An excerpt from The Catholic Church and Its Hospitals: A Marriage Made in Heaven?

The ability of Catholic hospitals and physicians to withhold some medically accepted care from patients based on their own religious and moral beliefs is made possible by numerous protections of religious freedoms. However, patients look to their physicians as trusted partners in their care who will act solely in their best interest and include them in care decisions. These two realities come into conflict at both the individual and societal levels, and therefore, deserve discussion. This chapter examines:

• The training of future physicians in Catholic health care.
• The responsibilities of physicians to their patients as dictated by their professional oaths.
• The intersection of these responsibilities with Catholic institutions’ mandate that physicians follow the ERDs.
• The breadth of the legal protection for Catholic hospitals and their physicians in the exercise of their religious beliefs.

Impact on physicians

Trainees

Patient care within the U.S. health system is directed by licensed professionals — frequently physicians. Often, they oversee and contribute to the training of medical students and physicians in their post-graduate years as interns, residents, and fellows. This training occurs in a hospital setting, including Catholic hospitals.

Two hundred eighty-one of the 550 Catholic hospitals are minor teaching hospitals and 14 are major teaching hospitals. These institutions assume responsibility for providing all the post-graduate training needed for a person to be a competent physician. However, in Catholic hospitals, trainees are not exposed to any of the services prohibited by the ERDs, nor do they engage in shared decision-making with their patients for these services. They may face moral dilemmas in withholding certain types of care. To obtain the required experience, trainees are often sent to other institutions for some periods of time.

Physicians

There is a belief that goes back to ancient times that physicians have unique responsibilities in relation to the care of patients. Since Hippocrates in the 5th century BCE, physicians have been expected to take an oath professing their responsibilities to the patients they serve.

Yet, the ERDs require physicians to follow the ERDs …

“So,” one must ask, “how does the Catholic institutional employment requirement to adhere to the ERDs intersect with the physician’s professed oath and the physician’s own conscience?” “What ethical principle would allow an employment contract to supersede a physician’s oath and her/his own conscience?” “How does the sacred covenant of physician with a patient, which is a mutual commitment, become a one-way transactional relationship?”

These dilemmas would be particularly likely among the obstetricians who feel that prohibitions on specific treatment negatively impact their autonomy and patient care.

An example of this dilemma is described by a physician who was prohibited from performing a tubal ligation at the time of a patient’s cesarean section, requiring the patient to have an additional procedure:

… [I]f you’re doing a c-section on somebody that wants a tubal and has had six other previous c-sections and… if I tie her tubes I’m going to get kicked off the staff. And I just don’t think that’s right but … instead of benefiting my patients, I benefit myself and don’t do the tubal and stay on staff. So that’s difficult sometimes.

How did we get from physicians’ primary responsibility being to the patient, to their right to exercise their own conscious, to religious institutions dictating the bounds of the doctor-patient relationship and the provision of care? The journey was much less about a debate within the profession or a debate by ethicists, and much more about the actions by politicians, lawyers, and judges.

Conclusion

The ERDs can create moral dilemmas for the physicians who practice in Catholic hospitals and other health care facilities, with tension between their professional oaths, their own conscience, and their employment contracts. One could, and should, ask how one religion can dictate the health care of so many others who do not share those beliefs. Ironically, this has been enabled by the First Amendment of the Constitution and subsequent laws, regulations, and judicial rulings that uphold the freedom to exercise religious beliefs, as individuals and as institutions, while impacting the freedom of others in something as basic as their health and life.

The intersection of this freedom with the First Amendment’s prohibition of government-sanctioned religion will continue to be examined, not only as it relates to Catholic health care and its prohibitions, but also regarding states’ laws that impact the provision of health care. Where the boundary lies between these two pillars of freedom does and will continue to profoundly affect the delivery of health care in America, impacting the health of many millions of Americans, especially those with limited choice of a provider. As Americans we must continue to discuss and examine this boundary.

Patricia A. Gabow is a nephrologist and author of The Catholic Church and Its Hospitals: A Marriage Made in Heaven?