Ethical and Religious Directives for Catholic Health Care Services

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Ethical and Religious Directives for Catholic Health Care Services
Surgical Code for Catholic Hospitals 1921.png
The original 1921 poster
Author United States Conference of Catholic Bishops
LanguageEnglish
Publication date
1921 (1st ed)
1971 (4th ed)
2001 (6th ed)
Publication placeUnited States
Pages30
LC Class RA975.C37 E85

Ethical and Religious Directives for Catholic Health Care Services (ERDs) is a publication that sets policy in Catholic hospitals and health systems. The document is written and published by the United States Conference of Catholic Bishops. The document derives medical and healthcare policy from Catholic theology and church teaching.

Contents

The document in its current form dates from 1971, with the most recent edition published 2001.

Publication history

In the 19th and early 20th centuries, religious rules for Catholic hospitals were published by various local and regional entities in America. An early example was published by the Archdiocese of Detroit in 1921, prohibiting abortion and sterilization. This document was a single-page poster. It was copied by other archdioceses, sometimes with modifications. These posters hung on operating room walls in American and Canadian Catholic hospitals in the early 20th century. [1]

The Catholic Hospital Association began work on a uniform set of rules in the 1940s. But, no rules became official for a particular hospital or location until approved and interpreted by local religious authorities. [1]

Publication was centralized by the Conference of Catholic Bishops in 1971 to avoid different rules in different places, which was derided as "geographical morality." [2] [1] The new rules resulted in "a storm of violent criticism" that the rules were inapplicable to a pluralistic society and beyond the scope of what the bishops should teach. [3] A report by the Catholic Theological Society of America found the Ethical and Religious Directives to be legalistic, inapplicable to concrete situations, and inferior to the Canadian Medico-Moral Guide. The report strongly disagreed that local bishops should possess "sole ultimate authority" to evaluate the morality of new scientific developments, and called for less attention to sex and reproduction. [3]

Cardinal John Krol persuaded most American bishops to adopt the controversial 1971 document because of the legalization of abortion in Roe v. Wade in 1973 and Taylor v. St. Vincent's Hospital, a lawsuit by a woman seeking tubal ligation, in 1975. [1] A revision in the 1990s is considered less legalistic than the 1970's document, containing more theological and philosophical explanations for its conclusions. [3] At this time, publication ceased to be attributed to the Catholic Hospital Association and changed instead to the Committee on Doctrine of the Conference of Catholic Bishops.

The document is considered to be in its sixth edition, which dates from 2001, although previous editions had different titles and publishers. The 2001 edition was updated in 2018. [4] In 2023, the Conference of Catholic Bishops voted to begin the process of updating the directives to prohibit gender-affirming care. [2] They view the transgender medical treatments as "not morally justified." [5]

Editions

The document's six editions are as follows: [1]

EditionTitleYearPublisher
1Surgical Code for Catholic Hospitals1921Archdiocese of Detroit
2Ethical and Religious Directives for Catholic Hospitals1948Catholic Hospital Association
3Ethical and Religious Directives for Catholic Hospitals1956Catholic Hospital Association
4Ethical and Religious Directives for Catholic Health Care Facilities1971Catholic Hospital Association
5Ethical and Religious Directives for Catholic Health Care Services1994National Conference of Catholic Bishops
6Ethical and Religious Directives for Catholic Health Care Services2001National Conference of Catholic Bishops

Directives

The Ethical and Religious Directives contains 49 directives within the document's six sections, many of which lay out rules that Catholic healthcare providers must follow. Notable rules include the following:

Allowed or required

Prohibited

A number of the directives that prohibit medical procedures — namely abortion, euthanasia, and sterilization — specify that the procedure is prohibited only when "directly intended." This is because of the principle of double effect, a Catholic teaching. [8] [9]

Impact

The ERDs apply in 600 Catholic general hospitals across the United States. Approximately 100 more hospitals are managed by Catholic chains that place religious limits on care. [17]

