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How Inadequate Referral Procedures at Catholic Health Facilities Create Ethical Dilemmas for Providers and Obstruct Needed Patient Care

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University of Chicago
Research Consortium on Religious Healthcare Institutions
University of California-San Francisco

Reproductive services related to sterilization, contraception, abortion and fertility are a standard part of modern medical care, especially for women and girls. But what happens when religiously affiliated healthcare institutions set policies that obstruct such services when patients need them? The dilemma is well posed by a physician we interviewed who worked in a Catholic hospital some years ago: “Say you have…a 45-year-old who comes in [at three in the morning] with heavy bleeding and irregular periods. The most common approach to stopping her bleeding is to give her high-dose birth control pills for a short period of time. So that became very difficult…‘cause they [the hospital] didn’t have them in stock. I won’t say it’s impossible to get them, because like the head pharmacist knows where there’s three secret packs, and if you happen to manage to find the head pharmacist at [that hour], you can. But it’s nearly impossible to get birth control pills to treat heavy bleeding.”

Catholic hospitals control a growing share of health care in the United States, yet prohibit many routine reproductive services. According to professional ethics guidelines, clinicians who deny patients reproductive services for moral or religious reasons should promptly refer patients who might be harmed to other providers. Referral practices in Catholic hospitals, however, have not been well explored by researchers. Our research aims to help fill this gap. We interviewed twenty-seven religiously and geographically diverse obstetrician-gynecologists who were currently working or had worked in Catholic facilities to learn about their perspectives and experiences with referral practices at Catholic hospitals. We found that referral policies and practices are not standardized across Catholic hospitals. Although some kinds of referrals are allowed, others happen only clandestinely or are entirely discouraged by hospital administrators. In reproductive health services, contradictory – and sometimes secretive – referral practices create bureaucratic headaches for doctors at Catholic facilities and have the potential to subject patients to significant harm.

The Spectrum of Referral Practices at Catholic Hospitals

Obstetrician-gynecologists reported a range of practices and attitudes about referrals for services that Catholic facilities cannot themselves provide:

  • Some physicians reported that administrators and ethicists encouraged referrals. One respondent explained how a clergyman from a major metropolitan area, described as a Catholic Church consultant, came to a small Southern town to visit the respondent’s hospital and instructed obstetrician-gynecologists to refer patients out for tubal ligations and other prohibited services. “He came in and spoke to us about the Catholic ethic.… And one of the things he recommended was that if we have a situation where a patient needs something that can’t be provided by the Catholic institution, that we should refer them to…the place where they could get things taken care of…as quickly as possible.… I was really surprised.”
  • Other respondents recounted scenarios in which referrals, especially for services less politically contentious than abortion, were not actively encouraged but were passively tolerated at their Catholic hospitals. As one explained, “I don’t think we were really allowed to prescribe contraception under hospital auspices, but generally what we would do is just recommend that they go to the local family planning clinic.… And nobody seemed to care about that. I could just tell people whatever I wanted to. It was just you couldn’t write a prescription for birth control pills on a [hospital] prescription pad.” Another physician said he was unsure if hospital administrators approved contraceptive referrals. “We would tell [patients] just pretty directly that we could not provide contraception … and usually would refer them to Planned Parenthood or to the health department. I’m not sure [the hospital administration] knew.”
  • In other cases, hospital authorities actively discouraged referrals or physicians hid them. Generally, our research team was told that patients seeking abortions were given less support and referrals than those who needed other prohibited services. Respondents felt referrals were not always sufficient to meet the needs of low-income patients or those with urgent medical conditions. A physician related one instance in which a hospital-produced handout on referrals was seen as too informative. After the local bishop learned that tubal ligations and other prohibited services were being provided at the respondent’s hospital, the bishop decided to tighten enforcement on reproductive care. As the physician explained, “we used to hand out a form also that did list places in town they could get contraception through Planned Parenthood or the health department and things like that, and that actually also went away. They didn’t want us… even providing information to the patients.”

How Public Officials Can Make Sure Patient Needs are Met

Assuring access to the full spectrum of reproductive health care regardless of the religious affiliations of patients and providers is a necessity and a basic right. When Catholic hospitals cannot offer needed services or do not refer patients to other providers in a timely and open way, risks are created for women’s health and doctors subject to basic professional ethical obligations. Public authorities have fundamental responsibilities to prevent such risks. Public officials should monitor the spread of Catholic healthcare services in their communities and support efforts to inform all patients where they can obtain key reproductive services.

Locally accessible facilities are also crucial. Rather than working to defund family planning clinics that in many cases are the only alternative for patients seeking prohibited services, policymakers should ensure that such clinics are available to compensate for the unmet need of patients from Catholic healthcare facilities. As long as referral services at Catholic institutions are inconsistent or inadequate, Planned Parenthoods and other reproductive health providers will be called upon to make the full range of services available to all. Closing down such clinics would leave many people with no practical access at all to health services they need and have a right to obtain.

Read more in Debra B. Stulberg, Rebecca A. Jackson, and Lori R. Freedman, “Referrals for Services Prohibited In Catholic Health Care Facilities.” Perspectives on Sexual and Reproductive Health 48, no. 3 (2016).