Obama: change for good?

André Van Mol outlines his concerns.

The election of Barack Obama gives the United States (US) its first African-American president and the developed world its first black head of state. For the media and much of the public, it has been an undiluted celebration. When I look beyond the historic milestone and through a Christian worldview, my enthusiasm dims for many of Obama's stated intentions. His campaign slogan was 'hope and change'; but how will his new policies actually impact medical ethics, research priorities, health care provision, and international aid? What differences from the Bush administration can we expect?

meet the new president

Before Obama's meteoric rise to the land's highest position, his time in elected office was limited to the Illinois state senate and a partial term as a US senator. But his intellect, drive and people skills were proven early on at law school (where he became the Harvard Law Review's first African-American president), and during his time teaching constitutional law at the University of Chicago.

His political convictions are starkly drawn: of 100 US senators, his was the most liberal voting record of any. (1) Obama's promise to reach across the political aisle is inviolable; he was at the leftward extreme of the Senate, thus making a policy compromise with anyone else a de facto move to the right.

Obama has professed Christianity for around 20 years. His home congregation was Chicago's Trinity United Church of Christ (belonging to a profoundly liberal denomination). Its pastor is Jeremiah Wright, whose incendiary comments and black-identity views brought widespread publicity, little of it flattering. (2)

a time for change?

President Bush left office with a dismal one third approval rating. (4) His post-9/11 favour steadily eroded over time due to negative perceptions and imagery associated with: the Iraq war, Abu Ghraib, Guantanamo Bay detention camp, the Patriot Act, the Homeland Security Act, wire taps, hurricane Katrina, Vice President Cheney, Defense Secretary Rumsfeld, the Wall Street meltdown, and the banking crisis among other controversies. Whichever of these names rings familiar, the general public's esteem of it will be poor. On the other hand, some (like Sir Bob Geldof) have expressed frustration at the lack of recognition for Bush's landmark initiatives. (5) He oversaw a vast expansion of non-military government spending. Prescription drug coverage was provided for 32 million Medicare recipients at a cost of $40 billion in 2008. (6) Likewise, the Bush team carried out the most sweeping overhaul of US foreign aid infrastructure in 40 years. (7)

Introduced the President's Emergency Plan for AIDS Relief (PEPFAR)
(8) Provided a third of all support for the Global Fund to Fight AIDS, Tuberculosis and Malaria (5)
Contributed half of all food aid to Africa (5)
Began a $350 million fund to fight neglected tropical diseases (9)
Launched the Millennium Challenge Corporation to reward poor nations for good governance and economic freedom (10)
Twice continued authorisation to allow tax-free imports to the US market (11)

As commander-in-chief of the world's largest military, Bush, like his predecessors, did not hesitate to exercise the global reach of American armed forces for disaster relief on many occasions (as he did within hours of the Asian tsunami).

Bush's vibrant pro-life ethics were well known. He prohibited government funding of embryonic stem cell (ESC) research on lines developed after 2001, but did not ban ESC research, (12) contrary to mistaken media reports. In 2003, he signed into law the Partial-Birth Abortion Ban Act and the Trafficking Victims Protection Reauthorization Act. His administration strongly championed rights of conscience. In 2001, he restored the 'Mexico City policy' of refusing US government funding for overseas family planning groups that provide or counsel for abortions.

meet the US and its government

Our constitutional separation of powers between government branches (executive, legislative, and judicial) is designed to ensure checks and balances. Americans inherently distrust government agencies with even the appearance of excessive authority. As reflected on our currency and in our national pledge of allegiance, this 'one nation under God' is the one most influenced by biblical Christianity. It is also the most ethnically diverse, aspiring to the national motto of 'E Pluribus Unum' (3) ('Out of many, one'). Even with the wide swing of leadership, the transition from the Bush administration to that of Obama's was carried out peacefully, as is our long tradition.

