A Collision of Medicine and Faith

Zina Campos is a most unlikely cheerleader for birth control. The infant in her arms is her ninth baby. Her obstetrician is just as unlikely an advocate for the women’s reproductive rights movement: He thinks abortion is murder.

Yet the two Gilroy residents have taken on those very roles in opposing the latest hospital purchase in California by a Catholic health care group--a transaction that overnight deleted an array of procedures here. Among them was tubal ligation, which Campos wanted and her doctor had promised to perform.

For Campos and other Gilroy women who want their Fallopian tubes tied, this fall’s metamorphosis of their community hospital into St. Louise Regional means having the surgery at another hospital 45 minutes or more away. If they have transportation. If that hospital will accept their insurance. And if it is not also Catholic-owned.

For their doctors, it means choosing between losing patients and traveling beyond the half-hour radius generally observed by obstetricians, whose patients can give birth at any moment.

“They’re putting religion in the way of good medical care,” says Campos’ doctor, Taki Anagnoston, who has practiced for 35 years in this semirural area south of San Jose.

Over the past decade, as Catholic Healthcare West has become the largest California hospital owner, the church’s objection to birth control has become an increasingly real factor for some patients and doctors.

About one in 10 California hospitals is owned by Catholic Healthcare West, a corporation formed by nine orders of Roman Catholic nuns. In Los Angeles County, 25% of acute care hospital beds are in nonsecular hospitals, all but two of them Catholic. Eight of the nation’s 14 largest health care systems are Catholic.

Representatives of these hospitals say they have every right to follow the tenets of the faith, which prohibit contraception and say life begins at conception and must be preserved thereafter.

Critics have reacted by objecting loudly to the government subsidies that make such nonprofit hospitals viable. In city and county meetings and in state hearing rooms, the activists are seeking to make public funding--tax-free bonds, grants and even Medi-Cal reimbursement--contingent on a full menu of reproductive services, including abortion.

That approach has stalled in Sacramento. Hospitals that get public funds must provide evidence of charity care, but nothing in state or federal law compels them to offer any particular services. Legislation by Assemblywoman Sheila Kuehl (D-Santa Monica) to tie bond approval to proof that a hospital makes referrals for any services it does not provide died on the Assembly floor after heavy lobbying by Catholic Healthcare West.

It’s unfair to ask a hospital to participate in any way--even through referrals--in a procedure it objects to on moral grounds, said company Vice President Wade Rose. Implying that such a restriction damages health care delivery, Rose said, ignores all that Catholic hospitals do offer.

“How can you compare the people’s needs for cancer treatment, heart disease treatment and treatment of diabetes to a handful of elective procedures?” he asked.

He called Kuehl’s bill a “bigoted attack on Catholics.”

Tubal Ligation Widely Used

For Campos, 34, deciding to have her tubes tied was a personal epiphany--a reaffirmation that getting off welfare last spring was for keeps. It was also a health decision.

“My body can’t take [pregnancy] anymore--not only my body, but economically,” said Campos, who got a job as a part-time county health worker last spring. “How else am I going to get these kids in college? How can I give them what I didn’t get?”

Tubal ligation remains the single most popular method of birth control in the United States, particularly among poor and minority women. In a recent National Survey of Family Growth, 28% of contraceptive users of childbearing age chose tubal ligation--also known as female sterilization. That proportion rose to 41% among the poor. And it is the only form of contraception difficult to provide outside a hospital setting.

(Vasectomies are favored by 11% of men, but only 3% of poor men. These days vasectomies are usually performed in outpatient clinics.)

Abortions most often take place at clinics and in doctors’ offices.

About nine abortions and 70 tubal ligations were performed last year at the 90-bed hospital in Gilroy, the poorest community in Santa Clara County.

Catholic Healthcare West announced its purchase of the former South Valley Hospital on Aug. 26. Within a week the local newspaper reported that soon tubal ligation, along with abortion and contraception services, would be discontinued.

Church rules say those services must end. However, some Catholic hospitals adopt a secular model, a complicated compromise that typically permits everything but abortion and in vitro fertilization.

In California, one of the earliest such negotiations occurred in 1994, after tiny Grass Valley’s community hospital in northeastern California was taken over by Catholic Healthcare West. Protests about the great distances women on Medi-Cal would have to travel for contraception and sterilization led the hospital to continue those procedures.

At present, 18 of 46 Catholic Healthcare West hospitals in California allow some birth control measures, but no such option has been offered in Gilroy.

Another Pregnancy Called Dangerous

Anagnoston was floored by the news that such services would end in Gilroy. A soft-voiced country doctor, the 68-year-old considers tubal ligation to be primarily a health matter best decided by a patient and her doctor. Campos’ most recent pregnancies were complicated, and it would be unhealthy for her to be pregnant again, he says. Tying her tubes after delivery would avoid a second hospital visit.

Anagnoston’s view of abortion is equally straightforward. It’s immoral, he says, explaining with a parable about three women in a hospital. One mourns a miscarriage. Another waits anxiously for news of her premature infant’s condition. The third recovers from an abortion.

He asks: How can a doctor involved with the first two participate in the third?

When Anagnoston told Campos about the hospital’s new policy, she was incredulous. Wasn’t the consent form she signed in August for the procedure a contract that both sides had to honor? Couldn’t Anagnoston appeal?