They have had more impact over time as the healthcare industry consolidates and Catholic hospitals expand. [18] The Directives state that "whatever comes under control of the Catholic institution — whether by acquisition, governance, or management — must be operated in full accord with the moral teaching of the Catholic Church." [17] [19]

The directives prohibit common reproductive health services. Some Catholic hospitals are literal in their application of the rules, while others are less restrictive in their interpretation. [4] A number employ workarounds to provide patient care. [20]

Enforcement

Within each hospital, the directives are enforced by ethics committees made up of clinical, religious, legal, and administrative members. Hospital ethics committees consult on medical questions, act as gatekeepers of ERD-restricted treatments, and sometimes perform surveillance of medical practices. [21]

Bishops have some power to enforce the prohibitions in the ERDs, but they lack the power to enforce the guarantees of care in the ERDs. For example, the ERDs statement that "a Catholic health care institution should provide prenatal, obstetric, and postnatal services" proved unenforceable when the largest Catholic hospital chain, Ascension, closed down many of its obstetric facilities. Charles Bouchard, a former director of the Catholic Health Association and vice president of theological education at Ascension, explained this limitation of the bishops' power: "They can keep hospitals from doing something if it’s seen as at odds with Catholic teaching. But they can't, unless they’re going to pay for it, they can't go out and say, 'you've got to keep this hospital open.'" [22]

Fit with medical standards

The Ethical and Religious Directives are often at odds with accepted medical standards, especially in areas of reproductive health. For example, guidelines of American College of Obstetricians and Gynecologists (ACOG) specify conditions under which women should be offered the option of an abortion. [17]

Nonviable and life-threatening pregnancy

At the time the Ethical and Religious Directives were first written, doctors in Catholic hospitals were not allowed to intervene in anything theologians considered a natural part of the reproductive process, even if deadly, such as ectopic pregnancy. [23] A 1919 medical ethics textbook by Austin O'Malley explains: "If the mother cannot be saved without emptying the uterus, the mother must die; there is no way out of the difficulty." [24] [25]

This absolute prohibition of abortion, even in life-threatening cases, is still included in the ERDs. In practice, there has been an increase over time in the number of exceptions allowed as "indirect" abortions or otherwise overlooked. This is particularly evident for ectopic pregnancy:

Kyleigh Thurman filed a complaint with the Department of Health and Human Services claiming that, in February 2023, Catholic institution Ascension Seton Williamson Hospital refused to treat her ectopic pregnancy or to transfer her to another hospital; she was instead discharged. She says the hospital again denied her treatment when she returned with vaginal bleeding, days later, a delay which caused her fallopian tube to rupture. [31] In national study of obstetrician-gynecologists in 2012, 5.5% of respondents at Catholic institutions reported that their options for treating ectopic pregnancy are constrained by their hospitals. [32]

Sexual assault

Emergency contraceptives are the standard of care for rape victims. Whether the ERDs contradict this standard is subject to different interpretations by different diocesan bishops. Some Catholic hospitals have policies prohibiting emergency room physicians from prescribing emergency contraceptives, or even from discussing them, while others do not. Some staff use "creative solutions" to circumvent emergency contraception prohibitions and meet the standard of care. [33]

The interpretation of the Catholic Medical Association rejects all emergency contraception after sexual assault, totally prohibiting Levonorgestrel (Plan B), Ulipristal acetate (Ella), insertion of an IUD, and all other measures a woman might use to avoid pregnancy after rape. [27]

Related Research Articles

Abortion is the termination of a pregnancy by removal or expulsion of an embryo or fetus. An abortion that occurs without intervention is known as a miscarriage or "spontaneous abortion"; these occur in approximately 30% to 40% of all pregnancies. When deliberate steps are taken to end a pregnancy, it is called an induced abortion, or less frequently "induced miscarriage". The unmodified word abortion generally refers to an induced abortion. The most common reasons women give for having an abortion are for birth-timing and limiting family size. Other reasons reported include maternal health, an inability to afford a child, domestic violence, lack of support, feeling they are too young, wishing to complete education or advance a career, and not being able or willing to raise a child conceived as a result of rape or incest.

