When religious doctrine clashes with health care

Louis Weisberg, Staff writer

Patient-history forms provide no option to designate a “same-sex spouse” or “registered domestic partner,” although the latter is recognized in Wisconsin and the former is legal in neighboring Iowa.

Surrounded by Catholic iconography and confronted wth church directives, do gay and lesbian patients hide relevant information from their physicians? Can women receive appropriate reproductive health care from institutions that ban contraception and abortion?

The Roman Catholic Church has sparked interest in these questions by its vehement opposition to the Patient Protection and Affordable Care Act. Led by former Milwaukee archbishop Cardinal Timothy Dolan, the church contends that its freedom of religion is violated by a provision in the law requiring organizations to offer insurance coverage for contraception. Church leaders have waged a furious, high-profile battle against the law – a battle that has drawn other fundamentalist Christian groups into the fray.

In southeast Wisconsin, two of the four largest health care systems are directly affiliated with the Roman Catholic Church and bound to abide by the Ethical and Religious Directives for Catholic Health Care Services  promulgated by the U.S. Conference of Catholic Bishops.  Although interpretation of the directives appears to vary from institution to institution, women’s health advocates are alarmed by the intrusion of religious orthodoxy into science-based medicine.

This issue has emerged as the latest salvo in the nation’s raging culture war – a war that has ramped into high gear during this contentious political year.

Perception of bias

According to Lambda Legal, LGBT people are routinely either denied health care or treated in a discriminatory manner by providers. In 2010, Lambda Legal released a survey on the health care experiences of LGBT people and people living with HIV. Nearly 56 percent of lesbian, gay and bisexual respondents reported having experienced discrimination while accessing health care. Seventy percent of transgender respondents said they’d encountered bias. The survey made no distinction between secular and religious-affiliated providers.

The report accompanying the survey results concluded that prejudice often prevents LGBT people from accessing care and, when it does not, it often prevents them from discussing their sexual orientation or gender identity with providers.

The perception of bias in the health care system – both secular and religious – persists among LGBT people. That has a direct bearing on the quality of health care they receive.

In a study conducted last year by researchers from the Medical College of Wisconsin and UW-Milwaukee, nearly 30 percent of 270 gay men interviewed in Milwaukee said their primary care physician did not know their sexual orientation. Half as many African-American men as white and Hispanic men said they’d disclosed their sexual orientation to their physicians.

That’s troublesome because a patient’s sexual behavior is a critical part of his or her medical history, according to Andrew Petroll, assistant professor of medicine and psychiatry at the Medical College of Wisconsin’s Center for AIDS Intervention.

“Providers need to be able to recommend and administer appropriate preventive health services, such as vaccinations, counseling on risk-reduction and even medications that can reduce the risk of acquiring HIV,” Petroll said. “In addition to the prevention of illnesses, providers need accurate information so that they can order proper screening tests, such as for HIV and other sexually transmitted infections.

“This is not to say that being LGBT automatically places a person at risk for certain illnesses. While many illnesses are more prevalent in the LGBT community, an individual’s own behavior determines the risk for acquiring an illness. However, being able to openly discuss sexual orientation and sexual behaviors with a health care provider is necessary to allow the provider to take the best care of each patient. If an individual feels uncomfortable discussing their sexual orientation or sex practices with their health care provider, they should probably find a provider with whom they can discuss these issues.”

Gary Hollander, executive director of Diverse & Resilient, said that he and his partner, who has advanced multiple sclerosis, have experienced both subtle and blatant bias in their frequent contacts with health care providers in Milwaukee. For example, a technician balked at performing an EKG on his partner because he’s gay, Hollander said. He’s frequently asked during emergency room visits if his problem is related to HIV infection.

Hollander’s partner receives care through the Columbia St. Mary’s system, but he doesn’t believe the discrimination is related to the affiliation. In both his personal and professional experience, he’s found that institutional policies don’t matter as much as the attitude of individual staff members toward LGBT people, he said.

A local secular health care system that employed “a disproportionate number of staff who were fundamentalists” was the source of numerous complaints several years ago, Hollander added.

During his partner’s hospitalizations, Hollander attenuates the religious overtones of the experience simply by removing the crucifixes from his partner’s hospital room walls. “It’s décor,” he said. “I don’t need to look at it. They’re removable. I put them in a drawer.”

It’s unknown whether crucifixes on the wall or the word “saint” in the name of an institution (which is commonplace even in secular health care systems such as Aurora) have a deterrent effect on an open dialogue between LGBT patients and providers. Also unknown is how religious affiliation might or might not affect physician training in LGBT health issues.

Past surveys have found that medical schools spend only two to four hours over four years addressing LGBT health issues.

Milwaukee advocates for LGBT health care, including AIDS Resource Center of Wisconsin president Mike Gifford, said systemic health care problems related to anti-gay bias have vastly diminished since the early days of the HIV/AIDS pandemic.

Terri Rocole, senior vice president of mission services for Wheaton Franciscan Healthcare, said her system’s religious affiliation heightens its commitment to nonjudgmental and compassionate care. Rocole noted that the Franciscan order has been at the forefront of HIV/AIDS care and advocacy globally. Wheaton Franciscan hospitals even offer an option to designate “domestic partner” on patient forms.

Rocole quoted Directive 23 from the Ethical and Religious Directives for Catholic Health Care Services. “The inherent dignity of the human person must be respected and protected regardless of the nature of the person’s health problem or social status,” Rocole read. “Human dignity extends to all persons who are served by Catholic health care.”

But on the level of operating policy, a difference clearly exists between secular and religious-affiliated health systems in Milwaukee. Aurora Health Care, which is secular and also the state’s largest employer, provides domestic partnership benefits, while Columbia St. Mary’s and Wheaton Franciscan do not.

Through a spokesperson, Columbia St. Mary’s declined any interviews for this story.

Potentially deadly

While religious affiliation might have little effect beyond perception for gay and lesbian patients, when it comes to end-of-life issues, the differences between Catholic and secular institutions are pronounced. Catholic directives, for example, prohibit the removal of feeding tubes, even for patients in persistent vegetative states with no hope for recovery. This policy potentially affects a large part of the nation, since half of all people are unable to make their own decisions at the time of death.

For women, the difference in care is potentially deadly. Women have endured unnecessary agony in Catholic hospital emergency rooms due to directives prohibiting an array of reproductive health services.

In southeastern Arizona, a woman was forced to travel 80 miles to terminate a pregnancy that her doctors said would have killed her, simply because the only hospital in her rural area was in the process of joining an out-of-state Catholic health system. As a result of the publicity surrounding that case, a coalition of residents, physicians and activists put a halt to the merger.

But such mergers continue – and with increasing frequency – according to a February story in The New York Times. Driven by a shift in health care economics, 20 mergers between Catholic and non-Catholic hospitals have been announced nationally in the past three years alone – and more are expected.

“We are starting to see what was rare in the past,” said Lisa Goldstein, analyst with Moody’s Investor Service who follows the hospital sector, in an interview with the NYT.

The nation’s 600 Catholic hospitals already treat one-sixth of all patients.

An advocacy group called “MergerWatch” was formed in New York 15 years ago to block or reverse mergers between religious-affiliated and secular health care systems. The group has halted 37 mergers and reached compromises in 22 other cases to preserve at least some reproductive services for area residents.

Mergers result in significant policy changes for the secular partner, since Catholic health systems require that all affiliated hospitals and clinics operate according to church directives. On the other hand, when a Catholic hospital is acquired by a secular system, its buyers often are forced to uphold the church’s bans on contraception, abortion and other critical services, even when women’s lives are in danger.

Adam Beeson, public affairs manager for Aurora Health Care, said none of the hospitals in his system operate according to religious doctrine, including those that were formerly associated with religious organizations.

How Catholic hospitals interpret church policies can vary. Some ban doctors from providing any treatment to a woman having a miscarriage as long as fetal heart tones are detected, according to the National Women’s Law Center. That policy is adhered to even when inaction could cost a woman’s life while she awaits transfer to another institution that will perform the necessary procedure.

Sometimes, Catholic hospitals delay action in such cases by requiring unnecessary tests, at a cost of great suffering to the patient, according to NWLC. Women who request tubal ligations following caesarean sections are refused, forcing them to needlessly undergo a second operation at another hospital.

Ectopic pregnancies, which occur outside the womb and cannot survive – but can kill the mother – are a particularly thorny issue. Treatment involves removal of the fetus and often one of the fallopian tubes, which is where most ectopic pregnancies occur.

Rocole said the Church’s directives do allow for the treatment of ectopic pregnancies, as well as any other medically necessary treatment to save a woman’s life.

“Medical review committees look at the circumstances of every situation to determine if there is an underlying medical necessity,” she said. “If there’s an underlying medical pathology that requires treatment, then we would allow these types of procedures to be performed.”

“I think there are a lot of misperceptions out there” about Catholic health care, Rocole added.

While Rocole’s assessment might apply to the Wheaton Franciscan health system, a study presented at the 2008 meeting of the North American Primary Care Research Group reported that 19 percent of doctors working in religiously-affiliated institutions had experienced conflicts between science-based medicine and church doctrine. Eighty-six percent of them said they would refer patients to secular institutions to get the care they required in such cases.

Although doctors are reluctant to complain publicly about these issues, some physicians are said to have fled when Columbia Hospital merged with St. Mary’s and became subject to Roman Catholic rules, according to local lore.

Critics charge that denying or delaying appropriate treatment for women due to religious views is unconscionable. They contend that medical decisions should always be made in the best interest of the patient, especially since taxpayers and private insurers pay for the care provided at hospitals.

Dr. Peter Lipson, an internist in southeast Michigan who writes about the current “de-enlightenment in medicine,” noted in a 2010 essay that appeared in “Science Based Medicine” that even denying a woman an abortion due to the practitioner’s religious views is a breach of medical ethics.

“Ethics demand that they serve their patients’ needs above their own,” Lipson wrote. “There is no set of data that says that ‘abortion is harmful to women,’ so doctors who oppose abortion cannot claim that science supports their bias.”