All five obstetrician-gynecologists, including Anagnoston, and three midwives who practice at the hospital wrote a letter to the editor of the Gilroy Dispatch criticizing the proposed changes as “unconscionable, un-Christian, un-Catholic and unwise.” The Santa Clara County Medical Assn. sent its own appeal to San Jose’s bishop.

Reconsider your position, the Oct. 8 correspondence from the medical association implored. “Failure to do so may force many women . . . to make unhealthy choices with regard to their future reproductive life.”

But Nov. 5, a letter from the bishop’s office arrived. Permitting tubal ligations would be “imprudent,” especially in light of Pope John Paul II’s comments to visiting U.S. bishops in June that allowing them is “a grievous sin.”

Across the country, bishops--who make the final determinations on moral matters at Catholic hospitals--are ensuring that Catholic health care systems recognize the import of the pope’s comments. In several areas, compromises allowing tubal ligations and other services have ended.

Catholic Healthcare West actually is considered liberal in Catholic circles for continuing some services after merging with secular hospitals. But in Gilroy, it bought the hospital outright, and a Catholic hospital must adhere to church tenets, Rose said.

There are no immediate plans to reverse the other California agreements, Rose said, but he concedes that there are no guarantees.

“It’s a very difficult issue,” he said. “The church teaching is very straightforward, and trying to adapt that to everyday life is tough.”

Difficulty in Finding Services

Saying patients can get services elsewhere--a common position of Catholic hospital representatives in Gilroy and elsewhere--is less and less realistic, said Elizabeth Graddy, a USC public policy professor. The trends that she and other researchers have observed include the following:

* No Catholic hospitals in California provide emergency contraception for rape victims, though about 60% do furnish referrals for “morning-after” pills, according to the nonprofit Catholics for Free Choice.

* In Santa Rosa and at Queen of Angels-Hollywood Presbyterian Medical Center in Los Angeles, doctors in hospital-owned medical buildings have complained that their leases prevent them from prescribing birth control or performing abortions or vasectomies in their offices.

* Of 22 religious-based hospitals in Los Angeles County that USC studied--20 Catholic, two Seventh-day Adventist--none allow abortions. Only four offer contraception and eight perform sterilizations.

“Women with money still don’t have access problems,” Graddy said. “But services are not necessarily available to poor women.”

Susan Fogel, director of the California Women’s Law Center in Los Angeles, is leading the fight to link California’s public funds to a full selection of services including tubal ligation and, if possible, abortion. She contends that since Catholic hospitals are not run with money from the collection plate, their rules should not come from the pulpit.

Historically, Catholic Healthcare West has received more than $1.6 billion in government bonds and loans. And an estimated third of state facilities funding for health care organizations goes to hospitals that do not offer all reproductive services.

The American Public Health Assn. recommended two years ago that state Medicaid agencies contract only with providers who give information about all reproductive health choices and make arrangements for all patients to obtain them.

Assemblywoman Kuehl brought the public funding issue to lawmakers’s attention last year in her bid to force hospitals to make referrals. Although her unsuccessful legislation did not mention Catholic or religious hospitals, they knew they were the target.

When the Legislature reconvenes next month, Kuehl said, she will offer a scaled-down version of her bill that would require health plans to inform patients of restrictions at their affiliated hospitals.

“Disclosure is a bottom-line demand,” said Lois Uttley, director of MergerWatch, a New York project that tracks hospital mergers. But often, she said, Catholic systems counter with this warning: If you force us to offer procedures counter to our faith, you’ll end up without a hospital.

That’s what happened in Gilroy, where Catholic Healthcare West hinted at possible closure if it was denied public bonds to refinance its $15-million purchase of the hospital. The priest at Gilroy’s Roman Catholic Church heard the warning from hospital officials and delivered it during his Sunday sermon. Worried parishioners subsequently testified on the hospital’s behalf at the bond hearing before the county Board of Supervisors.

Unwilling to risk losing the growing Gilroy area’s only hospital, the supervisors approved the bonds.

Failed Attempt to Obtain Procedure

As Campos’ due date neared, Anagnoston began researching her options for getting her tubes tied right after delivery.

Campos could deliver her baby in Hollister, where Anagnoston has hospital privileges. But it is in another county, where her Medi-Cal managed care insurance would not be honored. Or she could find another doctor in San Jose. But going to that hospital required a 45-minute drive.

Because Campos’ last baby arrived so fast she barely made it to the Gilroy hospital, she and her doctor figured that traveling while in labor was out.

But by the time Campos went to the hospital to have her baby on Nov. 17, she had a plan: She would demand that her informed consent “contract” be honored.

After delivery she begged Anagnoston for the operation, backing off only when he told her: “I can’t, Zina. I’ll lose my privileges here.”

Now home with baby Xochtil and preparing to go back to work, Campos doesn’t know when she’ll find time to travel to San Jose to have the operation. But she plans to keep fighting for tubal ligations to be offered in Gilroy.

“In Santa Cruz, they have options,” Campos said. “In San Jose, they have options. Here, we have no options.”

Anagnoston hasn’t given up either. He and the other four doctors are appealing to Catholic Healthcare West’s pocketbook: Their lost patients are the hospital’s lost dollars. They also are pushing the neighboring city of Morgan Hill to underwrite a surgical center, where they could perform tubal ligations.

“Catholic Healthcare West runs a good hospital, so I don’t want to bad-mouth them, but they are wrong on this issue,” Anagnoston said. “My solution is this: Allow it until another facility opens that can do it.”