GOVERNMENT, POLITICS, AND LAW

misoprostol for abortion. Contraception.
1999;59:1–6.
18. Prine LW, Lesnewski R. Medication
abortion and family physicians’ scope of
practice. J Am Board Fam Pract. 2005;
18:304–306.

22. American Academy of Family Physicians. Colonoscopy (position paper).
Available at: http://www.aafp.org/
online/en/home/policy/policies/c/colonoscopypositionpaper.html. Accessed July
9, 2008.

19. Prine L, Lesnewski R, Berley N, Gold
M. Medical abortion in family practice: a
case series. J Am Board Fam Pract. 2003;
16:290–295.

23. Bartlett LA, Berg CJ, Shulman HB,
et al. Risk factors for legal induced abortion-related mortality in the United States.
Obstet Gynecol. 2004;103:729–737.

20. Westfall JM, Sophocles A, Burggraf
H, Ellis S. Manual vacuum aspiration for
first-trimester abortion. Arch Fam Med.
1998;7:559–562.

24. Vats V, Nutescu E, Blackburn JC,
et al. Efficacy and safety of warfarin
management in US anticoagulation clinic.
J Thromb Thrombolysis. 2008 Feb;25:131.

21. Paul M, Nobel K, Goodman S, Lossy
P, Moschella JE, Hammer H. Abortion
training in three family medicine programs: resident and patient outcomes.
Fam Med. 2007;39:184–189.

25. Mehlhorn AJ. Safety concerns with
fluoroquinolones. Ann Pharmacother.
2007;41:1859–1866.
26. Food and Drug Administration.
Product labeling for Lotensin. Available

at: http://www.fda.gov/cder/foi/label/
2004/019851s028lbl.pdf. Accessed
January 24, 2008.
27. Keeton RE, Widiss AI. Insurance
Law: A Guide to Fundamental Principles,
Legal Doctrines, and Commercial Practice.
St Paul, MN: West Publishing;
1988:x4.8(b) at 965.
28. Medical Malpractice Insurance: Multiple Factors Have Contributed to Increased
Premium Rates. Washington, DC: Government Accountability Office; June 27,
2003. GAO-03-702.
29. Dailard C. Contraceptive Coverage:
a 10-year retrospective. Guttmacher Rep
Public Policy. 2004;7(2):6–9.

contraceptive pills. Obstet Gynecol.
2006;108(5):1272–1276.
31. Segal SJ. Liability concerns in contraceptive research and development. Int J
Gynaecol Obstet. 1999;67:S141–S151.
32. American Academy of Family Physicians. Professional medical liability.
Available at: http://www.aafp.org/
online/en/home/policy/policies/p/
professionalmedicaliability.html. Accessed January 23, 2008.
33. Keeton RE, Widiss AI. Insurance
Law: A Guide to Fundamental Principles,
Legal Doctrines, and Commercial Practice.
St Paul, MN: West Publishing; 1988:x4.8(b)
at 963–967.

30. Wynn LL, Trussell J. Images of
American sexuality in debates over nonprescription access to emergency

When There’s a Heartbeat: Miscarriage Management
in Catholic-Owned Hospitals
Lori R. Freedman, PhD, Uta Landy, PhD, and Jody Steinauer, MD, MAS

As Catholic-owned hospitals
merge with or take over other
facilities, they impose restrictions on reproductive health services, including abortion and
contraceptive services. Our interviews with US obstetrician–
gynecologists working in Catholic-owned hospitals revealed
that they are also restricted in
managing miscarriages.
Catholic-owned
hospital
ethics committees denied approval of uterine evacuation while fetal heart tones
were still present, forcing physicians to delay care or transport miscarrying patients to
non–Catholic-owned facilities.
Some physicians intentionally
violated protocol because they
felt patient safety was compromised.
Although Catholic doctrine
officially deems abortion

permissible to preserve the life
of the woman, Catholic-owned
hospital ethics committees
differ in their interpretation of
how much health risk constitutes a threat to a woman’s
life and therefore how much
risk must be present before
they approve the intervention.
(Am J Public Health. 2008;98:
1774–1778. doi:10.2105/AJPH.
2007.126730)
OVER THE PAST DECADE, AS
Catholic hospitals have merged
with and purchased nonsectarian
hospitals around the United States,
the lay press and legal journals
have featured discussion about the
impact of these mergers on patient
care, particularly with regard to reproductive health.1–5 The literature
has focused on policies prohibiting
tubal ligation, contraceptive

