Sandra Hapenney, Ph.D., M.P.H., M.A.

Conscience clauses are laws enacted by federal and state governments to protect health care providers from participating in those medical practices they consider morally objectionable. This study examines the practices of Catholic hospitals and their adherence to the Ethical and Religious Directives (ERD) for Catholic Health Care Services issued by the U.S. Conference of Catholic Bishops. If divergence of practice exists among Catholic hospitals, such diversity may pose judicial and political problems for providing protection under the conscience clauses.

Catholic hospitals in seven states—California, Illinois, Indiana, New Jersey, New York, Texas and Washington—were studied to determine if diversity of practice existed in the provision of direct female sterilizations. Inpatient discharge data was requested for three years (2007-2009) from the 1,734 hospitals, secular and Catholic, within the states. Of these hospitals, 239 Catholic hospitals were identified of which 176 provided obstetric services. The records of these 176 hospitals were searched for those containing the diagnostic code from the ICD-9-CM coding system for sterilization for contraceptive management. Eighty-five or 48% of these hospitals provided a total of 20,073 direct sterilizations in violation of the ERD.

An analysis of Catholic hospital systems owning hospitals within the seven state study area illustrated that 69.0% the hospitals were members of 26 various Catholic hospital systems. Ten systems operating in the seven states also have hospitals outside the study area. Within these 10 systems, 64.2% of the hospitals in the study area performed direct sterilizations. An analysis of the Catholic dioceses in the study area revealed that 69.8% of the dioceses had hospitals which provided direct sterilizations. Thus, diversity of practice resulting from varied interpretations and applications of the ERD exists among hospitals, and within hospital systems and dioceses. An analysis of the conscience clauses illustrates that Catholic hospitals are in jeopardy of defending themselves against judicial challenges and could strip themselves of the ability to mount a political front to aid in defending the conscience clauses

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Press Release - 2/26/2012 9:25pm CST
Public response to: Study: Catholic hospitals, church at odds over birth control
Asbury Park Press, Feb. 25, 2012 9:53 PM by Shannon Mullen: 732-643-4278

I wish to refute the following mischaracterizations of my research in the article:

If the quotes attributed to the spokesman of the Catholic Health Association and the ethicist for Catholic Health Initiatives are incorrect, then the respective institutions need immediately to state their representatives were misquoted. If either institution stands by the remarks, then I expect a public retraction and apology for the remarks which are, on their face, affronts to the professional standards of discourse.

As a Catholic woman scholar, I would be saddened if these remarks were what the press claims. The thought that Catholic health care institutions, in which religious women exercise leadership, would respond to reports of violations of human dignity by seeking to discredit the woman reporting the abuses is painful. The use of such discredited tactics would only further substantiate my finding that best practices need to be mandated at Catholic hospitals to provide independent, transparent, and public accountability. Were they to treat me, an outsider, in this fashion, no one could expect a doctor or employee to report ethical violations to hospital authorities.

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A detailed refutation of the remarks follows:

Catholic Health Association would be wrong to place “no credence” in responsible, academic research showing a significant number of sterilizations at Catholic Hospitals and in spreading an unsubstantiated claim that my doctoral research contains “gross errors”. I have placed my data, methodology, and findings in the public record. If CHA and its member health care systems believe the findings contain “gross errors,” they ought to publicly state what those errors are.

Catholic Health Initiatives would also be seriously mistaken to stand behind remarks that have the effect of minimizing and discrediting my research by implying that I have overstated the actual number of sterilizations or misinterpreted the meaning of the V25.2 code. The CHI ethicist’s agreement that “an elective sterilization performed solely for contraceptive purposes would violate the bishops’ directive” is potentially misleading as it might suggest that some forms of sterilization related to the V25.2 code are permitted by the directives. The fact is that the directives make no reference to the subjective criteria of “elective” or “sole” purpose in determining approval of a procedure. The only case in which a procedure that results in sterilization may be done involves the case of an existing pathology (and a future pregnancy is not considered an existing pathology). Hence, all sterilizations represented by V25.2 are prohibited regardless of what they are called by the hospitals or their ethicists because the code itself declares the sterilization is not being given for any existing pathology.

The CHI ethicist’s assertion regarding human error undermining my data lacks merit. The study specifically acknowledges the possibility of miscoding, but the research cross-checked the V25.2 sterilization code with the presence of codes corresponding to particular procedures for sterilization. It is highly unlikely that a coding error in a single patient record would have included not only a mistaken V25.2 entry, but an attendant error of miscoding for a sterilization surgery that did not actually happen. And to reduce 20,000 such codings to “human error” is insupportable. If CHI or its ethicist thinks otherwise, all they need to do is show where the data is substantially mistaken in this regard.

Furthermore, the public should be aware that there is no real doubt about the validity of the type of data used in this study since it is provided by the hospitals to the State in compliance with regulatory laws and is regularly used by researchers. As to the accuracy of my interpretation of the data, the findings parallel those of similar study for the State of Texas published in 2008. The 2008 study was validated in the Diocese of Tyler by the bishop and two hospitals, resulting in an end to V25.2 sterilizations at both hospitals. The cessation of V25.2 sterilizations in 2009 was verified by my recent study. If, as the CHI ethicist suggests, V25.2 sterilizations are permissible under some circumstances or are in the records only as coding errors, how is it that the hospitals in Tyler showed absolutely none for 2009?

If the CHA, their member hospitals, and their hired ethicists wish to disagree with my data or findings, they will need to present evidence that my count of V25.2 codes or interpretation of that code as a direct sterilization contains “gross errors.” Or without going over my research they could simply show a case in which a V25.2 diagnostic code for sterilization can be anything other than a direct sterilization prohibited as a violation of human dignity and the US Bishops’ ethical directives for hospitals. Until they establish facts contrary to the findings of my research, they should avoid inaccurate and uniformed disparaging characterizations. Such attacks are as unjust and unwarranted as they are unworthy of the Catholic heritage these institutions represent.

Hospital	City	State	Diocese	Health System	Women w/ Births	Sterilizations (V25.2 Codes Recorded)
						2006-10	Percentage	2006	2007	2008	2009	2010

Diocese	Hospitals (In Study) Reporting Births	Hospitals Reporting Sterilization (V25.2) Codes	Hospitals Not Reporting Sterilization (V25.2) Codes
Albany	4	1	3
Amarillo	1	1	0
Austin	8	5	3
Beaumont	3	1	2
Belleville	4	1	3
Brooklyn	2	0	2
Buffalo	4	0	4
Camden	1	1	0
Chicago	17	4	13
Corpus Christi	5	5	0
Evansville	2	0	2
Fresno	5	5	0
Ft. Wayne-South Bend	2	0	2
Galveston-Houston	2	0	2
Gary	5	0	5
Indianapolis	7	2	5
Joliet	2	0	2
Lafayette	6	1	5
Los Angeles	14	8	6
Lubbock	2	2	0
Metuchen	1	0	1
Monterey	1	1	0
New York	5	0	5
Newark	2	2	0
Oklahoma City	5	3	2
Orange	3	1	2
Patterson	3	3	0
Peoria	8	0	8
Rochester	1	1	0
Rockford	1	0	1
Rockville Centre	3	0	3
Sacramento	8	8	0
San Antonio	2	1	1
San Bernardino	3	1	2
San Diego	2	0	2
San Francisco	2	1	1
San Jose	2	1	1
Santa Rosa	5	5	0
Seattle	10	10	0
Spokane	5	5	0
Springfield	5	0	5
Stockton	3	2	1
Syracuse	2	2	0
Trenton	1	1	0
Tulsa	4	0	4
Tyler	2	2	0

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