UPDATE: In response to pressure originating from the California Medical Association’s concern over the Gilroy case outlined below, the AMA passed a compromise resolution on June 15, calling for preservation of services while simultaneously affirming that doctors and hospitals shouldn’t be forced to violate religious or moral principles. That statement marks the first stand the organization has taken on the question of religious hospital mergers.
Pregnant with her sixth baby, “Rosa,” a 36-year-old Hispanic woman, decided enough was enough. Her husband wouldn’t have a vasectomy, and other birth control methods either were unreliable, made her feel sick, or required her husband’s cooperation. After much soul searching, she decided to be sterilized right after she gave birth — the easiest time, when it could be done in the same hospital visit.
She wanted to have her baby with her usual doctor, but that doctor only delivered at St. Louise Hospital in Morgan Hill, Calif. St. Louise was a Catholic hospital, meaning that, in keeping with church opposition to any form of contraception, it didn’t perform sterilizations. So Rosa chose a different doctor who delivered at South Valley Hospital, a nonsectarian hospital in nearby Gilroy, a poor, rural, largely Hispanic town.
But in between that decision and Rosa’s delivery, St. Louise bought South Valley Hospital. It closed the old St. Louise and reopened in South Valley’s building last December as St. Louise Regional. Rosa had her baby in the new hospital with the new doctor, but the hospital was now Catholic; as a result, despite her decision and her planning, Rosa couldn’t have the sterilization procedure.
Now, she’s back on birth control pills. They make her feel sick and she dreads forgetting a pill, but she doesn’t have much choice. The nearest hospital that accepts her insurance is about an hour’s drive away, in San Jose. With no car, poor bus service, six kids to take care of, and an uncooperative husband, getting the tubal ligation is, for now, a practical impossibility.
Catholic hospitals, with their commitment to serve the poor, have long played an important role in providing medical services in the United States. But Catholic hospitals and hospital systems are expanding rapidly, riding a growing trend, spurred by cuts in Medicare payments and the growth of HMOs, toward consolidation among the nation’s health care providers. That trend has led to an increasing number of small hospitals being either merged or subsumed into chains. When a merger happens in an isolated community, it can leave a Catholic hospital the only game in town, often leaving women with limited or no access to services from sterilization and fertility treatments to abortion.
According to MergerWatch, an organization that tracks mergers between religious and secular hospitals, Catholic hospitals and hospital systems now constitute the nation’s largest non-profit provider of health care. Catholics for a Free Choice reports there were 117 mergers or affiliations between Catholic and non-Catholic health-care institutions from 1995 through September of 1999. Exactly how many of these leave communities with no other hospital is difficult to determine — no one collates the numbers quite that way. But Lois Uttley, executive director of MergerWatch, knows of nine mergers of this sort achieved or attempted during the 1990s in rural New York State alone, and there are at least six others around the country.
Many small Catholic hospitals, originally independent, have by now become part of one of the several sprawling Catholic health care systems that have arisen during the past decade. As a result, when a small hospital becomes involved in a merger and the terms of the deal are being ironed out, “the Catholic hospital is not sitting at the negotiating table by itself,” says Uttley. “It has a big national system behind it, with its lawyers and its PR people and all that. It makes for a rather unbalanced negotiation.”
If secular authorities balk, the Catholic hospital can threaten to back out entirely. When Gilroy ob/gyns asked the county to require allowing tubal ligations as a condition for St. Louise receiving county bond funds, Catholic administrators threatened to shut the facility down, leaving the community with no hospital at all. County supervisors approved the bonds with no restrictions.
The church’s Ethical and Religious Directives define the approved policies in Catholic institutions for medical issues, from family planning services to questions of death and dying. The directives aren’t applied in every merger that involves a Catholic partner. Partners in a merger often find a way to provide at least some of the services prohibited by the directives, like contraception and sterilization. In urban areas there may be another facility nearby that can take over services that a Catholic institution doesn’t offer. Some compromises have allowed services to stay in the same facility, insulated from the Catholic institution by cunning bookkeeping.
In that fraction of mergers that happens in small and isolated communities, though, where the only hospital for miles around is a Catholic one operating under the directives, the results can be devastating.
In the small office of prenatal coordinator Rosie Olivo at the Planned Parenthood clinic in Gilroy, the signs on the wall are in both Spanish and English. Olivo explains why St. Louise Regional’s ban on tubal ligations, the most common sterilization procedure for women, is such a hardship for her mostly Hispanic clients.
Olivo is Hispanic herself and understands the cultural reasons that make it hard to talk men into having vasectomies. “They think if they have a vasectomy they’re not going to be able to have another erection,” she says. It’s usually the women, she says, who take responsibility for limiting family size. Once a woman has made the decision that her family is complete, often after three, four, or more babies, she doesn’t want to take a pill every day, fuss with a diaphragm, or talk a reluctant partner into a condom. “She wants to have an operation and be done.” Olivo has seen several unwanted pregnancies among women who were unable to get tubal ligations since St. Louise Regional opened in December.