1774   Government, Politics, and Law   Peer Reviewed   Freedman et al.

services, emergency contraception, and abortion. Although other
religiously owned and nonsectarian hospitals may also prohibit or
limit some of these services, Catholic-owned hospitals are the largest group of religiously owned
nonprofit hospitals, operating
15.2% of the nation’s hospital
beds,6 and increasingly they are
the only hospitals in certain regions within the United States.7
The result is that Catholic and nonCatholic patients alike come to depend on these facilities for emergencies, childbirth, and routine
procedures without knowing how
some of their options are potentially curtailed.
The findings reported here
were not the original focus of our
research. In the process of conducting a qualitative study about

abortion provision in the clinical
practice of obstetrician–gynecologists, we interviewed 30 obstetrician–gynecologists around the
United States. During the interviews, which were conducted in
2006, 6 physicians working with
or within Catholic-owned hospitals revealed that they were constrained by hospital policies in
their ability to undertake urgent
uterine evacuation. They reported
that Catholic doctrine, as interpreted by their hospital administrations, interfered with their
medical judgment. For example,
some of them were denied permission to perform an abortion
when uterine evacuation was medically indicated and fetal heart
tones were still present.
Catholic-owned institutions
and their employees must adhere

American Journal of Public Health   October 2008, Vol 98, No. 10

 GOVERNMENT, POLITICS, AND LAW

to medical practice guidelines
contained in the ‘‘Ethical and
Religious Directives for Catholic
Health Care Services’’ (hereafter
called ‘‘the directives’’) written by
the Committee on Doctrine of the
National Conference of Catholic
Bishops.8 The directives state that
abortion is never permitted. However, regarding emergency care
during miscarriage management,
the manual used by Catholicowned hospital ethics committees
to interpret the directives states
that abortion is acceptable if the
purpose is to treat ‘‘a life-threatening pathology’’ in the pregnant
woman when the treatment cannot be postponed until the fetus is
viable.9 The experiences of physicians in our study indicate that
uterine evacuation may not be
approved during miscarriage by
the hospital ethics committee if
fetal heart tones are present and
the pregnant woman is not yet ill,
in effect delaying care until fetal
heart tones cease, the pregnant
woman becomes ill, or the patient
is transported to a non–Catholicowned facility for the procedure.
Although medical journals have
featured articles about a physician’s right to refuse patients
treatment, referral, or information
regarding services to which the
physician has religious objections,10–12 few articles in the medical literature published to date
have addressed the effect of
Catholic-owned hospital policies
on patient care and the professional conduct of physicians.13,14
One recent opinion piece in the
Journal of the American Medical
Association described how a patient was transferred from a religiously owned to a nonsectarian

hospital for labor induction to facilitate spontaneous abortion because the religious hospital would
not allow the procedure until after
she became septic.15 The following
interview excerpts demonstrate
how 5 different Catholic-owned
hospital ethics committees
responded to 6 physician requests
to evacuate the uterus during miscarriage and the resulting effects on
miscarriage management.

