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How do religious-based hospitals affect physician behavior?

Science-based medicine is, among other things, a tool.  Science helps us sequester our biases so that we may better understand reality.  Of course, there is no way to avoid being human; our biases and our intuition still betray us, and when they do, we use other tools.  Ethics help us think through situations using an explicitly-stated set of values that most of us agree upon (and in order to get wide agreement, these precepts must be pretty general).

Ethical problems are a normal part of medical practice. In medical school I received a bit of formal didactic education on ethics, and on the floors we often have formal ethical discussions to help understand and resolve conflicts.   But ethics are not a weapon used to obtain a result we want; they are a tool to give a framework for understanding and resolving dilemmas.  Ethical dilemmas can arise out of may types of conflicts, for example when our personal beliefs clash with those of our patients, or when patients’ and families’ desires conflict.  They can also arise when we as physicians are constrained in our actions by outside forces.

For example, if an outside agent, say a government, were to ask us to use our professional relationship with a patient to harm them, but the goal was to achieve a greater good (think Guantanamo), we could look at basic medical ethics principles to help clarify the conflict.  I would object on the basis of many of these shared ethics: it violates patient autonomy, it causes them harm, and fails to benefit them.   My responsibility to avoid harming my patient trumps my government’s desire to obtain information via torture.

Despite our attempts to use ethics as a tool, there are some areas that are so fraught with controversy that we may not always come to a satisfactory resolution.  Should doctors participate in executions? (I say “no” but the question is complex.) What about abortion (which is not, by the way, the topic of this post)?  My own interpretation of medical ethics requires me to support a right to abortion for my patients.  Some physicians find abortion so abhorrent that they cannot support it.  For doctors who cannot—for whatever personal reasons—support a right to an abortion, ethics demand that they serve their patients’ needs above their own.  There is no set of data that says that “abortion is harmful to women”, so doctors who oppose abortion cannot claim that science supports their bias.  But if  a doctor legitimately felt that a particular abortion would bring physical harm to a particular woman, then they must give her the advice they feel is necessary.  Conversely, if a doctor feels that a particular abortion may help a particular patient, they must tell the patient.

All this is by way of introduction to a big dilemma.  Most doctors don’t work in Guantanamo, and most don’t deal with abortion on a daily basis.  But many hospitals in the U.S. have some sort of religious affiliation.  Approximately 20% of U.S. hospital beds are religiously-affiliated.  How does this affect the care given by doctors working with these institutions?

A new study published in the Journal of General Internal Medicine aims to answer that question.  Among primary care physicians (PCPs) polled, about 43% had worked in religion-affiliated institutions.  Nearly 20% of these doctors had encountered conflicts with the institution’s religious-based policies.  Encouragingly, 86% of these doctors indicated they would refer patients to an institution where appropriate treatment was available.  Ten percent indicated that they would offer alternatives available at the religious institution, and about 4% said that they would provide the service in violation of hospital policy. (It wasn’t clear to me from my reading of the study whether this also indicated what doctors actually did, or just what they thought they would do.)

In their analysis, the authors found a number of variables that further illuminate these conflicts.  Older physicians where less likely to report conflict, but it isn’t clear whether this is because they fail to perceive an ethical conflict or they just don’t run into problems.  One of the most interesting findings was that, “[n]either religious affiliation nor physician-institution congruence was significantly associated with having experienced conflict with religiously affiliated institutions.”

From an ethical perspective, these data are mixed.  It is comforting that the polled doctors were more often willing to make decisions based on their patients’ needs rather than institutional policies, but it is disturbing that such significant barriers to care arise from these  policies.  Transparency is an important concept in the ethical delivery of medical care; motivations, limitations, and expectations should be clear.  If, for example, a health care system never allows prescription of birth control, this should be made explicit to all providers and patients, and insurance companies who deal with these institutions should make this clear to their customers to allow for informed decision-making.

On a personal and professional level, I find the intrusion of sectarian values into health care disturbing, especially since most of these institutions take money from federally-funded programs such as Medicare and Medicaid.  At the same time, many of these institutions provide significant amounts of charitable care.  I do not believe, however, that this creates a balance.  Charity is good, but treating human beings with dignity and allowing for the science-based delivery of medical care should be a minimum requirement.

References

Stulberg, D., Lawrence, R., Shattuck, J., & Curlin, F. (2010). Religious Hospitals and Primary Care Physicians: Conflicts over Policies for Patient Care Journal of General Internal Medicine DOI: 10.1007/s11606-010-1329-6

Posted in: Religion, Science and Medicine

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59 thoughts on “How do religious-based hospitals affect physician behavior?

  1. Kristen says:

    When I delivered my youngest daughter via c-section I was scheduled at a catholic hospital. My husband and I had decided that we didn’t want any more children, and after all I had been through in my other pregnancies (placental abruption and a threatened uterine rupture), our doctor thought it was the prudent choice.

    Somehow the nurse who does the scheduling didn’t know and put us at the wrong hospital. Our doctor noticed the error when we showed up, thank goodness, or else I would have had to have another surgery. It was completely foreign to me that a hospital would deny such a common procedure, I never considered it to be even a remote possibility that they would. I respect other’s religious beliefs, but nobody should have to forgo a needed procedure for someone else’s belief.

  2. BillyJoe says:

    “What about abortion (which is not, by the way, the topic of this post)?”

    :)

    There are doctors who find abortion so abhorent that they will not even refer any of their patients onto someone who will refer the patient for an abortion. They will not inform the patient about alternatives and they will try their best to persuade that patient no to have an abortion. They feel that if they were to help a patient in any way that leads to them having an abortion, they would be personally responsible fo the death of a human being.

    I don’t see a solution to this problem.

  3. tommyhj says:

    Ethics and religion are not part of the same paradigm, and as such pretty hard to combine.

    You aren’t really “ethical” if you do something out of strict religious dogma. Luckily, outcome may be the same though, but sometimes it is not (as with abortion, refusing blood trnsfusion etc).

