When the devastating Dobbs decision came down from the Supreme Court in late June, Americans all over the country — a vast majority of whom support Roe v. Wade — felt a collective surge of rage, frustration and fear. The concern was, undeniably, most profound in those states with trigger laws, where a wave of draconian restrictions have already been rolling out. But wherever you live, whether your state is for now red or blue, there's another growing obstacle to abortion access and comprehensive gynecological services. It's the Catholic Church.
Anyone familiar with how the Catholic church rolls would not be surprised that the Ethical and Religious Directives of the U.S. Conference of Catholic Bishops (ERDs) prohibit abortion and contraceptive — among other services like gender confirmation treatment, most fertility treatments and physician-assisted death — at a Catholic hospital. But Catholic doctrine is becoming a very big issue in subtler ways — in its ever widening role in American healthcare, and in the confusing, contradictory execution of religious dogma in medical options that can put patients at risk without their prior knowledge.
Your own local hospital may be taking its cues from the Vatican, and you may not know it.
"Catholic healthcare is now collectively the largest non-profit, non-governmental health care provider in the United States," Jason T. Eberl, Ph.D., the Director of the Albert Gnaegi Center for Health Care Ethics at St. Louis University, told me in a recent phone conversation. "In fact, my understanding is, in the world."
The Catholic Health Association reports that as of 2022, it represents 654 hospitals across the U.S. — including 299 that provide obstetrics services. And if a patient is not seeking services that conflict with the ERDs, then having more health care services in more places can be a win, especially for residents of rural and underserved communities. But if you're among that half of the population for whom the possibility or reality of pregnancy has ever loomed in your life, then you should know that the U.S. Conference of Catholic Bishops has a great deal to say about your care.
In some areas, Catholic facilities are the only community hospitals — including regions of California, Colorado and Illinois. People who might otherwise think their reproductive options are secure because they live in a blue state may end up discovering that privilege can depend on how far they can drive. And with nearly 900 hospitals across the country at risk of closing, most of them in rural areas, it might be a very long drive.
Related: How to access abortion in a post-Roe world
Four out of the 10 largest health systems in the country are Catholic. They are all beholden to those Ethical and Religious Directives. Your own local hospital may be taking its cues from the Vatican, and you may not know it. As a 2020 Community Catalyst report on the growth of Catholic health systems entitled "Bigger and Bigger" explains, "Historically-Catholic hospitals that were purchased by for-profit systems may still be following the Catholic ERDs [Ethical and Religious Directives] as a condition of the sale. Non-Catholic non-profit hospitals that have merged with Catholic facilities are often required to adopt all or some of the ERDs. Public hospitals that are being managed by Catholic health systems may have agreed to eliminate any services that conflict with the ERDs."
Where this becomes uniquely thorny for pregnant patients is this directive: "No intervention is morally licit which constitutes a direct abortion. Every procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion, which, in its moral context, includes the interval between conception and implantation of the embryo."
The vaguely positive news for patients with an ectopic pregnancy or a large tumor is that a Catholic doctrine known as the double effect allows patients to receive lifesaving treatment and surgery as long as the death of the fetus is only an unintended consequence of the procedure. Patients should also, if they have miscarried, be able obtain the appropriate procedure or medication to expel the fetal remains.
The bad news is that in a crisis, patients may not be able to get anybody to actually take the risk of performing the procedure. This isn't just about Catholic facilities, either. In 2018, Arizona woman Nicole Mone Arteaga's Walgreens pharmacist refused to fulfill a prescription for medication after her miscarriage, citing his "ethical beliefs." Now, post-Dobbs, health care advocates are concerned that will become more common practice. Texas physician Dr. Lauren Thaxton told NPR recently she's already hearing from miscarrying patients who can't get misoprostol prescriptions filled.
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Patients with ectopic pregnancies share similar risks. In Missouri, treatments are reportedly being delayed because the state's trigger law permits abortion only if "a serious risk of substantial and irreversible physical impairment." In other words, doctors may feel comfortable waiting to assist patients until they're in a provable life threatening emergency.
So while Jason Eberl said "Dobbs shouldn't change anything" in how Catholic health care is administered, when I tell him I'm afraid that Catholic health care workers will now be more reluctant to provide certain care, even in allowable circumstances, he replied, "I share that fear."
The Catholic church's medical track record here certainly bears out those apprehensions. Ireland's long-time-coming move toward reproductive rights was propelled in no small part by the 2012 death of Savita Halappanavar, a pregnant Galway woman who was refused appropriate intervention when she went into sepsis during a miscarriage as the hospital staff informed her, "this is a Catholic country."
And it's not just abroad. A 2008 report in the American Journal of Medical Health found that "U.S. obstetrician–gynecologists working in Catholic-owned hospitals revealed that they are restricted in managing miscarriages ... Some physicians intentionally violated protocol because they felt patient safety was compromised."
In 2011, the ACLU released a report, "The Growth of Catholic Hospitals and the Threat to Reproductive Health Care," highlighting case studies of women being denied appropriate miscarriage care, or not being informed of their risks. In 2016, the Guardian published the findings of former Muskegon County, Michigan, health official Faith Groesbeck, who accused Mercy Health Partners of "forcing five women between August 2009 and December 2010 to undergo dangerous miscarriages by giving them no other option…. In each incident, [Mercy Health Partners] withheld medically indicated treatment and information from pregnant women experiencing emergency situations."
And patients may not know about any of this potential harm until it's too late, because the fact that their care options are being dictated by a team of bishops may be not apparent. Catholic directives state that "Catholic health care institutions are not to provide abortion services, even based upon the principle of material cooperation. In this context, Catholic health care institutions need to be concerned about the danger of scandal in any association with abortion providers."
Patients may not know until it's too late, because the fact that their care options are being dictated by a team of bishops may be not apparent.
So a search for "abortion" on the Catholic health system Ascension's site gently redirects to "ablation." And even as they promote among their obstetric services "advanced care for high-risk pregnancy," they don't mention that a high-risk patient would not be able to get an abortion if necessary. A search on Catholic health care system Dignity returns nearly identical results. Emails to Ascension and to Catholic healthcare system this week went unanswered. During a brief phone call to one Dignity birth center, the person who answered the phone told me, "I would love to talk, but I'm not allowed to," before wishing me a good day.
The lack of transparency doesn't appear unintentional. As the New York Times reported in 2018, after reviewing the websites of 652 U.S. Catholic hospitals, "On nearly two-thirds of them, it took more than three clicks from the home page to determine that the hospital was Catholic. Only 17 individual Catholic hospital websites, fewer than 3 percent, contained an easily found list of services not offered for religious reasons."
This isn't just about abortion on demand. This is about the impact on the health and safety of pregnant individuals. This is about the absolute absurdity of a group of religious men making broad advancements in the practice of American medicine, and the increasingly prolific aggressive interpretation of their directives. This is about what could easily happen to you, or someone you love, in a dire medical situation, where your physicians are taking their cues regarding your care not from what's happening in your body but what the bishops have decided is best.
Even for practicing Catholics, it should be chilling. "I do fear Dobbs intersecting with a phenomenon we already have among Catholic and other Christian and even non-religious pro-life physicians or pharmacists or other healthcare workers," said Jason Eberl. "Being overly scrupulous about their valuing of embryonic and fetal life, and occluding the respect, the valuing of the life of, the pregnant patient in front of them."
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