the parking lot of a hospital in central California, nurses are handing
out plastic bags full of drugs to their patients. The nurses are not
dispensing illegal substances. They are handing out the morning-after pill.
But in the process, they are disobeying hospital policy.
Though emergency contraception is standard medical protocol in treating rape and incest, this hospital forbids prescribing the high dose of birth-control pills that can flush out a fertilized egg shortly after intercourse.
The hospital is Catholic, and the Roman Catholic Church says birth control is morally wrong.
where medical personnel are having to offer reproductive
health care with a wink and a nod are on the rise as religious hospitals and
clinics are merging at an accelerated pace with other health-care providers.
In this era of mergers and managed care, the Roman Catholic Church is having more of a say in all sorts of women's reproductive health-care services. Five of the ten largest hospital corporations are Catholic. (These are: Daughters of Charity National Health System, Catholic Health Initiatives, Catholic Healthcare West, Catholic Health Care Network, and Mercy Health Services.) There are more than 600 Catholic hospitals and 200 health-care centers serving some fifty million patients a year. And as the hospitals merge and affiliate with non-religious facilities, they often close off reproductive health care for women.
"We're seeing a huge increase in the number of hospitals and clinics being purchased by religious hospitals that refuse to offer the full range of reproductive care," says Susan Berke Fogel, legal director at the Women's Law Center in Los Angeles. Fogel tells the story of the nurses in the parking lot but declines to name the hospital or location, saying the nurses could lose their jobs for the stance they are taking.
"It's reprehensible at a time when medical trends are toward integrated health care that we are seeing this competing trend to isolate and marginalize women's health care," she says.
Catholic doctrine opposes abortion, contraception, tubal ligations, vasectomies, and fertility treatments. This doctrine applies not just to Catholics, but to any patient treated in a Catholic facility or even at a hospital or clinic affiliated with a Catholic institution that adheres to this doctrine.
And the number of these affiliated facilities is growing. Catholic Health Association estimates there were more than 100 mergers involving Catholic and secular hospitals in 1994 alone. Although other religious denominations, such as Baptists and Adventists, also run health-care facilities that may limit access to abortion, the biggest threat is from Catholic hospitals. A report by the Johns Hopkins School of Hygiene and Public Health found that 18 percent of all hospital affiliations in the past six years have involved a Catholic facility.
"We're seeing religious viewpoints being imposed in an extremely coercive way on people who don't share those views," says Catherine Weiss, director of the American Civil Liberties Union's Reproductive Freedom Project.
Often, the patients are the last to know that a hospital merger has restricted their reproductive health-care options.
27 percent of women understood that being part of a Catholic hospital
system could limit their reproductive care, according to a 1995 survey by
Catholics for a Free Choice.
Catholics for a Free Choice cites the example of Jenni Zehr, who in 1988 went to Sacred Heart General Hospital, a Catholic hospital in Eugene, Oregon, to give birth. She requested to have a tubal ligation. Her doctors not only did not perform the procedure, they neglected to tell her. She found out when she became pregnant again.
Three years ago, according to the Oregon Register Guard, the Oregon Supreme Court ruled that Zehr could sue her doctor for the costs of raising that child.
A nineteen-year-old woman from Troy, New York, had one child and was struggling to put herself through community college. One day, she visited her clinic to get her regular birth-control shot. She didn't know that her clinic had merged with a religious facility.
"She was simply told, 'We don't do that anymore,' and was not referred to any other provider," says Lois Uttley, director of MergerWatch, which is funded by Family Planning Advocates. "She did find a Planned Parenthood clinic, but many poor women in those circumstances might not have transportation or even a phone to help them find another clinic." For patients in smaller communities, there may be no other options.
Then there are the added problems that mergers cause.
Judy Stone is an infectious-disease doctor in Cumberland, Maryland. Two years ago, her employer, Memorial Hospital, affiliated with Sacred Heart, the Catholic hospital. This fall, Memorial decided to become a nursing home and planned to transfer all its hospital business over to Sacred Heart.