    A solution to this would be a federal database where all licensed doctors are mandated to answer a few questions:
    Are you religious? Would any of your professional decision be influenced by you being religious? Do you support abortion? Etc.

    That way people can avoid or choose the doctors who are biased if they wish.

  4. windriven says:

    I find myself in the uncomfortable position of arguing the right of Catholic institutions to refuse to perform elective abortions. Dr. Lipson frames his argument only in terms of the woman. Catholic dogma as I understand it holds that a human life imbued with a ‘soul’ begins at the moment of conception.

    We can argue the moment when a blastocyst / fetus / infant attains the status of human life but to the best of my knowledge science is silent on this point.

    In any event medical ethics is endlessly interesting and one hopes to see the subject explored regularly here.

  5. mxh says:

    I worked in a Catholic hospital last summer and decided to look into their religious policies… they’re outlined in the US Conference of Catholic Bishops’ Ethical and Religious Directives. There were some that were pretty concerning and would definitely conflict with the way I would practice medicine.
    I’d love to say that you could just avoid these types of hospitals, but in a lot of parts of the country, religious hospitals are your only option.

  6. papu says:

    I don’t believe for one second that abortion is as abhorent to some people as they claim. It is used as a hot button issue for evangelicals to “prove” they are more moral than the non-religious.
    Just look at “Christian Science abortion” that kills children unlucky enough to develop diabetes or pneumonia or any of thousands of potentially fatal, yet treatable, illnesses, who are allowed to die in horrible pain while their nutty parents look on and pray. Christians find this OK. But kill a blastocyst with no central nervous system? That makes Jesus cry!
    Religion is a way to justify immoral behavior, not eliminate it.

  7. MKandefer says:

    windriven,

    Science is silent depending on how one uses the term “soul”. Sometimes it’s taken as synonymous with consciousness, in which case, science is not silent on this. If the word “soul” is defined as an immaterial, causally inert substance, then no, science cannot say anything about that. Of course, if it’s causally inert, one must wonder what all the hubbub is over (or why we talk about it so much). Other possibilities include a substance dualism sense of soul, which science can also talk about, as the soul in this case is not causally inert.

    Nonetheless, the doctors at Catholic hospitals are still treating the woman as the patient, and should keep her health in mind when making medical recommendations.

  8. lamamaloca says:

    “Catholic dogma as I understand it holds that a human life imbued with a ’soul’ begins at the moment of conception.”

    Actually, Catholic dogma does not answer the question of when the embryo is a person and has a soul. You can’t really tell that from the actions of the US Bishops, though. Catholic dogma does declare that every human person has a soul, and the current official position is that science seems clear that an embryo is most likely a human person. Thus you end up with the absurd position of Catholic bishops dogmatically declaring that science says that the embryo has a soul from the moment of fertilization.

    From the encyclical Evangelium Vitae, “Furthermore, what is at stake is so important that, from the standpoint of moral obligation, the mere probability that a human person is involved would suffice to justify an absolutely clear prohibition of any intervention aimed at killing a human embryo. Precisely for this reason, over and above all scientific debates and those philosophical affirmations to which the Magisterium has not expressly committed itself, the Church has always taught and continues to teach that the result of human procreation, from the first moment of its existence, must be guaranteed that unconditional respect which is morally due to the human being in his or her totality and unity as body and spirit.”

    This is further confused by conflating the term “conception,” which has a philosophical or theological meaning of “the point at which a human person comes into existence,” and the medical idea of fertilization or conception. To add to the absurdity, Catholic doctrine doesn’t even officially allow abortion to follow the same principles of self-defense that apply to other instances of taking human life, allow it will allow a very limited use of the moral principle of double effect. Thus you end up with some Catholics arguing that while removing a fallopian tube containing an ectopic pregnancy may be morally acceptable, directly removing the embryo or taking medication to expel the embryo is not. The Catholic doctors, hospitals and clinics I know are nowhere near as legalistic as the Catholic theologians.

    Unfortunately, instead of allowing knowledgeable Catholic medical providers to determine ethical guidelines for their hospitals, the US Bishops are now dictating them. I fear that the end result of this will put Catholic organizations out of the medical business. Perhaps hospitals will just forgo their Catholic identity and free themselves from the Bishops’ control as has already been done in a few cases, although I’m not sure if that could be done while allowing the religious orders, who are much more reasonable than the Bishops, to continue to staff and run them.

    Sorry for the rant. I’m a Catholic who’s tired of watching the Bishops destroy my Church.

  9. mikerattlesnake says:

    A couple years ago I lived in a small town where the only nearby hospital was heavily religious (I was naive enough not to know better and would have travelled the extra 15 minutes to another hospital if I had known). I signed up for the only available doctor supported by insurance and went in for my first visit. Dr. Riffel had christian propoganda about my place in the afterlife strewn all over his waiting room. I was immediately concerned, but I went in.

    It was a “get to know you” type appointment, so we went over basic health and history questions. When I informed him that I didn’t know my father’s medical history because he left when I was born, I was told that it was ok because we all “have a father watching us from above.” My girlfriend of 5 years and I were encouraged to try abstinence (my response was laughter, met with a disappointed look and an entreaty that it was “still an option”). I felt really uncomfortable the whole time and didn’t feel as if I could be honest with him about the less christian details of my life. I didn’t pay my copay and I didn’t return. He was the worst doctor I have ever visited.

  10. Draal says:

    This article was only a questionnaire of less that 500 people (a 50% response); and only 167 people in a big part of their results. That’s by no means a definitive representation of doctors in religion-affiliated hospitals. The most statistically significant finding was in regards to the age of the doctor. All other variables has little or no influence.

    Anyone know how religion-affiliated hospitals compare to other private or public hospitals in terms of quality of care and outcome? I think that’s more relevant that what the Doctor’s think of policy. This survey only addressed what doctors thought and nothing else.