The problem doesn’t stop at tubal ligations. One particularly troubling incident took place after a secular-religious merger in Manchester, N.H. In spring of 1998, a patient of ob/gyn Dr. Wayne Goldner had her water break at 13 weeks. It was too early for the fetus to be viable, there was no possible way the pregnancy could continue to completion, and there was imminent danger of infection to the mother. But when an examination revealed a fetal heartbeat, and no infection had set in yet, hospital administrators considered the abortion elective and wouldn’t allow Goldner to schedule it. Goldner ended up paying himself for the woman to travel to another hospital 80 miles away where she had the pregnancy terminated.
Another issue has drawn particular anger from women’s groups and other supporters: A survey last year by Catholics for a Free Choice revealed that four out of five of Catholic hospitals did not offer emergency contraception to rape victims. The resulting outcry prompted Catholic hospitals to reconsider. The wording of the ethical directive on this question leaves some wiggle room, and, nationwide, the result is a patchwork, depending on local interpretation. Catholic hospitals belonging to the Catholic Healthcare West system, one of the nation’s largest, do provide emergency contraception in cases of rape, while a survey of New York Catholic hospitals released last December revealed that in New York, most still do not.
Incensed, New York Senator Eric Schneiderman has introduced legislation requiring any licensed emergency room to provide the service. “I think this is the most offensive possible intrusion of religious doctrine into situations of medical necessity,” says Schneiderman.
If a non-sectarian health care provider like Kaiser Permanente chose not to provide, say, eye exams, the fight to get eye exams back would be a straightforward one, with clear sides and clear motives. But the conflict over reproductive services offered by Catholic hospitals takes place on the uniquely swampy ground where sex and religion intersect, making the struggle particularly complicated.
Advocates for women’s health believe their fight is a tough one for the very reason that it affects women, bringing old-fashioned sexism into play. In an interview with The Los Angeles Times, Catholic Healthcare West Vice President Wade Rose responded thus to the charge that not providing reproductive services shortchanges communities: “How can you compare the people’s needs for cancer treatment, heart disease treatment, and treatment of diabetes to a handful of elective procedures?” The clear implication, says Ann G. Daniels of the California Abortion and Reproductive Rights Action League, was that women’s reproductive care “is a minor issue that women can have taken care of elsewhere.”
Religion clouds the discussion as well. “When I raise the issue that medical decisions should be between a doctor and patient, they portray it as anti-Catholic bigotry,” said one outspoken doctor who opposed the terms of a Catholic-secular merger in rural Maryland.
And — perhaps the biggest land mine — reproductive health care has become politicized like no other area of medicine. It covers questions from emergency contraception for rape victims to sterilization, but some people never get past what Jodi Magee, executive director of Physicians for Reproductive Choice and Health, calls “the A-word.”
“There’s no question,” says Magee “that when you mention the word ‘abortion’ that people’s red flags go up.” Abortion, a small part of the issue, can overshadow the rest. Her organization, founded by pro-choice physicians, considers part of its mission to reclaim this ground: “We’re trying to retrain physicians and the medical community at large … to see this as a medical issue and not as a political issue.”
Lori Cappello Dangberg, Vice President of the Alliance of Catholic Health Care, says it’s not the responsibility of the church to make sure local residents have access to all the health services they want. Dangberg points out that many hospitals drop certain services for economic reasons. The church’s choice to omit services on religious grounds, she says, “should be entitled to at least as much respect as another institution’s refusal to provide them because the profit margin is not high enough to satisfy their shareholders.”
“You could ask the question: Given the policies of Catholic Healthcare West, what is the county’s responsibility to step in to provide the services that Catholic Healthcare West can’t?” asks Catholic Healthcare West Vice President Wade Rose.
Government already takes some role. When non-profits merge, state attorneys general look at both monopoly concerns and what’s called “breach of charitable trust.” The idea is this: If past donors gave money to a hospital with an understanding of its philosophy, and it then becomes part of a partnership that operates under a different philosophy, that effectively defrauds those donors, and the attorney general can stop the merger on their behalf. In New York state, mergers have been held up for months or years on these grounds. Preventing a merger, though, may leave another shoe to drop. Mergers happen because a town can’t support two hospitals. Stopping a merger to prevent loss of reproductive services doesn’t change that financial reality.
In organized medicine, awareness seems to be bubbling up from the bottom. The local medical associations went to bat to save reproductive services in Enid, Okla. and in Gilroy when doctors at the hospitals involved called for help. In March, the California Medical Association, galvanized by the case in Gilroy, passed a resolution asking the American Medical Association to consider action to assure that services are preserved “in the case of mergers and/or acquisitions of health care systems.”
Santa Clara County Medical Association President James Hinsdale recounts part of the debate at the March CMA meeting. “A woman got up and said ‘What if a religion like Jehovah’s Witnesses … took over a hospital and said look, we’re not letting anyone get blood transfusions? What would we do about that?’ And people just gasped.” Nobody seems to have an answer yet about where to draw the line between religious freedom and public health, but doctors are starting to ask the questions.