April 2, 2012 | 38
The recent presidential candidate debates, fights over insurance coverage for contraceptives, and the Virginia and Texas legislatures’ imposition of intrusive, unnecessary ultrasounds prior to any abortions are highlighting the fundamental issue of the role of religion in health care and the separation of Church and State. While the emphasis has been on reproductive care, the imposition of religious beliefs on access to medical care is far more wide reaching in its deleterious effect on the ability of people to choose their care and have their medical needs met.
Since I first started medical school, two principles were inculcated in me as foundations of medicine. First was the importance of searching for—and following—evidence in medicine, and the large human cost of not doing so. Second was our promise to the public, via the Hippocratic oath and centuries of precedent, to put patients’ needs first, above our own. I’ve dedicated my professional life to these tenets.
I hope to share some historical background on the intersection between medical care and religion, and what happens when we deviate from these central tenets of patient-centric care and then, in a subsequent post, tell more about the impacts of religious beliefs on research and public health.
As you read, consider: “When religion collides with your medical care, who should decide what is right for you?”
Access to health care information, health services and medical research has being limited by two growing trends: the infusion of increasingly restrictive religious doctrines at faith-based health systems and the implementation of ideologically-driven, rather than scientific, evidence-based, public policies.
Many hospitals with religious sponsors (Presbyterian, Methodist, Episcopalian and Jewish) are functionally secular and do not limit patient choices based on theology. In contrast, religious doctrine dictates what services will (or will not) be provided at some Baptist hospitals and all Adventist and Catholic health care institutions (HCIs). Religious restrictions affect not only reproductive care, which has garnered the bulk of attention, but affects access to new technologies, end-of-life care choices, vaccination, risk reduction counseling, and even access to scientific information.
For perspective, religious institutions provided the inpatient care for more than 5.3 million people. As of 2003, almost 20% of community hospital beds in the U.S. had religious sponsors. (Because of their predominant role, this paper focuses to Catholic systems. Other sectarian groups may limit services, as noted.) In twenty-two states, Catholic hospitals account for 20-30+% of admissions. These institutions agree to abide by the rules of the National Conference of Catholic Bishops, the Ethical and Religious Directives (ERDs). Over the past two decades, Catholic health systems have been merging with secular hospitals; the Catholic restrictions have generally been adopted by the historically nonsectarian hospitals.
It has been noted that religious health systems received more than $45 billion in public, taxpayer-supported, funds, including Medicare and Medicaid funding. Catholic hospitals accounted for 2,486,769 Medicare discharges (16.6 percent of all US Medicare discharges) and 976,802 Medicaid discharges (13.6 percent of all US Medicaid discharges). There were almost 19 million emergency room visits and more than 100 million outpatient visits in Catholic hospitals during a one-year period.
Reviewing Dartmouth Atlas Medicare data—which is limited to the subset of care to Medicare decedents just in the last two years of life—showed that Catholic health care systems* received more than $38.3 billion during 2003-7, or $7.7 billion annually just for this limited group of patients. Of course, they also received substantial federal, taxpayer-funded monies for all other Medicare services and for Medicaid. And the Catholic Health Association, for example, also receives huge tax breaks as a “non-profit, charitable” organization. At the same time, less than 3% of Catholic hospital funding is received from the Catholic Church.
Ideologically driven policies impact our ability to care for our patients using evidence-based medicine and have wide-ranging repercussions. As an Infectious Diseases physician and clinical researcher, I’ll share some of the impacts I have witnessed, including those from the bitter merger between the Catholic hospital and secular hospital in my own rural community. (Disclosure: I opposed the merger, from the heretical belief that health care decisions should be between a patient and his or her physician, and not dictated by anyone else’s religious beliefs.)
Physician and community impact
On local levels, religiously based restrictions can interfere with access to care and physician privileges, the approval to practice in a specific health care institution. Physicians must apply for and be granted such “privileges” to practice at each hospital. Catholic-affiliated institutions require that any physician requesting privileges agree, in writing, to abide by the Ethical and Religious Directives as a condition of practice; s/he will not be granted privileges, or may have those privileges revoked if s/he violates the ERDs, even in the interest of saving a patient’s life.