    “I find the intrusion of sectarian values into health care disturbing..”

    Interestingly, medieval hospitals were strongly sectarian. Modern hospitals evolved away from this model. But the history of Catholic hospitals is long. They’ve been “intruding” from the very beginning. It’s always been there so there should be no surprise. Should it change? Well, they are a regulated private institutes. It’s unacceptable to expect a private company to change their policies when they aren’t breaking the law.
    Private companies and individuals receive public funds all the time. If they are legally abiding by the law, a private hospital has a legal right to set their own policies. State have their own laws in regards to many of the same issues brought up in the article. The state laws govern all hospitals within the state and not just the 13% of religion affiliated hospitals. State laws should be addressed first before poo-pooing the minority of hospitals.

  11. Kylara says:

    “I find the intrusion of sectarian values into health care disturbing, especially since most of these institutions take money from federally-funded programs such as Medicare and Medicaid. At the same time, many of these institutions provide significant amounts of charitable care.”

    In many states, the state has pulled out of providing public health services in impoverished and rural areas (where it’s expensive) and the only remaining hospitals are religious. If sectarian health care is problematic, the solution seems to be a more robust public health sector.

    The flip side of the fact that religious hospitals get state funds is that religious hospitals are serving patients the state can’t be arsed to serve, and using member donor funds to do so. It’s obviously much more convenient for the state to have middle-class and wealthy members of particular religion redistribute their wealth to the poor to give them health care, than it is to attempt to pass a tax increase or change spending priorities to provide ample health access to all citizens.

    On another note, my ob/gyn care and my GP are both part of a Catholic health care system. They all buy separate insurance to prescribe birth control — that way the hospital system isn’t violating the Catholic rules, but the doctors can all counsel on and prescribe birth control. But this system is run by nuns, who as a group tend to be a bit more realistic and subversive than the male hierarchy.

  12. AlexisT says:

    The issues with Catholic hospitals go beyond abortion and into numerous areas of women’s health. In the Albany area, a merger means that all the hospitals are practicing under Catholic health directives. They planned to set up a hospital within a hospital to perform sterilizations, but will that be viable? The OB/GYNs at my local hospital also practice under those directives. If you want to use them, be prepared to go elsewhere for contraception. The Catholic Church prohibits the use of methotrexate for ectopic pregnancy–only surgery is acceptable. That alone would have me running, along with a friend’s experience when she was told she could not have misoprostol for her miscarriage because the Church forbade it.

    I am not Catholic, and I have no intention of permitting my healthcare to be ruled by someone else’s beliefs. I can vote with my feet, but it concerns me that in some areas, it might not be so easy.

  13. windriven says:

    @MKandefer

    “Nonetheless, the doctors at Catholic hospitals are still treating the woman as the patient, and should keep her health in mind when making medical recommendations.”

    My point was clear that the defense was only for cases of elective abortion in the context of Catholic theology as I understand it. A woman seeking an elective abortion has many choices beyond religious hospitals.

    I do not accept your argument about how ‘soul’ is construed. If a tail is construed as a leg then a donkey can be said to have five. I would personally argue that the concept of soul in the religious sense as nonsense. But that is neither here nor there. What you or I, absent clear scientific evidence one way or the other, think about souls is immaterial. The issue is about elective abortion vis-a-vis Catholic theology. In this I will defer to lamamloco who says:

    [T]he Church has always taught and continues to teach that the result of human procreation, from the first moment of its existence, must be guaranteed that unconditional respect which is morally due to the human being in his or her totality and unity as body and spirit.”

  14. lamamaloca says:

    “The Catholic Church prohibits the use of methotrexate for ectopic pregnancy–only surgery is acceptable.”

    Many Catholic theologians disagree with this, as do many Catholic doctors and medical institutions. There isn’t an official Church wide policy.

  15. wales says:

    Interesting piece. Though I don’t have full access to the cited article, what I can glean from it doesn’t tell me much. 20% of US hospital beds are provided by religiously affiliated institutions, but only 13% of US hospitals are religiously affiliated. 19% of the 446 survey responding physicians say they have experienced conflict over religiously based policies. The article targets reproductive related services and end-of-life services as the conflict areas. Since about 95% of US abortions are performed outside of hospitals this cannot be the major area of conflict.

    http://www.prochoice.org/about_abortion/facts/access_abortion.html

    “According to the American Hospital Association, there were 5,801 hospitals in the United States in 2001. However, a 2001-2002 study by the Guttmacher Institute identified only 603 hospitals that provided abortions in 2001.” The US has about 5,800 hospitals, of which 13% are religiously affiliated (about 750) yet we have about 6,400 hospitals that do not perform abortions.

    http://www.aclupa.org/education/clarabellduvallreproductiv/duvallprojectresourcespubl/decliningnumberofhospitals.htm

    The ACLU link states that “Eighteen of the hospitals that responded to the survey were run by the Catholic Church. Although Catholic hospitals do not allow induced abortions, three stated they would provide abortions in emergency situations, five were unsure, and one leaves it to the discretion of the physician. Just over half of the non-Catholic hospitals reported that they would provide emergency abortions.” Interesting, I didn’t know that Catholic hospitals were willing to peform emergency abortions at all.

    So, that leaves tubal ligation and vasectomy as the likely areas of conflict for reproductive related services. I believe most vasectomies are performed outside of hospitals, not sure about tubal ligation. I only had access to the first page of the article, so don’t know what end-of-life treatments are at issue, but that is an interesting topic about which I’d like to know more. Certainly this is an area for further research.

  16. wales says:

    Correction: make that about 5,200 US hospitals that do not perform abortions.

  17. lamamaloca says:

    “Interesting, I didn’t know that Catholic hospitals were willing to peform emergency abortions at all.”

    If the mother’s life is in danger, Catholic moral theology allows one to do whatever is necessary to save her life, even if it results in the death of the unborn child. There’s all kinds of sophistical arguments as to why this is not a “direct abortion,” so we don’t have to admit that there are exceptions to moral law.