"I couldn't sleep at night keeping my mouth shut," says Dr. Stone. "The process was covert, and decisions that should have been being made by the community were hidden."
So at an October 28 city council meeting, Stone gave a speech rapping the hospitals.
"This will be particularly detrimental to the women of the community," she said. "Especially those who are poor and unable to seek reproductive care elsewhere." She claimed it could also overrule living wills and prevent the kind of research Stone does into new antibiotics or treatment for such conditions as blindness or Parkinson's Disease -- all of which use fetal tissue. The merger is still pending.
Other communities are in for some post-merger surprises. Not only can Catholic hospitals refuse to perform certain procedures; they often refuse to refer patients to other clinics.
"In many cases, there are gag rules written into these contracts," says the ACLU's Weiss. "Now you've got a patient who needs hormonal contraception because of problems she would experience if she were to bear children -- she's a high-risk patient. Well, they don't tell her that, and they don't refer her for that, and they don't provide it. She says to them, 'What should I do?' And they say, 'I'm sorry, I can't discuss that with you.' She says, 'Where should I go?' And they say, 'I'm sorry, I can't refer you.' "
health-care companies have policies against abortions, too.
Earlier this year, Physicians Plus Medical Group in Madison, Wisconsin, was
deciding among four potential merger partners. One was the Nashville-based
PhyCor, a management company.
In the process of questioning doctors in other markets who are managed by PhyCor, Physicians Plus doctors discovered that PhyCor has an unpublicized policy against allowing abortions in any clinic that it operates. PhyCor confirms that this is company policy: "In the agreements we enter into with physicians groups, we provide that abortions will not be done in any facility PhyCor owns or leases," says Joe Hutts, the company's president and CEO. He says the physicians -- who are partners, not employees -- are free to perform abortions as long as they don't do so in any hospital or clinic PhyCor owns. Hutts, who helped found PhyCor ten years ago, says his company will not take any of the profits from abortions. But he stresses that PhyCor, which is publicly traded, is not associated with any denomination.
"We're all Christians," says Hutts. "The idea isn't to impose our beliefs on anybody. We just want to be true to what we believe."
On October 29, PhyCor announced its plan to purchase the nation's other largest medical management company, Medpartners. If the shareholders approve the purchase in February, PhyCor will manage 35,000 physicians and have a presence in all fifty states.
Statistics from the ACLU show that 84 percent of U.S. counties have no available abortion services. With the recent spate of mergers, this percentage is likely to grow.
One problem abortion clinics have is guaranteeing backup in case of a medical emergency. Clinics need this guarantee to stay in business and to provide safe treatment for women. But if the local hospitals have merged with facilities that don't do abortions, these clinics may be out of luck.
They may also be easy marks.
"Abortion has been isolated for a very long time from mainstream medical care," says the ACLU's Weiss. "But this further isolates reproductive-health services in a way that endangers them. An isolated service is particularly vulnerable to anti-choice protest. If you force all these services into physically separate buildings, they are much easier to target. Patients going in and out are much easier to identify and harass."
Pro-choice advocates wonder why the government hasn't treated some of the mergers as violations of anti-trust laws. They also wonder why federal and state laws allow church hospitals to have "conscience clauses" that permit them to opt out of procedures on religious or moral grounds.
"What is essentially happening here is that religious doctrines that govern certain religious denominations are being imposed on everybody else," says Weiss. "I think that's wrong in any setting but it is particularly wrong where the government is involved. What of the separation of church and state?"
That separation is narrowing, as the government is signing more and more contracts with religious health-care providers.
are pushing poor women on Medicaid into managed-care plans. Some of
these plans refuse to supply services like birth control. One example is
Fidelis Care New York, an HMO formed by eight Catholic Dioceses. Fidelis
serves Medicaid recipients. The HMO will not cover services prohibited by
the U.S. Catholic Bishops.
