Doctors vs. Doctrine: Where Does Religion End and Medicine Begin?

Thanks to the debate over the "contraceptive mandate" in the Affordable Care Act, which requires health insurance policies to cover prescription birth control at no cost, it's not a secret that many Catholic institutions and employers object to providing contraceptives. A key point of their "conscience" objection to providing contraceptives is that they aren't medically necessary and are easily available elsewhere.

But what about types of reproductive health care where that isn't the case? What if a service to which the Catholic Church objects is necessarily for a woman's health and well-being and she can't easily get it elsewhere? In that case, where does the right of conscience leave off and the responsibility of Catholic institutions to provide women with medically appropriate care begin?

As I recently reported in The Atlantic, a new study of doctors working at Catholic hospitals finds that they have serious concerns about the denial of medically indicated contraceptive sterilization to women who are already having C-sections. Catholic hospitals technically aren't allowed to provide tubal ligations--which is the technical term for tube-tying--under the rules that govern Catholic hospitals. But it's been common practice for many hospitals to provide the procedure if a woman's health would be threatened by another pregnancy and she is already having a C-section. That's because it's not in the woman's best interests medically speaking to put her through another surgery at a later date when the sterilization can easily be done at the same time as the C-section.

The doctors interviewed say the denial of medically indicated sterilizations put women at "a risk of harm" and violates the standard of care. "[If] someone who's had four C-sections before has to have another operation to get her tubes tied, that's not what's in her best interest by any stretch of the imagination," said one doctor who was interviewed for the study.

But more and more Catholic hospitals seem to be putting a stop to the practice. As Nina Martin reported for ProPublica, the U.S. Catholic bishops appear to be cracking down on even medically indicated contraceptive sterilization. Genesys Health System, a Catholic hospital in Michigan, recently suspended the procedure, stranding at least one woman who was scheduled to have her tubes tied following a scheduled C-section.

Doctors in the study agreed. Whether the local bishop cracked down or their formerly secular hospital was sold to a Catholic system, doctors said they could no longer perform medically indicated tubals. "Two months ago having a tubal ligation wasn't a bioethical issue; it was a decision a patient made after consultation with the physician and it got carried out safely and that was what it was. The hospital was sold and all of a sudden this procedure becomes a bioethical issue," said one doctor.

Catholic hospitals say it's a matter of protecting their conscience to allow them to refuse to provide contraceptive sterilization because Catholic doctrine considers it nearly as big a sin as abortion. In 1974, following a series of court victories in which the ACLU successfully sued several Catholic hospitals in the Pacific Northwest that received public funding to allow doctors to perform tubal ligations, the hospitals threatened to stop providing all maternity care in the region if they weren't given the right to refuse tubals. When Congress considered the federal Church amendment to create a conscience right to protect individuals or hospitals from being forced to perform abortions shortly after the Roe v. Wade decision, the right to deny contraceptive sterilization was included at the behest of Catholic hospitals with little debate about the public health impact.

At the time, contraceptive sterilization wasn't a particularly popular form of birth control. But today, it's the second most common form of birth control. And while there are new outpatient options like Essure, there have been questions about its effectiveness and side effects. For many women, nothing beats the convenience and reliability of having their tubes tied in the hospital immediately following childbirth. In fact, inpatient tubal ligation is such a popular procedure that one in ten childbirths ends with one. Women who can't get a tubal in the hospital have to wait at least six weeks--and juggle caring for a newborn--before they can have the procedure done.

Because the rules that govern Catholic hospitals are created by the U.S. Conference of Catholic Bishops under the direction of the Vatican, there's more than a whiff of medieval barbarism about the idea that a woman who isn't even Catholic would be subject to an unnecessary second surgery--or an additional, unwanted pregnancy--at the behest of some 300 celibate prelates who answer to Rome. Some of the doctors in the study even noted that older doctors used to perform total hysterectomies on women who didn't need them in lieu of tubal ligations, and, as one doctor noted, "a cesarean hysterectomy is a pretty dangerous operation."

Today one in six patients in the U.S. is cared for in a Catholic hospital. And thanks to a series of mergers, the number of Catholic hospitals increased 16 percent between 2001 and 2011. And women don't always have a choice of what hospital they go to. Many OB/GYNs only have admitting privileges at one hospital. Insurance companies increasingly are limiting patients' choice of hospitals. In rural areas, there is often only one hospital. That means more and more women are at risk of having what medical care they get--and their reproductive futures--decided by bishops, not by their doctors.