The HHS mandate for contraceptive and abortifacient coverage in all health insurance plans has caused a flurry of activity among Catholics and others concerned about religious liberty. But current practices in some Catholic hospitals – notably contraceptive sterilizations – could put the political efforts of concerned individuals and groups in no little jeopardy.
Contraceptive sterilizations, more technically labeled direct sterilizations in the Ethical and Religious Directives (ERD) of the U.S. Conference of Catholic Bishops, are elective medical procedures that violate human dignity and Catholic moral teaching.
Rumors of these procedures at Catholic hospitals prompted an anonymous investigation of public health data from Texas in 2008. In July of that year, Our Sunday Visitor carried a four-page report on direct sterilizations at Texas Catholic hospitals and on the national problem of violations of the ERD.
The 2008 data also showed that there were some Catholic hospitals that provided no sterilizations. It also led one bishop, Alvaro Corrada of Tyler, immediately to address the issue at two offending hospitals and to bring an end to the problem in his diocese. The hospitals involved did not dispute the basic accuracy of the research data.
As a doctoral candidate with a background in public health and theology, I decided to quantify the level of compliance with the ERD on a national scale and to analyze the legal and political consequences violations might have on conscience-clause protections.
My study involved obtaining hospital inpatient data from the departments of health of seven states dispersed geographically (CA, IL, IN, NJ, NY, TX, WA), abstracting records for Catholic hospitals from over 47 million patient records, and comparing sterilization practices at the hospitals from 2007 to 2009.
For the institutions I studied, 48 percent of the 176 Catholic hospitals with obstetric services performed direct sterilizations in clear violation of the ERD. The findings were independently reviewed by the Computer Science Department of Baylor University. Interactive data tables and the dissertation itself are viewable here.
Clinically, the medical code used in the research (ICD-9-CM diagnostic code V25.2) explicitly calls for sterilization for the purposes of contraceptive management. The procedure treats no existing pathology (a future pregnancy is not a present pathology).
In Catholic moral teaching and in the ERD, a V25.2 sterilization is therefore always a direct sterilization and, as such, is forbidden. This prohibition includes those V25.2 sterilizations, popularly called “medically indicated,” done to prevent a future pregnancy that may risk the life of the mother and/or child.
Procedures permitted by the ERD for an existing pathology that result indirectly in sterilization would be coded with diagnostic and procedure codes related to the particular pathology rather than use V25.2 and its associated procedures. However, the offending hospitals in the study were reporting diagnostic and procedural codes for direct sterilizations. At the same time, the hospitals profess to have acted in accord with the ERD.
How are we to understand this claim of fidelity to the ERD in the face of the unambiguous clinical data showing direct sterilizations? The Holy See has for forty years repeatedly sought to put an end to aberrant moral theories, such as proportionalism, which falsely label as “indirect sterilizations” procedures the Church has always considered to be direct sterilizations.
Dr. John Haas of the National Catholic Bioethics Center and others have argued that despite the efforts of the Vatican many hospital ethics boards continue to provide direct sterilizations by labeling them indirect. Ann Carey’s article, “Shocking lack of understanding,” discusses the widespread “confusion” at the hospitals. Some moralists may label the V25.2 sterilizations indirect, but certainly many in authority at the hospitals have enough Catholic training to know these are direct.
Their knowledge explains their careful use of terms in defending themselves against accusations. Across the country, the same stock phrase is employed “we follow the ERD” without any description of the procedures involved or an unequivocal statement that “we don’t do tubal ligations.”
A major difficulty in achieving a uniform application of the ERD is, unfortunately, that the directives make no reference to clinical diagnostic and procedure codes and do not mandate transparent reporting or oversight of a hospital’s actual policies and practices. Nor does the ERD mandate reporting violations within the hospital settings.
The result is that subjective judgments of hospital personnel and ethics committees can readily prevail over the objective clinical situation and the teaching of the Church. Best practices for oversight, such as used in the protection of minors, could be included in future editions of the ERD. Important elements of best practices would include an independent review board, mandatory reporting of violations, objective clinical criteria for defining violations, and authoritative presentations to doctors and staff regarding the requirements of the norms.
Current practice is perilous not only to those sterilized in Catholic hospitals, but poses juridical and legal risks to all Catholic personnel and facilities. Individual Catholics or hospitals objecting to these procedures could find themselves isolated and more easily compelled by the courts or legislation to provide direct sterilizations.
The lack of agreement among the Catholic hospitals also undermines any cohesive defense of religious liberty in this matter by the bishops and the hospitals. Uniform application of the ERD at every Catholic hospital is therefore crucial to the protection of the conscience rights of every Catholic medical professional and of all Catholic health care facilities.