  18. windriven on the universal beneficence of the invisible hand:
    “A woman seeking an elective abortion has many choices beyond religious hospitals.”

    Which woman? Where? Paid for how?

    What choices does a woman have who has been sexually assaulted? The standard of care is to offer her the morning-after pill in the ED. If the ED doc is religiously opposed to morning-after pills, she won’t get it. If the ED is in a Catholic hospital, she won’t get it. Why should getting the standard of care be so dependent on random religious variables? Except they aren’t so random, they are geographically concentrated, and women with more money have more choices.

    Presumably people like to support the hospitals of their own religion because they like the thought of being able to impose their own religious values on other people whether they want them or not. Otherwise they would donate to non-religious hospitals. This isn’t purely market-driven.

    My friend’s mother experienced a fetal death when she was pregnant but did not miscarry. Her doctor wouldn’t do a D&C because that would be abortion, and she couldn’t get a D&C through her hospital either. When she became quite ill she opened the phone book and looked for doctors with english (french canadians are catholic) names, looking for a protestant or jewish doctor. If she hadn’t been able to do that, she would have died. Not all women are able to do that. And you can talk about what the church really says all you like, this is the kind of thing that religious doctors really do. Or refuse to do. It’s a problem. Sure, this was back in the sixties. But things didn’t change because people sat around thinking that it was ok for religious men to decide what what was best for their women patients against the judgement and wishes of the female patients. And if we sit around thinking it’s ok now, they could change back. They are changing back in many places.

    My own government has apparently decided that it’s ok for Canadian women to have abortions but it’s immoral for African and Asian women to do so. This is a change of policy. My fear is if they succeed in getting us to agree that it’s immoral for *other* women to have abortions that they will then move on to *us* Canadian women.

  19. lamamaloca says:

    “If the ED is in a Catholic hospital, she won’t get it.”

    Not true. Some Catholic hospitals DO offer the MAP, and it is expressly approved by the Bishops of Connecticut. The argument depends on the whole “does it or does it not prevent implantation” controversy, and as more science seems to indicate that it does not, I think it will become more accepted. The last I heard, the local Catholic hospital, which has a specific medically unit assigned to rape victims, doesn’t technically dispense the MAP but does arrange for it to be given by non-hospital personnel. That was 10 years ago, though, I don’t know what the current practice is.

  20. lamamaloca says:

    I do agree with this,

    “And you can talk about what the church really says all you like, this is the kind of thing that religious doctors really do. Or refuse to do. It’s a problem. Sure, this was back in the sixties. But things didn’t change because people sat around thinking that it was ok for religious men to decide what what was best for their women patients against the judgement and wishes of the female patients. And if we sit around thinking it’s ok now, they could change back. They are changing back in many places.”

  21. windriven says:

    @Alison Cummins

    “windriven on the universal beneficence of the invisible hand:
    “A woman seeking an elective abortion has many choices beyond religious hospitals.”

    Which woman? Where? Paid for how?

    What choices does a woman have who has been sexually assaulted? ”

    My post specifically limited itself to the interesting situation where Catholic theology on abortion collides with a woman’s right to elective abortion. The case that you suggest – sexual assault – is rather different than an elective abortion. I have no idea what Catholic doctrine would spell out in that circumstance.

    The point of my post was that there are situations where science is silent (i.e. at what moment can human life be said to commence) but where religious dogma is clear. In those situations the ethics are muddier than in the situations posited in Dr. Lipson’s blog.

    But you do bring up an interesting issue with: “[p]aid for how?” One supposes that the Catholic hospital is paid federal and state funds for Medicare and Medicaid patients and might therefore be expected to provide all legally allowable treatments to those patients. On the other hand these institutions are supported by the monies collected from adherents to the faith. Should tho faithful be expected to violate their religious principles to fund (in all or in part) elective abortions?

  22. weing says:

    This is always tough. I had a similar dilemma recently when an 18 year old unmarried patient came in with her boyfriend and asked for referral to a fertility specialist. She is on welfare.

  23. windriven says:

    @weing

    Great starting point for a post that could easily segue into an examination of rationing of medical care. If we presume that a society will countenance spending only X percent of GDP for medical care and if we further presume that medical science will continue to advance and that those advances will sometimes be quite expensive (stents, VADs, transplants, etc.), then it seems axiomatic that rationing will become an ever larger part of the debate.

  24. # windrivenon

    “A woman seeking an elective abortion has many choices beyond religious hospitals.”

    Yes, in the state of Mississippi there are two whole abortion providers. Mississippi is 352 miles long, so I hope that these two providers are located conveniently since getting insurance coverage across state line is a difficult endeavor.

    ”http://www.guttmacher.org/pubs/sfaa/mississippi.html

    “• In 2005, there were 2 abortion providers in Mississippi. This represents a 50% decrease from 2000, when there were 4 abortion providers.

    • In 2005, 87% of U.S. counties had no abortion provider. 1/3 of American women lived in these counties, which meant they would have to travel outside their county to obtain an abortion. Of women obtaining abortions in 2005, nonhospital providers estimate that 25% traveled at least 50 miles, and 8% traveled more than 100 miles.

    • In 2005, 99% of Mississippi counties had no abortion provider. 91% of Mississippi women lived in these counties. In the South census region, where Mississippi is located, 21% of women having abortions traveled at least 50 miles, and 10% traveled more than 100 miles.

    • In Mississippi, 3 metropolitan areas lack an abortion provider: Gulfport-Biloxi; Pascagoula; Hattiesburg”

    So I don’t think that we can say that the women of Mississippi have many options.

  25. Sastra says:

    Not long ago, I read somewhere (can’t remember where) that religious hospitals sometimes have different policies on pain relief during childbirth — meaning, they sometimes refuse to offer stronger forms of it, for religious reasons. As I understand it, the general rationale seems to be that God sentenced women to bring forth their children in pain, and heartfelt cries to God during labor please Him (or something like that.)

