Crime & Courts

April 20, 2011

Transplant case pits religion, Medicaid rules

As much as Mary Stinemetz wants to live, she's ready to die for her faith.

As much as Mary Stinemetz wants to live, she's ready to die for her faith.

Suffering from the late stages of liver disease, Stinemetz, 64, needs a transplant, a surgery that could cost more than $250,000, an insurmountable expense for her family.

Whether she gets a transplant could depend on how far she's willing to battle for her beliefs in a courtroom drama that will unfold in the Kansas Court of Appeals today.

Stinemetz, who lives in the western Kansas town of Hill City, could easily get a liver transplant that would be paid for by Medicaid at the University of Kansas Hospital.

But she would have to compromise her Jehovah's Witness principles because she would receive a blood transfusion, something she believes violates God's law.

She could undergo bloodless transplant surgery in Omaha, but the state refuses to pay for the out-of-state procedure when a transplant is readily available in Kansas.

That puts Stinemetz at the center of a constitutional controversy pitting the state's Medicaid rules against her right to exercise her freedom of religion. Her life hangs in the balance.

"I love life," Stinemetz said. "But when it comes to obeying our creator, I am going to obey my creator before I do anything else because he gave us our life. You've got to follow his laws."

Stinemetz is suing the Kansas Health Policy Authority, which administers the state's Medicaid program. She contends the state is violating her First Amendment right to exercise her religion. She lost one round in Graham County District Court in December.

State officials declined to comment before today's hearing. But in earlier court pleadings, the state contends that she didn't provide any evidence that her rights were infringed upon because coverage was denied.

"There is no medical necessity for the beneficiary to have a bloodless transplant — a regular liver transplant is available in Kansas and would be considered medically necessary," the state said in denying coverage in early February 2010. "The beneficiary's religious preference to have a bloodless liver transplant does not meet medical necessity."

Wayne Wallace, a doctor advising the state, also warned of the ethical issues a surgeon would face if a patient elects a bloodless transplant.

Although the surgical procedure is the same, the bloodless technique implies the surgeon would be willing to accept a patient's death, even if a transfusion might save the patient, Wallace said at March 2010 hearing.

Stinemetz said Jehovah's Witnesses follow biblical directives to abstain from blood, pointing to passages in the books of Acts, Genesis and Deuteronomy, according to court records. Church doctrine leaves it to the discretion of members to accept certain blood fractions and donor organs.

The Watchtower Bible and Tract Society of New York has filed a friend-of-the-court brief on her behalf. The group said that Kansas is forcing Stinemetz to choose "between foregoing all surgery or submitting to medical treatment that violates her religious beliefs."

But in court papers, state lawyers noted that Stinemetz acknowledged that she could redeem herself if she did receive a blood transfusion and was "truly repentant." They also argued that she acknowledged that she wouldn't be ostracized from her church if she was truly repentant.

Previous cases

The constitutional implications of this case are difficult to discern because it falls in the shadow of two U.S. Supreme Court decisions 30 years apart that take different positions.

In the most recent case from 1990, the high court decided that the government could adopt laws that might burden someone's religion as long the law was neutral and didn't target a specific faith. The case focused on two Oregon men who were denied unemployment benefits when they were fired from their jobs when they ingested peyote for sacramental purposes.

The court upheld the denial in a decision that seemed to cast aside decades of precedent.

But Stinemetz's legal team cites a 1963 Supreme Court case in which the justices ruled that government needed a compelling state interest to justify infringing on someone's right to freely exercise their religion.

That case involved a member of the Seventh Day Adventist Church who was denied unemployment benefits when she was fired from her job because she refused to work on Saturday, that church's sabbath. She couldn't find work elsewhere.

The state said she was ineligible for the benefit because she failed, without good cause, to accept a job when it was offered.

Doug Linder, a constitutional expert at the University of Missouri-Kansas City, said predicting the outcome of this case is tough. He noted that the Oregon case involved a criminal law and the Stinemetz case involves a benefits claim.

"It's an interesting case," he said.

Stinemetz's diagnosis

Stinemetz suffers from primary biliary cirrhosis, a chronic disease that inflames the bile ducts in the liver and eventually causes them to disappear. When the bile ducts become damaged, bile accumulates in the liver, injuring the organ and causing it to deteriorate and malfunction.

In 2009, after Stinemetz learned she would need a liver transplant, she went to the University of Kansas Hospital for an evaluation. She told KU physicians that she wouldn't accept a liver transplant that involved blood transfusions.

KU decided against moving ahead with any further work on the case and recommended she seek another hospital that might perform a blood-free surgical procedure.

The KU hospital doesn't perform bloodless transplants because its doctors don't believe they're in the patient's best interest, said spokesman Dennis McCulloch. "As one doctor put it, it's like going up in a plane and promising you'll land without the landing gear," he said.

Bloodless liver transplants have been around for about a decade. They are offered at only a few other hospitals nationwide and none in Kansas, said Jean Botha associate professor of surgery at the Nebraska Medical Center.

Botha conceded the surgery shouldn't be used routinely because the "safety is just not there." He said the surgery was done primarily to help Jehovah's Witness patients.

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