Catholic hospitals are a large and growing part of the U.S. health care system. Considerable public funding flows to these institutions, but they deny many reproductive health services and some kinds of end of life care to their patients. Catholic rules limit care in far-reaching ways, well beyond what many patients and health care providers understand or expect. These realities raise important issues about the future of religious restrictions in U.S. health care.

Restricted Care in a Growing Sector

Between 2001 and 2011, the number of Catholic hospitals increased by 16%, while public and secular not-for-profit hospitals decreased. One in six patients in the United States is cared for in a Catholic hospital, and in 2015, seven of the country’s 12 largest nonprofit hospital systems were Catholic. Although Catholic hospitals provide the same amount of charity care as non-Catholic hospitals, in terms of the percent of total revenues, they provide less care to Medicaid recipients than other kinds of hospitals.

Like other hospitals, Catholic institutions receive considerable public funding, yet they limit patient care to fit the Ethical and Religious Directives for Catholic Health Care Services written by the U.S. Conference of Catholic Bishops. As a condition of employment or medical privileges, doctors, nurses, and other clinical personnel are required to follow these directives when caring for patients in Catholic facilities.Legal rights mean little without practical access to reproductive health services.

In many specific ways, Catholic directives prohibit reproductive and other health services:

• Contraception, including permanent sterilization, is not allowed within Catholic hospitals, clinics, or in doctors’ offices that rent space from a Catholic facility. Rather, the Ethical and Religious Directives state that hospitals should provide, “for married couples and the medical staff who counsel them, instruction both about Church’s teaching on responsible parenthood and in methods of natural family planning.” This does not apply only to Catholic couples or patients, but to every patient receiving care in a Catholic facility, leading to restrictions that contravene what many expect. Women of all religious backgrounds in the U.S. use contraception. In fact, 98% of Catholic women who have ever had sex have used a contraceptive method other than natural family planning. And among women over age 40, 51% rely on female sterilization (i.e. permanent birth control) – a method the Catholic Church prohibits even if a woman’s doctor advises her that a future pregnancy may put her at risk of life-threatening

• Abortion is never permitted at a Catholic institution, even for women with life-threatening pregnancy complications. Such women have been denied medical care they need. In Arizona, a hospital was expelled from the Catholic Church after its ethics committee approved an abortion for a woman who was 11 weeks pregnant and learned that if she continued the pregnancy she would likely die from pulmonary hypertension made worse by her pregnancy. In Ireland, a woman who began miscarrying at 17 weeks asked her doctors repeatedly to terminate her pregnancy, and when they refused – because the fetus still had a heartbeat and they believed to do so would violate Catholic principles – she died from widespread

• In vitro fertilization is not allowed under the Catholic Directives because it “separates procreation from the marital act.” Similarly, any means to help a patient or couple conceive is prohibited unless it involves a married man and woman having sexual intercourse. This can affect all patients, and may have a disproportionate effect on gay and lesbian

• End-of-life care can also be restricted by Catholic doctrine. The Ethical and Religious Directives state that at a Catholic institution, patients can receive information about their legal right to make advance directives, but the hospital “will not honor an advance directive that is contrary to Catholic teaching.” This may mean that patients are required to accept feeding tubes against their will, or that legal physician aid to ease the process of dying will be withheld in Catholic

Limits Can Surprise Patients and Concern Doctors

Physicians working in U.S. Catholic hospitals have described facing harrowing situations – such as being unable to treat pregnant women with life-threatening complications and being forbidden to provide treatments that are safe, effective, and widely used in secular hospitals. Catholic hospital authorities may tie doctors’ hands and prevent them from helping patients in front of them. In fact, the majority of obstetrician-gynecologists working in Catholic hospitals have had at least one conflict with their hospital over its religious restrictions on patient care.

Most health care consumers, however, do not know that their providers may face restrictions and their doctors may not be able to offer the full array of safe and effective treatments. Even women who are not Catholic, or who have no choice among hospitals near their homes, may not understand that they cannot expect to receive contraception, sterilization, or abortion services in the same way at all hospitals, whether secular or Catholic.

Should Religious Institutions be Able to Limit Individual Health Care?

Now that the Supreme Court has refused to rule on whether religious hospitals, schools, and other nonprofit organizations are required to adhere to the Affordable Care Act’s requirements that all employees should have insurance coverage for contraception, the balance between institutional religion and individual choice remains unclear in the U.S. health care system. With the spread of Catholic hospitals, limits are becoming more serious for patients and providers.

The health benefits of reproductive care are well established, and Americans’ right to make personal reproductive decisions has been legally affirmed. But legal rights mean little without practical access, and it remains to be seen if all Americans will retain the true access to a full array of legal medical procedures, or if access will be placed in the hands of the Catholic bishops and the institutions they control.