It used to be Americans viewed Catholic hospitals and healthcare systems with universal respect and trust. They had no reason to do otherwise.

St. Charles Medical Center of Bend, Oregon (Amy Meredith / Flickr)

Founded in the nineteenth century by orders of nuns with a mission to care for the poor, Catholic hospitals grew and thrived in modern industrial medicine. Many became conglomerates and dominant sources of healthcare in cities and towns throughout the nation, especially in the Western United States. The trade association founded in 1915, the Catholic Health Association today represents 1200 Catholic health care sponsors, systems, facilities, and related organizations and services. Catholics and non-Catholics alike have considered Catholic Healthcare an unqualified good, delivering high quality medicine and serving their communities’ needs. It made little difference to most people whether their hospital was Jewish, Seventh Day Adventist, Episcopal or secular. Indeed, the image of selfless nuns running charitable institutions probably bestowed a brand advantage on the Catholic entities.

This is no longer the case.

A conservative theology and obsession with obedience have ruined the brand. Nowadays the phrase “Catholic hospital” is as likely to conjure images of unyielding bishops enforcing dogma on the irreligious as kindly nuns delivering succor to the suffering. Today most people realize that very few nuns actually run or work in Catholic hospitals. Knowledgeable people also know Catholic hospitals deliver no more charity care than their secular nonprofit counterparts.

Change came gradually, but high-profile power plays by the bishops recently pushed the brand onto a steep downward slide.

Activist Bishops

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Over and over we see the U.S. Conference of Catholic Bishops confuse the right to exercise their religion with a right to impose their religion on Americans who don’t share it. This is not a subtle difference.

And, as Bill Moyers points out in the context of their intransigence on access to birth control, the bishops aren’t content with an exception from the rule that, like other employers, they provide birth control coverage to workers in their hospitals and universities. They also want to be able to keep their employees from obtaining birth control pills from a third-party insurer, at no cost to themselves.

This stance grossly abuses the rights and privileges of American business owners. Let’s face it: Hospitals are money-making operations, dominant in the economy and relying in great measure on government Medicare contracts and employer-based health plans. To allow one very large employer to dictate private healthcare decisions of its employees would distort the American ideal of freedom of religion into a very un-American practice of religious tyranny. The bishops want to control everyone’s moral decisions, Catholics and non-Catholics alike.

In the context of end-of-life choice, the bishops enforce Ethical and Religious Directives for Catholic Healthcare. This document instructs doctors to ignore advance directives that conflict with Catholic moral teaching (ERD #24), requires patients in permanent vegetative states to overcome a presumption in favor of indefinite tube feeding (ERD #58), disallows as “euthanasia” a patient’s refusal of treatment such as kidney dialysis if intended to advance the time of death (ERD’s #59 and 60), and urges employees to offer religious teaching on the redemptive power of suffering when standard comfort care fails (ERD #61).

With regard to Oregon and Washington’s Death with Dignity Acts, the bishops use the machinery of Catholic healthcare to withhold information and support for aid in dying, a legal end-of-life choice. Catholic hospitals, hospices and healthcare systems in those states often impose a draconian gag rule on their employees to deprive patients in their care of comprehensive knowledge of end-of-life choices. As noted by The Seattle Times, the Sisters of Providence healthcare system imposed policy that employees can’t discuss the issue with patients, even if asked. In response, Steven Saxe, director of the state’s Office of Health Professions and Facilities, reassured healthcare workers that all healthcare providers, including those at Providence, have a “protected right to offer basic information” about the law to patients.

An oppressive gag rule not only violates a cardinal rule of informed consent in healthcare, it also tramples the free speech rights and professional ethics of hospital employees and physician contractors.

As with contraception, a free society must find the middle ground. Catholic Bishops must be free to exercise their religion, yet we cannot allow them to deny that same freedom to the rest of us.

Since November, when the United States Council of Catholic Bishops (USCCB) voted to change the Ethical and Religious Directives for Catholic Health Care, I have written frequently how the new policy could result in continued tube feeding for thousands of unconscious and severely demented patients in Catholic hospitals and nursing homes. Newly released research highlights the problem.

Representatives for Catholic hospitals downplay it. Sister Carol Keehan, executive director of the Catholic Health Association, said she doesn’t see much conflict between patients’ and families’ end-of-life wishes and the new directive. "Advance directives are held in great respect in Catholic hospitals," she said in a recent interview. "Some might like to say there’s a terrible problem, but there isn’t."