MISCARRIAGE
MANAGEMENT
According to the generally accepted standards of care in miscarriage management, abortion is
medically indicated under certain
circumstances in the presence of
fetal heart tones. Such cases include first-trimester septic or inevitable miscarriage, previable
premature rupture of membranes
and chorioamnionitis, and situations in which continuation of the
pregnancy significantly threatens
the life or health of the woman. In
each instance, the physician must
weigh the health impact to the
woman of continuing the pregnancy against the potential viability of the fetus. Ideally, the physician then engages in a sensitive
decisionmaking process with the
patient. The physician reviews
with the patient the risks of continuing the pregnancy and the
likelihood of fetal survival, as well
as management options that include ‘‘expectant management’’
(i.e., no intervention) and termination of pregnancy, with the
physician often recommending a
form of management. The patient
then chooses how to proceed;
when fetal survival is no longer

October 2008, Vol 98, No. 10   American Journal of Public Health

possible or when continuing the
pregnancy involves significant
risk, she may decide to terminate
the pregnancy. For spiritual or
psychological reasons, a patient
may prefer to delay induction of
labor or surgical uterine evacuation until there is no fetal heartbeat, even in cases in which the
risk of expectant management to
her health is great.
In general, this process of assisted decisionmaking is guided
by informed consent or informed
choice,16 which requires that the
patient understand all appropriate
medical options, as well as the
relevant risks and benefits of each,
before choosing and consenting
to a course of management. Informed choice and consent
may be compromised when hospital policies restrict physicians
from offering treatment options
routinely available in other
hospitals.

OVERVIEW OF CATHOLIC
POLICY
The standards of medical care
put forth in the directives are at
variance with those generally recognized in other medical settings,
particularly regarding care at the
beginning and ending of life. They
were codified over 50 years ago to
ensure strict obedience to Catholic principles by all employees of
Catholic-owned hospitals, without
local variation.17 The directives
sanction prenatal care and natural family planning but prohibit
nearly all other reproductive services, including all other birth
control methods, emergency contraception, infertility treatment,
sterilization, and abortion.8 In

Catholic-owned hospitals, physicians must request approval to
terminate a pregnancy for any indication from the ethics committee, which interprets and enforces
the directives. Such consultations
can be done quickly over the
phone with an on-call representative of the committee, typically a
priest or nun, if the medical situation is urgent. In theory, therefore,
consultation with the ethics committee presents only a minor delay
to urgent care. If the situation is
not urgent, the committee convenes to discuss the matter and
then offers its ruling.
An important qualification of
the prohibition of abortion is
made in Directive 47. Termination of pregnancy is permissible
if the health of the mother is at
risk:
Operations, treatments, and
medications that have as their
direct purpose the cure of a proportionately serious pathological
condition of a pregnant woman
are permitted when they cannot
be safely postponed until the unborn child is viable, even if they
will result in the death of the
unborn child.8

The death of the fetus is therefore acceptable as a secondary
consequence of actions intended
to preserve the health of the
pregnant woman. However, the
manual of Catholic hospital ethics
committees, used to help them
interpret and apply the directives,
warns, ‘‘The mere rupture of
membranes, without infection, is
not serious enough to sanction
interventions that will lead to the
death of the child.’’6 By contrast,
writing in a leading Catholic health
journal, other Catholic health
ethicists offer a more liberal

Freedman et al.   Peer Reviewed   Government, Politics, and Law   1775

 GOVERNMENT, POLITICS, AND LAW

interpretation of Directive 47:
uterine evacuation is indicated if
abortion is inevitable and delay
will harm the pregnant woman.18
Therefore, the former—and arguably more authoritative—source
approves of uterine evacuation
only after a woman becomes
sick, and the latter approves of it
as a measure to prevent sickness.
Our data indicate that despite
Catholic leaders’ desire for strict
standardization of Catholic-owned
health services, varying interpretations and executions of Directive
47 exist both at the individual
(practitioner) and institutional
(hospital ethics committee)
levels.

