Expansion of Catholic hospital systems is accelerating around the country, partly by acquiring non-Catholic hospitals. This trend is posing an increasing threat to access to care in two major areas -- reproductive services and end-of-life care. Ethical and Religious Directives for Catholic Health Care Services (the ERDs) are being enforced by the bishops more vigorously in many parts of the country, holding their employed physicians to strict adherence to the ERDs or loss of employment. Meanwhile patients in many locations, especially rural areas, are finding it increasingly difficult to gain access to essential care.
Ten of the 25 largest health systems in the U.S. are Catholic-sponsored, where health professionals are prohibited from providing health services or honoring patients' health care requests in these areas. Washington State has the highest proportion of acute care hospital beds -- 45 percent -- of any state in the country. In many instances, health professionals employed by Catholic hospitals cannot provide counseling or referrals based on religious grounds. Nuns have for years been more permissive in these areas, but increasingly the bishops are dictating what services can be provided.
These are some of the ERDs restricting common needs of women in their childbearing years: (2)
- Catholic hospitals may not promote or condone contraceptive practices. (Directive 52)
- Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. (Directive 45)
- In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion. (Directive 48)
- Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution. (Directive 53)
- The free and informed health care decision of the person. . . is to be followed so long as it does not contradict Catholic principles. (Directives 28 and 27).
- Catholic health care services must . . . require adherence to [the Directives] within the institution as a condition for medical privileges and employment. (Directive 5)
- Other ERDs prohibit abortion even in cases of rape or incest (Directive 45), and in-vitro fertilization (Directives 37, 38, 39) (3)
It appears that there is some variation from one institution to another how these Directives are interpreted under specific circumstances. Often there are gray areas when health care professionals are unsure how the ERDs will be interpreted. But the proscription against abortion is inviolate in all Catholic institutions.
The following cases in two parts of the country indicate how extreme and harmful strict adherence to the ERDs can be:
Sierra Vista is a rural community about 80 miles southeast of Tucson, AZ with one hospital serving a three-county area. The local hospital had been secular until purchased in 2010 by the Carondelet Health Network, a member of Catholic-sponsored hospitals. ERDs were to be followed at the time of transfer of ownership. Shortly thereafter, a woman presented to the Emergency Room 15-weeks pregnant with twins after miscarrying one of the twins at home. The remaining twin had a heart beat. The attending physician concluded that any attempt to continue the pregnancy would pose high risks of loss of the child as well as hemorrhaging and infection for the mother. As he and the staff were preparing to complete the miscarriage, a hospital administrator intervened and ordered the patient transferred to another hospital 80 miles away, where she did receive necessary care. The medical staff felt misled since they had previously been assured that they could provide appropriate care for miscarriages. (4)
- A woman 18 weeks along in her pregnancy came to Mercy Health Partners, a Catholic-sponsored hospital in Muskegon, Michigan, where it is the only hospital with two campuses in the community. Her water had broken at home and contractions had started. She was told that she had premature rupture of the membranes (PROM), that nothing could be done, and to go home. She was not informed that there was almost no chance that the fetus could survive and was not counseled about risks of non-treatment to herself. She returned to the hospital the following morning with painful contractions, bleeding and an elevated temperature. Her contractions were monitored and she was given Tylenol. She was again sent home after the temperature came down. Later that same night, she returned to the hospital again in severe distress. While the staff was preparing to send her home, she delivered a very premature son, who died within hours. She soon developed infection that had developed after her membranes ruptured. The American Civil Liberties Union (ACLU) has filed a lawsuit contending that "a young woman in a crisis situation was put at risk because religious directives were allowed to interfere with medical care. . . Patients should not be forced to suffer because of a hospital's religious conviction." (5)