Until recently, Fidelis Care had about 20,000 enrollees. But it tripled its enrollment with its purchase last September of Better Health, an HMO that served 40,000 Medicaid recipients and did offer reproductive health services. Federal law mandates that reproductive services must be covered for Medicaid recipients. In New York, even abortions must be covered. But under a conscience clause, Fidelis is allowed to tell women to go to another provider to access those services.
Annie Keating, who researches health-care mergers for the National Abortion and Reproductive Rights Action League in New York, is worried that many women will sign up with Fidelis unaware that it doesn't cover reproductive health care. Once in the plan, women must stay enrolled for one year.
"The government ought not be able to contract with religious-governed health-care providers who have their services driven by religious doctrine and then impose [that doctrine] on recipients of public assistance," Keating says.
In Ulster and Dutchess counties in New York, two nonsectarian hospitals have announced plans to merge with a third, the Catholic-run Benedictine Hospital. The merger requires all three hospitals to stop performing abortions, tubal ligations, vasectomies, and contraceptive counseling. The two nonsetarian hospitals plan to transfer their abortion services to a separate off-premises women's clinic. Currently, the nonsectarian Kingston Hospital performs about 120 abortions a year, mostly for Medicaid recipients.
But last May, when the three hospitals announced, with much fanfare, the plans to unify, the officials weren't prepared for the outcry from the two communities.
"This is part of a stealth war on reproductive rights," says Caryl Towner, who founded the group Preserve Medical Secularity to fight the merger. "It's being done under the guise of saving our hospitals, but we don't believe for a minute that this has to be done in a way that imposes all these restrictions on reproductive health care."
Towner's group joined forces with others, including twenty-six doctors at Northern Dutchess Hospital (who voted unanimously against the terms of the merger). They held a rally last July that attracted around 800 people. Since then, merger opponents have sent 2,000 postcards to the hospital officials, gathered 7,000 petition signatures, and repeatedly picketed the hospitals.
MergerWatch's Uttley, who is helping organize the opposition, says community involvement frequently makes the difference in preserving reproductive services. Many times, she says, physicians and representatives of non-Catholic churches end up voicing the strongest opposition.
Take the situation in Gloversville, New York. John A. Nelson, pastor of the First Congregational United Church of Christ, is fighting a proposed joint venture between Feldon County's only hospital, Nathan Littauer, and St. Mary's of Amsterdam, a Catholic subsidiary of St. Louis-based Carondolet. He says some of the more conservative pastors from other congregations are joining him in fighting the merger.
Arthur Brelia, a medical doctor at Nathan Littauer, has also proved a powerful opponent. The seventy-one-year-old obstetrician and gynecologist resigned from his position as medical chief of staff at Nathan Littauer after the two hospitals' governing boards voted to approve the affiliation. He says he resigned partly so he could have the freedom to criticize without violating any confidentiality requirements.
"I took a public stance and put out a position paper," says Brelia. "The loss of our hospital is not going to help our community. In this deal, the church-dominated hospital has ultimate veto power over any decision."
has announced it will stop performing abortions, even though it
is the only local facility offering the procedure. (Brelia estimates forty
to fifty abortions are performed annually at Littauer.) But Brelia says his
main concern is that pregnant women will be forced to go far out of their
way if they want to be sterilized. "Unless a woman travels forty or fifty
miles to the closest urban center, she won't be able to have a postpartum
tubal ligation," he says. "That's not a very good choice."
The Reverend Nelson believes it is his religious duty to oppose the potential restrictions on health care. He points out that as the only hospital in a county of 55,000, Nathan Littauer Hospital serves people of many faiths. (There's the added irony that its namesake and benefactor was Nathan Littauer, a prominent Jewish citizen.)
"Theologically it's dangerous to make an idol out of doctrine," says Nelson. "When doctrine and care collide, the only faithful and responsible resolution is for doctrine to retire or change."
Albion Monitor April 2, 1998 (http://www.monitor.net/monitor)
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