STUDY AND METHODS
Our findings arose from a study
that was not originally focused on
care in Catholic-owned hospitals.
In-depth interviews were conducted in person and over the
telephone with 30 obstetrician–
gynecologists to determine the
impact of residency abortion
training on their future medical
practice. Study participants graduated between 1996 and 2001
from residency programs in the
western, midwestern, northeastern, and southern United States
that offered routine abortion
training, as opposed to elective or
‘‘opt-in’’ training. Most physicians
in the study reported that they had
participated in such training.
Requests for study participation, contact information, and
consent forms were sent to all
residents (about 150 in total) of
4 residency programs, one in each
of the regions. In this way, we obtained interviews with 30

physicians—at least 5 from each
region. Questions were designed
to assess the effects of abortion
training during residency and obstacles to the subsequent practice
of abortion in their various professional environments. Transcripts of the interviews were analyzed with Atlas.ti 5.0 (ATLAS.ti
Scientific Software Development
GmbH, Berlin, Germany) for thematic content.
Thirteen of the physicians interviewed had worked in Catholicowned hospitals regularly or occasionally since their residency.
The following reports concerning
miscarriage management come
from 6 physicians working with
and within Catholic-owned health
institutions, each of whom reported at least one such event.
Five of the 6 physicians participated in abortion training. Two
of the 6 physicians currently work
in academic medical centers and
have continued to perform abortions after residency, and the
remaining 4 are prohibited from
doing so by their Catholic-owned
institutional employers.
In the interview excerpts, the
initials of physicians’ names are
based on pseudonyms. Physicians
offered their accounts in the context of questions about their work
history and whether they had experienced conflict with colleagues
or superiors over the issue of
abortion. Although the effect of
religious ownership of health care
was not initially a focus of our
study, we believe it is important
to examine and document these
cases to highlight miscarriage
management in Catholic-owned
hospitals and find ways to improve
care for pregnant women.

1776   Government, Politics, and Law   Peer Reviewed   Freedman et al.

For purposes of confidentiality, no
identifiers beyond the type of
physician and the region and size
of the city in which he or she
practices are given.

RESULTS
Nontreatment, Delays, and
Transport of Patients
Obstetrician–gynecologists working in Catholic-owned hospitals
described cases in which abortion
was medically indicated according
to their medical judgment but,
because of the ethics committee’s
ruling, it was delayed until either
fetal heartbeats ceased or the patient could be transported to another facility. Dr P, from a midwestern, mid-sized city, said that at
her Catholic-owned hospital, approval for termination of pregnancy was rare if a fetal heartbeat
was present (even in ‘‘people who
are bleeding, they’re all the way dilated, and they’re
only17 weeks’’) unless ‘‘it looks like
she’s going to die if we don’t do it.’’
In another case, Dr H, from the
same Catholic-owned hospital in
the Midwest, sent her patient by
ambulance 90 miles to the nearest
institution where the patient could
have an abortion because the
ethics committee refused to approve her case.
She was very early, 14 weeks. She
came in . . . and there was a hand
sticking out of the cervix. Clearly
the membranes had ruptured
and she was trying to deliver. . . .
There was a heart rate, and [we
called] the ethics committee, and
they [said], ‘‘Nope, can’t do anything.’’ So we had to send her to
[the university hospital]. . . . You
know, these things don’t happen
that often, but from what I understand it, it’s pretty clear. Even
if mom is very sick, you know,

potentially life threatening, can’t
do anything.

In residency, Dr P and Dr H had
been taught to perform uterine
evacuation or labor induction on
patients during inevitable miscarriage whether fetal heart tones
were present or not. In their new
Catholic-owned hospital environment, such treatment was considered a prohibited abortion by the
governing ethics committee because the fetus is still alive and the
patient is not yet experiencing ‘‘a
life-threatening pathology’’ such
as sepsis. Physicians such as
Dr H found that in some cases,
transporting the patient to another
hospital for dilation and curettage (D&C) was quicker and safer
than waiting for the fetal heartbeat to stop while trying to stave
off infection and excessive blood
loss.
Dr B, an obstetrician–gynecologist working in an academic
medical center, described how a
Catholic-owned hospital in her
western urban area asked her to
accept a patient who was already
septic. When she received the
request, she recommended that
the physician from the Catholicowned hospital perform a uterine aspiration there and not further risk the health of the woman
by delaying her care with the
transport.
Because the fetus was still alive,
they wouldn’t intervene. And she
was hemorrhaging, and they
called me and wanted to transport her, and I said, ‘‘It sounds
like she’s unstable, and it sounds
like you need to take care of her
there.’’ And I was on a recorded
line, I reported them as an
EMTALA [Emergency Medical
Treatment and Active Labor Act]

