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Conscience Magazine

The Harm of Bishops’ Restrictions on Healthcare – Part 2

By Jody Steinauer, MD, PhD September 15, 2020

cross caduceusAs debates intensify in the public policy arena over the broader issues of religious liberty and reproductive
freedom, nowhere do the issues more personally collide than in Catholic healthcare facilities. Conscience asked USCF professors LORI FREEDMAN and JODY STEINAUER to explore what happens when institutions impose a false notion of institutional conscience upon patients’ and providers’ agency, and how a community can protect the rights of those whose conscience should matter most in healthcare decision making.

JODY STEINAUER, MD, PHD, currently leads the University of California, San Francisco’s Bixby Center for Global Reproductive Health, where she works to improve sexual and reproductive healthcare, access and policy worldwide. She is also the national director of the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning. She is committed to equitable and patient-centered healthcare, and believes diversity and inclusion are essential to its fulfillment.
JODY STEINAUER, MD, PHD, currently leads the University of California, San Francisco’s Bixby Center for Global Reproductive Health, where she works to improve sexual and reproductive healthcare, access and policy worldwide. She is also the national director of the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning. She is committed to equitable and patient-centered healthcare, and believes diversity and inclusion are essential to its fulfillment.

Catholic hospitals account for one in six hospital beds in the United States, and their share of the healthcare market has been growing steadily. As health systems face challenges and look for new partners, more people are finding themselves in the position my colleagues and I did last year: Our institution was considering an affiliation with a faith-based healthcare system.

My colleague Dr. Lori Freedman writes in this issue about the real harms that come to patients when providers are limited by the United Stated Conference of Catholic Bishops’ (USCCB) Ethical and Religious Directives. This body of evidence inspired us at the University of California, San Francisco (UCSF) to work to keep our institution from pursuing this partnership. While we were not facing a full merger, UCSF wanted to enter a new partnership with Dignity Health, which was about to become CommonSpirit after receiving approval to merge with the more restrictive Catholic Healthcare Initiatives. Such a partnership would compromise care for our patients, degrade the quality of education for our students and send a message to the community that we are aligned with a discriminatory institution.

Over the course of a year, we worked to educate and engage our community around the concerns that pursuing this partnership was contrary to our core values. In May 2019, as the proposal was headed to the University of California Board of Regents for a vote, UCSF put a hold on the deal. It was a victory for everyone who loves our university and wants it to be its best self, and for the patients we serve.

We want to share the lessons we learned for others who may face a similar challenge in their communities.

Evoke shared values. Institutions have visions, mission statements and history that should be their lodestar when making decisions, especially major ones like partnering or merging with another healthcare entity. A partnership with a hospital system that restricts reproductive and LGBTQ+ care is inconsistent with UCSF’s legacy and mission as an institution. UCSF Health recently touted its status as a “Leader in LGBT Health Care Equality.” Our university has a long history of providing quality abortion care, going back to the “San Francisco Nine,” physicians in the 1960s affiliated with UCSF who were accused of providing illegal abortions for women infected with rubella.

In meetings, public hearings, online communications and media interviews, UCSF staff, faculty and learners opposed to this partnership made clear just how strongly it would contradict our commitment to public service, evidence-based healthcare and equity for our patients, students, faculty and staff.

Put the stories of people who are affected at the forefront. Stories hit home in a way nothing else can. People who aren’t close to these experiences and don’t provide care themselves often don’t understand how disruptive and even dangerous it can be to simply tell someone they have to go elsewhere for care. Statistics can’t compare to listening to Evan Minton talk about how Dignity Health canceled his hysterectomy the day before it was scheduled because he’s transgender. They can’t compare to hearing Dan Diaz talk about the burden on his wife Brittany Maynard having to move to Oregon to receive medical aid in dying because she couldn’t access that care in her home state. Doctors, students, researchers and some regents themselves made the potential consequences of the proposal vivid for everyone watching. These harms aren’t hypothetical: They’re real, deep, painful, dangerous and likely to fall on the most vulnerable people in our communities.

Back it up with research. Research demonstrates the impacts of faith-based, restrictive healthcare. The Research Consortium on Religious Healthcare Institutions[1] offers a wealth of information about the dangerous impact on care. Research shows that the Ethical and Religious Directives prevent doctors[2] from providing patients with the full range of information and access to treatment for ectopic pregnancy, exposing them to avoidable risk. It shows that they limit management of miscarriages,[3] causing some doctors to violate protocol because they’re concerned for patient safety. It shows that doctors at Catholic hospitals find themselves in conflict with these policies[4] that contradict the standard of care and what’s best for the patient. It shows that women of color are more likely to give birth at facilities governed by these religious restrictions,[5] exacerbating health disparities.

We also know from other institutions’ experiences that assurances about what enforcement looks like now are not guarantees for the future, because of changes in church and system leadership. This raised even more concerns for us, given that Dignity had just been approved to merge with an even more restrictive Catholic system.

