March 21, 2025
Dear Interested Readers,
A Constitutional Crisis? And Other Practical And Moral Injuries
Most presidents use the “honeymoon” of the first one hundred days of a new term to get much of their campaign agenda translated into laws that might endure past their years in office. Donald Trump has shown little use for Congress or legislation during the “shock and awe” blitz of the early days of his administration. President Trump has used executive orders to an extent rarely seen. Unlike President Franklin Roosevelt who had the most remarkable first one hundred days, Trump has had very little contact with Congress. Julius Krein writes about this in a recent guest column in the New York Times:
For all the initiatives and proposals in the relentless opening weeks of the second Trump administration, there has been little in the way of a legislative agenda. Across his expansive address to a joint session of Congress, President Trump boasted about an array of executive branch initiatives and proposals — but very little about legislation.
The limitations of this approach are becoming more visible. Mr. Trump’s seeming indifference toward Congress proved costly in his first term — and threatens to constrain his agenda once again. Without a compelling legislative agenda, the Trump administration risks an early slide into lame duck status.
From my point of view, it would be fine if Trump’s neglect of Congress turned out to be a political mistake. I hope that Democrats win back the House in 2026 and from that point forward his only option will be executive orders that can be quickly reversed in 2029. The Federal Register keeps a running list of all executive orders. By the end of last week, President Trump had signed ninety-two executive orders in the first two months of his presidency. If you are interested in how other presidents have used this power, there is a list that goes back to George Washington that gives the total numbers signed and the average signed per year. Joe Biden was forced to use executive orders after losing the house in 2022 and averaged forty-one executive orders per year. Barack Obama also leaned on executive orders following the mid-term elections of 2010. He averaged thirty-five per year over his eight years in office. Trump likes to describe himself using superlatives. When it comes to executive orders, Trump’s performance is truly “Like no one has ever seen before.”
My focus on executive orders as the “warm up” for this letter to you is because, like many others at this moment, I firmly believe that the president’s underlying motive is ultimately to extend the powers of the presidency far beyond the concept of three equal branches of government with checks and balances that maintain our democracy and avoid the emergence of authoritarian rule. I fear that the health of the nation, particularly the health of underserved populations will suffer as his powers expand. Institutions will deteriorate, progress in medical research will stall, the planet will continue to warm, ecosystems will be further damaged, and we will be subject to public health disasters that will make COVID seem like a dress rehearsal for “end times.” Based on the damage already done to international relationships, science, and established functions and agencies of government, the world we will have in 2029 may bear little resemblance to the country a majority of voters threw away in 2024. Our Constitution has allowed us to approach greatness over the last 236 years; throwing away or abusing it rather than continually improving what has provided progress does not seem to me to be a logical way of becoming greater. It will take decades if not several generations to repair what Trump has destroyed in less than one hundred days. Dr. Francis Collins, the long-serving head of the NIH warns us that perhaps our greatest and most costly losses will be in science.
For me, the most immediately abusive actions have not been the destruction or crippling of key government agencies, the appointment of laughable leaders to key cabinet and administrative positions, the cruel and often unconstitutional treatment of immigrants, the threats to the economy from tariffs and other ill-conceived trade policies, or the squandering of our leadership of the free world. My greatest concerns and the things that feel most likely to impact the future of healthcare are Trump’s growing abuse of our courts and system of laws, and his cultural attacks on diversity, equity, and inclusion efforts. The attack on the courts is a prelude to the seizure of more power, and the attack on DEI undermines the journey toward improvement in the social determinants of health and of moral progress as a nation. For more than two hundred years we have made halting progress toward equality. We accept our hesitations and delays and learn from our errors through collective self-observance as we reassure ourselves that “The Arc of the Moral Universe is Long, But it Bends Toward Justice.”Mr. Trump has no interest in progress toward justice and has conned a majority to throw away much of the progress along that arc that has been made since the mid-sixties.
