Debate Over Catholic Directives That Affect 13 Percent of US Hospitals

PHOTO: Bishops stand during a prayer at the United States Conference of Catholic Bishops annual fall meeting in Baltimore, Nov. 11, 2013.
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Hospitals that serve one in six Americans adhere to Catholic doctrine that threatens the lives of patients, the American Civil Liberties Union claims in a court case filed on behalf of a Michigan woman.

The ACLU is suing the U.S. Conference of Catholic Bishops for issuing guidelines that the group claims led to substandard medical care for the pregnant woman in Michigan.

The guidelines are called the Ethical and Religious Directives for Catholic Health Care Services and every Catholic hospital and Catholic healthcare institution must adhere to them or risk losing their classification as a Catholic institution. The guidelines cover such issues as end of life care to merging with secular organizations to the kind of patient who should be prescribed birth control. Medical ethicists say patients should be made aware of how the directives can affect their treatment at Catholic hospitals compared with secular hospitals especially in terms of abortion options or end of life care.

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Catholic officials say that the directives are no different than a code of ethics imposed by any other professional organization and that they have a right to define their own institutional moral values at their healthcare centers.

The directives led to controversy in 2010, when an administrator on the ethics committee at a Phoenix hospital approved an abortion to save the life of a pregnant woman. After the procedure, the administrator, who was also a nun, was excommunicated by the Phoenix bishop and the hospital could no longer identify as Catholic as a result of deviating from the directives.

Last week attention was again drawn to the 72 total Ethical and Religious Directives after the ACLU filed a lawsuit alleging these directives led to improper medical care for a pregnant Michigan woman during a miscarriage. The lawsuit alleges that under the Catholic directives the woman, whose pregnancy was likely no longer viable, was left in pain and at risk for infection because doctors refused to induce labor and end her pregnancy in the 18th week.

Additionally doctors allegedly never told the woman her pregnancy was no longer viable, or that ending it and removing the fetus was a safe course of action, according to the lawsuit.

"The case is about more than just one woman and one hospital," said Kary Moss, the executive director for the Michigan ACLU. "It's the ability for non-medical professionals to dictate medical care."

The U.S. Conference of Catholic Bishops said that as of Friday, they had not been formally served with the lawsuit, although they had received a copy from the media.

President of the U.S. Conference of Catholic Bishops Archbishop Joseph Kurtz wrote in a public response that the ACLU's lawsuit was "misguided" and their claim that the directives lead to substandard care for pregnant women "baseless."

"The Ethical and Religious Directives" (ERDs) urge respectful and compassionate care for both mothers and their children, both during and after pregnancy," wrote Kurtz. "The Church holds that all human life, both before and after birth, has inherent dignity, and that health care providers have the corresponding duty to respect the dignity of all their patients. This lawsuit argues that it is legally 'negligent' for the Catholic bishops to proclaim this core teaching of our faith."

Mercy Health Partners declined to comment on the suit. Catholic healthcare officials say that the ethical directives are not unique to the Catholic hospitals and that they are a useful guide for medical employees.

Dr. John Haas, president of National Catholic Bioethics Center, said the code of ethics is not uniquely Catholic and that all healthcare institutions and individual physicians abide by their own ethical code when treating patients. "In a sense this isn't anything that's uniquely Catholic, every professional society I know has a code of ethics," said Haas. "The code of ethics can help to facilitate with doing the right thing."

The church-affiliated National Catholic Bioethics Center is devoted to understanding how the teachings of the Church apply to developments in health care. The center has also consulted with bishops over changing the ethical directives and has a 24-hour hotline for medical center employees to call to ensure that they are following the directives properly. Haas said that Catholic directives do ban abortion, except in cases where the pregnancy endangers the life of the mother. Haas said the medical case as described in the lawsuit, would appear to be a case where abortion would be allowed under the directives. "If that hospital had called us and said may we proceed in terms of starting labor…it's perfectly legitimate," to save the mother, said Haas.

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Haas also questioned the ACLU's claim that the directives were the reason Mean's doctor allegedly did not fully explain her medical condition or treatment options.

Haas points out that the directive 27 says the patient should be given "all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all," in order to make informed decisions.

However, medical experts say that the way the directives are implemented at hospitals can be complex and confusing for patients and what may appear to be straightforward guidelines can become murky in practice.

Dr. Margaret Moon, a physician and professor at the Berman Institute of Bioethics at Johns Hopkins, said looking at directive 27, she worried about the phrase "any reasonable and morally legitimate alternatives," when describing all treatments that should be explained to the patient.

Moon said that a doctor in a Catholic hospital could in theory not consider an abortion to be a "reasonable and morally legitimate alternative" for certain medical conditions, while other hospitals might recommend that as one treatment option.

"They've taken the notion of informed consent and put it on its head. Patients don't anticipate that," said Moon. "The Catholic Church can say a lot of things, but when they're acting in the healthcare arena, it's necessary the patients working with them understand their care."

Moon said that institutions have the right to abide by their own values but that right is complicated when they are the only source for medical care in the region.

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According to the Catholic Medical Association, 12.6 percent of U.S. hospitals are Catholic and they had 34 million admissions in 2011.

The directives instruct Catholic hospitals to transfer patients who want treatments not available at a Catholic institution. However, in practice transferring patients can be complicated especially in emergency situations or in rural areas where a Catholic hospital might be the only place to receive care in the region. In Muskegon, Mich., the Mercy Health Partners hospital was the only hospital in the county.

"I want to agree that institutions are allowed to establish their moral values and system of care, but when they have monopoly in community, there's a challenge to that," said Moon.

Moon said in recent years more and more Catholic hospitals have merged with other secular institutions. Hospitals that are well-known in a community could suddenly start to abide by directives issues by the Catholic bishops after a merger.

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After a merger, Moon said, hospitals and their physicians could alter their behavior to adhere to the directives and suddenly stop prescribing medication like contraception for teenagers or other patients, even for people who they had been previously treated at the hospital before the directives were in place.

Moon worries that patients, who have created their own advanced directive to tell medical staff what treatment they want if they are incapacitated, could face problems if the hospital where they are treated merges with a Catholic institution. The Catholic directives state that the institution will not adhere to the patient's own advance directive if it conflicts with the Catholic guidelines issued by the bishops.

"We want people to have the right of their own conscience," said Moon of patients deciding on their end-of-life care.

Haas said the guidelines were not dissimilar to other institutions, where a patient's advance directive would be disregarded if it conflicted with the hospital guidelines.

The ACLU is suing on behalf of Tamara Means for an unspecified amount of money and "a declaration" that actions of the U.S. Conference of Catholic Bishops were negligent. According to the lawsuit, Means is asking for this "not only to provide a remedy for the trauma she suffered, but also to prevent other women in her situation from suffering similar harm in the future."

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