This body of research makes it clear that our concerns about affiliating with a restrictive institution aren’t exaggerated. We should all learn from what patients and healthcare providers have gone through around the country and not repeat their mistakes.

Form a coalition of stakeholders. The vocal opposition to these proposed partnerships shows how their impacts would be widespread and serious. From within UCSF, healthcare providers passionately shared their concerns about being prohibited from providing the best possible care. Educators talked about how damaging it would be to learners to be taught how to provide healthcare based on workarounds aimed to circumvent the restrictions and be able to offer the care their patients needed. Students talked about how it would impede their educational experience and betray the values that drew them to UCSF as an institution. Researchers shared their evidence illustrating the real and dangerous impacts this could have on patients.

While the proposal was about UCSF, the plan to partner with Dignity had to be approved by the UC Regents, a governing board of all nine universities in the system. Taken together, UC represents the largest public university system in the country. UC-wide faculty leadership became involved in reviewing and ultimately voicing strong opposition[6] to partnership with institutions with policies that contradict the many antidiscrimination statutes of the State of California and the UC system. As voices of opposition from all campuses began to emerge, the stakes rose to the state government level.

The voices of those closest to the decision were complemented by an array of external stakeholders. Legal organizations like the ACLU, National Health Law Program and National Center for Lesbian Rights pointed to ways the partnership could violate federal and state law. Advocacy organizations mobilized concerned community members worried about the impacts on care for vulnerable patients and the idea of discriminatory practices abetted by a public institution funded by their tax dollars. Politicians like the members of the legislature’s LGBT caucus raised concern that Dignity’s practices were contrary to California’s values.

With voices from all different sectors speaking out, it was clear that concerns about the implications of such a partnership are widespread.

Have an inside strategy and an outside strategy. At the beginning, we focused on communicating within our UCSF community to talk through concerns with people on both sides, sending letters and having meetings. We found this to be an important first step, to identify partners and to hear from all stakeholders. We then turned outward, to communicate our concerns to the public. We participated in public meetings with the University of California Board of Regents, and the public video footage of these meetings helped get our message out. Media could identify people inside and outside UCSF, allowing our story to be heard and ensuring the public truly understood what was at stake in this decision. Highly critical coverage of the possible affiliation in our state’s largest newspaper raised the profile of our concerns.

Remain vigilant. While this was a victory that once seemed nearly impossible, it was only the first round in a larger battle. The proponents put a lot of time and effort into pursuing the partnership and faced financial and other pressures to find a way to make it work. A UC-wide working group recently released a proposed set of values to guide such partnerships. The leadership’s preferred option does not offer any guarantees that we could provide the care our patients need, but it is packaged in a way to respond to the public scrutiny we generated. The UC Regents postponed voting on the working group’s report in April. In the meantime, Public Records Act requests showed that while the university was assuring us that it would never prevent providers and students from providing standard of care, it had signed training agreements that prohibited procedures like “promoting contraceptive practices” and performing an abortion even when the pregnancy is outside the uterus, a potentially life-threatening condition. This made us even more wary of vague promises.

It’s highly unlikely that any kind of partnership can both adhere to Catholic hospitals’ obligations enforcing the Ethical and Religious Directives and honor our commitment to provided evidence-based, patient-centered care.

The number of Catholic hospitals in the US has increased by 22 percent.[7] If the University of California, a public institution with a long history of leadership on reproductive freedom and LGBTQ+ care, housed in a state that champions the same values, joins a partnership with restrictive Catholic health systems, it sends a terrible signal to the rest of the country. In the midst of one of the most hostile environments for reproductive and LGBTQ+ health in recent memory, we must raise the profile of this threat and speak up early and often. We will continue to advocate for our patients and for our institution’s and state’s values.

[1] “Research Consortium on Religious Institutions”. Advancing New Standards in Reproductive Health.

[2] Foster AM, Dennis A, Smith F. Do religious restrictions influence ectopic pregnancy management? A national qualitative study. Womens Health Issues. 2011;21(2):104-109.

[3] Freedman LR, Landy U, Steinauer J. When there’s a heartbeat: miscarriage management in Catholic-owned hospitals. Am J Public Health. 2008;98(10):1774-1778.

[4] Lori R. Freedman & Debra B. Stulberg (2013) Conflicts in Care for Obstetric Complications in Catholic Hospitals, AJOB Primary Research, 4:4, 1-10.

[5] Shepherd, Kira, Platt E., Franke, K., Boylan, E. “Bearing Faith: The Limits of Catholic Health Care for Women of Color”.  The Law, Rights, and Religion Project. Columbia Law School. January 2018.

[6] “The UC Academic Senate Non-Discrimination in Healthcare Task Force Final Report”. July 24, 2019. University of California.

[7] “Denial of Care at Catholic Hospitals”. Advancing New Standards in Reproductive Health and University of California San Francisco.

Jody Steinauer, MD, PhD