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10/05/2015

Elective or Life-Saving? Catholic Hospitals and the Ban on Tubal Ligation

A Catholic hospital came under fire recently for stating that it would not permit doctors to perform a tubal ligation during a c-section scheduled for October.  According to news reports (including an article written by the patient herself), the pregnant patient has a brain tumor, and her doctor have advised her that another pregnancy could be life-threatening.  Her doctor has recommended that she have a tubal ligation at the time of her c-section.  While my knowledge about this hospital, this case, and the participants is limited to what has been reported in the media, it raises an interesting question: in our pluralistic society, where conscientious objection is respected while maintaining a patient’s right to a certain standard of care, is it ethical to allow a religiously-affiliated health care institution to refuse to provide certain treatments it finds morally objectionable?

As background, the Catholic Church has historically been outspoken on bioethical issues and has a strong and robust bioethical teaching.  Catholic hospitals are governed by the Ethical and Religious Directives for Catholic Health Care Services (ERDs), a document promulgated by the United States Conference of Catholic Bishops (USCCB) that clearly articulates the bioethical policies that must be followed in a health care institution based on the Church’s moral teachings.  It explains the Church’s teaching against direct sterilization as a method of birth control based on the principle of double effect.  “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution.  Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.” (Directive 53).  In other words, if the sterilization procedure directly treats a pathology, it is licit; if it is used as a form of birth control to prevent a pregnancy, even if that pregnancy would be life-threatening, it is not licit.

According to the ACLU, Genesys Hospital enacted this policy prohibiting tubal ligations for non-therapeutic purposes on November 1, 2014, and the ACLU of Michigan quickly sent a letter to the state licensing and regulation agency urging it to force Genesys to lift the ban.  This is not the first time that a Catholic hospital has been criticized for its refusal to provide this service; a hospital in California reversed its decision to refuse tubal ligation after a threat of a lawsuit by the ACLU in August.

Opponents of this ban on tubal ligations argue that a hospital that treats the public should not be allowed to limit the care it offers based on religious beliefs.  They argue that performing a tubal ligation at the time of c-section is the safest way to perform the procedure, since it only adds about 30 minutes to the procedure and the patient is already anesthetized.  The sterilization is effective immediately and does not add to the patient’s recovery time.  If the procedure is not performed at the time of delivery, the patient must wait 6 weeks before the surgery can be performed, and the patient would need to be anesthetized again and undergo all of the risks associated with surgery a second time.  The procedure is considered to be the standard of care for women seeking postpartum sterilization.

On the other hand, it is well-accepted that hospitals can refuse to provide services that are not medically appropriate or violate hospital policies, even if those policies are based on religious beliefs.  Much like a health care worker’s qualified right to conscientiously object to participating in a procedure he or she is morally opposed to, a hospital is permitted to set moral parameters that prohibit the provision of certain procedures such as sterilization and abortion, which Catholic hospitals do through the adoption of the ERDs.  

Even if a Catholic hospital is justified in its policies, traveling to another hospital to deliver can, in some cases, be difficult or impossible.  The patient’s obstetrician may only have admitting privileges at the Catholic hospital, so going to another facility means finding a new doctor.  The patient’s insurance may not be accepted at another facility, or worse, the next closest hospital that can perform the procedure may be hundreds of miles away.  Can a patient be denied this procedure if she faces hardship attempting to have the procedure done elsewhere?  If it is an emergency and treatment is necessary to save a patient’s life, it is hard to justify withholding such treatment if no other facility can provide it. But is this an emergency?  Is this procedure life-saving?

Whether or not this is a life-saving treatment is precisely the dilemma.  A tubal ligation is an elective procedure.  Catholic hospitals view the procedure in this context as one aimed at preventing pregnancy, not aimed at directly treating a life-threatening condition.  The life-threatening condition is pregnancy, not another condition that is directly treated by the tubal ligation.  Under this view, the procedure is purely voluntary and contraceptive.  While opponents may argue that this procedure prevents the life-threatening condition from arising, and therefore should be considered a life-saving procedure, that view is not the one espoused by the USCCB.  And so the question remains: if it is an elective procedure and other forms of contraception are available, is it ethical to maintain a policy prohibiting elective sterilizations based on religious beliefs, or should a Catholic hospital be required to provide services that are contrary to its stated moral code?  

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.

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