<span class="mw-page-title-main">Emergency contraception</span> Birth control measures taken after sexual intercourse

Emergency contraception (EC) is a birth control measure, used after sexual intercourse to prevent pregnancy.

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

<span class="mw-page-title-main">Mifepristone</span> Medication

Mifepristone, also known by its developmental code name RU-486, is a medication typically used in combination with misoprostol to bring about a medical abortion during pregnancy and manage early miscarriage. This combination is 97% effective during the first 63 days of pregnancy. It is also effective in the second trimester of pregnancy. It is taken by mouth.

Late termination of pregnancy, also referred to politically as third trimester abortion, describes the termination of pregnancy by inducing labor during a late stage of gestation. In this context, late is not precisely defined, and different medical publications use varying gestational age thresholds. As of 2015 in the United States, more than 90% of abortions occur before the 13th week, 1.3% of abortions in the United States took place after the 21st week, and less than 1% occur after 24 weeks.

<span class="mw-page-title-main">United States Conference of Catholic Bishops</span> American Catholic episcopal conference

The United States Conference of Catholic Bishops (USCCB) is the episcopal conference of the Catholic Church in the United States. Founded in 1966 as the joint National Conference of Catholic Bishops (NCCB) and United States Catholic Conference (USCC), it is composed of all active and retired members of the Catholic hierarchy in the United States and the territory of the U.S. Virgin Islands.

Prior to the 20th century, the three major branches of Christianity—Catholicism, Eastern Orthodoxy and Protestantism —generally held a critical perspective of birth control. Among Christian denominations today, however, there is a large variety of views regarding birth control that range from the acceptance of birth control to only allowing natural family planning to teaching Quiverfull doctrine, which disallows contraception and holds that Christians should have large families.

<span class="mw-page-title-main">Swedish Health Services</span> Health system in the Seattle area

Swedish Health Services, formerly Swedish Medical Center, is the largest nonprofit health provider in the Seattle metropolitan area. It operates five hospital campuses, ambulatory care centers in the cities of Redmond and Mill Creek, and Swedish Medical Group, a network of more than 100 primary-care and specialty clinics.

<span class="mw-page-title-main">Crisis pregnancy center</span> Organization that persuades pregnant women against having abortions

A crisis pregnancy center (CPC), sometimes called a pregnancy resource center (PRC) or a pro-life pregnancy center, is a type of nonprofit organization established by anti-abortion groups primarily to persuade pregnant women not to have an abortion.

Conscience clauses are legal clauses attached to laws in some parts of the United States and other countries which permit pharmacists, physicians, and/or other providers of health care not to provide certain medical services for reasons of religion or conscience. It can also involve parents withholding consenting for particular treatments for their children.

<span class="mw-page-title-main">Beginning of pregnancy controversy</span> Cultural-linguistic, not scientific question

Controversy over the beginning of pregnancy occurs in different contexts, particularly as it is discussed within the debate of abortion in the United States. Because an abortion is defined as ending an established pregnancy, rather than as destroying a fertilized egg, depending on when pregnancy is considered to begin, some methods of birth control as well as some methods of infertility treatment might be classified as causing abortions.

<span class="mw-page-title-main">Dignity Health</span> US not-for-profit healthcare system

Dignity Health is a California-based not-for-profit public-benefit corporation that operated hospitals and ancillary care facilities in three states. Dignity Health was the fifth-largest hospital system in the nation and the largest not-for-profit hospital provider in California.

This is a timeline of reproductive rights legislation, a chronological list of laws and legal decisions affecting human reproductive rights. Reproductive rights are a sub-set of human rights pertaining to issues of reproduction and reproductive health. These rights may include some or all of the following: the right to legal or safe abortion, the right to birth control, the right to access quality reproductive healthcare, and the right to education and access in order to make reproductive choices free from coercion, discrimination, and violence. Reproductive rights may also include the right to receive education about contraception and sexually transmitted infections, and freedom from coerced sterilization, abortion, and contraception, and protection from practices such as female genital mutilation (FGM).

