The University of California regents are wrestling with a question that should have an easy answer:
Should they approve an “affiliation” between UC San Francisco, one of the leading teaching hospitals in America, and Dignity Health, a Catholic hospital chain that openly discriminates against women and LGBTQ patients and requires its doctors to comply with religious directives, some of which run counter to medical science and ethical practice?
The easy answer, and the right answer, is “no.”
Dignity’s adherence to Catholic Church directives affecting medical care, including a near-total ban on abortion, is hopelessly at odds with the values of a public institution such as UCSF. What’s worse, UCSF, by implicitly accepting Dignity’s model discriminating against women and LGBTQ patients, would empower that model’s expansion.
“It’s as if we would provide a crutch” for that model “not just to be sustained, but to grow, to flourish, to increase,” Vanessa Jacoby, an associate OB-GYN professor at UCSF, told the regents on Tuesday. She pointed out that the church restrictions fall disproportionately on low-income women and LGBTQ patients.
Judging from that meeting of the regents’ health services committee, UC’s governing board is flummoxed by the intricate ramifications of this proposal. The proposal also has roiled UCSF itself. While some of its clinicians are in favor of the arrangement, a petition drive in opposition has collected some 1,600 signatures from faculty, physicians, students, staff and alumni.
“We’re asking them to really rethink the affiliation,” says Daniel Grossman, a professor of obstetrics and gynecology at UCSF and an organizer of the petition drive. “A lot of us believe this should not move forward.”
Grossman couldn’t say what percentage of the UCSF community has signed the petition, since the net has been cast so widely.
Grossman points to one of the paramount problems with the proposal: The details are still not public. What is clear, however, is that UCSF faculty and doctors practicing at Dignity Health’s four Bay Area hospitals would be bound to comply at those locations with the Catholic Church’s restrictions on abortion, sterilization procedures, treatments of transgender patients, and other services. That should be a deal-breaker.
UCSF says affiliating with the four Dignity hospitals is necessary to relieve a desperate capacity crunch at its 1,276-bed San Francisco medical centers, which it says had to turn away 855 patient transfers last year for lack of available beds. “We don’t have a good Plan B,” Mark Laret, the chief executive of UCSF Medical Center, told the regents. Laret also said UCSF expects a “revenue flow” from Dignity to help offset its financial losses from caring for low-income San Franciscans.
UCSF has had clinical associations with Dignity hospitals for decades, covering specialties such as cardiology, pediatric burn services, neurosurgery and thoracic surgery. This proposal would mean a dramatic expansion of the relationship, however, covering Dominican Hospital in Santa Cruz, Sequoia Hospital in Redwood City, and St. Francis Memorial and St. Mary’s Medical Center in San Francisco.
Of those, Dignity labels St. Francis and Sequoia “non-Catholic” hospitals subject to the church’s “statement of common values,” which bars “direct abortions,” physician-assisted suicide and fertility treatments such as in vitro fertilization (IVF) — the only way, as the petition states, that gay and lesbian couples can conceive a biological child. St. Mary’s and Dominican are “Catholic” hospitals subject to the much more restrictive “Ethical and Religious Directives for Catholic Health Care Services,” a creation of the U.S. Conference of Catholic Bishops who are, obviously, all males.
The ERDs, as they’re known, ban “direct abortions,” IVF, contraceptives, assisted suicide and “gender affirming care” such as hormone treatments and surgeries for transgender patients, among other treatments. They treat life as beginning from the moment of conception. (“Direct abortion” is not a medical but a Catholic term, signifying the termination of a pregnancy by destroying a developing fetus any time after conception.)
The ERDs’ language about some of these therapies, all of which are legal, is uncompromising. They define abortion, assisted suicide and “direct sterilization” such as tubal ligation as “intrinsically immoral.” They place the ultimate judgment about whether to permit such procedures, regardless of a patient’s medical needs or desires, in the hands of local bishops, not doctors.
The issues this presents for doctors and their patients have become more urgent as Catholic hospitals have expanded their footprint in American healthcare, often through mergers with secular or non-Catholic institutions in which they’re the dominant partner.
Currently, they account for 1 out of every 6 hospital beds in the country. That gives abortion restrictions and other limitations on women’s reproductive rights a backdoor route to expansion.
After a recently completed merger with Englewood, Colo.-based Catholic Health Initiatives, Dignity will be part of the second-largest private chain of hospitals in the U.S., with 142 facilities. It already was the largest chain in California, with 31 hospitals. The merged system is being renamed CommonSpirit Health.
The Catholic restrictions are being tested in court. According to a lawsuit brought by Rebecca Chamorro of Redding against Dignity and its Redding-based Mercy Medical Center, she was denied a tubal ligation to take place during a caesarean section at Mercy, even though performing the procedures together is the accepted medical standard of care because it means one surgical operation rather than two.
Instead, the ERDs required her to wait at least several weeks to undergo the second procedure. Chamorro’s lawsuit is currently in its pretrial phase.
