«Lori R. Freedman, Ph.D. (corresponding author) Assistant Professor, ANSIRH, Department of Obstetrics, Gynecology & Reproductive Sciences University ...»
Conflicts in Care for Obstetric Complications in Catholic Hospitals
American Journal of Bioethics Primary Research
Received: 28 Jun 2012
Accepted: 16 Oct 2012
Accepted author version posted online: 18 Dec 2012
Lori R. Freedman, Ph.D. (corresponding author)
Assistant Professor, ANSIRH, Department of Obstetrics, Gynecology & Reproductive Sciences
University of California, San Francisco
Debra B. Stulberg, M.D., M.A.
Assistant Professor, Department of Family Medicine
The University of Chicago Background: A recent national survey revealed that over half of obstetrician-gynecologists working in Catholic hospitals have conflicts with religious policies, but the survey did not elucidate the nature of the conflicts. Our qualitative study examines the nature of physician conflicts with religious policies governing ob-gyn care. Results related to restrictions on the management of obstetric complications are reported here.
Methods: In-depth interviews lasting about one hour were conducted with obstetrician- gynecologists throughout the United States. Questions focused on physicians‘ general satisfaction with their hospital work settings and specific experiences with religious doctrine- based ob-gyn policies in the various hospitals where they have worked.
Results: Conflicts reported here include cases in which Catholic hospital religious policy (Ethical and Religious Directives for Catholic Health Care Services) impacted physicians‘ abilities to offer treatment to women experiencing certain obstetric emergencies, such as pregnancy-related health problems, molar pregnancy, miscarriage, or previable premature rupture of membranes (PPROM), because hospital authorities perceived treatment as equivalent to a prohibited abortion. Physicians were contractually obligated to follow doctrine-based policies while practicing in these Catholic hospitals.
Conclusions: For some physicians, their hospital's prohibition on abortion initially seemed congruent with their own principles, but when applied to cases in which patients were already losing a desired pregnancy and/or the patient's health was at risk, some physicians found the institutional restrictions on care to be unacceptable.
INTRODUCTIONA recent national survey found that 52% of obstetrician-gynecologists (ob-gyns) working in Catholic hospitals experience conflict with religiously-based policies about care (Stulberg et al.
2012). These findings have significant implications for care because four of the ten largest hospital systems in the U.S. are Catholic (Modern Healthcare 2011), and one in six patients receives care in a Catholic institution (CHA 2012). With some very recent exceptions 1 (Greenhouse 2012; Severson 2011), the depth and breadth of the effect of Catholic doctrine on care has been relatively unclear to thepublic. People may be aware that abortions are not permitted in Catholic hospitals because of the Catholic Church's well-known opposition to it, but they may not know the extent to which other care is affected by the prohibition. Individuals of all faiths interact with Catholic health entities with regularity—whether as patients, physicians, nurses, and staff at Catholic hospitals or as employees of Catholic agencies or schools with Catholic health insurance.
This paper is based on in-depth interviews conducted in 2011 with 31 ob-gyns, most of whom work or have worked in Catholic hospitals. In particular, physicians recounted experiences that demonstrate how Catholic bioethical directives affect their management of complications that can arise during pregnancy. We will show how certain treatments can be perceived as morally imperative or neutral and medically necessary care by the ob-gyns interviewed, and as prohibited, illicit acts by Catholic health care authorities. We will start by describing the governing Catholic doctrine about pregnancy. Then, using qualitative data, we will illustrate what kinds of conflicts emerge for physicians working under Catholic doctrine. In particular, we will focus on physicians‘ and hospital authorities‘ (clergy, administrators, and ethics committees) conflicting beliefs about care for cases in which patients were already losing a desired pregnancy, the patient's health was at risk and/or the fetus would never be viable, and treatment to facilitate the end of the pregnancy represented the standard in non-Catholic settings.