Congress has been stymied by a lack of strategy and courage on the part of Democrats. Perhaps you remember the famous quote that Will Rogers made almost a hundred years ago. The great humorist, vaudevillian, actor, author, and general media king of the nineteen-teens, twenties, and early thirties quipped something like: “I am not a member of any organized political party. I am a Democrat.” He also said “Democrats never agree on anything, that’s why they’re Democrats. If they agreed with each other, they’d be Republicans.” The truth is sometimes painful to hear. On the other side of the aisle, any attempt at compromise or common sense expressions of resistance from Republicans is met with the withering and intimidating anger of the president, and the vow that any Republican who is out of line will be “primaried” at the next election.
Since the Democrats seem to be too disorganized to develop a coherent strategy to oppose Trump through Congress at least until after 2026 or some other miracle and the Republicans are afraid to cross him, the idea that Congress would hold the president accountable for bizarre behavior that threatens Democracy and moves us toward authoritarian primacy of the president, our only Constitutional defense becomes the courts. Any failure of the president to abide by a court decision would constitute a “Constitutional crisis.” Since Andrew Jackson in the 1830s, no president has defied a court decision or order. In a New York Times article published yesterday and authored by Maggie Haberman and colleagues, we get an update on Trump’s attack on the courts, our last great barrier to his unrestrained rule. The article is entitled “How Trump Is Trying to Consolidate Power Over Courts, Congress and More: President Trump’s expansive interpretation of presidential power has become the defining characteristic of his second term.” It is a long title for a very important concern. The authors begin:
President Trump called for one federal judge seeking basic information about his deportation efforts to be impeached amid mounting concern about a constitutional showdown.
Another judge found that Mr. Trump’s efforts to shut down a federal agency probably violated the Constitution and stripped Congress of its authority.
The president was accused of overstepping his executive authority yet again in firing two Democratic commissioners from an independent trade commission.
And that was just Tuesday.
Nearly two months into his second term, Mr. Trump is trying to consolidate control over the courts, Congress and even, in some ways, American society and culture.
For our system of “checks and balances to work” each “co-equal” branch of the government must respect political “norms” and accept the designated responsibilities of the other two branches of government. One aspect of Project 2025 that is frequently overlooked by someone who is a casual voter is that it calls for the primacy of the presidency. Haberman and her co-writers continue:
His expansive interpretation of presidential power has become the defining characteristic of his second term, an aggressive effort across multiple fronts to assert executive authority to reshape the government, drive policy in new directions and root out what he and his supporters see as a deeply embedded liberal bias.
Andrew Jackson understood the power of violating norms as a way of disrupting the power of the courts. When the Supreme Court told him that he could not march the native Americans of the Southeast off to Oklahoma in what became known as the “Trail of Tears,” he responded, “John Marshall has made his decision; now let him enforce it!” In my mind, Jackson and Trump share the desire to get rid of people who are inconvenient to their plans. I think Trump, like Jackson, understands that since the courts have no army or police, their opinion and orders can be disregarded as long as you have intimidated Congress and you claim to be making the changes that a majority elected you to make. What has been most powerful about our courts and our Constitution is that they were designed or evolved to protect the rights of minorities. The rights of minorities were further clarified by the Fourteenth Amendment and its “Equal Protection Clause.” For the Constitution to work, the president needs to honor those established principles and not offer an alternative interpretation of his oath of office.
The last two months have been horrible and frightening for anyone who cares about minority rights and the due process of law. The president and the law seem to be moving toward being synonymous as they are in Russia, Venezuela, and other authoritarian states. The Haberman article gives us a chilling overview of the moment.
Congress, which is controlled by Republicans, has ceded some of its core duties to Mr. Trump, handing off elements of the legislative branch’s spending authority to the White House and standing aside as congressionally chartered agencies are shuttered. The president has threatened to “lead the charge” against the re-election of the rare Republican who dares challenge his agenda, and the party has bent to his will at every turn.
Mr. Trump has dismantled independent measures of checks and balances, fired inspectors general and installed loyalists at the Justice Department willing to carry out his campaign of retribution. He has targeted private law firms with connections to those he views as political enemies and cowed previously skeptical or hostile business leaders into pledging public support, even as he has imprinted his “MAGA” stamp on the private sector by trying to dictate hiring practices.
