers’ ability to participate in the program. We strongly urge you to withdraw the rule.

The proposed rule would irreparably harm the patient-provider relationship. High-quality health care is founded on complete, accurate, and unbiased information. It also relies on a relationship of the utmost trust between a patient and their health care professional. Currently, consistent with the highest professional and ethical standards of care, Title X-funded providers must offer pregnant patients counseling on and referrals for all of their options, including adoption, prenatal care, and abortion.i The proposed rule would inject politics and ideology into the examination room by prohibiting providers from giving patients information on how and where to access abortion. This restriction would hinder open and honest conversations between patients and their providers, undermining that pivotal relationship, and threatening providers’ ability to provide care in line with their best medical judgement.

The proposed rule would put providers in ethically compromising positions. The American Medical Association’s Code of Medical Ethics stipulates that providers “present relevant information accurately and sensitively, in keeping with the patient’s preferences” and that “withholding information without the patient’s knowledge or consent is ethically unacceptable."ii,iii The Code of Ethics for Nurses similarly stipulates that patients have the right “to be given accurate, complete, and understandable information in a manner that facilitates an informed decision,” iv and the American Nurses Association’s position is that health care providers must “share with the client all relevant information about health choices that are legal and to support that client regardless of the decision the client makes.”v These foundational principles, shared across health care professions, recognize that a patient’s informed consent and access to medically appropriate care is dependent upon both having all treatment options presented and referrals to appropriate providers. The rule, if finalized, could place Title X providers in a situation whereby they could be forced to withhold full information from patients in order to participate in Title X, which is an untenable position for any health care provider.
 
The proposed rule would reduce access to preventive care. Under Title X, program funds already cannot be used to provide abortion; however, the proposed rule goes further, prohibiting Title X grantees from independently offering abortion services with non-federal funds.vi Collectively, with the prohibition on abortion referrals, these provisions are clearly designed to make it impossible for providers who offer comprehensive reproductive health care, like Planned Parenthood, to serve patients in the Title X program. Given that Planned Parenthood alone serves over 40 percent of the program’s patients nationwide, its elimination from Title X would result in massive gaps within the remaining Title X provider network.vii This decreased access to services would, almost certainly, lead patients to delay or even forgo critical care.

Finally, these changes would further entrench inequity in our nation’s health care system, which too often denies high-quality care and information to underserved populations including low income people and communities of color. The undersigned organizations therefore stand in opposition to the proposed rule and any other policy proposals that interfere with the patient-provider relationship, violate professional ethics, and limit access to high-quality, affordable family planning care under the Title X program.

Sincerely,

Planned Parenthood Federation of America
Abortion Care Network
American Academy of HIV Medicine
American Academy of Nursing
American Academy of Pediatrics
American College of Nurse-Midwives
American College of Obstetricians and Gynecologists
American Medical Student Association
American Medical Women’s Association
American Nurses Association
American Society for Reproductive Medicine
Aphrodite Medical
Association of Nurses in AIDS Care
Association of Women’s Health, Obstetric and Neonatal Nurses
Bixby Center for Global Reproductive Health, UCSF
Blue Mountain Clinic
Doctors for America
Fellowship in Family Planning
Feminist Women’s Health Center
HIV Medicine Association
Kennth J. Ryan Residency Training Program
Lancaster Health Center
Medical Students for Choice
Midwives Alliance of Hawaii
National Abortion Federation
National Association of Social Workers
National Hispanic Medical Association
National Physicians Alliance
Physicians for Reproductive Health
Society for Adolescent Health and Medicine
Society for Maternal-Fetal Medicine
University of New Mexico School of Medicine, Department of Obstetrics and Gynecology
Women’s Care of Hartsville

i Christina Fowler, et al., Family Planning Annual Report: 2016 National Summary, RTI International (Aug. 2017), available at
https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2016-national.pdf (“FPAR 2016”).
ii American Medical Association Code of Medical Ethics Opinion 2.1.1.
iii American Medical Association Code of Medical Ethics Opinion 2.1.3.
iv American Nurses Association. Code of Ethics for Nurses Provision 1.4
v American Nurses Association. Position Statement: Reproductive Health (1989, 2010). https://www.nursingworld.org/practicepolicy/
nursing-excellence/official-position-statements/id/reproductive-health/
vi 42 U.S.C. § 300a–6.
vii Jennifer J. Frost, et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, Guttmacher Institute (Apr. 2017), available at
https://www.guttmacher.org/sites/default/files/report_pdf/publicly_funded_contraceptive_services_2015_3.pdf.

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