Catholic Hospitals Limit Procedures – As Catholic Hospitals Expand, So Do Limits on Some Procedures
Catholic Hospitals Limit Procedures
Catholic Hospitals Limit Procedures
After experiencing life-threatening pre-eclampsia during her first two pregnancies, Jennafer Norris decided she could not risk getting pregnant again. But several years later, suffering debilitating headaches and soaring blood pressure, she realized her I.U.D. had failed. She was pregnant, and the condition had returned.
At 30 weeks, with her health deteriorating, she was admitted to her local hospital in Rogers, Ark., for an emergency cesarean section. To ensure that she would never again be at risk, she asked her obstetrician to tie her tubes immediately following the delivery.
The doctor’s response stunned her. “She said she’d love to but couldn’t because it was a Catholic hospital,” Ms. Norris, 38, recalled in an interview.
Experiences like hers are becoming more common, as a wave of mergers widens the reach of Catholic medical facilities across the United States, and the Trump administration finalizes regulations to further expand the ability of health care workers and institutions to decline to provide specific medical procedures for moral or religious reasons.
One in six hospital patients in the United States is now treated in a Catholic facility, according to the Catholic Health Association, a membership organization that includes 90 percent of the Catholic hospitals in the United States. In a 2016 report, MergerWatch, a nonprofit group in New York that tracks hospital consolidation, found that in 10 states, 30 percent or more of the acute-care hospital beds were under Catholic ownership, or in a hospital affiliated with a Catholic health care system. In a growing number of rural areas, a Catholic hospital is the sole provider of acute care.
Most facilities provide little or no information up front about procedures they won’t perform. The New York Times analyzed 652 websites of Catholic hospitals in the United States, using a list maintained by the Catholic Health Association. On nearly two-thirds of them, it took more than three clicks from the home page to determine that the hospital was Catholic.
Only 17 individual Catholic hospital websites, fewer than 3 percent, contained an easily found list of services not offered for religious reasons, and all of them were in Washington State, which requires that such information be published on a hospital’s site. In the rest of the country, such lists, if available, were posted only on the corporate parent’s site, and they were often difficult to find.
“I think that any business is not going to lead off with what they don’t do,” Charles Bouchard, senior director of theology and ethics at The Catholic Health Association, said in response to the Times analysis. “They are always going to talk about what they do do. And that goes for contractors and car salesmen. They are not going to start off by saying, ‘We don’t sell this model,’ or ‘We don’t do this kind of work.’”
Responding to a growing number of mergers and affiliations with secular institutions, the United States Conference of Catholic Bishops updated its instructions to Catholic hospitals in June, ordering them to continue to provide care consistent with church teaching when entering into such business arrangements, including prohibiting procedures that are “intrinsically immoral, such as abortion, euthanasia, assisted suicide, and direct sterilization.”
Evan Minton, a transgender man, said Dignity Health declined to perform his hysterectomy.
The A.C.L.U. has sued Dignity on his behalf, arguing that the withholding of medical care based on his gender identity violated his civil rights.
Sometimes secular hospitals merging with Catholic health care institutions have preserved access to procedures such as postpartum tubal ligations (the procedure Ms. Norris wanted) by carving out an area of the hospital as a separate legal entity that is not subject to the Catholic restrictions, said Lois Uttley, the founder of MergerWatch. However, she said the new directives for partnerships from the bishops could be interpreted to mean “such a carved-out hospital might not be permitted in the future.”
Many Catholic health care institutions also discourage clinicians from providing referrals for abortions or having conversations with patients about medical aid in dying for people who are terminally ill, which has been legalized in seven states and the District of Columbia.
So-called conscience protections for health care workers began in the 1970s with enactment of a number of state and federal measures, and they generally received bipartisan support, said Holly Fernandez Lynch, a professor of medical ethics and health policy at the University of Pennsylvania. “But,” she said, “they’re now moving in an extreme direction that ignores patient access to both services and information.”
Earlier this year, the Department of Health and Human Services unveiled a Conscience and Religious Freedom Division with the stated goal of ensuring that health care workers and institutions are never forced to deliver medical services they object to.