Indirect abortion is the name given by Catholic theologians to a medical procedure which has a beneficial medical effect and also results in an abortion as a secondary effect. Edwin F. Healy makes a distinction between "direct abortions" that is, abortion which is either an end or a means, and "indirect abortions", where the loss of the fetus is then considered to be a "secondary effect".

The official teachings of the Catechism of the Catholic Church promulgated by Pope John Paul II in 1992 oppose all forms of abortion procedures whose direct purpose is to destroy a zygote, blastocyst, embryo or fetus, since it holds that "human life must be respected and protected absolutely from the moment of conception. From the first moment of his existence, a human being must be recognized as having the rights of a person – among which is the inviolable right of every innocent being to life". However, the Church does recognize as morally legitimate certain acts which indirectly result in the death of the fetus, as when the direct purpose is removal of a cancerous womb. Canon 1397 §2 of the 1983 Code of Canon Law imposes automatic excommunication on Latin Catholics who actually procure an abortion, if they fulfill the conditions for being subject to such a sanction. Eastern Catholics are not subject to automatic excommunication, but by canon 1450 of the Code of Canons of the Eastern Churches they are to be excommunicated by decree if found guilty of the same action, and they may be absolved of the sin only by the eparchial bishop. In addition to teaching that abortion is immoral, the Catholic Church also generally makes public statements and takes actions in opposition to its legality.

The excommunication of Margaret McBride occurred with the sanctioning by the American religious sister Margaret McBride in November 2009 of an abortion at a Roman Catholic hospital, the St. Joseph's Hospital, in Phoenix. It was lifted in December 2011. Her decision and her subsequent excommunication aroused controversy in the areas of medical ethics and Catholic theology.

<span class="mw-page-title-main">Catholic Church and health care</span> Relationship between the Catholic Church and health care

The Catholic Church is the largest non-government provider of health care services in the world. It has around 18,000 clinics, 16,000 homes for the elderly and those with special needs, and 5,500 hospitals, with 65 percent of them located in developing countries. In 2010, the Church's Pontifical Council for the Pastoral Care of Health Care Workers said that the Church manages 26% of the world's health care facilities. The Church's involvement in health care has ancient origins.

The Protection of Life During Pregnancy Act 2013 was an Act of the Oireachtas which, until 2018, defined the circumstances and processes within which abortion in Ireland could be legally performed. The act gave effect in statutory law to the terms of the Constitution as interpreted by the Supreme Court in the 1992 judgment in the X Case. That judgment allowed for abortion where pregnancy endangers a woman's life, including through a risk of suicide. The provisions relating to suicide had been the most contentious part of the bill. Having passed both Houses of the Oireachtas in July 2013, it was signed into law on 30 July by Michael D. Higgins, the President of Ireland, and commenced on 1 January 2014. The 2013 Act was repealed by the Health Act 2018, which commenced on 1 January 2019.

A medical abortion, also known as medication abortion or non-surgical abortion, occurs when drugs (medication) are used to bring about an abortion. Medical abortions are an alternative to surgical abortions such as vacuum aspiration or dilation and curettage. Medical abortions are more common than surgical abortions in most places around the world.

Ascension is a large private healthcare system in the United States. Ascension had 142,000 employees, 142 hospitals, and 40 senior living facilities operating in 19 states and the District of Columbia as of the end of 2021. Ascension is the largest nonprofit and largest Catholic health system in the United States. It also operates a conglomerate of for-profit firms, including subsidiaries involved in private equity, venture capital, insurance, medical software, and pharmacy delivery. From 2014 to 2017 it co-owned a facility in the Cayman Islands.

