It was my first interview of the season, and I was interviewing for Obstetrics & Gynecology residency at a university-affiliated Catholic hospital. Because Catholic institutions do not allow abortion, patients are generally referred to other clinics and hospitals for termination needs. As the daughter of a religion scholar and professor, I was already very familiar with the stance of the Catholic Church on reproductive health care and thought I was prepared for the implications. What I learned during this interview day, though, was shocking.
The residents in the program noted that there was a woman with an ectopic pregnancy currently hospitalized, and she was at twenty weeks gestation. Ectopic pregnancies are pregnancies that have spontaneously implanted outside the uterus, most often in the fallopian tubes or elsewhere in the abdomen. These pregnancies are nonviable. Ectopic pregnancies are ended (via medication or surgery) as soon as possible to preserve the life of the patient. The ectopic structure that contains the developing fetus generally ruptures at approximately six to sixteen weeks gestation (long before viability); at the time of rupture, blood loss is severe and often life-threatening. The later gestational age of rupture, the greater risk of death. Allowing an ectopic pregnancy to progress to twenty weeks gestation is extremely dangerous for the patient and ethically questionable on the part of the institution.
Unfortunately, this situation is not unique to that particular hospital and raises serious concerns about threats to public health when private belief systems dictate health care access and medical decision-making in reproductive care. It is true that some patients choose to receive care at a religious-affiliated healthcare institution, and in the case I described, the patient did have geographic access to other hospitals that would terminate her ectopic pregnancy. However, in emergency situations, patients may be transported to the closest available hospital. In other cases, patients may not have the option to choose their medical provider because there are regions within the United States where Catholic hospitals are the only geographic option or the only “in-network” option covered by an individual’s insurance policy.
As of March 2016, 14.5% [PDF] of all acute care hospitals in the United States adhered to Catholic Directives [PDF], and one in six hospital beds in this country are in an institution that abides by Catholic restrictions to reproductive healthcare. There are 46 [PDF] Catholic hospitals designated by the United States federal government as the “sole community hospital” for their geographic region. For other patients, their health insurance plan may include only one local hospital, and if that hospital is Catholic, patients are then faced with accepting the institution’s religious restrictions to healthcare or paying out-of-pocket for healthcare needs at a different hospital. Such financial decisions may further increase the socioeconomic and healthcare equity gap in this country. More importantly, restrictions on health care access can be life-threatening to patients, as in the example described above and as detailed in this report by the American Civil Liberties Union [PDF].
An additional cause for concern is the recent development of the United States Department of Health and Human Services Division of Conscience and Religious Freedom, which aims to protect physicians, nurses, and other healthcare workers from engaging in care that is not in line with their religious beliefs. For patients who only have access to a religious-affiliated hospital or clinic, there are legitimate concerns that these protections might further compromise their access to reproductive healthcare. The guiding principles of bioethics include autonomy, beneficence, utility, and justice. With these principles in mind, we must carefully navigate how private religious organizations can operate within the healthcare field in this country. How do we balance the competing interests of providers who have ethical and/or religious objections to specific medical care with the rights of patients who seek reproductive healthcare? I’ll explore these issues further in a future policy analysis post. Stay tuned.