Now that I have vented my concerns about the possible demise of our democracy which will have a profound impact on the funding of medical research and care delivery, let me tell you what galls me most. What seems totally at variance with the principles our country claims are foundational to our existence is the Trump attack on DEI efforts. We have long been aware of the discrepancy between statements in our foundational documents like “all men (theoretically all humans) are created equal” and the lived reality of many women and minorities. For several decades we have had evidence that diversity in academics, the workforce, and military service–indeed in every human endeavor leads to improved outcomes.
The evolution of these ideas predates the Civil Rights movement and embracing the “other” has more than a two-thousand-year history in the “Abrahamic” monotheistic religions. It is the core concept of the “golden rule.” We also know from history the devastating impact of governments suppressing free speech or banning intellectual exploration of controversial ideas.
DEI efforts are not an invention of Barack Obama or Joe Biden. I was involved in efforts to create diversity, equity, and inclusion in our practice more than thirty years ago. There have been real changes in healthcare that have improved the experience of care for both patients and providers. I frequently think about our recent DEI progress in healthcare. I have witnessed dramatic improvements over the last sixty years, but I know there is still much to do if we are to overcome our implicit biases that harm patients.
I matriculated at Harvard Medical School in September 1967. My class was originally composed of 120 students. About forty more were added from two-year medical schools like Dartmouth at the beginning of the third year. There were about ten women in my class. I remember two African American classmates, one Hispanic classmate, and one Asian classmate. Most of the class came from Ivy League schools, elite small colleges like Amherst or Bowdoin, plus other top-tier institutions like Stanford or the University of Chicago. I remember looking around and thinking that I was admitted to add geographic and academic diversity. I was a Southerner from a state university. Now Harvard Medical School admits a class that is at least fifty percent female and has a racial distribution that more closely matches, but not perfectly, the population of the country. I firmly believe that the changes toward more diversity in the class have been good for Harvard, good for patients, and good for the young future physicians who will be the next generation of professionals in a country that can’t be prevented from becoming more diverse.
One of the more ridiculous aspects of Trump’s second term so far is the combined disaster of DOGE plus the federal ban on DEI that resulted in the temporary expunging of information about Jackie Robinson, the Navajo Code Talkers, the Tuskegee airmen, and two native American Marines at Iwo Jima and so many others this week. That is what you get with a computer-aged purge when you type in a directive to eliminate all language related to DEI. The idiocy was quickly discovered and the travesty was corrected, but I assume that there have already been more uncorrected atrocities that will never be recognized. The damages that will occur will go far beyond the impact on our freedom of speech and have already had an impact on science, healthcare, and our universities that may plunge us into a second coming of the “dark ages.” It is true that collectively we can be dumber and more dangerous in a society controlled by an autocrat than in an environment of free speech. I also recognize the same tendency to quash the expression of ideas that is characteristic of the far left. Someone has suggested that “the far right and the far left meet in the back.” Stalin was as intolerant of diversity as was Hitler.
To further explore the impact of the Trump Administration’s aversion to DEI initiatives I decided to consult my AI oracle. So I asked the ChatBot:
How will Trump’s recent orders banning DEI programs and efforts in the government impact healthcare?
ChatGPT said:
President Donald Trump’s recent executive orders banning Diversity, Equity, and Inclusion (DEI) programs across federal agencies are poised to significantly impact the healthcare sector. These orders mandate the removal of DEI offices and programs within the federal government, including the Department of Health and Human Services (HHS), and prohibit the use of preferred pronouns in official communications.
The elimination of DEI initiatives may hinder efforts to address healthcare disparities among marginalized communities. For instance, the National Partnership for Women & Families warns that dismantling DEI practices could undermine the federal government’s ability to hold hospitals accountable for their treatment of Black birthing individuals, potentially exacerbating existing inequities in maternal healthcare.