References

Footnotes

  1. 1 2 3 4 5 O'Rourke, Kevin D.; Kopfen-Steiner, Thomas; Hamel, Ron (November–December 2001). "A Brief History: A Summary of the Development of the Ethical and Religious Directives for Catholic Health Care Services" (PDF). Health Progress.
  2. 1 2 O'Loughlin, Michael J. (June 22, 2023). "The controversial history of the U.S. bishops' Catholic health care guidelines". American Magazine.
  3. 1 2 3 Hamel, Ron (November–December 2019). "100th Anniversary - The Ethical and Religious Directives: Looking Back to Move Forward". Health Progress.
  4. 1 2 Penan, Hayley; Chen, Amy (January 2, 2019). The Ethical & Religious Directives: What the 2018 Update Means for Catholic Hospital Mergers (Report). National Health Law Program.
  5. ↑ Boorstein, Michelle (June 16, 2023). "U.S. Catholic bishops to create first guidelines for transgender health care". The Washington Post.
  6. 1 2 3 Committee on Doctrine 2018, p. 9.
  7. ↑ Committee on Doctrine 2018, p. 10–12.
  8. ↑ Seeds, John W. (2012). "Direct Abortion or Legitimate Medical Procedure Double Effect?". Linacer Quarterly. 79 (1): 81–87. doi:10.1179/002436312803571546. PMC   6027086 . PMID   30082962.
  9. ↑ O'Rourke, Kevin D.; Boyle, Philip J. (2011). Medical Ethics: Sources of Catholic Teachings (4 ed.). Georgetown University Press. pp. 12–13. ISBN   9781589017566. OCLC   648934582.
  10. ↑ Committee on Doctrine 2018, p. 18.
  11. 1 2 3 Committee on Doctrine 2018, p. 19.
  12. ↑ Committee on Doctrine 2018, p. 15.
  13. 1 2 Godoy, Maria (September 4, 2022). "Catholic health care's wide reach can make it hard to get birth control in many places". NPR.
  14. ↑ Committee on Doctrine 2018, p. 21.
  15. ↑ Committee on Doctrine 2018, p. 13–14.
  16. ↑ Committee on Doctrine 2018, p. 17–18.
  17. 1 2 3 Pradhan, Rachana; Recht, Hannah (February 17, 2024). "The Powerful Constraints on Medical Care in Catholic Hospitals Across America". KFF Health News.
  18. ↑ Hafner, Katie (2018). "As Catholic Hospitals Expand, So Do Limits on Some Procedures". The New York Times.
  19. ↑ Committee on Doctrine 2018, p. 26.
  20. ↑ Freedman 2023, p. 87–125.
  21. ↑ Freedman 2023, p. 29.
  22. ↑ Hertzler-McCain, Aleja (April 8, 2024). "Catholic bishops silent as Ascension hospital system shrinks maternity care". Religion News Service.
  23. ↑ Freedman 2023, p. 42.
  24. ↑ O'Malley 1919, p. 181.
  25. 1 2 Joyce 2002, p. 100.
  26. ↑ Freedman 2023, p. 44.
  27. 1 2 Catholic Medical Association 2017.
  28. 1 2 Freedman 2023, p. 83.
  29. ↑ Freedman 2023, p. 81.
  30. ↑ Freedman 2023, p. 43–44.
  31. ↑ Vinall, Frances (August 13, 2024). "Women claim Texas hospitals denied them abortions for ectopic pregnancies". The Washington Post.
  32. ↑ Stulberg, Debra B.; Dude, Annie M.; Dahlquist, Irma; Curlin, Farr A. (2012). "Obstetrician-gynecologists, religious institutions, and conflicts regarding patient-care policies". American Journal of Obstetrics and Gynecology. 207 (1): 73.e1–73.e5. doi:10.1016/j.ajog.2012.04.023. PMC   3383370 . PMID   22609017.
  33. ↑ Smugar, Steven S.; Spina, Bernadette J.; Merz, Jon F. (September 2000). "Informed Consent for Emergency Contraception: Variability in Hospital Care of Rape Victims". American Journal of Public Health. 90 (9): 1372–1376. doi:10.2105/ajph.90.9.1372. PMC   1447633 . PMID   10983186.

Bibliography


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