What happens when religious institutions get to manage public funds, absorb secular hospitals, and put theology above medical science and individual patient conscience? Religious freedom suffers.
In 2010, in Tulsa, Oklahoma, an elderly woman was rushed to a local hospital called St. John. She had suffered a massive stroke and could no longer eat, drink or speak. Mercifully, she was one of the growing percent of Americans who have prepared for such an eventuality by writing an end-of-life directive. Hers said that said she did not want artificial hydration or nutrition if she wasn't going to recover. Unfortunately, St. John is a facility where the directives of the Catholic bishops take precedence over the directives of individual patients, and one such directive orders hospitals to feed and hydrate end-of-life patients whether they want it or not.
Americans would do well to consider what happens when theology dictates health care.
In the official language of the bishops, St. John is a "Catholic health care ministry," their term for all Church-affiliated hospitals and clinics. Catholic health care ministries are publicly licensed institutions intended to serve the general public. They are highly subsidized by public dollars. To fund them, the Church uses a variety of public revenue streams including Medicare, Medicaid, county appropriations, federal dollars allocated through the 1946 Hospital Survey and Construction Act, and tax-exempt government bonds. As with any hospital, additional revenues come from insurance payments and investments, with the end result that the Catholic Church contributes less than 5 percent of the funds flowing through their hospitals and clinics. And yet the bishops place theological restrictions on care for all patients and sometimes forbid providers from telling patients that treatment options exist elsewhere.
According to MergerWatch, Catholic control of health dollars and hospital facilities is on the rise across the United States. In Washington State, for example, if all currently proposed mergers go through, almost half of hospital beds will lie in the hands of religious institutions by the end of 2013. Across the US, as Catholic systems such as Peace Health and Catholic Health Initiatives (CHI) quietly absorb secular hospitals, the bishops are fighting in court for the religious equivalent of corporate personhood, claiming that the constitution gives them institutional conscience rights that trump patient choice. Meanwhile, Catholic-owned pharmacies are suing for the right to deny services; and other Catholic-owned business are demanding (and winning) religious exemptions from health insurance obligations.
In an effort to standardize the rules of Catholic institutions and the advice that priests give laypeople, the bishops have created what they call "Ethical and Religious Directives for Catholic Health Care," called ERDs for short. When secular and religious institutions merge, the bishops' directives often restrict services in both. Patients may not realize that a once secular institution named Swedish or Highline is now subject to theology and could impose religious beliefs at odds with those of the patient. Following mergers, changes often are gradual, occurring slowly as staff leave and are replaced with believers, which makes the shift even harder for patients to detect. (Religious hospitals are exempt from non-discriminatory employment practices, somewhat remarkable given that so much of their funding is public.) Hospital administrators may state that they do not interfere in the doctor-patient relationship while at the same time advertising for staff who are "deeply familiar" with the bishops directives.
From a consumer standpoint, one problem with putting religion rather than science in charge of health care is that patients may not know they are being denied the full range of medically appropriate options. They may have no idea when institutional rules prevent doctors and nurses from honoring end-of-life wishes or discussing services that are available in secular settings - services like contraception, abortion, tubal ligation, vasectomy, fertility treatment, or death with dignity. For example, one woman tells of being diagnosed with an ectopic pregnancy at a religious hospital. She was advised that she needed to have her fallopian tube removed. Fortunately, she consulted her smart phone and realized that elsewhere she could simply obtain a medication to end her nonviable pregnancy. The medication is safer and leaves fertility intact, but the Catholic directives treat this as a direct abortion, while the surgery (which damages long term fertility) kills the fetus indirectly and so is acceptable.
Other countries where Catholic theology limits health options offer a dire warning of what might happen here if the Church had an equal hold on the levers of power. In El Salvador, Catholic theology was written into law in 1998, banning all abortions, even those intended to save the mother. As a consequence, a 22-year-old mother named Beatriz, who carries a nonviable fetus, lies in a hospital bed with her kidneys failing, hoping to be granted an exception by El Salvador's Supreme Court. She has been waiting for over a month. In Catholic Ireland last October, a young dentist, Savita Halappanavar, died after being refused an abortion.
In an ironic twist, the extremity of Catholic directives leads many people to believe that they couldn't possibly be implemented here. Consider the case of Beatriz. She is the mother of a young child. Her fetus is anencephalic, meaning it has no brain and never will be a person under any circumstance. (Note: Somewhere between 60 and 80 percent of human fertilized eggs self-destruct naturally before a full-term gestation, most before a woman knows she is pregnant, and many because they are defective.) In other words, the Salvadorian anti-abortion law risks the life of a young mother for an incomplete fetus that is a normal failed reproductive product rather than a potential child. For someone who thinks that morality is about well-being, this just sounds crazy. Of course, this could never happen in the United States, right? You may be astounded to learn that a Phoenix nun was excommunicated and her hospital was forcibly disaffiliated from the Catholic Church for allowing an abortion under similarly hopeless circumstances.