    I had a ‘caudal’ with the first child, but the religious hospital I went to for the second one refused to do them for childbirth, so my obstetrician had to use less effective pain relief. At the time, it didn’t occur to me that there might be a religious reason for the refusal. I think I assumed they thought it too expensive, time-consuming, or drastic. Perhaps. My doctor seemed frustrated, though.

    Has anyone else heard about this distinction?

  26. windriven says:

    @micheleinmichigan

    Michele, are you seriously suggesting that Catholic hospitals (if there even are any in MS) make a difference in abortion availability in the Magnolia State? MS still has all the hospitals built back during Hill-Burton or at least most of them. If there are only 2 or 4 abortion providers in the state I suspect that is a political rather than a Catholic hospital issue.

  27. windriven says:

    @ Sastra

    Could you tell us the religious affiliation of the hospital in question. I’d love to look into their teachings and how that translates into restrictions on medical services.

    But this brings up another point. Why didn’t your physician discuss pain management with you prior to delivery. One presumes that your physician had privileges at that hospital before you came along and s/he would have been aware of any institutional restrictions.

  28. wales says:

    Good point windriven. I have never heard of a religiously affiliated hospital not offering epidurals for childbirth. But more importantly, I cannot imagine an OB not discussing this with the patient well in advance of delivery. Sounds strange.

  29. mxh says:

    I’ve definitely heard of people complaining of poor pain control in the local Catholic hospital (especially with childbirth). It could be just the hospital, but the fact that point #61 of the Catholic Bishop’s Directive talks about how patients “should be helped to appreciate the Christian understanding of redemptive suffering.” Granted it refers to patients who have uncontrollable pain, but if the employees think that “redemptive suffering” is important, they may be less than willing to give out pain killers or epidurals.

  30. Zoe237 says:

    Thanks for this article. There’s nothing more woo-based than religious intrusion (because bible/god says so) into medical decisions and scientific inquiry. Catholics ought not to operate if they can’t offer basic emergency care because of their belief in a FSM. In fact, I do wonder how many deaths the Catholic church is responsible for because of their refusal to allow contraception (particularly condoms) in third world countries.

    http://www.guardian.co.uk/world/2009/mar/17/pope-africa-condoms-aids

    Great post on the National Day of Prayer, btw. There were hundreds of people at our city hall today praying for our country. :P

  31. BobbyG says:

    Very interesting article and discussion.

    “My responsibility to avoid harming my patient trumps my government’s desire to obtain information via torture.”

    See http://bgladd.blogspot.com/2008/02/catachresis.html

    It trumps it both on lofty abstract Kantian moral grounds and utilitarian grounds. Dispositively so, IMHO.

    How about the hardy perennial, weasely “life begins at conception” red herring? I’ve ruminated on that as well.

    http://bgladd.blogspot.com/2008/04/diploid-dave-et-al.html

    “Ethics” is ultimately about making rational decisions that meld the moral, logical, and empirically utilitarian. Excruciatingly difficult in many cases. But, then, if all we had to do was sign up for the checks, we’d all be millionaires.

    I really love this newly discovered blog. I have much to learn from all of you. My hope is that I can contribute a nourishing crumb or two episodically.

  32. GeoffreyCoe says:

    In Australia there is an interesting arrangement of “Third schedule hospitals”. These hospitals are defacto public hospitals and part of the public hospital system but are governed by religious or charitable bodies. Some outstanding hospitals are third schedule hospitals (eg St Vincents Hospital Sydney and St Vincents Hospital Melbourne) and there seems to be virtually no intrusion of religious dogmas on the practice within the hospital. These hospitals are highly regulated by the appropriate state and federal authorities. I have never heard of abuses such as failure to provide abortions or adequate pain relief in childbirth, or distortions of evidence-based contraception

    However these institutions do provide a disproportionately large share of palliative Beds and services in Australia which is probably motivated by religious values.

    This is a very different situation from a private religious hospital which is less regulated and but it is an interesting arrangement – does show effective partnerships can exist

  33. windriven – As I understand it, part of your defense of Catholic Hospitals not providing abortions was that women have many other options. As you said – “My point was clear that the defense was only for cases of elective abortion in the context of Catholic theology as I understand it. A woman seeking an elective abortion has many choices beyond religious hospitals.”

    I believe if you google it you will find Catholic Hospitals in Mississippi. I am merely pointing out that, factually, in some regions women do not have many choices. So if denying abortions on religious grounds is only ethical when there are other facilities available within a reasonable distance, then I would say it’s not okay in Mississippi at this point.

    I am not drawing any conclusion about the Catholic Hospitals causing the situation in Mississippi. Obviously, there is a political component that is caused by religious influences from many churches.

  34. windriven says:

    @micheleinmichigan

    It is not my assertion that “[d]enying abortions on religious grounds is only ethical when there are other facilities available within a reasonable distance.” My argument was that failure of Catholic hospitals to provide elective abortions did not mean that elective abortions are unavailable. One does not go to Goldman’s Delicatessen for a ham sandwich and one does not go to a Catholic hospital for an elective abortion. The fact that Goldman keeps kosher does not mean that ham sandwiches can’t be had.

  35. I’m working on a major investigation of Catholic hospitals’ approach to managing inevitable miscarriages and ectopic pregnancies. There are anecdotal reports of Catholic hospitals refusing to do uterine evacuations on women with inevitable miscarriages until the fetal heart tones stop–even when there’s bleeding. I’ve also read about Catholic hospitals that will remove a woman’s entire fallopian tube to treat an ectopic pregnancy instead of simply giving her methotrexate or surgically removing the ectopic pregnancy and sparing the fallopian tube.

    If you know anyone who has experienced anything like this, as a health care provider, a patient, or a family member–please get in touch with me at frege(at)mac(dot)com. I would be honored to hear your story.