“I think this issue has not gotten the attention it has deserved for far too long,” said Roger Severino, the department’s director of the Office for Civil Rights, which is responsible for enforcing federal conscience laws.
Mr. Severino, a Catholic who said he takes his faith “seriously,” noted that since the 2016 election, the number of conscience complaints has risen markedly. During the Obama years, up until the 2016 election, there were just ten. In the 21 months since the election, he said, there have been 165.
“We’re open for business and word has gotten out,” he said. “There is a real need out there to be addressed.”
The department accompanied its announcement of the new division with a lengthy proposed federal rule that expands the types of people and entities that can assert conscience or religious objections. Critics of the proposed rule say that it would allow, say, an office assistant to refuse to schedule a vasectomy, or for a nurse to refuse to take the vital signs of a transgender patient.
Mr. Severino said he was loath to engage in “hypotheticals” about how the rule might be interpreted, but emphasized that one of the goals was to ensure that health workers were more aware of their rights.
“We’re changing the tone of the federal government, “ he said. “We’re moving away from a posture of indifference to hostility to claims of religious beliefs and moral conviction — to one of respect in accordance with the law.”
The health care rules from the Conference of Catholic Bishops are known as the Ethical and Religious Directives for Catholic Health Care Services, or E.R.D.s, and were originally written in 1948.
The level of adherence to the directives varies. “Many hospitals strictly interpret the directives and don’t make exceptions to the prohibitions,” said Lori Freedman, a medical sociologist at the University of California, San Francisco. “But others have more permissive cultures where the authorities are willing at times to look the other way on things like sterilization and contraception.”
The Times’s analysis of individual Catholic hospital websites found that only one out of four hospitals mentioned the directives on its site. Even on sites that did, the mentions were difficult to find.
Ms. Norris said nothing led her to believe that the hospital where she gave birth, Mercy Hospital Northwest Arkansas, or her obstetrician, Dr. Tiffany Weathers, who had cared for her throughout her pregnancy, would not perform a common procedure.
Ms. Norris said it was only after she was admitted to the hospital and hooked up to intravenous magnesium sulfate to prevent a seizure that Dr. Weathers told her of the ban against tubal ligations. At that point, it was too late to switch hospitals.
“If we were informed, we would have had time to make an informed choice on the best medical care for our pregnancy and unborn baby,” Ms. Norris said.
Dr. Weathers, whose medical practice is in the same complex as Mercy, did not respond to multiple requests for comment. A spokeswoman for the hospital also declined to comment.
Mercy Hospital Northwest Arkansas, part of a network of hospitals in four states, prominently displays on its website the services it offers, including prostate screening and bariatric surgery, but there is no mention of those it will not provide.
Some states, including Illinois and Washington, require health care providers who object to a procedure on religious grounds to provide patients with their treatment options. Under the Washington State law health systems must post their policies on reproductive and end-of-life care on their websites “where it is readily accessible to the public, without requiring a login or other restriction.”
Yet, of the 20 Catholic hospitals in Washington, the Times found that only six listed policies in a place that was easily accessible. On the websites of others, the policies took multiple clicks to find, and then only if one knew what to look for.
Many patients across the country are unaware that a hospital is Catholic to begin with. In a study published last year in the journal Contraception, researchers surveyed 1,430 women, and of those whose primary hospital was Catholic, 37 percent were not aware of the religious affiliation.
“When the hospital had a very Catholic-sounding name, women were much more likely to get it right,” said Professor Freedman, one of the authors of the study.
“At the end of the day, it appears that Catholic systems want to diminish their Catholic identity to be more marketable,” Professor Freedman said.
Further, the religious icons and imagery found in the lobbies of most Catholic hospitals have decreased markedly in recent years, said Barbra Mann Wall, a professor of nursing at the University of Virginia and the author of a history of Catholic hospitals in the United States. At the same time, she said, American bishops have grown stricter about enforcing the E.R.D.s.
“The religion component is getting more important, but less transparent,” Professor Wall said.
Father Bouchard of the Catholic Health Association acknowledged the gradual change in the look of many Catholic hospitals. “Especially because of partnerships that we’ve developed with other entities in some cases, there might be a less prominent Catholic identity,” he said. “But it is certainly not in an attempt to deceive anybody.”