A 2012 national study by clinician researchers at the University of Chicago found that 53 percent of obstetrician-gynecologists practicing in Catholic-sponsored hospitals had conflicts over religious-based policies. (6)
The above cases and ERDs raise a number of important questions about the influence of religious directives in medical care. One relates to the Emergency Medical Treatment and Active Labor Act (EMTALA) enacted in 1986. It requires any hospital that operates an Emergency Room and receives Medicare funds to stabilize a patient determined to have an emergency situation, including active labor, regardless of ability to pay. Centers for Medicare and Medicaid Services (CMS) requirements further state that "If a hospital is unable to stabilize a patient within its capacity, or if the patient requests, an appropriate transfer should be implemented." (7)
Other issues are involved in this controversy over ERDs interference with generally accepted, evidence-based health care. Here are just two:
- Given the various forms of tax benefits that Catholic hospitals receive as not-for-profits, shouldn't we expect them to serve the public interest above their private religious interests? Many Catholic hospitals have a long tradition of public service in both patient care and medical education, and have often been located in areas of special need. But that is changing too. Some have drifted away from their traditional safety net responsibilities. Their high costs often create financial barriers to care, and they provide less charity care than one might think. A recent study comparing charity care by different kinds of U.S. hospitals found that Catholic-sponsored hospitals spend just 2.8 percent of their total gross patient revenue on charity care, one-half that spent by public hospitals. (8)
- Should Catholic-sponsored hospitals receive funding from public hospital districts when they restrict access to maternity services based on the ERDs? A recent ruling by the State Attorney General in Washington State stated that "public hospital districts that offer maternity services must provide equivalent benefits, services or referrals for birth control and abortion as required by Washington State's Reproductive Privacy Act." (9) The fallout of that ruling is still unclear.
From the above, we can conclude that the ERDs, zealously interpreted by Catholic Bishops in U.S. Catholic-sponsored hospitals, constitute a threat to the health and well-being of many women seeking reproductive services in these hospitals. More oversight is needed by public agencies to ensure that the public interest is being served. This issue is even more important at this particular time as the Tea Party and the Christian right accelerate their attacks on women's reproductive rights and freedoms, despite the fact that more than two-thirds of voters support women's rights to abortion, a constitutional right since the Roe v. Wade Supreme Court's decision in 1973. Michigan's mostly male Republican-dominated Legislature, without hearings or substantive debate, recently passed the Abortion Insurance Opt-Out Act, which bans abortion coverage, even in cases of rape or incest, from nearly all health insurance policies issued in the state. Other states are restricting access to care by closing abortion clinics. Some 24 states have banned some forms of abortion coverage from policies purchased on the health care exchanges. (10) So this issue is even more critical in the heat of political battles in this election cycle. The medical profession and forces in the public interest need to prevail against undue influence of religion in health care
1. Uttley, L, Reynertson, S, Kenny, L et al. Miscarriage of Medicine: The Growth of Catholic Hospitals and the Threat to Reproductive Health Care. ACLU and MergerWatch. December 2013.
2. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (5tg ed, 2009), available here [hereinafter Directive(s)].
3. O'Brien, J. How the Bishops' Directives derail medical decisions at Catholic hospitals. Catholics for Choice, December 4, 2013.
4. Cohn, J. Unholy alliance. The New Republic, February 22, 2012.
5. Hausman, JS. ACLU's abortion lawsuit claims Catholic policy barred care for Muskegon woman at Mercy Health Partners. All Michigan, December 2, 2013.
6. Stulberg, DB, Dude, AM, Dahlquist, I et al. Obstetrician-gynecologists, religious institutions, and conflicts regarding patient-care policies. Am J Obstet Gynecol 207 (1): 73, 2012.
7. Centers for Medicare & Medicaid Services. Emergency Medical Treatment & Labor Act (EMTALA). Available at: cms.gov
8. Ibid # 1, Table 4.
9. Connelly, J. State AG: Public Health Districts must offer birth control, abortion. Seattle Post Intelligencer, August 21, 2013.
10. Reitman, J. The stealth war on abortion. Rolling Stone Politics, January 15, 2014.