American Journal of Public Health   October 2008, Vol 98, No. 10

 GOVERNMENT, POLITICS, AND LAW

violation. And the physician
[said], ‘‘This isn’t something that
we can take care of.’’ And I [said],
‘‘Well, if I don’t accept her, what
are you going to do with her?’’
[He answered], ‘‘We’ll put her on a
floor [i.e., admit her to a bed in the
hospital instead of keeping her in
the emergency room]; we’ll transfuse her as much as we can, and
we’ll just wait till the fetus dies.’’

Ultimately, Dr B chose to
accept the patient to spare her
unnecessary suffering and
harm, but she saw this case as a
form of ‘‘patient dumping,’’ because the patient was denied
treatment and transported while
unstable.

Circumventing the Ethics
Committee
Some doctors have decided to
take matters into their own hands.
In the following case, the refusal of
the hospital ethics committee to
approve uterine evacuation not
only caused significant harm to the
patient but compelled a perinatologist, Dr S, now practicing in a
nonsectarian academic medical
center, to violate protocol and resign from his position in an urban
northeastern Catholic-owned hospital.
I’ll never forget this; it was
awful—I had one of my partners
accept this patient at 19 weeks.
The pregnancy was in the vagina.
It was over. . . . And so he takes
this patient and transferred her
to [our] tertiary medical center,
which I was just livid about, and,
you know, ‘‘we’re going to save
the pregnancy.’’ So of course, I’m
on call when she gets septic, and
she’s septic to the point that I’m
pushing pressors on labor and
delivery trying to keep her blood
pressure up, and I have her on a
cooling blanket because she’s 106
degrees. And I needed to get
everything out. And so I put the

ultrasound machine on and there
was still a heartbeat, and [the
ethics committee] wouldn’t let
me because there was still a
heartbeat. This woman is dying
before our eyes. I went in to
examine her, and I was able to
find the umbilical cord through
the membranes and just snapped
the umbilical cord and so that I
could put the ultrasound—‘‘Oh
look. No heartbeat. Let’s go.’’ She
was so sick she was in the [intensive care unit] for about 10
days and very nearly died. . . .
She was in DIC [disseminated
intravascular coagulopathy]. . . .
Her bleeding was so bad that the
sclera, the white of her eyes,
were red, filled with blood. . . .
And I said, ‘‘I just can’t do this.
I can’t put myself behind this.
This is not worth it to me.’’ That’s
why I left.

From Dr S’s perspective, the
chances for fetal life were nonexistent given the septic maternal
environment. For the ethics committee, however, the present yet
waning fetal heart tones were evidence of fetal life that precluded
intervention. Rather than struggle
longer to convince his committee
to make an exception and grant
approval for termination of pregnancy, Dr S chose to covertly
sever the patient’s umbilical cord
so that the fetal heartbeat would
cease and evacuation of the uterus
could ‘‘legitimately’’ proceed.
Dr G also circumvented the
ethics committee in her southern
Catholic-owned hospital. She
opted not to check fetal heart
tones or seek ethics committee
approval when caring for a miscarrying woman for fear that documentation of fetal heart tones
would have caused unnecessary
delays. This led to conflict with the
nurse assisting her.
She was 14 weeks and the membranes were literally out of the

October 2008, Vol 98, No. 10   American Journal of Public Health

cervix and hanging in the vagina.
And so with her I could just take
care of it in the [emergency
room] but her cervix wasn’t open
enough . . . so we went to the
operating room and the nurse
kept asking me, ‘‘Was there heart
tones, was there heart tones?’’ I
said ‘‘I don’t know. I don’t know.’’
Which I kind of knew there would
be. But she said, ‘‘Well, did you
check?’’ . . . I said, ‘‘I don’t need an
ultrasound to tell me that it’s inevitable . . . you can just put, ‘The
heart tones weren’t documented,’
and then they can interpret that
however they want to interpret
that.’’ . . . I said, ‘‘Throw it back
at me . . . I’m not going to order
an ultrasound. It’s silly.’’ Because
then that’s the thing; it would
have muddied the water in this
case.