Catholic Health Care in the United States
The full history of Roman Catholic sponsorship of health care institutions in the United States is beyond the scope of this article and has been described elsewhere (Joyce 1995; McCauley 2005;
Mohr 1978; O‘Rourke et al. 2001; Reagan 1997; Wall 2011). For the purposes of this paper, it is important to know three things about Catholic health care institutions: they are prevalent; they employ and serve diverse individuals; and they are ethically governed by a document called the Ethical and Religious Directives for Catholic Health Care Services (henceforth ―the Directives‖), written by the United States Conference of Catholic Bishops (USCCB 2009) and enforced by local Catholic bishops, and in some cases the Vatican.
Catholic hospitals are financed by Medicaid, Medicare, and private insurance, and provide charity at 2% of their revenues, a rate equal to other not-for-profit hospitals (Bazzoli et al. 2010;
Uttley 2002). Patients who receive care at Catholic hospitals tend to reflect the religious make-up of communities geographically near the hospital rather than consisting primarily of adherents to the Catholic faith. Some public safety net hospitals are Catholic, and approximately 8% of ―Sole Community Hospitals‖ (a federal designation for hospitals located 35 miles or more from any others) are Catholic-owned as well (Stulberg 2012; Uttley 2002).
Regarding physician make-up, a national survey found that ob-gyns who work in Catholic facilities are religiously diverse, with similar religious and demographic characteristics to those who work in non-Catholic facilities (unpublshed tabulations from Stulberg et al. 2012).
Furthermore, ob-gyns who work in Catholic facilities are no more religious—that is, they do not report religion as a more important motivation in their lives—than other ob-gyns (Yoon et al.
2 Health care providers in Catholic hospitals are required to adhere to the Directives. Directive 5
Catholic health care services must adopt these Directives as policy, require adherence to them within the institution as a condition for medical privileges and employment, and provide appropriate instruction regarding the Directives for administration, medical and nursing staff, and other personnel. (USCCB 2009) Like most hospitals, Catholic hospitals have ethics committees, and these individuals or committees are responsible for interpreting the Directives and advising medical personnel on how to apply them in specific medical situations. The ethics committee is under the authority of the local bishop and can include clergy, bioethicists, clinicians, hospital administrators and others (USCCB 2009, Directive 37). The Directives include descriptions of the general principles and motivation behind Catholic health care as well as specific instructions for clinical care typically pertaining to reproductive and end-of-life care. For example, speaking generally, the introduction states, ―The mystery of Christ casts light on every facet of Catholic health care” (USCCB 2009). Speaking more instructively, the document goes on to include 72 directives that concretely advise on matters of clinical, administrative, and ethical relevance, including at least 17 about care related to pregnancy and which particular services or procedures are prohibited.
Catholic Bioethics in Pregnancy
Observers of the field of bioethics have argued that the field has not succeeded in rising above the so-called culture wars, specifically in reference to debates about care relating to reproduction and the end of life (Evans 2012; Fox and Swazey 2008). This bears directly on the predominant ways in which care in Catholic hospitals differs from care in other American hospitals, which generally follow secular bioethical principles (Bradley 2009; Joyce 2002; O‘Rourke et al. 2001).
While the realm of ―secular bioethics‖ is itself heterogeneous, there is a basic body of Western medical ethics from which Catholic bioethicists have sought to differentiate themselves (Nelson 2009; Smolin 2005; Solomon 2005). From the standpoint of secular obstetric ethics, physicians are obligated to provide care with respect for a woman's autonomy, acting in her best interest at all times, and acting in the best interest of the fetus conditional on the pregnant woman's wishes (ACOG 2005). Some ethicists make conditional exceptions requiring physicians to intervene to save the fetus‘ life (regardless of the pregnant woman's wishes) after the point at which the fetus could be viable outside the womb (McCullough and Chervenak 1994).