Furthermore, these executive orders extend beyond federal agencies, targeting private sector entities, including healthcare organizations. The administration contends that DEI policies may violate the Civil Rights Act of 1964 by undermining individual merit and potentially engaging in discriminatory practices. Consequently, the Attorney General is tasked with identifying and pursuing legal actions against organizations deemed to be implementing “illegal” DEI practices. This shift raises compliance concerns for healthcare providers, particularly those participating in federal programs like Medicare and Medicaid. Organizations may need to reassess their DEI initiatives to ensure alignment with the new federal directives, balancing the promotion of inclusive practices with adherence to evolving legal standards.
Additionally, the removal of DEI-related content from government websites and databases poses challenges for healthcare research and education. The deletion of thousands of web pages and datasets related to DEI and public health research impedes access to critical information necessary for addressing health disparities and developing inclusive healthcare practices.
In summary, the recent executive orders abolishing DEI programs are likely to have far-reaching implications for healthcare, potentially affecting efforts to reduce disparities, altering compliance requirements, and limiting access to essential research and educational resources.
My concerns about the deleterious effects of Trump’s anti-DEI policies were also well expressed in a recent New England Journal Of Medicine article written by Samantha X.Y. Wang, M.D., M.H.S., and Kevin Chi, M.D. from Stanford. Their article is entitled “Answering the Call — Sustaining Equity Efforts in the Face of Regression.’’
The article begins with a brief story:
“I’m so sorry,” the caller began, “I never thought I’d have to tell you this.” She was the site lead at a Veterans Affairs hospital — a linchpin of our ongoing national study of a health equity curriculum aimed at training physicians to consider diversity, equity, and inclusion (DEI) principles in clinical decisions — and she sounded hesitant, her voice heavy. “We have to pull out of the study. It’s illegal for us to participate because of the new ban on DEI.”
The air seemed to leave the room, replaced by disbelief. Surely what she was saying couldn’t be true. Our study was not controversial, let alone something that could ever be described as illegal. Years of work — starting with a local needs assessment conducted along with community partners and evolving into a multi-institutional effort to equip clinicians with the tools to address the historical and systemic roots of health disparities — were suddenly unraveling. The call also reflected something deeper: a turning point, a reckoning.
Welcome to academic freedom in the MAGA world. They continue:
As a field, medicine has been grappling with its own inequities. Racial health disparities are well documented, persistent over time, and resistant to change despite the best intentions of many clinicians. These disparities are not accidents: they are the result of historical policies, codified biases, and systemic neglect. Addressing them requires more than acknowledgment. It demands action that is deliberate, evidence-based, and sometimes uncomfortable…Work to mitigate health disparities, whether through education or research, is grounded in a substantial body of research and science that identifies such inequity as an urgent health care crisis.
I think that anyone who works in healthcare knows the truth of that statement. We have been trying hard for more than thirty years to make corrections, but our progress is slow. Change requires much more than knowledge. It requires more than self-observing honesty. It is a slow process of releasing bidirectionally damaging biases and diligently practicing new behaviors. For many of us, there is a long time while we fake our improvements before they become deeply genuine and natural reflexes. The authors give us a good definition of “health equity,” and then ask some very probing questions that can’t be answered without deep introspection.
Health equity, as defined by the Centers for Disease Control and Prevention, is “the state in which everyone has a fair and just opportunity to attain their highest level of health.” This principle is embedded in the missions of accrediting bodies (the Joint Commission), regulatory agencies (the Centers for Medicare and Medicaid Services), and medical education institutions (the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education). Casting equity initiatives as controversial or even criminal, as the new U.S. administration is doing, forces our field to confront its own conscience. What does it mean for medicine to be complicit in systems that uphold inequity? And what is its responsibility in dismantling them?
As the authors continue their story we see how surprised they were by the call and the realization of the threat that it revealed to them.
Our work felt acknowledged and valuable. But with one call, it came to a screeching halt. For our project, the impact was swift and devastating. Yet the implications of the DEI ban extend beyond individual studies like ours. The message is unmistakable: the pursuit of equity is now under threat.
