Prescription For Disaster

Hospital Mergers And Heavy-Handed Tactics Are Giving The Catholic Hierarchy An Increasingly Problematic Role In American Health Care

The situation facing doctors at St. Joseph’s Hospital in Phoenix in November of 2009 was something right out of a television medical drama.

A 27-year-old pregnant woman had been rushed to the hospital suffering complications from pulmonary hypertension, an affliction that undermines the heart and lungs. Doctors concluded they could save her life only if they aborted the 11-week-old fetus she was carrying; the patient agreed.

At many hospitals, the patient would have been wheeled into surgery right away. But St. Joseph’s was at that time a Roman Catholic institution governed by the Ethical and Religious Directives for Catholic Health Care Services, a series of doctrine-based rules imposed by the U.S. Conference of Catholic Bishops. Those directives forbid abortion for any reason – even to save the life of the mother.

Sister Margaret McBride, an Irish nun and longtime administrator at St. Joseph’s, pulled together the hospital’s ethics committee to deliberate the issue. In the end, the board voted to approve the abortion, saving the woman’s life.

“In this tragic case, the treatment necessary to save the mother’s life required the termination of an 11-week pregnancy,” read a statement issued by the hospital. “This decision was made after consultation with the patient, her family, her physicians, and in consultation with the Ethics Committee.”

For her trouble, McBride was excommunicated from the Catholic Church. About six months after the incident, Bishop Thomas J. Olmsted of Phoenix met with McBride and told her that her actions had created a “scandal” and that she had automatically excommunicated herself. McBride was also demoted to a lesser position at the hospital.

Olmsted had no intention of stopping there. In January he announced that St. Joseph’s can no longer call itself a Catholic institution.

McBride has never spoken publicly about what happened. But her demotion, as unfortunate as it was, may have had one positive effect: The story made headlines around the nation (and even the world), putting a spotlight on the mixture of religion and medicine at sectarian hospitals. These facilities receive generous public subsidies and in some parts of the country may be the only medical option for residents, yet they impose a strict interpretation of Catholic dogma on all patients – Catholic and non-Catholic.

The church’s ethical directives not only ban abortions, they also address end-of-life issues. In some cases, patients grappling with terminal illnesses have seen their advanced directives and “living wills” trumped by church doctrine.

Most Catholic hospitals also provide no access to artificial forms of birth control. They don’t perform sterilizing operations such as vasectomies and tubal ligations and don’t make certain services available to infertile couples. The ban is so strict that some religious hospitals won’t even provide “morning after” pills – drugs that can prevent pregnancy after intercourse – to rape victims.

In the wake of several recent controversies, the bishops are digging in. In a recent letter, Sister Carol Keehan, president of the Catholic Health Association, conceded to New York Archbishop Timothy Dolan that the church’s bishops – not doctors or hospital staff – have the final say on interpreting the directives.

In response, Dolan wrote, “Where conflicts arise, it is again the bishop who provides the authoritative resolution based on his teaching office.”

The Vatican also plans to weigh in. Church officials in Rome say a new set of guidelines governing medical issues will be published this year, along with a separate document dealing with AIDS.

During a press conference, Bishop José L. Redrado, secretary of the Vatican’s Pontifical Council for Health Care Workers, mentioned the incident in Phoenix and said Catholic hospitals are confronting a “culture of death.”

“The language should be clear explaining what the church says, where the frontiers are, where there is a risk of crossing the line,” Redrado said.

But a Vatican crackdown isn’t likely to resolve matters. Increasingly, the church’s restrictive directives are being challenged. A round of hospital mergers in the 1990s and 2000s led to more cities with medical institutions operating under Catholic dogma. In some cases, public or non-sectarian hospitals that merged with Catholic institutions were forced to drop certain services. A backlash began building.

MergerWatch Project, based in New York City, tracks this issue nationwide. Lois J. Uttley, director of the group, told Church & State that a growing number of hospitals are at risk of losing services – and that people are speaking out and mobilizing to block these unions.

