The death of Savita Halappanavar in Ireland has created a tremendous amount of coverage. Whether or not this tragedy is the result of Catholic policies, it has reignited the debate about women’s health and reproductive care. In some of my reading, I came across a 2008 report in the American Journal of Public Health by Lori R. Freedman, Uta Landy, and Jody Steinauer entitled “When There’s a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals“.
Abstract As Catholic-owned hospitals merge with or take over other facilities, they impose restrictions on reproductive health services, including abortion and contraceptive services. Our interviews with US obstetrician–gynecologists working in Catholic-owned hospitals revealed that they are also restricted in managing miscarriages.
Catholic-owned hospital ethics committees denied approval of uterine evacuation while fetal heart tones were still present, forcing physicians to delay care or transport miscarrying patients to non–Catholic-owned facilities. Some physicians intentionally violated protocol because they felt patient safety was compromised.
Although Catholic doctrine officially deems abortion permissible to preserve the life of the woman, Catholic-owned hospital ethics committees differ in their interpretation of how much health risk constitutes a threat to a woman’s life and therefore how much risk must be present before they approve the intervention.
They report a selection of instances where these policies have caused or almost caused tragedies.
Dr P, from a midwestern, mid-sized city, said that at her Catholic-owned hospital, approval for termination of pregnancy was rare if a fetal heartbeat was present (even in “people who are bleeding, they’re all the way dilated, and they’re only 17 weeks”) unless “it looks like she’s going to die if we don’t do it.”
In another case, Dr H, from the same Catholic-owned hospital in the Midwest, sent her patient by ambulance 90 miles to the nearest institution where the patient could have an abortion because the ethics committee refused to approve her case.
She was very early, 14 weeks. She came in … and there was a hand sticking out of the cervix. Clearly the membranes had ruptured and she was trying to deliver… . There was a heart rate, and [we called] the ethics committee, and they [said], “Nope, can’t do anything.” So we had to send her to [the university hospital]… . You know, these things don’t happen that often, but from what I understand it, it’s pretty clear. Even if mom is very sick, you know, potentially life threatening, can’t do anything.
Dr H found that in some cases, transporting the patient to another hospital for dilation and curettage (D&C) was quicker and safer than waiting for the fetal heartbeat to stop while trying to stave off infection and excessive blood loss.
Dr B, an obstetrician–gynecologist working in an academic medical center, described how a Catholic-owned hospital in her western urban area asked her to accept a patient who was already septic. When she received the request, she recommended that the physician from the Catholic-owned hospital perform a uterine aspiration there and not further risk the health of the woman by delaying her care with the transport.
Because the fetus was still alive, they wouldn’t intervene. And she was hemorrhaging, and they called me and wanted to transport her, and I said, “It sounds like she’s unstable, and it sounds like you need to take care of her there.” And I was on a recorded line, I reported them as an EMTALA [Emergency Medical Treatment and Active Labor Act] violation. And the physician [said], “This isn’t something that we can take care of.” And I [said], “Well, if I don’t accept her, what are you going to do with her?” [He answered], “We’ll put her on a floor [i.e., admit her to a bed in the hospital instead of keeping her in the emergency room]; we’ll transfuse her as much as we can, and we’ll just wait till the fetus dies.”
Ultimately, Dr B chose to accept the patient to spare her unnecessary suffering and harm, but she saw this case as a form of “patient dumping,” because the patient was denied treatment and transported while unstable.
In the following case, the refusal of the hospital ethics committee to approve uterine evacuation not only caused significant harm to the patient but compelled a perinatologist, Dr S, now practicing in a nonsectarian academic medical center, to violate protocol and resign from his position in an urban northeastern Catholic-owned hospital.
I’ll never forget this; it was awful—I had one of my partners accept this patient at 19 weeks. The pregnancy was in the vagina. It was over… . And so he takes this patient and transferred her to [our] tertiary medical center, which I was just livid about, and, you know, “we’re going to save the pregnancy.” So of course, I’m on call when she gets septic, and she’s septic to the point that I’m pushing pressors on labor and delivery trying to keep her blood pressure up, and I have her on a cooling blanket because she’s 106 degrees. And I needed to get everything out. And so I put the ultrasound machine on and there was still a heartbeat, and [the ethics committee] wouldn’t let me because there was still a heartbeat. This woman is dying before our eyes. I went in to examine her, and I was able to find the umbilical cord through the membranes and just snapped the umbilical cord and so that I could put the ultrasound—“Oh look. No heartbeat. Let’s go.” She was so sick she was in the [intensive care unit] for about 10 days and very nearly died… . She was in DIC [disseminated intravascular coagulopathy]… . Her bleeding was so bad that the sclera, the white of her eyes, were red, filled with blood… . And I said, “I just can’t do this. I can’t put myself behind this. This is not worth it to me.” That’s why I left.
