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When Denise was in her mid-30s and pregnant with her daughter, the nurse practitioner working with her OB-GYN informed her that after giving birth, she would not be permitted to have a tubal ligation — commonly known as getting one’s tubes tied. If she wanted one, she would need to have a separate procedure at a different hospital, even though tubal ligations are commonly and safely performed either immediately after a cesarean section when the abdomen is still open or 24 to 36 hours after childbirth, when the fallopian tubes are sitting higher in the abdomen, making for easy below-the-navel incisions. Getting the procedure done at a later time after childbirth means an additional surgery and recovery, with a small child at home and with the attendant monetary, physical and time costs of a second surgery. That was enough to deter Denise.
“If it was an option to have my tubes tied at the hospital post-birth, I very well could have done it,” said Denise, now 43, in an email from Massachusetts. (She asked that only her first name be used for privacy reasons.) “I did not do it because I actually couldn’t fathom having the separate surgery (cost, etc.) done with a newborn or toddler.”
Why was Denise not permitted to have a safe, legal procedure at a medically indicated time? Because she gave birth at a Catholic hospital.
A public-health giant
Catholic hospitals provide care for 1 in 6 patients in the United States; they are, collectively, the largest not-for-profit health care provider in the country. As secular hospitals merge with Catholic ones, many health care organizations and the communities they serve are on edge. In Washington state, for example, mergers mean that nearly half of hospital beds are in facilities controlled or influenced by the church, and in many regions a Catholic hospital is the sole provider. Nationwide, Catholic health care providers grew by 16 percent from 2001 to 2011. The number of secular nonprofit hospitals dropped by 12 percent in that period; the number of public hospitals fell by 31 percent.
Catholic health care providers are bound by the Ethical and Religious Directives for Catholic Health Care Services, a document issued by the U.S. Conference of Catholic Bishops that governs how health care providers should deal with reproductive issues, end-of-life care, the “spiritual responsibility” of Catholic health care and a variety of other concerns. The range of women’s health care options that Catholic facilities offer is limited — sometimes, like when a pregnancy goes wrong, to a deadly degree. And while most doctors have an ethical obligation to inform patients of all their options, Catholic facilities routinely refuse to offer even abortions necessary to save a pregnant woman’s life; their doctors are also barred from telling a patient with a nonviable pregnancy that there are other, often safer options available elsewhere, lest the patient seek care at another facility. (LGBT patients may also run into problems, whether it is with hormone therapy for transgender patients or simply the right of married same-sex partners to be treated as next of kin in making health care decisions).
Denise was lucky, in some ways. After the birth of her daughter, two subsequent pregnancies ended in miscarriage, making a tubal ligation — the procedure she desired and was denied — unnecessary. And her miscarriages did not require the kind of hospital intervention that, at a Catholic facility, could have put her life at risk.
Tamesha Means, a Michigan woman, had a different, more terrifying experience. Her water broke at 18 weeks, too early for the fetus to be likely to survive. A friend drove her to the closest hospital, a Catholic facility where medical providers told Means the baby would probably not live, but they refused to terminate her pregnancy. She went back a second time and was sent home, despite being at risk of infection and in excruciating pain. The third time she went back, this time bleeding, in pain, running a fever and suffering from an infection from a miscarriage in progress, she was again directed to go home. She went into labor while filling out hospital discharge paperwork. Only then did hospital employees begin to attend to her. She delivered, and the very premature infant died shortly thereafter.
The ACLU is now suing on Means’ behalf. But most stories like hers are not told. And the smaller, non-life-threatening decisions — the refusals to provide contraception, in vitro fertilization or sterilization — fly even further below the radar, tinged with the humiliation of someone seeking medical care and receiving moral judgment.
Follow the money
Proponents of Catholic health care say that which services religious hospitals offer is a First Amendment issue and that the separation of church and state requires the government to remain hands off. Catholic hospitals provide necessary care to the sick and in need, through a well-funded religious institution with many devotees and volunteers who do excellent, important work.
Catholic hospitals should have a duty to serve the actual health needs of their patients and the ethical obligations of their staffs over church dogma. Instead, they put the dogma first.