  36. Sastra says:

    windriven wrote:

    Could you tell us the religious affiliation of the hospital in question. I’d love to look into their teachings and how that translates into restrictions on medical services.

    My vague recollection was that it was Lutheran, but I looked it up and it says something about an Episcopalian founder (it’s named for a saint.) The issue may be moot, however, since nothing was said at the time about any religious reasons against epidurals. This hospital simply did not do them, or allow them, except in ‘drastic’ cases, I was told. And yes, I was informed of this well in advance, and alternatives were discussed. I was disappointed, but thought I ought to be able to handle it.

    I wasn’t giving a personal illustration so much as background for why I was asking the question. Somewhere, years later, I read that some religious hospitals frowned on painkillers for childbirth, and it occurred to me for the first time that that might have been the issue, or part of it. I was wondering if others had heard of that particular rationale.

  37. BillyJoe says:

    So…

    …what is the solution to the situation where a doctor is unable to offer an abortion, or even discus this option, let alone refer to another doctor for this purpose, for fear of suffering eternal damnation?

  38. BillyJoe,

    Confession and prayer. Even if telling the truth were a mortal sin (“There is such a thing as abortion. People who provide abortions exist”) it would still be possible to obtain absolution. But I am not positive that telling the truth is a mortal sin. If it were, it would not be possible to oppose abortion. (“There is such a horrible thing as abortion.”) It certainly would not be possible to picket abortion clinics. (“There is such a horrible thing as abortion. The evil people who provide abortions are located here.”)

    In fact, tracts and rants have been important sources of sexual information in different times and places.

    It is also possible for the poor sinning woman to obtain absolution for having an abortion if she repents.

  39. BillyJoe says:

    Alison,

    No, I mean, what is the solution for society at large if the doctor is determined to act in the way I described because his beliefs will not allow him to act otherwise.

    The problem being that his female patients with unplanned pregnancies are placed at a disadvantage with repect to appropriate information and assistance according to their circumstances.

    (This is not a hypothetical scenario. I came across just such a situation many years ago – the doctor was the son of one of my father’s political mates. This doctor was a genuinely pleasant and friendly person, but he had such a dogmatic and conscientious view about abortion that he was unable to offer any assistance to his patient that would lead to her having an abortion. On the contrary, he felt duty bound to do everything in his power, to convince her not to have an abortion. To do otherwise would mean to be aiding and abetting, or to be complicit in, the murder of a human being.)

  40. Ah. Well then, you don’t allow this doctor to treat women between 10 and 55, period, because s/he is unable to behave ethically and provide the standard of care to this population. Geriatrics would be a good specialty.

  41. trin says:

    weing: if we’re talking an 18 yr old on MedicAID, there will be NO fertility specialist that will accept that insurance, it will all be self pay. (Yes the doctor can decide if they accept MedicAID or not)

    In my city, it is nearly impossible to find a RHEUMATOLOGIST who accepts medicaid. I’m in a largish city, and apparently there are 5 in the whole city (for Rheumatology) that accept Medicaid.

    a Fertility specialist has enough business from selfpay and private insurance that they’ll feel no need to accept medicaid patients, even if medicaid would cover the services.

    So the reality is, even IF medicaid would cover the treatment there will be no doctor in that specialty that will be taking medicaid patients.

  42. tcw says:

    Aristotelian ethics (is that too sectarian?) was perhaps the first that said when a non-disease is treated as a disease, the treatment often causes pathology. This is medicine flipped on its head. It took 32 seconds on google to find articles that refute the claim that no set of data that says induced abortion is harmful to women. Here’s just one: David M. Ferugsson, L. John Horwood and Joseph M. Boden, “Reactions to abortion and subsequent mental health,” The British Journal of Psychiatry 195: 420-426 (2009).
    The abortion industry serves men, as they can jump from bed to bed and it is the woman who has to get the abortion, if the guy is so kind enough to fork over the cash for it after coercing her into it. “I love you sweety, and if you love me, you will take care of this.”
    As long as Mississippi was mentioned, you should know about Carol Everett, who did most of the abortions in MS at one time. She wrote a book about it in 1992 called Blood Money. I am more concerned about the lack of neurologists and cardiologists in MS than abortion providers, although depopulating the state would relieve our burden so there would be less poor, rural welfare kids in our country. That’s probably what Margie Sanger hoped for when she spoke at the Klan meeting. If you didn’t know, she founded what was to become the largest abortion provider network in the world, which somehow gets millions of federal funds. Ay! the Klan, religious eugenicists, and their sectarian intrusions. Not to mention the sect of Hegel, Heidegger, and Nietzsche.
    This sectarianism is one reason why people become suspicious of “mainstream” medicine and turn to woo. They have lost trust on ethical issues and hence throw out the baby with the bathwater, losing trust in science. It is one simple thing to tear apart the statistics on a poorly written journal article promoting, say, echinicea, but it is another to venture into ethics, call one’s position science-based, and not be equipped to argue on well-trod ground. At least learn an opponent’s argument before trying to dismantle it. Judging from the posts, apparently this is the opponent: http://www.ncbcenter.org

  43. tcw – “At least learn an opponent’s argument before trying to dismantle it.”

    It doesn’t look like an argument. It looks like a hodge-podge of innuendo, rumor and tenuous conclusions unsupported by any evidence. Been watching any Glenn Beck lately?

    But hey, have at it. I’m guessing you’ll do a great job convincing people who already agree with you.

  44. weing says:

    “Not to mention the sect of Hegel, Heidegger, and Nietzsche.”

    I never new there was such a sect. I learn something new everyday. But I can’t seem to find it anywhere. Must be one of those super-secret sects.

    “This sectarianism is one reason why people become suspicious of “mainstream” medicine and turn to woo.”

    You mean they go to a homeopath or naturopath for an abortion, or the morning after pill? That’s interesting.