Catholic hospitals have attracted unwanted attention over this change in policy, and they assert the attention is unwarranted, because mentally compromised patients are in nursing homes, not hospitals. Alan Sanders, director for the Center for Ethics at St. Joseph’s Hospital in Atlanta, says that as an acute care facility, St. Joseph’s is unlikely to encounter a decision to remove a feeding tube from a patient in a persistent vegetative state.

Well, not exactly. Recent evidence indicates hospitals, not nursing homes, are the usual site of decisions to insert feeding tubes. A 2003 study reported more than one-third of nursing home residents with advanced dementia have a feeding tube, and a new study shows whether they get one depends much on the hospital they’re admitted to. The Providence Journal reports,

Dr. Joan M. Teno, the chief author of the study, said the results show that it’s not the wishes of the patients that are driving these decisions. "It really is the hospital culture that is determining this…. This doesn’t look like a process that is respecting patient choice."

Hospitals vary widely in their incidence of feeding tube insertion. Even hospitals in the same community can differ greatly in how often they place a feeding tube in demented patients. In spite of evidence proving the tubes increase suffering and do not prolong life, some hospitals have even increased their utilization in recent years.

The survey of more than a quarter-million hospital admissions from 2000 to 2007 showed that during the last two years of the survey, Roger Williams Medical Center and Kent Hospital stopped using the tubes.

Nationally, 12 percent of the hospitals fell into the same category.

But at St. Joseph Health Services of Rhode Island, which runs St. Joseph Hospital and Our Lady of Fatima Hospital, use of the feeding tubes actually increased during the last two years of study – 7.7 percent of patients got them, up from 6.9 percent during the broader period of 2000 to 2007.

That’s more than the national rate of 6.2 percent in 2007, an average that has been declining since 2000.

Teno said that within the past year, U.S. bishops decreed that feeding tubes must be given for all patients – Catholic and non-Catholic – who have lost the ability to eat or drink, unless they are actually close to death.

That philosophy, "I think, partially explains the results with St. Joe’s, being a Catholic health-care system," said Teno.

The study illuminates other factors influencing feeding tube insertion.

For-profit hospitals and larger hospitals were more likely to use the tubes, Teno and her colleagues found. Black and Hispanic patients were nearly twice as likely to get them as whites.

Teno said she is concerned that Catholic hospitals may be trying to override the wishes of patients when they insist on feeding tubes.

Advance care planning, the study says, also has an important role in reduction of potentially unnecessary procedures. Although it’s not fool-proof (590 patients were given feeding tubes despite written orders to forgo artificial hydration and nutrition!) patients with a living will and durable power of attorney for health care were far less likely to have tubes inserted.

Once again, our advice proves sound: prepare an advance directive, talk to your doctor, talk to your loved ones. Because you can’t be sure whether the policies of a for-profit hospital, or a Catholic one, might impose an unwanted feeding tube, consider adding this Sectarian Health Care Directive addendum. And help Compassion & Choices set enforceability standards for advance directives. We want feeding tube decisions to follow your wishes, not institutional policies of profit or doctrine.

Compassion & Choices, the nation’s largest and oldest nonprofit organization working to improve care and expand choice at the end of life, today marked National Healthcare Decisions Day, releasing new language every American may consider to strengthen their advance directive. The new addendum, My Directive Regarding Healthcare Institutions Refusing to Honor my Healthcare Choices, is designed to protect patients in the event that they are an inpatient in an institution that will not honor their advance directive due to religious, moral or ethics policies. Individuals might find themselves in such an institution due to an unplanned emergency or because circumstances provide them no other choice.

The addendum addresses potential problems arising from the United States Council of Catholic Bishops’ instructions to Catholic providers to disregard healthcare choices that conflict with Catholic moral teaching. Most recently, the Bishops instructed 624 Roman Catholic-affiliated hospitals, 499 nursing homes and 48 Catholic Health Maintenance Organizations that artificial feeding of permanently unconscious patients is almost always morally obligatory, regardless of advance directive instructions or family wishes.
Adding the language in this addendum:

• clarifies admission to a religiously-affiliated facility does not imply consent to particular care mandated by the institution’s religious policies, and
• directs a transfer if the facility declines to follow the wishes outlined in an advance directive.