Though a left-of-centre president was elected, we remain a solidly right-of-centre nation. Nonetheless, a cultural war has been afoot for decades - liberal versus conservative; secular versus believing; and it only heats up with time. Obama's leftist supporters expect vast policy, legal, and - ultimately - cultural transition.

For example, gay marriage is a consistent loser at state ballot boxes (even here in my liberal California), but it is advanced through activist judges and courts. The left looks for Obama to nominate liberal Supreme Court justices, with similar appointments anticipated for lower positions in the judiciary. If the highest court becomes leftward stacked, new options for change would manifest that might not otherwise be feasible strictly democratically. Though Democrats now hold large majorities in both the House and Senate (the government's legislative bodies), a number are at least as conservative as their Republican counterparts and could side with them on economic and social issues, so not all is as it seems.

changing of the guard

The 'Mexico City policy' was reversed by Obama as one of his first reforms. A national poll exposed this decision as his least popular so far, with a 58% disapproval rating. (13) He will attempt to do precisely what he promised regarding medical ethics, health care provision, and research - namely drive through the most radical policy changes in memory. Obama is already using executive orders to speed his agenda; including putting a hold on Bush's end-of-term orders until his team reviews them.

Obama has been a supporter of abortion on demand. (14) In 2003, he voted against the Born Alive Infants bill 15 (patterned after a 2001 federal bill protecting babies who survived abortions, entitling them to medical care rather than disposal). How far will he go? Will he mandate that federal insurance plans pay for abortions, overturn the ban on late-term abortions, remove fetal coverage from the Children's Health Insurance Program, and reverse state laws either limiting abortions or requiring waiting periods or parental notification? (16)

He asserted last year that he would sign the Freedom of Choice Act (FOCA) designed to remove most impediments to abortion on demand. But even in a Democrat-controlled Congress he is unlikely to garner the necessary votes. Pro-life groups consider defeating FOCA their first priority, and eagerly welcome a vigorous public debate to expose its extremist implications (such as listed in the previous paragraph) which will assure loss of public support. (16) (17) (18) The pressure from the far left on Obama aggressively to liberalise abortion-related laws will be relentless.

'Keep abortion safe and legal' is a motto of the pro-abortion lobby, but its safety is now being questioned. It is a functionally unregulated industry, with abortion clinics exempt from many of the extensive federal regulations governing outpatient surgical centres. A Kansas Planned Parenthood abortion clinic is facing 107 criminal counts based on confidential review of only 29 patient records, while a late-term abortion provider in Kansas is under investigation for alleged malpractice. (19) (20) May Obama soon ascertain the dangers of abortion. (21) (22)

attacking rights of conscience

Prior to leaving the White House, the Bush administration finalised regulations enforcing existing laws (23) protecting medical practitioners' rights of conscience, including penalties against entities which coerce employees to comply with treatments (such as abortion) against their will. The Obama team is already planning to reverse these. (24) Erosion of protection for conscientious objection would be deeply compromising for bioethics, a field with a Christian origin birthed to protect human dignity. (25) Exposing healthcare providers to prosecution for non-complicity with procedures they deem unethical or immoral guarantees a Supreme Court challenge, whilst inviting a mass exodus from obstetrics and gynaecology, family medicine, and paediatrics for pro-life physicians and medical students. The ensuing provider shortage would be crippling, considering the US is one-third evangelical. (26)

stem cell research

Obama supports federal funding for ESC research. (27) The public and press share misconceptions regarding ESC versus adult stem cell (ASC) research results. Every one of more than 80 stem cell treatments benefiting humans has come from ASCs and their corollaries from placental, umbilical, amniotic fluid and other sources. With the advent of induced pluripotent stem cells (human adult stem cells reprogrammed to an embryonic-like state) in 2007, the full potential of stem cell therapy may well be realised without the sacrifice of another embryo. Sir Ian Wilmut (University of Edinburgh), of Dolly the sheep fame, is walking away from the cloning technology he created in favour of the new direct reprogramming method. Nobel Prize winner Sir Martin Evans concurs, 'This will be the long-term solution'. (28) 'Even a scientist who cares not a whit about the morality of embryo destruction will adopt this technique because it is so simple and powerful. The embryonic stem cell debate is over,' (29) proclaimed Dr Charles Krauthammer. If only life were such smooth sailing. California's Geron Corporation announced in January its plans to begin the first human treatment trials with human ESCs. 'The one hope that everybody has is that nothing bad happens,' was the less than reassuring comment from another stem cell researcher. (30)

