Doctors' beliefs can hinder patient care

What's best for the patient
If there's one thing both sides can agree on, it's this: In an emergency, doctors need to put aside personal beliefs to do what's best for the patient. But in a world guided by religious directives, even this can be a slippery proposition.

Ob/gyn Wayne Goldner, M.D., learned this lesson a few years back when a patient named Kathleen Hutchins came to his office in Manchester, New Hampshire. She was only 14 weeks pregnant, but her water had broken. Dr. Goldner delivered the bad news: Because there wasn't enough amniotic fluid left and it was too early for the fetus to survive on its own, the pregnancy was hopeless. Hutchins would likely miscarry in a matter of weeks. But in the meanwhile, she stood at risk for serious infection, which could lead to infertility or death. Dr. Goldner says his devastated patient chose to get an abortion at local Elliot Hospital. But there was a problem. Elliot had recently merged with nearby Catholic Medical Center — and as a result, the hospital forbade abortions.

"I was told I could not admit her unless there was a risk to her life," Dr. Goldner remembers. "They said, 'Why don't you wait until she has an infection or she gets a fever?' They were asking me to do something other than the standard of care. They wanted me to put her health in jeopardy." He tried admitting Hutchins elsewhere, only to discover that the nearest abortion provider was nearly 80 miles away in Lebanon, New Hampshire — and that she had no car. Ultimately, Dr. Goldner paid a taxi to drive her the hour and a half to the procedure. (The hospital merger has since dissolved, and Elliot is secular once again.)

"Unfortunately, her story is the tip of the iceberg," Dr. Goldner says. Since the early 1990s, hospitals have been steadily consolidating operations to save money; so many secular community hospitals have been bought up that, today, nearly one in five hospital beds is in a religiously owned institution, according to the nonprofit group MergerWatch in New York City.

What is standard of care?
Every Catholic hospital is bound by the ethical directives of the U.S. Conference of Catholic Bishops, which forbid abortion and sterilization (unless they are lifesaving), in vitro fertilization, surrogate motherhood, some prenatal genetic testing, all artificial forms of birth control and the use of condoms for HIV prevention. Baptist and Seventh Day Adventist hospitals may also restrict abortions. Which means that if your local hospital has been taken over — or if you're ever rushed to the nearest hospital in an emergency — you could be in for a surprise at the services you can't get.

You wouldn't necessarily know a hospital's affiliation upon your arrival. "The name of the hospital may not change after a merger, even if its philosophy has," Morrison notes. "The community is often in the dark that changes have taken place at all." The burden to know falls entirely on the patient, who can either search the Catholic Health Association's directory of member hospitals (at CHAUSA.org) or ask her doctor outright. Either way, says Morrison, "it requires you to be an extremely educated consumer."

Family physician Debra Stulberg, M.D., was completing her residency in 2004 when West Suburban Medical Center in Oak Park, Illinois, was acquired by the large Catholic system Resurrection Health Care. "They assured us that patient care would be unaffected," Dr. Stulberg says. "But then I got to see the reality." The doctor was struck by the hoops women had to jump through to get basic care. "One of my patients was a mother of four who had wanted a tubal ligation at delivery but was turned down," she says. "When I saw her not long afterward, she was pregnant with unwanted twins."

And in emergency scenarios, Dr. Stulberg says, the newly merged hospital did not offer standard-of-care treatments. In one case that made the local paper, a patient came in with an ectopic pregnancy: an embryo had implanted in her fallopian tube. Such an embryo has zero chance of survival and is a serious threat to the mother, as its growth can rupture the tube. The more invasive way to treat an ectopic is to surgically remove the tube. An alternative, generally less risky way is to administer methotrexate, a drug also used for cancer. It dissolves the pregnancy but spares the tube, preserving the women's fertility. "The doctor thought the noninvasive treatment was best," Dr. Stulberg recounts. But Catholic directives specify that even in an ectopic pregnancy, doctors cannot perform "a direct abortion" — which, the on-call ob/gyn reasoned, would nix the drug option. (Surgery, on the other hand, could be considered a lifesaving measure that indirectly kills the embryo, and may be permitted.) The doctor didn't wait to take it up with the hospital's ethical committee; she told the patient to check out and head to another ER. (Citing patient confidentiality, West Suburban declined to comment, confirming only that as a Catholic hospital, it adheres to religious directives "in every instance.")

Turns out, the definition of emergency depends on whom you ask. Dr. Christiansen, the pro-life ob/gyn, says she would not object to either method of ending an ectopic pregnancy. "I do feel that the one indication for abortion is to save the mother's life — that's clear in my mind," she says. "But the reality is, the vast majority of abortions are elective. There are very, very few instances where the mother's life is truly in jeopardy." She can recall having seen only one such situation: During Dr. Christiansen's residency, a patient in the second trimester of pregnancy had a detached placenta; the attending physician performed an abortion to save the woman from bleeding to death. "That was a legitimate situation," Dr. Christiansen says. But in general, "it's a pure judgment call. A doctor would have to be in the situation and decide whether it constitutes a life-threatening emergency or not."

Raise your hand if you'd like to be the test case.

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