New Battleground for Religion and Healthcare: Tying Your Tubes
When is a routine procedure, one preferred by over 25 percent of women who use contraception in the U.S., "intrinsically evil?" When your Catholic hospital network is allowed to insert its religious directives between you and your doctor.
Illustration by Julia Carusillo
Rebecca Chamorro, 33, a married mother of two, was six months pregnant with her third child when she asked her obstetrician, Dr. Samuel Van Kirk, to perform a postpartum tubal ligation (the procedure is typically referred to as getting one's 'tubes tied') on her after she gave birth. The procedure would take only a minute or two in Van Kirk's estimation, and would add no additional cost, risk, or recovery time. Van Kirk also agreed that it would be the safest, simplest, and most effective form of contraception for Chamorro and her husband.
Chamorro is a patient at Mercy Medical Center in Redding, California, a rural region of the state about a two-hour drive from the Oregon border. The next closest labor and delivery ward that accepts Chamorro's insurance is 160 miles away. Short of moving her husband and two children to another city several hours away for the last month of her pregnancy, Mercy Medical is her only option for delivery.
When Van Kirk sought authorization for Chamorro's procedure, however, hospital administrators denied the request based on a set of Ethical and Religious Directives put forth by the U.S. Conference of Catholic Bishops (USCBB) and prescribed by Dignity Health, the hospital's corporate parent and California's largest healthcare network. Made up of all active and retired bishops, priests, and deacons in the United States, the USCCB's stated mission is to spread the gospel of Jesus Christ across all Catholic institutions through everything from evangelism, to political action, to movie reviews. The Conference's Ethical and Religious Directives outline standards for acceptable care in church-affiliated medical facilities and label direct sterilization—in this case, a form of contraception preferred by Chamorro and more than 600,000 other women per year in the United States—as "intrinsically evil."
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This is not a case of a small rural or private hospital denying care to a single patient. This is a multi-billion dollar corporation with billions in public funding, more than 50,000 employees, and 39 hospitals open to the public across California, Arizona and Nevada using a set of religious mandates written by a group of Catholic Bishops to prevent doctors from providing pregnancy-related care to their patients.
Founded in 1986 as an official ministry of the Roman Catholic Church, Catholic Healthcare West underwent a corporate restructuring in 2012 and re-emerged in its current form as Dignity Health, a nonprofit corporation that enjoyed tax-exempt status on $8.7 billion in revenue that same year. According to federal tax records, Dignity Health also received $3.3 billion in Medicare and Medicaid payments, $23 million in government grants and over $575 million in revenue from "government programs" in 2012. By 2015, Dignity Health's revenues reached $12.4 billion, over half of which came from Medicare and Medicaid. Finally, Mercy Medical Center Redding itself received $51,615 from the state of California to train employees in Mercy Medical's labor and delivery ward.
According to Elizabeth Gill, the ACLU attorney leading the suit against Dignity Health on behalf of Chamorro and Physicians for Reproductive Health, this policy is a clear case of sexual discrimination and, due to the rapid expansion of Catholic hospitals in the past 15 years, one that poses a danger to women's right to basic health care.
"Nationwide, almost one of every nine hospital beds is in a Catholic hospital," Gill explains, and most of those hospitals follow the same religious directives set out by the church. "For us, it's becoming an increasingly real threat that women just won't be able to get care."
Because the hospital is open to the public and receives significant state funding, Gill argues, preventing Dr. Van Kirk from providing basic care, "is sex discrimination, given that our state law defines sex discrimination to include pregnancy-related care."
According to the ACLU's lawsuit, both Dignity Health and Mercy Medical have authorized tubal ligations and other forms of medical sterilizations in the past, but hospital administrators only offered the vaguest explanation to Dr. Van Kirk when he asked for specific reasons why the procedure was not deemed medically necessary. In an exchange cited in the ACLU's complaint, hospital administrators stated it takes into account several factors when assessing the "risk to the mother in future pregnancies."
We don't really know the extent of the problem, but we do know that it's greater than we have any idea.
Then there's the matter of who gets to determine what is in an expecting mother's best medical interest: the woman and her doctor, or a prudence of vicars waving a religious directive. Under the longstanding California Medical Practice Act, no corporate entity is allowed to interfere with the doctor-patient relationship or otherwise circumvent the decision of a licensed, medical professional for the "corporate practice of medicine" based on non-medical criteria, whether that be in service of a bottom line or a higher power.
Despite the ACLU's argument that Dignity Health's religious directives are in direct violation of multiple California laws, Superior Court Judge Ernest Goldsmith disagreed earlier this month, when he delivered a lukewarm verdict in favor of the church on January 15th. In his decision, Judge Goldsmith writes, "Religious-based hospitals have an enshrined place in American history and its communities, and the religious beliefs reflected in their operation are not to be interfered with by courts at this moment in history." The ACLU plans to appeal after Chamorro delivers.
It's currently unclear just how far religious-affiliated hospitals could take this newly confirmed right to religious freedom in California. "One thing that's troubling about the way Dignity Health is framing its rights here, is that it's hard to see any limit," Gill explains. "It's an even broader principle than just the Ethical and Religious Directives, because this would give them license to discriminate based on religious freedom." And the issue could have implications beyond Dignity Health's opposition to medical sterilization, as well. "If a state-funded institution can invoke religious doctrine to discriminate against anyone," Gill says, "then that is a problem for the law in general." In another recent case, Trinity Health (a Catholic hospital network even larger than Dignity Health) has already tried to argue that federal law allows its hospitals to refuse abortions, even in emergency situations when the mother's life or health is at risk.
On the other hand, it may turn out that the Catholic church is on the wrong side of history once again here; in 2004, the ACLU won a similar case in which the California Supreme Court ruled that Catholic Charities of Sacramento, which operates in connection with the local diocese, must provide its employees with medical coverage for birth control, even though the group claimed it should be exempt from doing so on the basis of religious freedom. In their suit against the state of California, Catholic Charities was, as Gill put it, "making basically all the same religious freedom arguments that the hospitals are making in this case." The California Supreme Court rejected those arguments at the time, stating that the church had entered the general labor market by choice and thus the law requiring employers to include prescription contraceptives in their benefits plans did not, in fact, impair its religious freedoms.
For us, it's becoming an increasingly real threat that women just won't be able to get care.
For now, though, Chamorro will deliver without the tubal ligation and she will have to undergo a second procedure at a different hospital in order to obtain a common form of birth control that she and her doctor decided upon.
As an advocate for evidence-based medicine with Physicians for Reproductive Health, Dr. Pratima Gupta sees this as a major problem on both an individual level and as a greater public health issue. "Preparing for a new child is both exciting and stressful," Gupta says. "And to have to be told what kind of birth control you can and cannot use by someone who is not your physician has got to just add to the stress and anxiety around welcoming a new child. A time that should be really exciting and joyful is being contaminated, for lack of a better word, by this case and by the directives of the church and the Catholic bishops."
Gupta's organization has joined Chamorro as a co-plaintiff in the lawsuit against Dignity Health.
Yet, without more patients stepping forward to pursue further action after being denied care, it would be impossible to know how many women are being affected. "We don't really know the extent of the problem," Gupta explains, "but we do know that it's greater than we have any idea."
"And that's exactly why we're moving forward with the lawsuit despite the fact that unfortunately Ms. Chamorro herself might not benefit," Dr. Gupta continued. "We want to have other women not suffer the same denials and stress and anxiety that she's had to endure."