From Dr S’s perspective, the chances for fetal life were nonexistent given the septic maternal environment. For the ethics committee, however, the present yet waning fetal heart tones were evidence of fetal life that precluded intervention. Rather than struggle longer to convince his committee to make an exception and grant approval for termination of pregnancy, Dr S chose to covertly sever the patient’s umbilical cord so that the fetal heartbeat would cease and evacuation of the uterus could “legitimately” proceed.
Dr G also circumvented the ethics committee in her southern Catholic-owned hospital. She opted not to check fetal heart tones or seek ethics committee approval when caring for a miscarrying woman for fear that documentation of fetal heart tones would have caused unnecessary delays. This led to conflict with the nurse assisting her.
She was 14 weeks and the membranes were literally out of the cervix and hanging in the vagina. And so with her I could just take care of it in the [emergency room] but her cervix wasn’t open enough … so we went to the operating room and the nurse kept asking me, “Was there heart tones, was there heart tones?” I said “I don’t know. I don’t know.” Which I kind of knew there would be. But she said, “Well, did you check?” … I said, “I don’t need an ultrasound to tell me that it’s inevitable … you can just put, ‘The heart tones weren’t documented,’ and then they can interpret that however they want to interpret that.” … I said, “Throw it back at me … I’m not going to order an ultrasound. It’s silly.” Because then that’s the thing; it would have muddied the water in this case.
Dr G’s main concern was sparing the patient extended suffering during loss of pregnancy. She disregarded the authority and protocol of the hospital ethics committee by not checking for fetal heart tones, which, she believed, would have led to significant delay in the inevitable treatment.
Dr J, an obstetrician–gynecologist working in a small town in the West, had success navigating his ethics committee by presenting patients to them in the language of the directives themselves. A nun advised him that terminology such as “inevitable abortion” and “maternal complications” should be highlighted.
I [received] a good bit of advice actually … from the sister that sits on the ethics committee the first time I tried to have one of these conversations with her. She said, “Well, what are you concerned about with the mom?” … [T]hat’s just the way that the conversation gets started… . I don’t know if she was trying to give me a hint or whether she was … just interested in doing what she really considers to be the right thing, the moral thing … but it certainly helped me out.
Dr J described how he applied this advice in another case. The patient, at 20 weeks, was dilated with a placental abruption and fetal heart tones present, and she preferred to expedite uterine evacuation. He presented her case to the ethics committee in this fashion: “If we continue to watch this placental abruption, it could end up being dangerous, [leading to] transfusions or potentially even maternal death, if left untreated.” This was the only case of approval by a Catholic-owned institution’s ethics committee for urgent uterine evacuation with fetal heart tones present that was mentioned in the interviews.
As part of the conclusion, they state:
Physicians working in Catholic-owned hospitals in all 4 US regions of our study disclosed experiences of being barred from completing emergency uterine evacuation while fetal heart tones were present, even when medically indicated. As a result, they had to delay care or transfer patients to non–Catholic-owned facilities.
Another instance of Catholic policies impairing appropriate care care was published in
JAMA in 2007. Entitled, A Question of Faith, it describes how a woman carrying twins was almost certain to miscarry with the potential of severe complications was transferred while in distress to another hospital where the procedure could be carried out.
Much of health care, including hospitals, is privately owned in the US. This has resulted in the Catholic Church providing over 15% of all health care in the US, limiting the ability for physicians to provide the most appropriate care for their patients.
Last week, the Catholic Church reiterated its objection to abortion.
The president of the Pontifical Council for Health Care, Archbishop Zygmunt Zimowski, said the Nov. 15-17 gathering in Rome will discuss “the serious challenge of preserving the identity of Catholic hospitals.”
He criticized the “political pressure” levied against Catholic hospitals in some countries to force them to provide abortions in violation of Church teaching.
Of course, in their minds, women wouldn’t request abortions if they weren’t manipulated into having them.
“If the head obstetrician is not pro-life and family care is not offered, either abortions are performed there or patients are referred to other places to obtain them,” he said.
“This is terrible, but it happens. I think mothers should always be given the best care, so that nobody manipulates them into abortion.”
With approximately 120,000 health institutions worldwide, the Catholic Church has a huge impact on the availability of health care for women. Although the official Catholic position is that abortion may be performed to save the live of the mother, in actual practice, the result is often either delayed or improper care for women. As long as the church holds so much political power in many countries around the world, this problem is unlikely to be addressed at government levels unless a large portion of the population stands up and pushed changes to legislation and health care standards.
Access to abortion services is a critical part of women’s health care, and religion has no place insinuating itself between a women and her doctor.