This addendum is available now on the end-of-life planning page of Compassion & Choices’ website: http://www.compassionandchoices.org/g2g

The right to make health care decisions is hollow unless those decisions actually determine the care received. National Healthcare Decisions Day is intended “to encourage patients to express their wishes regarding healthcare, and providers and facilities to respect those wishes, whatever they may be.” It is troubling to think that over 20% of America’s health care providers operate under ethical and religious policies that may prevent them from honoring the wishes expressed in advance directives. I suggest that people making an advance directive consider including this addendum, because you just cannot know whether a religiously-affiliated institution will carry out specific end-of-life choices.

The addendum, developed in consultation with experts in hospice and palliative care and elderlaw attorneys, is as follows:

My Directive Regarding Healthcare Institutions Refusing to Honor my Healthcare Choices

I understand that circumstances beyond my control may cause me to be admitted to a healthcare institution whose policy is to decline to follow Advance Directive instructions that conflict with certain religious or moral teaching.

If I am an inpatient in such a religious-affiliated healthcare institution when this Advance Directive comes into effect, I direct that my consent to admission shall not constitute implied consent to procedures or courses of treatment mandated by ethical, religious or other policies of the institution, if those procedures or courses of treatment conflict with this Advance Directive.

Furthermore, I direct that if the healthcare institution in which I am a patient declines to follow my wishes as set out in this Advance Directive, I am to be transferred in a timely manner to a hospital, nursing home, or other institution which will agree to honor the instructions set forth in this Advance Directive.

I hereby incorporate this provision into my durable power of attorney for health care, living will, and any other previously executed advance directive for health care decisions.

On National Healthcare Decisions Day I encourage Americans – of all ages – to talk with their doctor and loved ones and document their wishes in an advance directive. People may also want to strengthen their advance directive by addressing the unknown question of whether a religiously-affiliated institution will honor those wishes.

For more information about end-of-life planning, visit Compassion & Choices Good to Go resource page: http://www.compassionandchoices.org/g2g.

I have written how recent changes to Ethical and Religious Directive (ERD) Number 58 compel Catholic hospitals and nursing homes to either disregard your end-of-life choices or violate the letter of the Directive.

The powerful Catholic Health Association says Compassion & Choices and I are exaggerating; the change is insignificant.

To bolster its claim of “no change” CHA points to another Directive, Number 59, that the free and informed judgment of patients should always be respected. What CHA fails to note is the condition at the end of that sentence, “unless contrary to Catholic moral teaching.”

But, one might ask, what exactly does that mean? How broad is that caveat? Who decides – doctor, bioethicist, Bishop? What sort of request, expressed in a living will, may not be honored in a Catholic hospital or nursing home, even before the recent change in ERD 58?

Picture this situation:

My mom received an Alzheimer’s diagnosis when she was just 59, and we both had a pretty good idea what lay ahead. Not far from my home northwest of Chicago is a fine long-term care facility with a wing dedicated to patients with Alzheimer’s.

My mom has been there ten years. She has been well cared for, getting the day-to-day support I couldn’t give on my own. Even as I have watched and grieved her drifting away, I am grateful for the time we have had together over those ten years.

Then she lost her appetite and her ability to feed herself. It’s hard for her even to swallow. Two days ago her care coordinator asked me about a feeding tube. I knew what Mom would choose. My family was supportive. I told the care coordinator Mom wouldn’t want a feeding tube in this condition and I took another little step down that slow path of grief.

But the care coordinator wants me to meet with their chaplain before making a decision. She says my mom is not actively dying and there’s no indication that she wouldn’t tolerate a feeding tube. Will I have to find another facility and arrange a transfer to honor what I know would be my mother’s wishes?

The recent change to the ERD sets out some narrow exceptions when artificial nutrition and hydration (ANH) is not obligatory: if a patient is actively dying; if the tube causes serious side effects like infection; if the patient’s body cannot assimilate the food and water.

But, “My loved one doesn’t want to eat and can’t swallow. I don’t want to force them to stay alive.”— will that justify an exception?
Here’s another scenario:

The phone rings. It’s the assisted living facility’s care supervisor; my father collapsed just after dinner. “The EMTs are taking him to Mercy Hospital.” An hour later I am driving down Baltimore Pike into southwest Philadelphia.

I find my father in the ICU. Hooked up to all the tubes and equipment he looks so much older than a week ago. Over the next day and a half of tests and waiting – learning it’s a stroke – he doesn’t wake or stir. I’m sitting with him mid-morning when the neurologist arrives. He goes over results and treatments they’ve tried. “It’s unlikely that your father will regain consciousness, and if he did, very unlikely that he would return to normal mental function. We need to think about next steps.”

