Most Catholic hospitals don't disclose religious care restrictions

A large majority of U.S. Catholic hospitals do not disclose on their websites that they have religious policies limiting the types of reproductive and end-of-life services offered at their facilities and by their affiliated physicians, a new study found.

Only 28% of 646 Catholic hospitals listed in the Catholic Health Association's directory specified how their religious affiliation might influence patient care, according to a new research letter in the Journal of the American Medical Association.

Twenty one percent did not explicitly disclose their Catholic identity, according to the researchers' analysis of websites conducted from July 2017 to January 2018.

The study authors said greater transparency about religious affiliation and care restrictions would enhance the ability of patients to make informed choices.

Catholic hospitals operate under the Ethical and Religious Directives published by the U.S. Conference of Catholic Bishops and updated last June. They prohibit procedures that are "intrinsically immoral," including abortion, contraception, physician-assisted suicide and what the bishops call "direct sterilization."

Direct sterilization has been taken to mean tubal ligation, vasectomy and ending pregnancies when a fetus is no longer viable after a woman's water breaks early in her pregnancy.

The religious policies also have created uncertainties about whether feeding tubes or ventilators can be removed for terminally ill patients, even if patients have an advance directive requesting such removal. In addition, there is disagreement about whether Catholic rules allow providers to offer gender reassignment-related care.

These care limitations have raised growing concerns as Catholic health systems extend their reach nationally through mergers and acquisitions, including with non-Catholic providers. One sixth of hospital patients now receive treatment in a Catholic facility, according to the Catholic Hospital Association. In some markets, Catholic hospitals, nursing homes and hospices are the sole or dominant providers.

Previous research has found that many patients don't realize that a hospital is Catholic or that such facilities have religious restrictions on care.

Arthur Caplan, a professor of bioethics at the NYU School of Medicine, said there's no ethical justification for Catholic facilities not to disclose their policies that may limit the types of care they provide.

"Patient autonomy absolutely requires being told of any limits, differences, or variations from what a patient might expect to receive in terms of care in a secular hospital," he said. "It's a key part of informed consent. It should be on the website, in handouts and it should be part of the admissions process for nursing homes and hospices."

The Catholic Health Association's senior director of ethics, Rev. Charles Bouchard, said Catholic hospitals "aren't deliberately trying to hide anything" and that he "would encourage them to be open about our mission and commitment" by mentioning the Ethical and Religious Directives on their websites.

But he added that the ERDs are technical and wouldn't be helpful to many patients. In addition, there are individual situations where a Catholic provider might provide a tubal ligation, for instance if a woman had cancer.

"You can't make treatment decisions by looking at a website," he said.

Among the 646 hospital websites analyzed, the JAMA researchers found that 24% cited the Ethical and Religious Directives, and 15% provided a direct link.

Among the 494 hospitals that did not cite the directives, 20 mentioned end-of-life care restrictions, while eight others mentioned both end-of-life and reproductive care restrictions.

Modern contraception methods like copper IUDs are among the services patients often are denied by Catholic facilities, said Dr. Maryam Guiahi, an associate professor of obstetrics and gynecology at the University of Colorado School of Medicine and a co-author of the study. She formerly practiced in a Catholic hospital.

"Because of the lack of upfront information about care restrictions, it takes a savvy patient to figure it out," she said. "What really happens most of the time is patients spend time and money going to an appointment, then are told they can't get the most effective method of contraception. Or women come in for a delivery and are shocked to find they can't get a tubal ligation."

Washington is the only state that requires hospitals and health systems to publish their policies on reproductive and end-of-life care on their websites. But the New York Times reported last year that even in that state, only six of 20 Catholic hospitals listed their religious policies in an easily accessible place.

Guiahi said her experience is that Catholic healthcare administrators prefer not to fully disclose the religious care restrictions because they don't want to lose patients to non-Catholic facilities.

Caplan agreed but argued that's no justification for lack of transparency. "They should stop thinking that and start thinking about putting patients first," he said.