Native pluripotent ASCs and ASCs reprogrammed to embryonic state can provide all the benefits of embryonic stem cells without the ethical pitfalls and therapeutic complications of carcinogenesis and tissue rejection. (31) (32) They require no eggs, destroy no embryos, produce genetically matched cells, and qualify for federal funds. The science, ethics, success and hope are proven so far to rest in adult stem cells and their corollaries. President Obama and much of the public have been told otherwise.

faith-based initiatives

Obama's executive order continuing and expanding Bush's White House Office of Faith-Based and Neighborhood Partnerships (helping groups to provide federally-funded social services) may cut both ways. (33) Monies and opportunities may well increase, but what of the faith part? For religious groups accepting these federal funds, potential restrictions on personnel practices and evangelistic efforts might cause many to opt out rather than compromise. Liberal religionists and secularists hope Obama will restructure the faith-based office so as to rein in more conservative elements. (34)

health system: weaknesses exaggerated?

Medicare (for the aged)
Medicaid (for the poor)
Public Health Service (division of the Department of Health and Human Services responsible for health promotion and meeting urgent public health needs)
US Military (for service people)
Veterans Administration (for former service people)

The troubling assertion that around 46 million Americans are without insurance is clouded with confounding variables. The 'uncovered' include many in the aforementioned five national systems (none are technically 'insurance policies', adequate though they may be) and those of middle or higher incomes who have opted not to purchase health insurance.

No emergency department in the US can turn away a patient, particularly if penniless, which accounts for 'health tourists' from other industrialised nations who make their first stop an emergency room for prompt access to treatment for which they were denied or put on long waiting lists at home.

Yet genuine problems exist. The Economist reports that the US spends 'twice as much per head on health care as other rich countries. Yet for $2.2 trillion a year - twice the GDP of India - Americans get mediocre results. They die, on average, nearly two years earlier than west Europeans.' (36)

Ten million unregistered immigrants fall through the cracks
Few age restrictions on expensive treatments (eg chemotherapy, renal dialysis, and surgeries)
Infant mortality is counted from birth (rather than the international standard of two weeks old)
Advanced pre- and post-natal care: expensive, and enable high survival of extremely premature infants (whose expected health problems bring down the average)
Advanced intensive care medicine
The US keeps honest records for all to see and criticise

modern day slavery

Opposition to human trafficking is one thing on which pro-life believers and the Obama administration see eye-to-eye. This rare island of common ground can serve as a launch point for interaction amidst our sea of non-concordance. We expect continuation and advancement of the Trafficking Victims Protection Reauthorization Act 2008. From a historical perspective, this is the third time Christians are leading the charge to end slavery (the first being the institution of the medieval serf system; (35) the second was William Wilberforce and the abolitionists).

health care provision

The US is in a unique predicament: it is the world's third largest nation of both area and population. Americans reside in over 200 urban areas. The most challenging element of national health systems, regionalisation and rationing, would be magnified here. Worse yet, many Americans conceive that government-run health care equates to having all the current choices and benefits, but for free! These expectations cannot be met by any administration. The Obama-Biden health plan (40) is estimated to cost an immense $50-65 billion. It proposes using and expanding the current structure with some twists such as:

Tightening controls on and reforming insurers
Covering a portion of catastrophic care
Lowering insurance premiums
Creating a Small Business Health Tax Credit (rewards small businesses for providing insurance to employees)
Limiting malpractice insurance costs
Raising the contributions toward insurance from large employers previously not offering such
Developing a National Health Insurance Exchange (to assist people in finding private and public medical plans)
Liberalising rules on generic drugs and their import