Nearly one-third of all Catholic hospitals are located in rural areas. In many cases, the Catholic health system becomes the sole provider of care in a county or entire region. This particularly impacts rural patients, who may be unable to seek health care in larger metropolitan areas, hours away. Depending on the nature of the medical problem, the weather and road conditions, the state of public transportation, and lack of money/support, it is often not practical or feasible for a patient to seek healthcare elsewhere.
In general, stricter interpretations of religious doctrine are being applied to a variety of issues. The general public and health care consumers are often unaware of these restrictions until confronted with a problem, as negotiations are often conducted behind closed doors. This was true in my own community, where all negotiating parties—even the mayor—were under a gag order not to reveal details of a proposed merger.
Following are some of the less publicized aspects of the impact of religion on access to health care.
Refusal Clauses: the Wolf in Sheep’s Clothing
Demanding exemptions from providing comprehensive health care for women on the basis of religious beliefs is one of the most recent assaults on women. While these demands are couched innocently as “conscience” clauses, they are, in fact, outright refusals to provide services.
Last summer, the Institute of Medicine recommended that women receive full coverage of contraceptives as part of essential preventive care for them, stating, “To reduce the rate of unintended pregnancies, which accounted for almost half of pregnancies in the U.S. in 2001, the report urges that HHS consider adding the full range of Food and Drug Administration-approved contraceptive methods as well as patient education and counseling for all women with reproductive capacity.
Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy. Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which raise their chances of health and developmental problems.”
This recommendation makes eminent sense, as unintended pregnancies cost the public approximately $11 billion annually. Contraception reduces the need for abortions, and the vast majority of American women of reproductive age (15–44)—including 99% of all sexually experienced women and 98% of those who identify themselves as Catholic—have used contraception. Yet the U.S. Conference of Catholic Bishops (USCCB) is vehemently opposing this rational decision as an affront to their beliefs and attack on their religious freedom—at the same time imposing their rigid beliefs not only on Catholics (who already disagree demonstrably by their use of contraception), but on the entire country—no matter the cost to the health and well-being of women and infants.
Similarly, some state legislatures have become more conservative, eroding what have been broad standards of medical care and patients’ rights to access to care. One such states’ rights trend also uses so-called “conscience clauses,” which are being used not only to exempt individuals from participating in acts that they personally find morally objectionable, but increasingly to allow organizations, including hospitals and insurers, to exempt themselves from providing services, counseling, or referral.
For example, legislation passed in Mississippi gives health providers, institutions, payers, and potential employees the absolute right to refuse to participate in (including providing services, counseling, or referring patients for) any health service to which they have a moral objection. There are no exceptions to protect a patient’s health or life.
This is not an idle threat. For example, after Elliot Hospital in Manchester, NH merged with a Catholic institution, a woman who was 14 weeks pregnant was refused an emergency abortion after her water broke, forcing her to be transferred to a hospital 80 miles from her home or risk life-threatening sepsis.
At Louisiana State University Medical Center, a young woman with cardiomyopathy was denied a medically necessary abortion, forcing her to be transferred to Texas to save her life. And in 2010, in Phoenix, Sr. Margaret McBride was excommunicated for allowing an abortion to save the life of a critically ill 27-year old mother of four. There is a pattern of religious mandates that endanger a woman’s life by requiring that “physicians act contrary to the current standard of care.”
Arizona’s Senate has just passed a bill that shields physicians from litigation for failing to inform pregnant women of prenatal problems or lying to their patients if the truth could lead to the decision to seek an abortion. Texas has just sacrificed cancer screening and preventive care for poor women because some of those funds go to Planned Parenthood—even though the funds are not used for abortion. This is guilt by association, as the law will cut off clinics with any affiliation to a provider, no matter how tangential.
Similar bills are pending in several other states and in Congress. The American Bar Association responded, passing a resolution opposing “governmental actions and policies that interfere with patients’ abilities to receive from their healthcare providers … all of the relevant and medically accurate information necessary for fully informed healthcare decision making. . .as defined by the applicable medical standard of care, whether or not the provider chooses to offer such care.”
So we now have pharmacists refusing to dispense medications necessary for a woman’s health and well-being, some physicians increasingly refusing to provide women health care, and now legislators restricting access to care. What is lost is the devastating impact of these policies on women—particularly lower-income, rural, and women of color—who have no alternatives. As physicians and other health care workers, our historic responsibility has always been to meet the needs of our patients, even if that conflicted with our personal beliefs.