In a second lawsuit, Evan Minton, a transgender man, says that Dignity’s Mercy San Juan Medical Center in Carmichael, Calif., canceled his hysterectomy two days before it was scheduled, when the hospital discovered he was transgender. His lawsuit on sex discrimination grounds was dismissed by a San Francisco Superior Court judge but is on appeal. Dignity acknowledged that it canceled the operation in observance of the ERDs, but said it arranged for the operation to take place a few days later at a “non-Catholic” Dignity hospital.
Doctors report that they often run into problems when religious overseers insist on balancing the threats to the lives of mothers even after it becomes clear that a fetus has virtually no chance of survival.
“Managing miscarriages is a very gray area,” says Lori Freedman, an expert at UCSF who has been conducting interviews with doctors at Catholic hospitals about their experiences.
In some cases, she found, the ethics committees wouldn’t approve terminating a pregnancy even when the mother was facing death, as long as a fetal heartbeat could be discerned. One doctor reported pleading for permission to do so for a pregnant woman whose condition was so septic her temperature had shot up to 106 degrees. The ethics committee refused to allow him to terminate the pregnancy, even though “this woman is dying before our eyes.” The fetus died, but she survived, after spending 10 days in intensive care.
Critics observe that the UCSF deal, if approved, could become a model for affiliations between other UC medical campuses and Catholic hospitals in their areas. The ACLU of Northern California has questioned whether it’s even legal, given state and federal constitutional requirements for the separation of church and state, as well as state and federal anti-discrimination laws.
What has been especially dispiriting about UCSF’s discussion of this deal is the lengths it has gone to sugarcoat the impact of the religious rules. During the regents’ meeting Tuesday, Laret referred to the rules as fostering “care that’s viewed as discriminatory.”
No. We’re not talking about conflicting “views” of discrimination. When a woman, unlike a man, can’t receive the full range of legal treatments that meet the medical standard of care, or a transgender patient can’t undergo a procedure that a woman can routinely receive, that’s discrimination — full stop.
UCSF also hints, nudge-nudge, that some religious directives can be quietly circumvented by nimble doctors. At a regents’ health committee meeting on Dec. 11, Dana Gossett, the chair of obstetrics and gynecology at UCSF and a proponent of the affiliation, observed that there are “usually workarounds” for doctors to prescribe contraceptives, which the ERDs ban if they’re for birth control but allow if they address some other medical problem.
“Every Catholic institution prescribes birth control,” Gossett said, adding slyly, “There are a lot of women out there with ‘menstrual disorders’ there apparently.” Of course, that would mean falsifying a patient’s chart. What sort of ethics is UCSF teaching its students?
Dignity told me in an emailed statement that “at all of our hospitals, all healthcare decisions are made between patients and their doctors.” The statement said that Dignity doesn’t “restrict a physician’s ability to fully inform patients about treatment options and facilitate access to care, even if it’s not provided at one of our facilities. We don’t believe that conflicts with the ERDs or the provision of evidence-based care.”
UCSF administrators seem to think that by affiliating with Dignity, they might be able to limit its adherence to the church dictates, like a fifth column of science-based practitioners working from the inside.
“Do we engage with the biggest healthcare system in the state of California, or do we say we’ll have nothing to do with this system?” Laret asked the regents.
Jacoby crisply disabused the regents of any such reverie. “They never compromise their values,” she said of Catholic healthcare systems. “They’re not allowed to change. They’ll never provide contraceptives. They’ll never do an abortion to our standard of care.”
UCSF seems to be entering this affiliation as a junior partner, in effect bowing to Dignity’s Catholic restrictions. That’s the opposite of what should happen with an institution as eminent as UC. “The only reason to move forward with a relationship like this is to use it to get Dignity to expand its reproductive services,” says Amy Chen, a senior attorney at the National Health Law Program.
Yet the authority in these relationships often seems to flow in the other direction. When Hoag Memorial Hospital in Newport Beach, a Presbyterian hospital, affiliated with the Catholic St. Joseph Health System in 2013, Hoag’s doctors were assured that nothing in their practices would change. That was a lie. Almost immediately, St. Joseph halted abortions at Hoag.
As Catholic hospital systems have expanded through affiliations, the bishops have demanded more control over their secular partners. The latest iteration of the ERDs, issued in 2018, states specifically that in any collaboration with non-Catholic partners, anything “under the control of the Catholic institution” must adhere to the ERDs. They also state that the Catholic institution can’t allow its employees to “assist” or “make referrals” for “immoral procedures.”
How that would affect the work of UCSF clinicians working at Dignity locations isn’t clear, but it would seem to contradict the assurances from UCSF that its own professionals’ work won’t be impeded by the ERDs.
No one can deny that UCSF faces a critical challenge in meeting its capacity constraints, or that Dignity hospitals do good works, especially in delivering care to low-income patients.