“Because of the recession, more and more hospitals are looking to merge with nearby facilities or join large systems,” Uttley said. “Our caseload at the MergerWatch Project is the highest it has been since we started our work back in 1997. We are receiving calls and e-mails from physicians, nurses and patients all across the country who are facing proposed hospital transactions that threaten to seriously curtail the availability of comprehensive health care services in their communities.”

MergerWatch has worked with local advocates to oppose the imposition of restrictive religious doctrine at secular hospitals in more than 90 cases across the country. Nationwide, about 13 percent of hospitals are religiously affiliated; but because many of these facilities are larger than average, they account for 18 percent of the country’s hospital beds.

Advocates of women’s rights and reproductive choice often oppose these mergers, and they’ve had some success. Public education is one way to block proposed mergers, but courtroom action is also an option. A Catholic health-care group pulled out of an alliance with a public hospital in St. Petersburg, Fla., in 2000 after Americans United and its allies filed legal action.

But many other mergers have gone through, and religiously affiliated hospitals are getting nods from the government in some parts of the country.

In the Washington, D.C., suburb of Montgomery County, Md., a recent flap over construction of a new hospital left women’s rights advocates seething after state hospital regulators granted a Catholic group the right to build a new facility, bypassing a plan put forth by a Seventh-day Adventist health-care group. (The Adventist group, although also religious, has promised to provide reproductive services.)

A coalition of organizations known as the Montgomery County Complete Care Coalition formed to press for a facility that would offer the full range of reproductive health services. Groups taking part included the Maryland Chapter of the National Organization for Women, NARAL Pro-Choice Maryland, Women’s Law Center, Catholics for Choice, and Americans United.

Maryland’s Health Care Commission was not swayed, however. The body voted 9-0 Jan. 20 to approve the Catholic group’s plan to build a 93-bed hospital in Germantown, the county’s first new hospital in 30 years. Commission Chair Marilyn Moon said women could go elsewhere for reproductive services.

Beth Corbin, national field director for Americans United, worked to rally opposition to the plan.

“Treatment should be based on what is in the best interest of the patient, not on religious directives,” Corbin said. “Women, who make up more than 50 percent of the population, will be the most affected.

“Opponents of comprehensive reproductive health care for women will try to paint this as an ‘abortion’ issue,” Corbin said. “While I think abortion is a part of the care some women need, the church’s restrictions also effect infertility treatments for couples trying to have a child, HIV/AIDS prevention and end-of-life matters.”

Concluded Corbin, “There are clear church-state separation issues in this decision that cannot be ignored.”

The issue goes beyond who controls hospitals. Increasingly, pharmacies are becoming battlegrounds as well.

Some Catholic and fundamentalist Protestant pharmacists have insisted on a right to refuse to fill certain prescriptions that violate their religious beliefs, usually “morning after” pills or birth control.

Women’s rights advocates have insisted that pharmacists should be required to fill doctor-provided prescriptions, but legislators in some conservative states disagree. While the state of Washington has a law requiring pharmacists to provide certain time-sensitive drugs such as morning-after pills, other states have gone the other way. They’ve passed laws protecting pharmacists.

The results can be devastating for people facing serious medical problems. In Nampa, Idaho, a pharmacist at a Walgreens drug store refused in November to fill a prescription for Methergine, a medicine used to control bleeding of the uterus.

Idaho legislators in 2010 passed a law giving pharmacists the right to refuse to dispense abortifacients – drugs that induce abortion – as well as emergency contraception. The pharmacist cited the law and insisted that Methergine is an abortifacient. In fact, it is often used to control bleeding after child birth.

A nurse who was trying to obtain the drug for a patient said the pharmacist would not fill it unless she were first assured it was not being used following an abortion. The pharmacist also refused to provide a referral to another pharmacy. Planned Parenthood filed a complaint with the Idaho Board of Pharmacy over the incident and also contacted Walgreens’ corporate office, which, the group said, took corrective action against the pharmacist.

Other national organizations are stepping up their activism against sectarian interference in health care. In the case from 2000, Americans United joined forces with the American Civil Liberties Union of Florida, the National Organization for Women Foundation and Planned Parenthood of Southwest and Central Florida representing local plaintiffs in Pinellas County, Fla., who wanted to put an end to the merger of a public and Catholic hospital in St. Petersburg.