“Conscience” vs. Refusal: An Historical Perspective
This struggle between conscience and refusal, or individual rights vs. that of the community good, goes far back, and is not limited to the reproductive arena. Even in the time of the Great Plague in the 1600s, there was a societal expectation regarding the behavior of physicians and the presumption that they would put patients needs first. Especially since the HIV/AIDS era began, the consensus has been that along with whatever benefits and status being a physician brings, is also a unique social responsibility. In historical cases and discussions regarding the duty to treat, the only exceptions have related to health care worker’s personal risk, usually due to epidemics of life-threatening infectious diseases.
Although they may be cloaked innocently, as “conscience” clauses, this belies their nature. They are, instead, unconscionable clauses, allowing health care workers to shirk the professional responsibility to put their patients first. Refusal clauses deny our patients the care that they need. They should be publicly identified and bluntly referred to as such—a refusal to provide care.
End of Life issues
Religious restrictions affect far more than contraception and abortion.
For example, living wills (advance directives) may not be honored, even at some secular but affiliated institutions, because of religious restrictions, violating patient preferences and Medicare notice requirements. (42 C.F.R. §§ 482.13(b)(3), 489.100 to 489.104, as discussed in 60 Fed. Reg. 33280-83 (June 27, 1995). In March, 2004, Pope John Paul stated it is “morally obligatory to continue use of artificial nutrition and hydration in patients in persistent vegetative state.” While there have not yet been changes made as a result of this pronouncement, Rev. Michael Place, CEO of Catholic Health Association, acknowledges the Pope’s statement could even affect “those patients who are not in a persistent vegetative state.”
Many organizations have appealed to the JCAHO to require health care entities that have institutional ethical or religious restrictions concerning certain health care services and information to provide explicit and timely written notice of those restrictions to prospective patients and staff. (After the merger in our community, services were shifted between the secular and Catholic hospitals.
My elderly mother had to be hospitalized at the Catholic hospital to receive necessary services (or travel a considerable distance). No one in registration, admitting, the operating room, or her floor could tell us what the policy “Living wills will be honored if not in conflict with hospital policy” meant, adding considerable needless stress to an already difficult situation. This was also in violation of the Patient Self-Determination Act (PSDA), which requires institutions receiving Medicare or Medicaid funding to provide notification as to whether a patient’s Advanced Directive will be honored.
Historically, combined Medicare and Medicaid payments accounted for half the revenues of religiously-sponsored hospitals–more than $45.2 billion in public funds: $35.7 billion in Medicare payments, an estimated $8.8 billion in Medicaid payments and nearly $700 million in other types of government appropriations.
The NY Times got it right it their recent editorial characterizing the wave of mergers between Catholic and secular hospitals as putting “Women’s Health Care at Risk.” And they were right in noting the valuable role that MergerWatch has played in helping to block or reverse a number of mergers. But they, too, need to address the broader impact of these mergers on your right to health care.
Far more is at stake than “just” women’s reproductive choices. (I will discuss more impacts, particularly on research and on infectious diseases, in an upcoming post). Governor Steve Beshear was wise to reject the merger of Louisville’s publicly-funded University Hospital with a Catholic run consortium, as it would have imposed the Catholic restrictions on all of the parties. Other communities should similarly carefully look at details of such bargains, and ensure that there is broad public involvement and full transparency and disclosure of potential impacts on the entire community.
If religious organizations want to impose their beliefs on others who do not share them, should they be receiving public monies—our monies—to deny care that we need and deserve? Should their “conscience” trump yours? Who should decide what care is right for you?
Footnote: *The figure is likely to be higher as this analysis only included systems that were readily identified as being Catholic. It does not, for example, included merged institutions that may have agreed to abide by the Catholic ERDs.
Previously in this series:
Molecules to Medicine: Clinical Trials for Beginners
Molecules to Medicine: From Test-Tube to Medicine Chest
Lilly’s Shocker, or the Post-Marketing Blues
Molecules to Medicine: Pharma Trumps HIPAA?
Molecules to Medicine: Should pepper spray be put on (clinical) trial?
Molecules to Medicine: FDA at a Crossroads—a Tough Place to Be
Molecules to Medicine: Plan B: The Tradition of Politics at the FDA
Molecules to Medicine: “Conscience” Clauses versus Refusal: An Historical Perspective
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