  45. weing says:

    “It took 32 seconds on google to find articles that refute the claim that no set of data that says induced abortion is harmful to women.”

    I googled it too and could only find your one poor study. Sorry, not enough.

  46. weing says:

    But I must admit. I am not good at googling.

  47. cloudskimmer says:

    Not to mention the studies which show no psychological harm to women who obtain abortions. For many women, the primary emotion following an elective abortion is relief, not regret. And remember, the anti-choice faction will believe that abortion harms women, regardless of the evidence. And if they can’t find evidence, they’ll invent some, just like the anti-vax and anti-evolution crowd.

  48. cloudskimmer says:

    My biggest objection to Catholic hospitals is that, as in the case of abortion, when good medical practice conflicts with religious doctrine, good medical practice is not allowed. Hospitals should be places for the practice of scientifically based medicine. Does it concern anyone here when a small group, untrained in medical practice, controls medical decisions, and does so based on interpretations of ancient writings?

  49. tcw says:

    michelleinmichigan, It is no rumor that Sanger spoke at the Klan meeting, no rumor that she was a eugenicist. One secondary/tertiary source is the book Medical Apartheid by Harriet Washington. The primary source is Sanger’s autobiography. Not to mention the Birth Control Review which can be found in most major university libraries. I have perused every original issue of those to see if the accusations were legitimate. I was going to link to a You Tube regarding this, and I realized why, possibly, you made the Glenn Beck reference, as there was a link on the YouTube page to a clip from his show. I have never watched him, his description appears Randian and bombastic, but I suppose I should watch him once to understand popular references to him.
    weing, my sect comment was an attempt at irony, not literalism; complaining about sectarianism deals with the sect, not the argument. Complain all day about catholic hospitals because they are run by drones of Popery, but we can’t pretend we then own some enlightened, pure reason devoid of any historical development, and are thereby free of categorical constraints or secular doctrine, i.e., a “sect”, if you will. All philosophy is a footnote to Aristotle (that is hyperbole, weing, so try not to take it too literally). When you deconstruct something, what fills the void? Nietzsche, interpretator of ancient writings, proposed the Ubermensch. Today, some seem to think there is pure science, that floats around untethered to philosophy, that can fill the void. I do not believe in such utopian smoke.

    “You mean they go to a homeopath or naturopath for an abortion, or the morning after pill? That’s interesting.”

    No, some people turn to woo because some doctor talked them into an abortion when they were 18 and scared. Regret builds (cloudskimmer–studies that actually follow the post-abortive women out for longer than 5 minutes after the abortion do show regret), so they won’t trust doctors and along comes happy homeo, with copious god-talk, and they take the bait.

    A few more references, all poor studies made up by crazy pro-lifers, I imagine:

    A. Kersting et. al., “Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth–a 14-month follow-up study,” Archives of Women’s Mental Health 12:193-201 (2009)

    Catherine Coyle, Priscilla Coleman and Vincent Rue, “Inadequate Preabortion Counseling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Men,” Traumatology XX(X): 1-15 (2010)

    P.S. Shah and J. Zao, “Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analysis,” BJOG 116(11): 1425-1442 (2009).

  50. Sanger died in 1966 she retired from running American Birth Control League (which eventually became Planned Parenthood) in 1940.

    I believe the policies of Planned Parenthood have been shaped by current ethics, events and politics in the last 70 years. This is the guilt by association that I was referring too.

    To say that Planned Parenthood is a eugenics organization because of Sanger is the same thing as saying that I shouldn’t buy a Ford because of Henry Ford eugenics beliefs or I shouldn’t buy a Toyota because of Pearl Harbor. Please. I’m pretty sure if you look at any organization that has history dating back 60-80 or more years you will be able to find some unsavory philosophy, behavior or association.

    Try the Boy Scouts of America.

  51. tcw – “No, some people turn to woo because some doctor talked them into an abortion when they were 18 and scared. Regret builds (cloudskimmer–studies that actually follow the post-abortive women out for longer than 5 minutes after the abortion do show regret), so they won’t trust doctors and along comes happy homeo, with copious god-talk, and they take the bait.”

    I’m sure this has happened. I have also heard from women who have chosen adoption that felt that they were manipulated into placing their child. I have heard from women who raised their children that felt like they were manipulated into being a mom and were not up to the task or suffered consequences.

    A choice is a choice. There is no guarantee of a happy outcome. The point is, it should be the choice of the women who’s body and health is affected. Not the choice of a doctor, political group, religious group. Any doctor (healthcare professional, social worker) who pressures a woman to make any of these choices is wrong in my book. A doctor’s job is to offer science-based health information regarding all the choices, not to make the choice.

  52. weing says:

    “A few more references, all poor studies made up by crazy pro-lifers, I imagine”

    I don’t know. Did you check them out? The New Zealand study you first mentioned is from Christchurch and I presume there is no conflict of interest? And even they admit that 90% of the women believed they made the right decision. Why does the German study not compare them with women who gave birth abnormal, unhealthy babies? Where do the authors of the second study work and how do they get paid? And a litigation attorney is definitely not trying to drum up business for himself? The Canadian study you cite is the only one that is interesting and merits further study in my opinion.

  53. Mark P says:

    I don’t believe for one second that abortion is as abhorent to some people as they claim. It is used as a hot button issue for evangelicals to “prove” they are more moral than the non-religious.

    Absolutely.

    My personal favourite is anti-abortionists who support the death penalty. I really cannot get my head around how they manage two such directly contradictory positions.

  54. Steve says:

    I would like to point out that religious based hospital do affect how things are practiced. As a NP I once worked in a free clinic, affilated with a catholic hospital, in RI. It treated an underserved population that had a high degree of prostitution related visits. Despite rampant STD issues, birth control or condoms were forbidden. After pursuing this issue I ran into the stone wall of the board of regents half of which were the catholic bishop and/or his representatives. I was unable to change department policy for supposed cost and other issues. I walked away from that employer in protest. To my knowledge they are still restricting care. Interestingly they at one time had a labor and delivery department which was restricted as well. I sent patients to another site that offered these services. However I know that many will never take the time to go to another site and probably this clinic directly fostered the spread of incurable infectious disease. Directly affecting public health. despite formal complaints to state Licensing boards nothing was done.
    even though I walked away I had zero impact on this insane practice.

