SCA WA Chapter officers interview on Nov. 19, 2013, with Monica Harrington, co-chair of Washington Women for Choice and site editor, CatholicWatch.org, an advocacy and watchdog site dedicated to increasing awareness about the dangers inherent when religious doctrine controls health care systems decision making.
What's the crux of the problem?
In Washington State, almost half our health care system is subject to the “moral authority” of three Catholic bishops. This is because Catholic health care ministries, including Providence/Swedish, PeaceHealth, and Franciscan, have been aggressively buying up and/or taking control of formerly secular hospitals, medical clinics, physician practices, and labs, and imposing the bishops’ Ethical and Religious Directives for Catholic Health Care.
The Bishops’ Directives forbid:
• Vasectomies and tubal ligation
• Abortion under any circumstances, including an ectopic pregnancy, which is a life-threatening condition
• Most fertility treatments
• New treatments (e.g., for Parkinsons or Juvenile Diabetes) that make use of embryonic stem cells
• Any participation or referrals for patients who want to exercise their legal rights under Death with Dignity laws
The Bishops’ Directives require:
• tube feeding in the case of a persistent, vegetative coma (similar to Terri Schiavo) regardless of any Advance Directive to the contrary
• Employees to override patients’ Advanced Directives if they conflict with the Bishops’ Moral code
• Adherence to all of the Directives by all employees associated with a Catholic health system
The Catholic bishops are focused on expanding the reach and influence of Catholic Health Care and on using control of Catholic hospital systems (now self-described as “Catholic Health Care Ministries”) to impose health care restrictions on Catholics and nonCatholics alike. These Catholic health care ministries are heavily supported with public tax dollars, including Medicare and Medicaid, and in many instances, with direct tax subsidies, negotiated to give the Catholic systems complete control over what and how services will be provided. On San Juan Island, for example, the hospital opened in November 2012 is Catholic owned and controlled and it is supported with a direct tax subsidy levied on property owners. PeaceHealth will continue to get a tax subsidy over the 50-year life of its contract with the local hospital taxing district even as it retains all rights to determine what services are appropriate and fit within its moral code. Moreover, the way the deal is constructed, because PeaceHealth gets 95-97% of all funds available under the hospital taxing district’s levy authority, there are no funds left to support any services, including reproductive or end-of-life services, which PeaceHealth chooses not to provide.
Broadly speaking, the bishops are smart, focused, absolutely certain that they are in the moral right, and in it for the long haul. They have a very deliberate strategy to control health care policy by leveraging their control over Catholic health care institutions, especially in areas of the country where they cannot impose their conservative social agenda through legislative action or at the ballot box.
We’ve got a “boiling frog” issue; no one objected when the heat was first turned on because medically, Catholic health care wasn’t different from nonCatholic health care and the Catholic bishops’ directives didn’t even exist. The first Washington State Catholic hospitals were opened and run by nuns in the 1800s. The earliest precursor to the ERDs, developed by the Catholic Hospital Association, didn’t exist until 1921, and a nationwide set of rules sanctioned by the Catholic bishops didn’t exist until the 1970s. When Catholic hospitals first started in many areas of the U.S., it was largely because nuns were compassionate and wanted to serve (they didn’t have children they needed to take care) and most of what they offered was palliative care. In addition, for many decades the nuns stood up to the bishops and quietly offered contraceptives and other services in defiance of the bishops’ edicts.
Now, however, the nuns have retired and/or died out (the average age is over 70), health care has become more expensive and complicated, and control of Catholic health systems has transitioned to highly compensated lay professionals (the former CEO of Providence, John Koster, made $6.4 million in 2011), who ultimately answer to the Catholic bishops. Because CEO paychecks depend on keeping the local bishop happy, these lay professionals are implementing medical policies that are in line with the Catholic bishops, but that are opposed by the vast majority of Americans, and which run counter to the advice and recommendations of physicians and other health experts. The American Congress of Obstetricians and Gynecologists, for example, says that women should have easy access to contraception and to the “best available, scientifically-based health care.”
Is it truly a nationwide problem?
According to a July 8, 2013 article in Becker’s Hospital Review, the three largest nonprofit health systems nationwide, and five of the top 10, are Catholic. All of these systems are expanding rapidly.
A few years ago, the penetration of Catholic health systems (as measured by acute care hospital beds, which is a proxy for the health system more broadly) in Washington State was less than 30%. Today it’s about 45% and rising. Catholic health systems control more than 30% of the market in eight states, and they are aggressively expanding their reach.
Why is this issue coming to the forefront now in our state?