My father designated me his health care proxy for a moment like this. His advance directive is clear, and he’s been blunt in conversation. “Look, I’m eighty-three years old, and I’ve had all the breaks. If something happens, I don’t want to sit in a chair and drool for years.”

I make an appointment to see the social worker in her office, where we’re joined by a priest. I tell them we’re ready to remove life support. She turns to the priest. He says, “Mercy Hospital is committed to honoring advance directives for health care decisions as long as they do not contradict Catholic principles,” The priest has a copy of my father’s advance directive and reads from it. “If I am ever consistently and permanently unable to communicate, swallow food and water safely, care for myself and recognize my family and other people, and it is very unlikely that my condition will substantially improve, I would want to die rather than have life-sustaining treatments.”

The priest looks up. “Your father’s living will suggests that in his unconscious state his life is no longer worth living. Under these conditions, removing life support would be an act of euthanasia by omission.”

Catholic bioethical thought has evolved over centuries. The ERDs that govern care in Catholic hospitals and nursing homes are extremely nuanced. Your directions about life support may or may not be honored in a Catholic institution. Your concern about the burdens of medical interventions might justify forgoing life-sustaining medical treatment. But a wish to be allowed to die under certain circumstances might not.

Have you talked with your family about end-of-life options? Good.

Is an advance directive in place? Excellent!

Will that directive be honored in a Catholic health care facility? We cannot know for sure.

The enforcement arm of the Catholic Church has ordered feeding tubes to be inserted in all comatose and vegetative patients in Catholic institutions and maintained indefinitely. Compassion & Choices has warned of the impact this will have on your healthcare choices. I want to make clear the sources of the outrage I expressed in my last blog.

For years I have been well-acquainted with the Ethical and Religious Directives for Catholic Health Care Services (ERD’s). But the Bishops’ recent action prompted me to review the document again, and its arrogant presumption of moral superiority struck me anew.

I understand the history and spirit of sectarian health care, and I feel open and accepting of its role in America. In the 1970′s I practiced as a physician assistant in a Seventh Day Adventist healthcare system and I delivered both my children in its hospital. I truly appreciated the staff’s attitude of spiritual calling and the prayers they offered for my safety and my babies’. True, those awful soy patties from cans almost turned me away from vegetarianism for life. But it seemed to me the Adventists ranked service and humility ahead of doctrine and I never saw their religion dominate a conversation or a medical decision.

The ERD’s are different. They are all about dominance. Four aspects are especially chilling in their authoritarian pronouncement.

First, the Bishops explicitly target everyone, of every faith, with the "revealed truth" reflected in their ERD’s. The document specifically directs its mandates beyond hospital employees and Catholics, to every patient, resident or recipient of Catholic services. Everyone — Buddhist, Muslim, Jewish, Protestant or Unitarian — must obey.

Second, the Bishops may acknowledge a pluralistic society where various spiritual disciplines lead to different moral conclusions, but they do not hesitate to over-ride them. Your conscience and religious beliefs just don’t count because, according to the ERD’s, "…Catholic health care does not offend the rights of individual conscience by refusing to provide or permit medical procedures that are judged morally wrong by the teaching authority of the [Catholic] Church." Well, those who believe artificial maintenance of an insensate body degrades God’s gift of life might disagree. They might well think insertion of a feeding tube against their will does offend their right of conscience.

Third, doctrine always trumps individual decision-making. Dealing with advance directives, ERD’s specify that hospitals "will not honor an advance directive that is contrary to Catholic teaching." So, too, "The free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic principles." They’ll honor your decision — but only if they agree with it.

Fourth, many find shocking the exaltation of suffering as "participation in the redemptive power of Christ’s passion." And few non-Catholics find comfort in Directive #61. There we find that dying patients "experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering." Apparently the nurses are to deliver a theology lesson to patients dying in agony.

The ERD’s demonstrate that one purpose of Catholic health care is to coerce people of all faiths into following Catholic moral teachings. Employers facilitate the coercion when the only health plan they offer is Catholic. States facilitate the coercion when they approve hospital mergers rendering large geographic areas devoid of any but Catholic health care. Insurers facilitate the coercion when they fail to offer a broad choice of providers within their coverage.

My sense is the feeding tube mandate finally crossed a line, where states, employers, and insurers will no longer be willing to participate in the coercion. Personal dignity, individual right of conscience and autonomy in healthcare decisions are too important to continue to pretend Catholic healthcare is not prejudicial and discriminatory against non-Catholics.