Obama's colossal financial stimulus/recovery bill includes provisions for the new National Coordinator of Health Information Technology, a federal bureaucracy monitoring physicians for treatment cost containment over safety and effectiveness. (41) (42) The concept is not new in Europe, but it is a chilling idea for Americans.

providing for the poor and marginalised

The national-level safety nets of Medicare, Medicaid and the Public Health Service are joined by numerous organisations supporting free or very low cost facilities. These include charity hospitals (eg Shriners and St Jude's) and clinics, community health centres, Indian healthcare clinics (often funded by tribal casinos), Christian rescue missions, and pregnancy centres (often pro-life).

A recognised problem remains the working poor, those whose income levels exceed qualification for Medicaid while being insufficient for private insurance. Their safety valve remains emergency departments, which cannot turn patients away, but the consequence is the over-taxing and sometimes closure of such. In addition to the Obama-Biden health plan, the new team intends to help the poor by: (43)

Raising the minimum wage
Investing in transitional jobs for upward mobility
Providing tax relief
Developing a prison-to-work incentive programme and helping ex-offenders rehabilitate
Supporting affordable housing
Promoting the Responsible Fatherhood and Healthy Families Act

foreign aid

Americans claim to be the most generous people on earth, yet books are published contesting that claim. In 2007, the US gave only 0.16% of its gross domestic product (GDP) in aid compared to Norway, Sweden and the Netherlands who gave over 0.8%. Although those countries gave more per capita, they do not have 304 million people. The US' '$21.8 billion aid budget was still the biggest in absolute terms'. (44)

Figures based on GDP penalise the US for having a massive economy (25% of the global total). (45) Often excluded from comparative statistics are the magnanimity of American businesses, private giving (45% of worldwide philanthropy), and volunteerism, along with obviously robust military aid. (45) (46) The Obama administration will likely continue the strong American tradition in foreign aid, though just following through with Bush-era commitments like PEPFAR will be costly in a time of recession.

leadership values matter

No organisation can rise above the constraints of its leadership. A nation, non-governmental organisation, hospital, church or study group will find its limitations are those of its leaders - regardless of its other assets. Consider how some Christian entities have suffered due to the lack of integrity in their directors. Conversely, marvellous things have come through underestimated teams led by individuals, with the anointing and favour of the Lord, who conducted themselves in excellence and made the most of what they had. It's a very small rudder that steers a large ship, (47) for good or bad.

As members of the body of Christ and co-labourers with him, (48) we can influence the atmosphere where we work, rather than being victimised by it. Take the example of Daniel serving a world-class demoniac like Nebuchadnezzar. (49) Through understanding of honour, protocol and loyalty - he served with his gifts in a foreign place without compromising his integrity and relationship with God. Esther was in the king's court during a difficult time, but one for which she was positioned, as are we. (50) Joseph, also an outsider in a strange land, was another for whom multiple rejections were key stepping stones to advancement (51) - a spiritual principle to keep in mind. Few of us will be the chief advisor or second in command of a country, yet each of us is certainly the finest Christian some of our patients and contacts will ever meet.

how can we pray?

Scripture reveals that it is our heavenly Father who raises up leaders and makes them great, (52) that their hearts are in his hands to direct, (53) and that we are to pray for them. (54)

Pray for President Obama, his wife, his children and their family life. Pray for his team, that they be surrounded with the wise counsel of God's people of excellence, anointing and favour. Pray for the Lord to meet the president, his family, and administration in a life changing way. Pray for divine appointments. The many Christian organisations and staff fighting the good fight also need prayer and financial support. Pray specifically that God grants his generals and leaders the divine wisdom and insight to navigate these present seas.

André Van Mol is a family physician in the US who speaks about the Christian worldview in the media