In Ireland, after Halappanavar's unnecessary death, thousands of men and women demanded medical services based on scientific evidence and individual conscience. Halappanavar became the tragic face of an international movement. Even so, given the power of religious institutions and traditions, legal change in Ireland is likely to be minimal. The largely Catholic Irish Medical Association has declined to request abortion rights even in cases of incest, rape and nonviable fetal anomalies. Currently Irish law allows abortion only when a mother's life is threatened, which is not good enough for a case like Halappanavar's. A leading obstetrician testified that Halappanavar probably would have survived if she had gotten an abortion during the first three days of her hospital stay. But at that time, there was not a "real and substantial threat to her life." By the time she met the legal criteria, it was too late.
Patients count on their doctors to know and suggest their best options to protect health and well-being. But as medical options increase, especially at the beginning and end of life, the range of services excluded for theological reasons also increases. Catholic "ethicists" devote millions of dollars to analyzing biomedical technologies in the pipeline and then advocating policy based on theological priorities. They block certain lines of research and prevent affiliated hospitals from participating in clinical studies that require participants to be on contraception, for example a study of a cancer treatment that might cause fetal defects. Procedures opposed by the theologians are likely to be absent altogether from patient-doctor conversations.
Some patient advocates say that mandatory disclosure is part of the solution: Pharmacies that refuse to fill some prescriptions should post the fact that they are not full-service. Church-run abortion diversion centers known as crisis pregnancy centers should post that they are not medical providers. Treatment consent forms should list the scientifically and medically accepted practices that a doctor or hospital refuses to provide so that patients know that these services are available elsewhere. Conversely, providers who sign onto a Patients' Bill of Rights promising to base care only on medical science and patient conscience could get the equivalent of a Good Housekeeping Seal of Approval.
But disclosure alone won't ensure state-of-the-art health care for many Americans, especially those living in small towns or rural settings. Sometimes one clinic or pharmacy serves a wide area, or all nearby services are managed by the same religious institution. In these cases, a woman with a painful and life-threatening ectopic pregnancy might not be able just to get in her car and drive to another clinic. Denial of service hits low-income communities hardest because members often have less flexible time off work and more restricted access to transportation and child care. The right of religious doctors and institutions to deny services obstructs the right of patients to receive timely care that meets normal medical practice standards, which are designed to maximize well-being.
That is because Catholic theology isn't necessarily about well-being; it is about submitting to the perceived will of God. Sometimes these two align, and sometimes they don't. To serve God's will, Catholic theologians attempt to derive moral principles that are about the inherent goodness or evil of certain beliefs and behaviors, regardless of their consequences. In this way of thinking, contraceptives or abortions should not be provided because they are "intrinsically evil," even when contraception or abortion may save a woman's life.
To make matters worse, Catholic theology values passive submission to harm when it is believed to serve Catholic practice or faith. Saints are heralded for their commitment to theological principle even in the face of outrageous and foreseeable outcomes, including martyrdom. In fact, Catholic theology sees pain as having positive soul-purifying benefits. This is called redemptive suffering. In the ERDs, it is offered up as an alternative for patients whose unbearable pain leads them to seek death with dignity:
Dying patients who request euthanasia should receive loving care, psychological and spiritual support, and appropriate remedies for pain and other symptoms so that they can live with dignity until the time of natural death.... Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.
Former nun Mary Johnson (author of An Unquenchable Thirst) spent 20 years working with Mother Teresa's organization, the Missionaries of Charity, which has been accused of providing substandard treatment and pain management. She explains the sometimes abysmal conditions in their facilities thus:
Most people today would say that we help the poor by helping them out of poverty. That was never Mother Teresa's intention. Mother Teresa often told us that as Missionaries of Charity we did not serve the poor to improve their lot, but because we were serving Jesus, who said that whenever service was rendered to one of the least, it was rendered to him. Jesus promised eternal life to those who fed the hungry and clothed the naked.
The point, in other words, is not necessarily to solve the problem but simply to perform service. Ultimately, it isn't about real world outcomes for the person on the receiving end, but about eternal outcomes for the person on the giving end. The difference is important. And although Johnson doesn't mention it, the passage she quotes mentions the ill as well as the hungry and naked. The Jesus of the gospel promises eternal life to those who feed the hungry, clothe the naked, visit prisoners and care for the ill. When religion and healing are at odds, the way to get to heaven is to offer theologically principled care, even when more compassionate options are available.
This difference in objectives seems like reason enough to separate religion from medicine. Thanks to science, fertility treatment has come a long way from the mandrakes and dove blood prescribed in the Bible. Victims of sexual assault now have options other than being forced to bear rape babies (also the Biblical solution). As we face death, we have alternatives to convincing ourselves that suffering is redemptive. Do we really want theology at the helm of our biggest hospital and clinic systems?
If not, it may be time for ordinary men and women to speak our minds. In Washington State, where the battle over Catholic hospital mergers is heating up, the state constitution specifically prohibits the use of public funds to support religious institutions. Despite that prohibition, one district actually has a line-item in the property tax code to subsidize a Peace Health facility, leaving the local community with no secular alternative. With the Peace Health clinic newly open, the local bishop has already tried to block the now-Catholic system from providing lab work for Planned Parenthood, as was done in the past. Legal challenges may play out in court thanks to a patients' rights campaign by the ACLU and grassroots groups, but the broader question is this:
When it comes to medical options, whose beliefs count: the bishops', or the patient's? Who gets to say whether one woman is forced to incubate a pregnancy gone wrong or another is force-fed at the end of life? Whose version of god gets to dictate how you live and how you die?