Don’t be fooled into thinking that Trump’s ban on DEI is limited to federal facilities like the VA, the CDC, and the NIH. It also advocates for a very oppressive “report you neighbor” component and it extends to any organization or business that has a federal contract, or a federal grant. Any entity that provides care through a publicly funded program like Medicaid or Medicare is subject to the decree and risks the loss of vital government funding if it does not “fall in line” with the president’s executive order. Does that meet the definition of oppressive? Can you imagine the improvement of care delivery in such an environment? The authors get philosophical.
Backlash in the face of progress is not an anomaly; it is part of a historical pattern that underscores the duality of progress: it is fragile yet persistent. The civil rights movement of the 1960s didn’t end with the passage of the Voting Rights Act; it laid the groundwork for generations of activists. The women’s liberation movement didn’t stop with securing the right to vote; it created a platform for ongoing efforts for gender equality. Each push for equity has been met with a counterforce — a recalibration, as society grapples with discomfort and change. The pendulum swings, and with each push forward, there is a pull back. This moment is no different. Though public opinion may shift in favor of justice over time, the pendulum’s swing reminds us that progress is neither linear nor inevitable.
One wonders how many people would be able to write such a knowledgeable history a few decades into a MAGA world where students will not hear about the history of our progress following that arc that bends toward justice. Those concerns are long-term. The authors have some short-term worries.
But the costs of regression are not theoretical: they are lived. Patients from marginalized communities bear the brunt of regressive policies in medicine, and they will continue to face unchecked biases, widening disparities, underrepresentation, and eroded trust in systems that are meant to serve them. The consequences can be measured in missed and late diagnoses, inadequate treatment, and lives damaged by structural failures.
The authors move quickly from “contemplation to a call for action.” They are not wavering in their response to the challenge. I hope that what they say will inspire you to persist in DEI efforts if you are now involved, or get involved if you have been observing from the sidelines, content in your assessment that you need not be part of the effort to move forward toward true diversity, equity, and inclusion in healthcare. They say it well:
The call from our colleague marked a loss, but it was also a call to action. For the medical community, this moment demands a renewed commitment to equity. It calls for clinicians, educators, and researchers to sustain the work toward equity and justice, despite the headwinds we face. It calls for institutions to protect and prioritize initiatives that address disparities. And it calls for all of us to confront the discomfort of change with courage and resolve. Equity in medicine is not an ideal to be debated or a goal to be deferred — it is a necessity. The barriers we face today are reminders of why this work matters, of the lives it touches and the future it shapes. Despite the obstacles, this work will endure — because it must.
Spring Is Here–On The Calander
I rode around town this week on my bike and enjoyed the fact that the temp was in the mid to high fifties on several days even though with a breeze it felt colder. Spring is a state of mind. Much of our snow has melted, especially in South-facing areas. I was looking for crocuses or any evidence that spring will soon be “busting out all over.” Unfortunately, I saw no buds. What I did see were streams that were full of melting snow.
Today’s header is a picture taken in Elkins village which is the part of New London that lies below Pleasant Lake. The waterfall, which unfortunately you must look closely to see because I took the picture from too great a distance, is part of the waterworks that powered the industry that was once located in Elkins which was then called Sytheville.
I have told this story before in these notes, but it is worth repeating. In the 1800s, Sytheville was the site of most of the agricultural blades produced in America. Many of the bayonets and swords used in the Civil War were produced in Sytheville. There is nothing left of all that industry now other than the falls and some stonework that directed the water over the falls where the power of the falling water turned the wheels of a critical industry of the day.
Perhaps the fact that in less than a hundred and fifty years most of the evidence of a once strong industry is gone should remind us or teach us something. As the snow under the trees melts I plan to stop and sit down by the falls and contemplate what the disappearance might teach me. I know I will be there many times because my massage therapist lives in an antique house about a hundred yards away.
I love it when I discover some hidden history. I learned the history of Elkins several years ago. Besides the falls and taking an occasional boat ride on the gorgeous lake above the falls with a friend who has an electric boat that was built in 1910, we love taking our grandchildren to an alpaca farm that is just down the road a few yards.
I hope that your weekend will be conducive to exploring what you might be overlooking near you. If it’s raining, enjoy a basketball game. I hear that we are into “March Madness.” We all could use a brief reprieve from “Trump madness.”
Be well,
Gene
