Wednesday, December 5, 2007

Religious Hospitals, Secular Hospitals, and Democratic Process

A fascinating hospital purchase drama with medieval undertones is unfolding in Wheat Ridge, Colorado.

The Sisters of Charity of Leavenworth Health Systems is seeking to purchase Exempla Lutheran Medical Center. If the Attorney General approves the transfer of ownership, procedures prohibited under Catholic health care rules – such as abortion and tubal ligation – will no longer be permitted at Lutheran. A group of Lutheran doctors, supported by the ACLU, Planned Parenthood, NARAL, and other organizations, are lobbying against the sale.

The contending parties have rich histories. The Sisters of Charity opened the first private hospital in Kansas in 1864. Lutheran was founded in 1905 as a tent colony for tuberculosis patients. Both entities are mission-driven and committed to care of the poor.

The issue of merger between secular and religious hospitals is common enough to be the single focus of an activist organization, MergerWatch. The secular/religious conflict in Colorado is a vintage good vs good ethical dilemma. Catholic health care has a noble history of devotion to the poor and vulnerable. But in our pluralistic society, many do not share Catholic views on reproductive ethics. Lutheran, with its own noble history, has provided these services to its community.

Two days ago the Rocky Mountain News carried a moving plea for compromise from Dr. Lawrence Rust, a retired trauma surgeon who had practiced at Lutheran. Dr. Rust seeks a path whereby “both sides of this dispute can salvage their most important principles.” Specifically “the medical staff at Lutheran needs assurance that they will be free to practice on a daily basis without interference,” and “the Sisters of Charity need to know that the organization that they own faithfully represents their core values.”

I am committed to deliberative discussion as a key process for ethical governance of the health system. I would sorely love to believe Dr. Rust’s proposal could work:

“When a physician disagrees with a policy, the disagreement would be handled openly by peers. The Catholic voice would be joined with other professional voices in committees, and the resulting decisions would be forged from reason and discussion. If the decision disagreed with the Catholic approach (such as allowing tubal ligations) both sides would have had the opportunity to fully present their side, but the consensus approach would prevail.”

Unfortunately, this won't work. The Catholic perspective on reproductive services does not arise from particular facts about individual situations. The Conference of Bishops "Ethical and Religious Directives for Catholic Health Services" prohibit abortion and sterilization under all circumstances. If the Directives are to be followed the hope that "decisions would be forged from reason and discussion" is, alas, entirely quixotic.

Hospitals drop "service lines" all the time, especially if the service in question is a money loser. In Wheat Ridge the issue is principle, not money. It is hard to see how the Sisters of Charity could respect pluralism and allow the prohibited procedures to be done, say, by a nominally independent portion of the hospital. Apart from logistical complexities, the Bishops are clear: "Catholic health institutions are not to provide abortion services, even based upon the principle of material cooperation."

So what should be done? If I were the Sisters of Charity I would not want to be seen as imposing my moral perspective -- even though I fervently believed it was absolute truth -- on those who did not share it. But that is exactly how buying Lutheran and dropping the forbidden services would appear. But if I were a physician at Lutheran I would want to be sure that I was protesting because the purchase would make the services significantly less available to those who want them, and not because, like Martin Luther himself, I was opposing "Catholic power" on principle.

The decision is in the lap of the Attorney General. In my view, if the purchase would significantly reduce access to services that are legal and, by a majority of the population, seen as ethically acceptable as well, I would not allow it to go through. But if I concluded that the services were readily available I would allow it to go ahead.

Pluralism does not come easily. We need to learn all we can about how to respect principles and pluralism from cases like Wheat Ridge. I hope to be able to follow the story, and invite readers to comment.


Isaac Holeman said...

Hi Jim,

This may be a silly question, but why is the attorney general the decider in this case? Practically speaking, what gives him legal veto power over hospital ownership?

Additionally, I noticed that of the solutions offered by the hospitals, the retired trauma surgeon, you, and I imagine the attorney general, none aimed to directly take into account the opinions of patients. I understand the Catholic hospital's commitment to it's directives, but they apparently don't have the final word here. As an ethics commentator, would it be exceedingly idealistic to suggest that the process consult the patients who, theoretically, the (practicing Catholic) attorney general should be serving?

Anonymous said...

The Attorney General reviews all hospital transactions in Colorado, as they are considered charitable organizations. The review first determines that the transfer will enact no “material change in purpose”. Granted this is not the case, further review determines the effect on the community.

The consultation of the patients, so to speak, occurs through the advocacy of the Attorney General. His intentions in the review must be to protect the interests of the people of the state of Colorado, making sure the transaction is both legal and devoid of favoritism based on religion or special interest.

I am a supporter of the government's right to supercede in matters of faith when the matter in question has to do with the welfare of the population at large (being affected by the issue). This does not necessarily include all matters of medicine that are prohibited in some form by one faith or another, but matters that can be proven to have a physical, not spiritual, outcome on the population. As is often the case, this issue toes the blurry line between these two outcomes.

It will be interesting to see the case that is laid out by the Attorney General, whether to accept or decline the approval of this proposed merger.

It will be just as interesting to see the input, and eventual reaction, from Kaiser Permanente, one of the predominant insurers in the region. They currently contract heavily with Exempla, but a transition of coverage to a Sisters of Charity-run hospital is not guaranteed. One can assume that both the state and Sister's of Mercy will lobby hard to sway Kaiser to adopt their perspective standpoints. Without much bargaining power, in this regard, the current practitioners of Exempla will need to, I think, base their case on the detrimental effect the merger would have on public health, and lobby the Attorney General exclusively.

Jim Sabin said...

Isaac -- your question about the Attorney General and comment about the importance of consulting the local population are right on target. Ian explained why the Attorney General has a role -- thanks, Ian! The Attorney General's duty is to consider the public interest. Even if the AG endorses the Catholic health teachings, the stance s/he should take is to consider public desires (within the limits of the law), not private morality. I agree with Ian that there will be much to learn from following how this drama plays out.

Anonymous said...

Another thought to ponder is whether the secular world is imposing its morality on the Sisters. Respecting the Sisters views and letting them function as they wish could be more positively pluralistic than blocking there attempt to run the hospital because of individuals with different belief systems. I say if they buy it they should be able to run it how they personally feel called to do so, whether we agree with it or not.

Jim Sabin said...

Dear Anonymous -

Thank you for the comment.

I agree with you that pluralism requires respect for the Sisters of Charity view. If they were opening a new private facility there are no valid ethical grounds for opposing their governing it by their moral code.

But taking away services that Lutheran is providing to the community raises the question of whether the reproductive services will continue to be available. Imagine that an enormously wealthy zealot decides to purchase every facility offering the prohibited services. Taken to its extreme, the principle that "if they buy it they should be able to run it how they personally feel called to do so" would allow the zealot to eliminate services that a majority of the population believe are part of our obligation to provide needed health services. That's why I believe that the attorney general should consider the availability of services as well as the rights of the Sisters in making his decision about the purchase of Lutheran.