But Catholic hospitals receive enormous amounts of state and federal funding, in the form of large tax exemptions, Medicare and Medicaid dollars and specific grants for certain types of care. In 2011, Catholic hospitals received $27 billion in public funding, not including tax breaks — nearly half their revenue. Catholic hospitals employ and serve populations that are not predominantly Catholic. One-fifth (PDF) of physicians at religious hospitals reported facing a “clinical ethical conflict” in which their medical judgment was at odds with the hospital’s religious policy. Because Catholic hospitals receive public funds and care for a diverse population, they should have a duty to serve the actual health needs of their patients and the ethical obligations of their staffs over church dogma.
Instead, they put the dogma first. As a result, rape victims are routinely refused emergency contraception in Catholic hospitals. Women with life-threatening ectopic pregnancies, which are easily ended by a shot of methotrexate or a minor surgery, often find an entire fallopian tube unnecessarily removed — decreasing the odds of future pregnancy — if they seek care at a Catholic facility. And, as Means discovered, even in life-threatening emergencies, Catholic hospitals regularly refuse to terminate pregnancies and may face penalties, including removal of church-affiliated status, if they do so to save the life of the mother. In one case in Arizona, a pregnant mother of four went to a Catholic hospital’s emergency room with a condition so life-threatening that her chances of imminent death without an abortion were nearly certain. She was too ill to transfer to another facility, so the hospital’s administrator, a nun, approved an emergency termination. The woman lived. The nun was excommunicated. Her standing with the church was eventually restored, but the hospital lost its 116-year affiliation with the Catholic Church.
Refusing to provide female patients with a full range of reproductive care is discrimination. Intentionally providing substandard care when safer, better options are available is monstrous. It means women see their bodies damaged, their fertility impaired and their lives threatened. Low-income women and women in rural areas face the greatest hardships, since they may have no other option for care except a Catholic hospital. Rural living means there may not be another hospital for miles. Poverty means finding a provider that accepts Medicaid and is nearby; distance equals more gas money or more time on public transportation and off work. For many women, the closest abortion clinic is hundreds of miles away. Religion should not be an excuse for public health institutions to discriminate so broadly and do such harm.
Humane health care
Good luck changing the status quo, though. Religious interests in the United States are moneyed and powerful, and Americans have been browbeaten into accepting the idea that what happens to women’s bodies should be up for a national vote. It is difficult to imagine such widespread, federally funded discrimination going so unchallenged, but even the ACLU demands simply that when secular hospitals merge with Catholic ones, state departments of health “publicize which hospitals are constrained and specify what their restrictions are and provide practical, appropriate alternatives for patients who need access.” I can’t blame it; challenging the Catholic health care system is a loser of a case, with well-funded conservative legal organizations happy to go to bat for the church. It is nonetheless disheartening that we so widely accept second-rate care for women as long as there is a religious excuse.
To be more specific, we widely accept second-rate care for women when there is a Christian excuse. Daniel Pipes, a conservative commentator, has spent years frothing at the mere specter of Muslim doctors’ building gender-segregated facilities or demanding that patients dress modestly, neither of which has come to fruition in the U.S. But suggest that Catholic hospitals should have to abide by medical-treatment best practices — and not, say, remove a woman’s entire fallopian tube when a simple injection could do the same job — and prepare for a deluge of accusations that you are violating religious freedom. The Affordable Care Act alone has already faced 91 constitutional challenges, largely from Catholic organizations opposing its birth-control mandate. The Becket Fund for Religious Liberty, which is funded by right-wing groups, including the Koch brothers and the Lynde and Harry Bradley Foundation, is behind many of the suits.
In reality, the so-called religious freedom of health care providers to accept massive federal and state funding while refusing to provide comprehensive health care violates women’s bodies and endangers their health. The grossness of this discrimination and the dangers it poses become transparent in neighborhoods affected by mergers, where women in need of emergency care may not have the option of seeking out a non-Catholic hospital. If the Catholic Church sees women as second-class citizens and wants to continue barring them from positions of power within the church while fruitlessly demanding they abstain from contraception use and premarital sex, that is the church’s prerogative. But if they are working in the health care space, they must provide the most appropriate, humane and effective health care. Even to women.
Jill Filipovic is a lawyer and writer. She blogs at Feministe and is a weekly columnist at The Guardian. She was the recipient of a 2013 United Nations Foundation reporting fellowship in Malawi.
The views expressed in this article are the author's own and do not necessarily reflect Al Jazeera America's editorial policy.