The Catholic bioethical perspective takes a very different starting point on pregnancy. In Catholic theology, the joining of egg and sperm creates a new, complete human being. The developing conceptus is thus treated, in Catholic bioethics, as a patient from the moment of fertilization. The pregnant woman and her embryo (and later fetus) are two people, both with equal claims and independent moral status. The fetus‘ physiologic dependence on the pregnant woman is seen as merely a matter of geography, with a fetus deserving no less care and protection while inside its mother's body than after it is born. Any act that intentionally harms or kills the fetus is thus prohibited (Diamond 2001, 15–24).
3 In Catholic ethical reasoning, when complications arise during pregnancy, the pregnant woman and her physicians are obligated to act in the best interests of both the woman herself and the fetus. When these interests conflict, that is, when a treatment or intervention (such as a cesarean section or induction of labor) is available that would improve the well-being of the fetus at the expense of the woman, or vice versa, the right course of action is found through the Principle of Double Effect (Kelly 2004). This holds that when an action is expected to have a good outcome (such as improving fetal survival) and a bad outcome (such as increasing maternal morbidity), the action should be taken if: the good outweighs the bad, the good does not come about as a direct result of the bad, the bad effect is not intended even if it is anticipated, and the action in and of itself is not bad. Applying this principle in pregnancy, Catholic bioethicists have determined that direct abortion is never allowed because it is, in and of itself, a bad act (Kelly 2004, 112–113). In other words, any medical intervention that directly and intentionally kills a fetus or ends a pregnancy before viability cannot be done no matter how important the proposed good effect (Diamond 2001, 11–24).
On the other hand, indirect abortion can be allowed for proportionately good reasons.
Directive 47 states:
Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child. (USCCB 2009) This directive may be interpreted and applied variably in practice. A commonly cited application of this directive in the Catholic bioethics literature is the treatment of a pregnant woman with uterine cancer. Catholic ethics allow a physician to perform a hysterectomy to treat the woman's cancer, even though it is entirely predicted that the fetus inside the uterus will die as a result of the hysterectomy. Because the intended effect is the removal of the uterus in order to cure a proportionately serious condition (uterine cancer) in the woman, and the death of the fetus is both unintended and brought about indirectly, it meets the conditions of the Principle of Double Effect (Kelly 2004, 113).
Previous Research and Unanswered Questions
This Catholic bioethical perspective on pregnancy has been of interest in the Catholic bioethics literature (deBlois and O‘Rourke 1995), and legal advocates and journalists have taken an interest in how Catholic health care restrictions may impact patients generally (Charo 2005;
Ginty 2011; Stein 2011). However, there is scant empirical research on the topic. Prior research has identified two pregnancy-related areas in which physicians reported restrictions on standard treatments: ectopic pregnancy (Dickens et al. 2003; Foster et al. 2011) and inevitable miscarriage (Freedman et al. 2008). These studies generated new questions, such as: Are such standard treatments restricted in a wider range of Catholic hospitals? How are a wider variety of obstetric complications handled in Catholic hospitals? How do physicians interpret and respond to the conflicts with ethics committees around treatment decisions? What are the implications for patients? We aim to shed light on these questions and to elucidate the nature of conflicts reported by the majority of ob-gyns working in Catholic hospitals (Stulberg et al. 2012).
4 METHODS The sample of physicians in this study was recruited purposively from a group of 237 physicians who answered a national survey (n = 1,154) of ob-gyns about physician beliefs and practices related to sexual and reproductive health care and checked a box stating they were willing to be contacted for a follow-up interview by phone (Stulberg et al. 2012). IRB approval was obtained for the study at both the University of Chicago and the University of California, San Francisco.
The authors first recruited by email and phone those who disclosed in the survey that they worked for a Catholic hospital. We then began to recruit others on the list who worked in other religious and secular hospitals, being mindful of achieving geographic balance; several of these physicians incidentally also had experience working in Catholic hospitals in the past. We pursued a snowball sample from the physicians interviewed from this list, asking at the close of the interview if subjects would forward our recruitment email to a colleague they deemed appropriate for the study, which yielded a minority of interviews.