It’s a mixture of history and strategic opportunity. Catholic hospitals opened on the Western frontier because the nuns who came to this area were motivated by the mission of providing compassionate care and making sure that Catholics, who were discriminated against in the 1800s and first half of the 1900s, had access to care.
The original intent was benign. However, strategists for the Catholic Church and for the bishops saw an opportunity to leverage their existing control of Catholic health care ministries (their terminology) to expand the reach and influence of the Catholic Church in areas where they cannot assert their moral positions at the ballot box. USA Today once called Washington State the “least religious” state in the union. The “live and let live” approach that so many Washingtonians have towards religion generally means that as Catholic health systems were expanding aggressively, few people saw that expansion as part of a broader strategic effort. It wasn’t until the American Civil Liberties Union quantified the reach and control of Catholic health systems in Washington State early in 2013 that many people understood the breadth of the problem.
In many ways, Washington State is the canary in the coal mine. What happens in terms of regaining control of our health system from the Catholic Bishops will have a strong influence on how this issue plays out across the United States.
Who are you working with?
I work with advocates from many different groups who care about patient rights, and especially the rights of patients and doctors to make decisions rooted in best care standards of medical ethics, free of religious interference. I’m in regular contact with people from the ACLU, Planned Parenthood, PFLAG (Parents, Friends and Family of Lesbians and Gays), NARAL, Compassion & Choices, the National Women’s Law Center, Legal Voice, and many other groups.
How many more acquisitions or mergers are underway or known to be upcoming?
MergerWatch, which is a nonprofit dedicated to helping communities organize and advocate in the face of takeovers and mergers between religious health systems and secular providers, has said that Washington State has more mergers in the work than any other state. The pace and scale of what’s happening here is unprecedented.
What other options for hospital care and emergency treatment are available in the affected areas?
In many areas of Washington State, the only hospitals are Catholic controlled. Because of statewide policies meant to encourage efficiencies, smaller cities and towns and other rural areas often have only one hospital. For residents of San Juan Island, Bremerton, Bellingham, and many other areas of the state, the only hospitals are Catholic owned and/or controlled. Many Washingtonians now have to travel more than an hour away to get emergency care from a non-Catholic facility. And even in urban areas, most people have no idea that when they enter a Catholic facility (many of which are not “branded” Catholic), that the medical care they receive is subject to the “moral authority” of the Catholic bishops.
How many “variations on a theme” do we have in WA State when it comes to Catholic/secular affiliations and is one really different than the other? We have the UW/PeaceHealth “affiliation,” the Swedish/Providence “partnership,” but we also have other combinations that seem to be true mergers resulting in loss of services. What do we need to know about all of these variations and how to monitor them?
The Catholic health care ministries use language as a tool to minimize opposition and regulatory oversight of the deals they enter into with secular facilities. The high level goal, expressly stated in the bishops’ directives, is to look at deals with secular facilities as opportunities to expand the reach and influence of the Catholic ministry.
Ultimately, regardless of what a specific deal is called or how it’s described, what really matters is who sets the rules. When Providence took over Swedish, within weeks the legal staffs and ethical staffs were combined, management positions were shuffled, and the management of Swedish started to report up a chain of command that is ultimately accountable to the local Catholic bishop. Despite any protestations to the contrary, Swedish is now a Catholic health system, subject to the bishops’ rules. With the University of Washington/PeaceHealth deal, what matters is that in PeaceHealth facilities and in any shared medical practices or clinics, the bishops’ rules apply. UW Medical students are being taught in Catholic hospital settings that severely restrict patient rights. I’ve spoken to UW medical students and physicians who are deeply fearful of the effects of the UW relationship with PeaceHealth on physician training.
What are the implication of these mergers as they relate to reproductive services, including contraception, sterilization, and abortion?
Access to legal, medically appropriate services are being denied and/or severely curtailed around the state, often without communities or patients even understanding what’s happening. Last year, the Catholic bishop tried to stop Bellingham’s PeaceHealth system from doing lab tests for Planned Parenthood patients, even though PeaceHealth owns the only labs in the area that can process the tests in a timely and efficient manner. The bishop’s “request” would have put patient lives at risk, especially in the case of ectopic pregnancies, and it was only because of the outcry from concerned citizens and donors to PeaceHealth that the bishops’ “request” was put on hold. For now, those lab tests are being done, but in many areas of the country, including Eugene, Oregon, and Spokane, Washington, the major labs are owned by Catholic systems and those labs refuse to process tests for Planned Parenthood patients. It’s a systematic assault on patient rights and access, and it’s being done with our tax dollars and because of public policy decisions that were designed to encourage consolidation as a way to make things more efficient, not restrict patient rights.
