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Nina Martin: A Dispute at a Catholic Hospital

November 15, 2013

Gag rules at Catholic hospitals limit what doctors can do—and say.

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Image from Flickr via elentir

By Nina Martin
By arrangement with ProPublica

A dispute between a Colorado cardiologist and the hospital he works for has highlighted a growing area of concern among patient advocates and civil libertarians: gag rules imposed on doctors and nurses by Catholic health-care providers.

In a complaint filed Wednesday, ACLU of Colorado accused Mercy Regional Medical Center in Durango, in the remote southwest corner of the state, of illegally telling doctors and other employees that they cannot discuss abortion with patients, even if a pregnancy threatens a woman’s life. The complaint was filed with the Colorado Department of Public Health and Environment, which oversees the state’s hospitals.

“Mercy Regional’s moral objection to abortion does not exempt the hospital from complying with [state and federal] laws,” the ACLU’s Sara Rich wrote to the health department, “and the hospital cannot invoke its religious status to jeopardize the health and lives of pregnant women seeking medical care.”

In a statement, hospital spokesman David Bruzzese said the complaint was “based on inaccurate information.” He said Mercy takes “very seriously the care we provide to our patients.”

The hospital chose not to respond to specific allegations in the complaint.

The case involves Dr. Michael Demos, a cardiologist for 36 years, and a female patient with a family history of Marfan syndrome, an inherited disorder of the connective tissues that has been called “one of the most feared cardiovascular complications associated with pregnancy.”

In women with the condition, the strains on the body brought on by pregnancy can cause the aorta to rupture, almost always killing the mother. Thus the American College of Cardiology and American Heart Association recommend that if a patient’s aorta becomes enlarged beyond a certain point, her pregnancy should be terminated.

According to the complaint, Demos met with the patient, who was eight weeks pregnant and displayed signs of having the disorder, in early 2012. As he tells it, he recommended follow-up testing and discussed the treatment options — including abortion — should the results indicate that her life was in danger. Fortunately, an echocardiogram showed that the patient’s blood vessels were normal, Marfan syndrome was ruled out, and she went on to have a healthy baby. “I never saw her again,” Demos said.

But more than a year later, the woman complained to hospital officials that Demos and others on Mercy Regional’s staff had recommended that, based on “a presumptive diagnosis of Marfan syndrome” (the ACLU’s words), she should end her pregnancy. “It was a misunderstanding on her part,” Demos said in an interview, adding that there was “no harm done. Usually in these cases, there’s harm.”

Demos was reprimanded and told that he was “not permitted to recommend an abortion, nor is he permitted to even discuss the possibility of terminating a pregnancy with a Mercy Regional patient, regardless of the circumstances.”

But Demos seems to have been caught up in another misunderstanding, too. A Brooklyn native who has lived in Durango since 2008, he said he became a Mercy employee in July 2011, when his private practice group was bought out by another group that eventually became part of Mercy. He can’t recall whether he knew what Mercy’s policies were on abortion: “Perhaps I should have known, but I didn’t.” And he had more than the usual reason to be cautious about a patient who might have Marfan: many years ago, he said, he treated another pregnant woman with the condition who died. Not to have discussed the option of abortion with someone who might suffer from the disorder “would have been malpractice,” he said.

But hospital officials apparently saw it differently. Demos was reprimanded and told (in the words of the complaint) that he was “not permitted to recommend an abortion, nor is he permitted to even discuss the possibility of terminating a pregnancy with a Mercy Regional patient, regardless of the circumstances.”

Later, Mercy Regional’s chief medical officer, John Boyd, assured the patient in writing that the hospital would “provide education to all our employed providers, reminding them that they should not recommend abortion — even to patients who may have serious illnesses,” the ACLU’s complaint says, quoting his letters. Boyd also reaffirmed that under The Ethical and Religious Directives for Catholic Health Care Services, Mercy Regional’s staff was “precluded … from providing or recommending abortion.”