  55. lamamaloca says:

    So you don’t believe that it would be ethical for a doctor who refuses to perform or refer for abortions to offer care to those women who would prefer a doctor who doesn’t perform or refer for abortions? I know many women like this, but then I live in a very conservative area.

    I will say that while I dislike the misinformation and manipulation of data that some organizations in the pro-life movement engage in, the pro-life individuals I know are very sincere, and many really do have a strong, visceral reaction to the notion of abortion.

  56. lamamaloca on ethical providers:
    “So you don’t believe that it would be ethical for a doctor who refuses to perform or refer for abortions to offer care to those women who would prefer a doctor who doesn’t perform or refer for abortions?”

    Only if it could be guaranteed that this doctor would never offer care to any woman not explicitly and viscerally choosing a doctor who refuses to acknowledge the existence of alternatives to carrying actual and potential pregnancies to term.

    For instance, this doctor must never offer care to those women who thought they opposed abortion (because only immoral women have them) until they themselves needed one (and realized that actually, ordinary women have them too).

    This doctor must never work in an ED.

    This doctor must never cover for a doctor who does offer the standard of care.

    Most people don’t choose their oncologists, say, on the basis of whether they are “abortionists.” But if I am pregnant and have cancer I need to be able to discuss all the options with my doctor before starting radiation or chemotherapy. An oncologist that ethically opposed to abortion would presumably advise me to meet with a special anti-choice ob/gyn of their own choosing (who also neither provides nor refers abortions) and would not tell me to talk to my own ob/gyn if they thought that my own ob/gyn might discuss all the options with me.

  57. clgood says:

    There is no set of data that says that “abortion is harmful to women”, so doctors who oppose abortion cannot claim that science supports their bias.

    Abortion is 100% fatal to the child, though. And I believe that science supports the argument that it is a human life being terminated, unless I completely misunderstand modern embryology. There is no change of species during pregnancy of which I am aware.

    Not everybody who is pro-life has religious reasons for being so. There is a rational, moral basis for opposing elective abortion.

  58. Calli Arcale says:

    First off, I think we need religious hospitals. Not because I like the idea, but because we need hospitals, period, and I do not see a good path to replacing all of the religious hospitals at this time. Also, not all of them allow religious doctrine to interfere, and I would not want to throw the babies out with the bathwater (so to speak). It’s not an easy problem to solve. I greatly prefer secular care — but the way healthcare is in America, the alternative in many cases will be *no* care.

    Not a good situation, but I see no immediate solution.

    Kristen:

    My friend’s mother experienced a fetal death when she was pregnant but did not miscarry. Her doctor wouldn’t do a D&C because that would be abortion, and she couldn’t get a D&C through her hospital either. When she became quite ill she opened the phone book and looked for doctors with english (french canadians are catholic) names, looking for a protestant or jewish doctor.

    Something similar happened with my mother-in-law’s second pregnancy. When she finally found a doctor willing to perform D&C, she was finally able to conceive my brother-in-law. Ironically, thus, the commitment to “life” was preventing her from producing a new life. (It is probably worth pointing out that this was in South Dakota, a traditionally anti-abortion state.)

    That wasn’t her first run-in with doctors driven by their own personal beliefs. When she was pregnant with my husband, she contracted hepatitis A. Her doctor wanted her to abort, and she wanted to give it the old college try instead. He would have none of it, saying that if she took her life in her own hands, that was her business, not his, and referred her to a Catholic hospital. There, she had the peculiar experience of nurse-nuns who were a) upset about her Protestant faith, and b) unwilling to treat her hepatitis lest the drugs harm the baby. (Never mind that some treatment would probably be better for the baby than none, as the baby wouldn’t do well if she actually died.) They would give her no medication for symptoms of any kind, lest it affect the baby, and they treated her only grudgingly. All she got was supportive care. It did turn out well in the end, fortunately.

    It’s a thorny ethical question. Doctors are expected to make difficult decisions in vast gray areas; how can we circumscribe their ability to do so based on arbitrary rules? (Laws are always arbitrary, and will inevitably be unjust for someone. That’s the whole point in allowing doctors discretion to make difficult decisions.) I think the way my mother-in-law was treated was absolutely wrong. Refusing to remove deceased fetuses on the basis of opposing abortion is insane; one might as well refuse to remove an inflamed appendix on the basis of denying divine authority over illness. But how can I circumscribe a doctor’s discretion to perform or not perform procedures? It’s not simple. I think it should be managed through the medical boards, as it is when a doctor arbitrarily refuses to treat ethnic minorities or people of certain religious backgrounds. Laws are blunt instruments; I fear their misuse. It feels very wrong for a doctor to refuse to remove a dead fetus. But what if the doctor is refusing on some other grounds? Some ectopic pregnancies are extremely dangerous to remove; if the woman has survived as long as she has, doctors might prefer to leave well enough alone. (Placentas are astonishingly invasive organs, and set themselves up with very strong blood supplies.) There’s also squeamishness; perhaps a doctor has limits in what he/she can do while maintaining a proper emotional distance, and if a doctor realizes that he/she is getting close to that danger zone, they need to discretion to be able to back off and let someone else handle it.

    I would fear a law that would require doctors to perform procedures that they are not comfortable performing, and I think that for me, that outweighs the benefit of letting women get abortions when needed. And I am generally pro-choice.

  59. mdiehl says:

    Tangential, but maybe of interest is the work of Brandeis University sociologist Wendy Cadge, see: http://www.brandeis.edu/departments/sociology/cadge.html

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