“We want to make everybody feel welcome,” he said. “If a Catholic hospital maybe doesn’t emphasize overtly Catholic identity as much as they used to, it is not to trick anyone. It’s simply to make people feel comfortable and welcome in an increasingly pluralistic society.”
A patient can generally figure out whether a hospital is under Catholic ownership or affiliation by searching the Catholic Health Association’s member directory.
Nationwide, Catholic facilities make up about 10 percent of all “sole community providers” (49 out of 514), according to MergerWatch, compared with 6 percent (or 29 hospitals) in 2011. In some states the percentage is much greater: in Wisconsin and South Dakota, Catholic hospitals account for at least 50 percent of sole community providers.
Lorie Chaiten, a lawyer with the A.C.L.U. of Illinois, recommended that patients ask their doctor whether an affiliated hospital limits care based on religious or other restrictions. “They can also try calling the hospital with very concrete and specific questions,” she added.
Patients interviewed for this article said that even when they knew they were at a Catholic hospital, they were only aware that Catholic health facilities did not perform abortions, and were taken aback to learn of other services that were off limits.
“People have told me I was incredibly naïve for never having considered it, but I was completely surprised that there was any difference in the level of care that would be provided to someone in a Catholic hospital,” said Angela Valavanis, 45, who was denied a tubal ligation following an emergency cesarean section at a Catholic hospital in Evanston, Ill.
Even some procedures that might appear to be necessary safeguards against medical complications are prohibited by the E.R.D.s. For instance, if a fetus is no longer viable after a woman’s water breaks early in her pregnancy, most Catholic hospitals will not perform an abortion until after a fetal heartbeat is no longer detected, or the pregnant woman’s life is in imminent danger.
“I had no idea this could even happen,” said Mindy Swank, whose water broke in her second trimester, endangering her health. Her local hospital in Silvis, Ill., refused to remove the fetus for two months.
Catholic hospitals have strong roots in America. They were established by nuns in the latter part of the 19th century. “It wasn’t until the 1970s and Roe v. Wade that the bishops started getting more involved,” said Professor Wall, referring to the landmark 1973 Supreme Court decision that legalized abortion.
The growing transgender rights movement has created new issues. Two years ago, Dr. Lindsey M. Dawson, an obstetrician-gynecologist in private practice in the Sacramento area, scheduled a patient for a hysterectomy at Mercy San Juan Medical Center, one of 39 hospitals owned by Dignity Health. The patient, Evan Minton, 37, was transgender and planned to undergo sex reassignment surgery three months later.
During a phone call with a nurse two days before the planned hysterectomy, he mentioned that he was transgender and that he used the pronouns “he,” “him” and “his.”
“She seemed really welcoming and understanding and I had a good feeling when I got off the phone,” Mr. Minton recalled.
The next day, Dr. Dawson got a call from the hospital saying it considered the hysterectomy to be sterilization and had canceled the surgery.
Dr. Dawson was furious. “No one would ever, ever do a hysterectomy exclusively for sterilization,” she said. “I have never even had a hysterectomy questioned. It wasn’t until he brought up his pronouns that they even paid any attention.”
The A.C.L.U. sued Dignity Health on behalf of Mr. Minton, arguing that the withholding of medical care based on Mr. Minton’s gender identity violated his civil rights.
“It was discrimination directed against the core of who I am,” said Mr. Minton, adding that his insurance company had approved the procedure as a medically necessary treatment for gender dysphoria.
A California Superior Court judge dismissed the case, citing Mr. Minton’s ability to schedule a hysterectomy at a different hospital. Officials at Dignity Health declined to comment, as the case remains on appeal.
Father Bouchard said Catholic institutions do not discriminate against transgender patients.
“Catholic hospitals are committed to receiving transgender patients hospitably and providing the same quality care for them as we do for anybody else,” he said.
Father Bouchard said he was aware that the centuries-old system of tenets and beliefs can occasionally be at odds with modernity.
“We’re struggling to make a very old principle relevant to an era when we know a lot more,” he continued. “We talk about it a lot. We just don’t have the solution ethically. It’s always open to debate.”
Catholic Hospitals Limit Procedures
Catholic Hospitals Limit Procedures