The ERDs, a set of 72 guidelines issued by the U.S. Conference of Catholic Bishops, restrict a range of reproductive health options that conflict with church teachings — abortion, birth control, sterilization, fertility treatments — as well as certain end-of-life care possibilities and stem cell research. The directives also have been interpreted by many hospitals to prohibit emergency abortions for miscarriages and ectopic pregnancies as well as emergency contraception after sexual assault (which generally works by preventing implantation of a fertilized egg).

The directives have long been controversial with women’s health advocates and civil libertarians, and the Colorado episode, they say, underscores why. The guidelines don’t just restrict what doctors and nurses at Catholic providers may do; they can even limit what health professionals are allowed to say.

Mercy’s policy “prevents physicians from fulfilling their ethical obligations” to patients and “interferes with patients’ rights to make informed decisions regarding their medical care,” the complaint said. The policy also violates patient safeguards under Medicare and Medicaid as well as a Colorado law protecting physicians’ autonomy, the ACLU said.

Mark Silverstein, ACLU of Colorado’s legal director, said that by barring doctors from informing patients about all possible treatment options, Mercy Regional poses “a potential threat to the health, safety and even the lives of its patients.”

The potential risk to patients is especially grave in communities like Durango, where a Catholic hospital is the only one for miles around, added Sheila Reynertson of MergerWatch, a New York–based nonprofit that tracks Catholic hospital consolidations and their impact. She noted that so-called “sole provider” hospitals — there are 30 of them in mostly isolated parts of the country — receive additional federal funds to serve the needs of their communities, as well as Medicare, Medicaid and other tax breaks.

But vague gag rules may be just as problematic, Reynertson added, especially at secular hospitals and practices, like Demos’s, that find themselves under Catholic control.

Reynertson said that gag policies like Mercy’s are “absolutely” common — and are becoming more so as Catholic health-care systems gobble up other providers in a merger boom touched off by health-care reform. “What’s unusual about this case is that you have it in writing,” Reynertson said. “Usually, the policies are not so clear cut.”

But vague gag rules may be just as problematic, Reynertson added, especially at secular hospitals and practices, like Demos’s, that find themselves under Catholic control. “People tend to overreact to keep their jobs. This is what we’ve heard many times — the nurse in the emergency room who is suddenly very nervous about that pregnancy emergency because there’s a heart beat. Doctors become nervous, hospital administrators become nervous. It’s a chilling effect.”

Also unusual is that Demos is a heart specialist, suggesting that the gag rules can have a broader reach than many people realize. “Usually you would expect to see this kind of thing happening to an OB/GYN” — the doctors who have historically been most likely to come into conflict with the ERDs, Silverstein said.

In his statement, spokesman David Bruzzese acknowledged that, as a faith-based hospital, Mercy is committed to carrying out its mission and ministry “in a manner that is consistent with our religious and ethical directives.”

But, he added, patients and physicians “are free to use all information in the medical literature to make appropriate medical decisions.”

The ACLU, meanwhile, urged state health department officials to intervene to stop Mercy Regional from enforcing its gag policy and from “inappropriately interfering with its physicians’ practice of medicine.” It has requested a response from the state by the end of the month.

For his part, Demos — who remains a Mercy employee — said that he had only good intentions in bringing the complaint. “I love Durango. I’m not going away. I really want this hospital to thrive — someday I will be a consumer [here] too. I always try to do my best, and I want my hospital to be the best, too. I want to practice the best we can practice. If you’re looking for a motive, that’s it.”

Nina Martin is ProPublica’s first reporter covering gender and sexuality. She joined the staff in September 2013 after spending much of the last decade at San Francisco magazine as articles editor (since 2007) and executive editor (2003-2005).

Martin has been a reporter and editor specializing in women’s, legal and health issues for more than 30 years. Her early career included stints at The Baltimore Sun, The Washington Post, and the International Herald Tribune. Her work has appeared in many magazines, including Health, Mother Jones, Elle, and The Nation.

Martin is based in Berkeley, Calif.

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