Does the Vatican Have a Say in Your Health Decisions?

Personal Health

In the first months of her pregnancy, Candace Rich informed her doctors that she wanted to have her tubes tied. Tubal ligation is cheaper and easier on the patient's health when done during a Cesarean section, so Rich asked her doctors to perform the procedure if she required one. Two days after her due date, Rich was told that she would need a Cesarean but that the hospital refused to perform the simple operation because St. Luke, formerly a secular facility, now operated under Catholic doctrine.

"The doctor told me that 'because of the Vatican,' St. Luke could no longer do that procedure," said Rich in an affidavit. She was forced to find another hospital in the last few days before her surgery and to pay for the full cost of the operation.

Across the country, an increasing number of secular medical facilities are merging with Catholic hospitals to stave off the effects of a difficult economy; a union that proves less than holy for those, like Rich, who seek medical procedures no longer performed by the joined facilities. And many hospitals under Catholic management operate according to doctrine that restricts or prohibits performance of "non-Catholic" procedures, including tubal ligation, a surgical method of sterilization that devout Catholics consider an infringement on God's plan for reproduction.

There are currently about 600 Catholic hospitals in the United States. They manage nearly 20 percent of all hospital beds or one in five of all medical visits logged every year. Forty-eight of these hospitals are considered “sole providers” for a region, rendering many communities without vital medical care options. These organizations are under the direct supervision of the United States Conference of Catholic Bishops (USCCB). Local bishops and both the institutions and their employees are held to strict standards of care dictated by Ethical and Religious Directives (ERDs), which are approved by the Vatican.

The Ethical and Religious Directives are 72 points that outline Catholic medical doctrine. Some of the more contested directives specifically prohibit patient access to, information on, or referrals for procedures or counseling. For instance, Directive 52 denies the use of all contraception except “natural family planning.” Even when addressing patients on HIV or STD prevention, abstinence is advised. Voluntary sterilization (Directive 53) is prohibited for men and women, even when the procedure is easiest after a Cesarean section birth.

In the case of emergency contraception (also known as Plan B or the "morning after" pill), variations in state law have rendered Catholic issuance of emergency contraception inconsistent. A November study from the Guttmacher Institute reports that 17 states and the District of Columbia require hospitals to provide emergency contraception, and 16 states and the District of Columbia require hospitals to provide information about emergency contraception. Stories of non-compliance with these laws abound. A 2003 survey conducted by Catholics for Choice found that 23 percent of Catholic hospitals offered emergency contraception only to victims of rape; only 5 percent offered it without question.

Directive 45 of the Ethical and Religious Directives states that abortion "is never permitted" although it allows for exceptions including surgical procedures for ectopic pregnancies. (A medical abortion is prohibited because the purpose of the drug is to bring about an abortion; surgery, a much more invasive and expensive procedure, is allowed because the objective is to save the woman’s life.)

Various directives address fertility treatments. Fertility procedures are permitted only when a married couple uses their own egg and sperm; third-party donors are prohibited. Drugs that induce egg and sperm production are permitted. Lesbians and unmarried women are not allowed fertility treatments of any sort. And Directive 50 prohibits prenatal diagnosis "when undertaken with the intention of aborting an unborn child with a serious defect."

Regarding advance directives and end-of-life care, Directives 24 and 25 state in part, “The institution...will not honor an advance directive that is contrary to Catholic teaching," and "decisions by designated surrogates should be faithful to Catholic moral principles." Several weeks ago, the USCCB announced that it will revise the directives to address use of artificial nutrition and hydration (ANH). While it's legal in all 50 states to request removal of oneself from ANH, or in the case of a medical proxy, to remove a family member, the Catholic church will re-classify ANH as “an ordinary and proportionate means of preserving life" and not treatment, thus rendering it “obligatory.” Patients are not offered the possibility of removal, regardless of their advance directive requests.

Directive 60 prohibits euthanasia of any sort, and Directive 61 chillingly declares, “Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.”

In most Catholic health care facilities, the conscience of the church supersedes the rights of patients and individual doctors by limiting care services according to Catholic doctrine. Men, women, the elderly, the poor, and the victimized -- effectively, entire communities served by Catholic hospitals -- suffer a drastic and often traumatic loss of patients’ rights when information or services are denied, particularly when a Catholic hospital is the only game in town. Women's reproductive choices are especially compromised. 

"In 50 percent of merger cases," says David Nolan, editor of Conscience, a quarterly journal published by Catholics for Choice, "Some if not all reproductive services are curtailed" in direct opposition to the community’s and patients’ wishes and, in some cases, despite state laws. “It is very difficult for an individual to stand up to these hospitals and it requires a great deal of courage,” Nolan told me.

This is the case for two reasons: The personal nature of reproductive services and the power of the Catholic church. “Women's reproductive health has been marginalized to the point where women sadly expect to travel for these services, or want to because of their desire for privacy,” Nolan says. Limited access to facilities that provide abortion, contraception, tubal ligation and sterilization has, Nolan says, unfortunately become, “an accepted aspect of women’s reproductive health.” In other words, women don’t complain because they’ve gotten used to it.

Full blame for this breach of patients’ rights, however, does not fall solely on the Catholic Church. Federal and state governments continue to defer to religious ideology. (Frequently the justice system does too; note the case of a woman in Maine who was recently ordered by a judge to be confined to a hospital for bed rest until the end of her pregnancy. The judge prioritized the life of her fetus over her rights as a woman and patient.) The Catholic health industry maintains and imposes a "pro-life" standard of care on religiously diverse communities with the implicit -- and often explicit -- approval of those entities whose duty it is to protect individual patients’ rights.

"Too often the work of opposing limitations in these cases is left to a smallish group of advocates,” Nolan says. As with the case of Candace Rich in Kentucky, the denial of services often comes without warning.

“The primary protection patients have is public scrutiny,” says Jane Wishner, executive director of the Southwest Women’s Law Center and an active observer of the merger negotiations. "Community members must stay vigilant.” 

Medical advancements have caused the USCCB to periodically update the governing ERDs to comply with religious doctrines. During the ‘90s when Catholic and non-Catholic hospitals began to merge at a greater rate, bishops were encouraged by the USCCB to pay closer attention to the resulting arrangements. Greater stipulations regarding financial practices, referrals, and physical situation of “carved-out” reproductive centers are being made. A local bishop reviews the merger contract to confirm the acceptability of the arrangement and to ensure that the Catholic entity is held to strict standards of ERDs. (Last year, the board of a British Catholic hospital was fired by the Archbishop of Westminster for not complying with Catholic doctrine.)

Some communities and activists have found “creative solutions" in order to meet the Catholic directives -- such as the hospital-within-a-hospital created in 2001 at Austin’s Brackenridge Hospital when Seton Health System took over management. Despite these creative solutions, mergers still often result in a loss of patients’ access to care.

“Hospital mergers are a microcosm of what is happening at the national level with health care,” says Lois Uttley, director of the MergerWatch Project, an advocacy organization that raises awareness and works to maintain patients’ rights when religiously affiliated hospitals merge with secular ones. According to Uttley, MergerWatch is involved in 11 ongoing mergers around the country.

A seminal report produced by the organization, titled “No Strings Attached: Public Funding of Religiously Sponsored Hospitals in the United States,” states: “While it is permissible to accommodate religious beliefs, government cannot abandon secular goals to give preferential treatment to religion. There is a point at which a policy meant to protect the free exercise of religion can become an impermissible accommodation that favors or 'establishes' religion over secular concerns. The First Amendment, while protecting the free exercise of religion, also has a clause prohibiting government establishment of religion.”

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