The case, National Organization for Women v. City of St. Petersburg, was settled out of court after the Catholic group pulled out of the alliance and the hospital agreed to operate in a secular manner.

More recently, the ACLU in December wrote to federal officials to urge them to require religious hospitals to save women’s lives when they are in danger. In the letter, the ACLU referred to the controversy in Phoenix.

The ACLU says religious hospitals that deny life-saving abortions are violating the Emergency Medical Treatment and Active Labor Act, a 1986 federal law that requires hospitals that participate in Medicare (which is nearly every hospital in America) to provide care to anyone in an emergency situation, regardless of that person’s immigration status or ability to pay.

“[T]his confrontation never should have happened in the first place, because no hospital – religious or otherwise – should be prohibited from saving women’s lives and from following federal law,” wrote the ACLU.

Increasingly, Americans are waking up to the fact that they don’t have to accept the loss of health services. MergerWatch’s Uttley notes that since 1997, the group has worked on 92 proposed mergers in 34 states. The group says that in 25 of those cases, the merger was defeated outright, and in 22 a compromise was fashioned that kept at least some reproductive services in place. In addition, the group has helped reverse 12 mergers after services were lost.

“Communities need not passively accept the loss of vital services and choices at their local hospitals,” Uttley said. “Non-profit hospitals are vital community resources, not private businesses unaccountable to the community. Non-profit hospitals benefit from tax exemptions, receive millions in public dollars for serving Medicaid and Medicare patients and benefit from volunteer hours and charitable donations from local residents. They are licensed to serve the public, and should be expected to do so in a way that meets accepted medical standards of care.”

Uttley added that educating the community is essential. Faced with loss of services, people will often begin to speak out, she said.

“We find that when community residents and physicians are informed about the potential impact of a religious/secular hospital merger and mobilized to action, they often can have a positive impact on the outcome,” said Uttley. “In some cases, community activists have stopped mergers that would have damaged their access to care. In other cases, they have been able to work productively with secular hospital officials to devise creative solutions, such as ‘carve outs,’ that preserve access to reproductive health care within separately-incorporated areas of secular hospitals before they merge with religiously-sponsored partners.”

Back in Phoenix, McBride’s dilemma has put a human face on this contentious issue. Even though months have passed since her demotion, the nun’s story continues to reverberate in the city and beyond. When Olmsted yanked the hospital’s religious affiliation in January, it led to another round of comment by bloggers and even sparked a column by Nicholas Kristof of The New York Times, who called the nun someone who “truly seems to me to have emulated the life of Jesus” and labeled Olmsted “a Vatican bureaucrat climbing the career ladder.”

Some staff members at the hospital have also spoken out. Dr. John J. Garvie, chief of gastroenterology at St. Joseph’s, defended McBride in a letter to the editor of the Arizona Republic.

“Everyone I know considers Sister Margaret to be the moral conscience of the hospital,” Garvie wrote. “She works tirelessly and selflessly as the living example and champion of compassionate, appropriate care for the sick and dying.”

Others, wary of the power of Bishop Olmsted, spoke out anonymously.

A doctor at St. Joseph’s, who requested anonymity, sent an e-mail about McBride and her situation to several friends, including a conservative Anglican blogger in England who calls himself Cranmer. Cranmer reprinted portions of the message.

“She is a kind, soft-spoken, humble, caring, spiritual woman whose spot in Heaven was reserved years ago,” wrote the doctor. “The idea that she could be ex-communicated after decades of service to the Church and humanity literally makes me nauseated.

“True Christians, like Sister Margaret, understand that real life is full of difficult moral decisions and pray that they make the right decision in the context of Christ’s teachings,” continued the doctor. “Only a group of detached, pampered men in gilded robes on a balcony high above the rest of us could deny these dilemmas.”

St. Joseph’s, meanwhile, is standing by its decision – even if it means loss of church support.

“Morally, ethically, and legally we simply cannot stand by and let someone die whose life we might be able to save,” said hospital officials in a statement.