What’s the impact on end of life care?
Catholic health systems consider any participation with Death with Dignity to be “intrinsically evil.” Catholic health systems forbid their doctors from participating with Death with Dignity and will not allow them to refer patients to Compassion & Choices, the nonprofit entity that counsels patients and helps them find physicians who can and will help them exercise their rights under Washington’s Death with Dignity law. Moreover, in 2009, the Catholic bishops adopted a new directive that states that a patient in a persistent, vegetative coma, similar to Terri Schiavo, must be kept on a feeding tube regardless of what any advanced directive might say.
What about LGBT patients and their partners/spouses?
The Catholic bishops believe that gay relationships are immoral. Catholic health care ministries are aggressively fighting for the right to avoid compliance with state antidiscrimination laws in terms of employment, and we’re also hearing complaints where married gay patients are finding that their relationships are not being recognized by hospital staff.
It’s difficult to provide fair and equitable medical treatment to LGBT patients when the controlling doctrine of the institution is that gay relationships are immoral.
I’ve heard from sources highly placed within Swedish that Swedish has an “ironclad” agreement with Providence that ensures Swedish can provide all services provided in the past. Is this true?
I’ve heard this claim as well. However, given that Providence refuses to disclose the agreement it made with Swedish, we can only look at the evidence. Swedish is now operated as a “brand” within Providence, reporting up through a structure that ultimately answers to the Catholic bishop on “moral issues.” Swedish now refuses to provide “elective” abortions, and I know firsthand a patient who was denied an abortion at Swedish even after doctors told her she was miscarrying and the pregnancy needed to end. Swedish was once a secular brand, but it’s now a Catholic brand, operating by Catholic rules and I and many others fully expect all of the bishops’ conservative rules to be implemented over time until even the pretense of any distinction between the two brands is gone.
For those mergers that have already taken place, if it is clear that services available to patients have been adversely affected, can anything be done?
Several advocates are working on these issues. Proposed WA Department of Health rule changes will require more transparency about what the actual reproductive and end of life policies are at each hospital and they’re a good start. However, we also need to make sure the Constitution, which forbids the use of public funds to support any religious establishment, is enforced. And we need to ensure that, under state law, physicians cannot be compelled to compromise care because of religious edicts.
Is there a source (website, publicly available document, etc.) that lists specific incidents in WA State and around the country where care has been denied to a patient after one of these Catholic/secular hospital affiliations?
Patients are being negatively impacted today around the state. The ACLU is gathering patient and physician stories and will share them as appropriate with policy makers and with the public. Of course, patient confidentiality needs to be protected. Because the policies that interfere with patient health often happen in difficult circumstances (a woman being denied an abortion, a terminal patient being denied access or counseling related to Death with Dignity), it can be difficult for patients to step forward. The ACLU can tell these stories in ways that protect a patient’s privacy and yet help make sure everyone understands patient rights are being affected today.
My own sister’s best friend died after the physicians in the Catholic hospital she entered refused to consider an abortion or start chemotherapy for her newly diagnosed cancer. This happened years ago in a different state, but it’s part of what caused me to dive deeper into these issues when I first heard that Swedish was becoming part of a Catholic system.
We’re hearing from physicians across the state that the care they deliver is being compromised. Very recently, I was made aware of two cases here in WA from impeccable sources where women suffered unnecessarily because of the bishops’ rules. And a few months ago, a Compassion & Choices volunteer testified before the Department of Health about a patient who shot himself after being unable to find a physician locally who would help him exercise his rights under the Death with Dignity laws. He lived in an area where the only hospital is Catholic. The imposition of religious doctrine on patients and physicians is an outrage and needs to stop.
A study conducted by researchers at the University of California provides an excellent overview of miscarriage mismanagement issues in Catholic hospitals. You can find the link here:
Can you comment on legal strategies?
Beyond saying that some very smart litigators are carefully evaluating the situation and that I expect litigation to happen, I can’t. I believe change will come from a variety of approaches, including litigation, public policy changes, and advocacy and awareness.
What are the most important actions members can take to be the most effective in preventing these mergers and religious oversight of our health care system?
Communicate with your legislators at the local, statewide, and national level and insist that patient and taxpayer rights be protected. Share your knowledge of these issues with friends and encourage them to advocate to protect and assert their own rights and the rights of people who cannot speak for or protect themselves.
Relevant background articles and other resources are also available at the following link: