摘要：As Catholic-owned hospitals merge with or take over other facilities, they impose restrictions on reproductive health services, including abortion and contraceptive services. Our interviews with US obstetrician–gynecologists working in Catholic-owned hospitals revealed that they are also restricted in managing miscarriages. Catholic-owned hospital ethics committees denied approval of uterine evacuation while fetal heart tones were still present, forcing physicians to delay care or transport miscarrying patients to non–Catholic-owned facilities. Some physicians intentionally violated protocol because they felt patient safety was compromised. Although Catholic doctrine officially deems abortion permissible to preserve the life of the woman, Catholic-owned hospital ethics committees differ in their interpretation of how much health risk constitutes a threat to a woman's life and therefore how much risk must be present before they approve the intervention. OVER THE PAST DECADE, AS Catholic hospitals have merged with and purchased nonsectarian hospitals around the United States, the lay press and legal journals have featured discussion about the impact of these mergers on patient care, particularly with regard to reproductive health. 1 – 5 The literature has focused on policies prohibiting tubal ligation, contraceptive services, emergency contraception, and abortion. Although other religiously owned and nonsectarian hospitals may also prohibit or limit some of these services, Catholic-owned hospitals are the largest group of religiously owned nonprofit hospitals, operating 15.2% of the nation's hospital beds, 6 and increasingly they are the only hospitals in certain regions within the United States. 7 The result is that Catholic and non-Catholic patients alike come to depend on these facilities for emergencies, childbirth, and routine procedures without knowing how some of their options are potentially curtailed. The findings reported here were not the original focus of our research. In the process of conducting a qualitative study about abortion provision in the clinical practice of obstetrician–gynecologists, we interviewed 30 obstetrician–gynecologists around the United States. During the interviews, which were conducted in 2006, 6 physicians working with or within Catholic-owned hospitals revealed that they were constrained by hospital policies in their ability to undertake urgent uterine evacuation. They reported that Catholic doctrine, as interpreted by their hospital administrations, interfered with their medical judgment. For example, some of them were denied permission to perform an abortion when uterine evacuation was medically indicated and fetal heart tones were still present. Catholic-owned institutions and their employees must adhere to medical practice guidelines contained in the “Ethical and Religious Directives for Catholic Health Care Services” (hereafter called “the directives”) written by the Committee on Doctrine of the National Conference of Catholic Bishops. 8 The directives state that abortion is never permitted. However, regarding emergency care during miscarriage management, the manual used by Catholic-owned hospital ethics committees to interpret the directives states that abortion is acceptable if the purpose is to treat “a life-threatening pathology” in the pregnant woman when the treatment cannot be postponed until the fetus is viable. 9 The experiences of physicians in our study indicate that uterine evacuation may not be approved during miscarriage by the hospital ethics committee if fetal heart tones are present and the pregnant woman is not yet ill, in effect delaying care until fetal heart tones cease, the pregnant woman becomes ill, or the patient is transported to a non–Catholic-owned facility for the procedure. Although medical journals have featured articles about a physician's right to refuse patients treatment, referral, or information regarding services to which the physician has religious objections, 10 – 12 few articles in the medical literature published to date have addressed the effect of Catholic-owned hospital policies on patient care and the professional conduct of physicians. 13 , 14 One recent opinion piece in the Journal of the American Medical Association described how a patient was transferred from a religiously owned to a nonsectarian hospital for labor induction to facilitate spontaneous abortion because the religious hospital would not allow the procedure until after she became septic. 15 The following interview excerpts demonstrate how 5 different Catholic-owned hospital ethics committees responded to 6 physician requests to evacuate the uterus during miscarriage and the resulting effects on miscarriage management.