Dr G’s main concern was sparing the patient extended suffering
during loss of pregnancy. She disregarded the authority and protocol of the hospital ethics committee by not checking for fetal heart
tones, which, she believed, would
have led to significant delay in the
inevitable treatment.

Strategic Communication
With Ethics Committees
Dr J, an obstetrician–gynecologist working in a small town in the
West, had success navigating his
ethics committee by presenting
patients to them in the language of
the directives themselves. A nun
advised him that terminology such
as ‘‘inevitable abortion’’ and ‘‘maternal complications’’ should be
highlighted.
I [received] a good bit of advice
actually . . . from the sister that
sits on the ethics committee the
first time I tried to have one of
these conversations with her. She
said, ‘‘Well, what are you concerned about with the mom?’’ . . .
[T]hat’s just the way that the
conversation gets started. . . . I

don’t know if she was trying to
give me a hint or whether she
was . . . just interested in doing
what she really considers to
be the right thing, the moral
thing . . . but it certainly helped
me out.

Dr J described how he applied
this advice in another case. The
patient, at 20 weeks, was dilated
with a placental abruption and
fetal heart tones present, and
she preferred to expedite uterine
evacuation. He presented her case
to the ethics committee in this
fashion: ‘‘If we continue to watch
this placental abruption, it could
end up being dangerous, [leading
to] transfusions or potentially even
maternal death, if left untreated.’’
This was the only case of approval
by a Catholic-owned institution’s
ethics committee for urgent uterine evacuation with fetal heart
tones present that was mentioned
in the interviews.

DISCUSSION
Physicians working in Catholicowned hospitals in all 4 US regions of our study disclosed experiences of being barred from
completing emergency uterine
evacuation while fetal heart tones
were present, even when medically indicated. As a result, they
had to delay care or transfer patients to non–Catholic-owned facilities. Some physicians violated
the authority and protocol of the
ethics committee to deliver what
they considered safe medical care
that reflected the standard of care
learned in residency. The extent to
which this might occur needs to be
researched further but may be
difficult to assess, because most
physicians are not likely to discuss

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 GOVERNMENT, POLITICS, AND LAW

such behavior even in a confidential interview.
Contradictory interpretations of
Directive 47 in the Catholic health
literature and in practice indicate
that ethics committees are either
uncertain or in disagreement
about how to manage miscarriage
when fetal heart tones are present
and what exact circumstances allow for termination of pregnancy
in Catholic-owned hospitals. In
cases in which physicians judge
their patients’ health or comfort to
be compromised by delay, they
may, like Dr J, obtain safer and
more-expeditious patient care by
emphasizing to the ethics committee the inevitability of fetal death
and the risk of maternal complications. When physicians are unable to persuade the committee
to approve pregnancy termination
in emergency cases, however, it
appears that patients may receive
treatment that is riskier and less
comfortable than the care provided in non-Catholic medical
settings.
Given the prevalence of Catholic-owned health care today, these
issues bring to light important
policy questions about standards
of medical practice and a patient’s
right to information. Patients entering a Catholic-owned hospital
may be aware that abortion services are not available there, but
few prenatal patients conceive of
themselves as potential abortion
patients and therefore they are not
aware of the risks involved in being treated there; these include
delays in care and in being transported to another hospital during
miscarriage, which may adversely
affect the patient’s physical and
psychological well-being.

For women to make informed
decisions about care, physicians
must be able to communicate
clearly with them about the
chances of fetal survival, all management options, and their recommendations. After such counseling,
which also includes a discussion of
the patient’s personal beliefs, she
will give informed consent to a
specific management option of her
choice. As with other examples of
medical decisionmaking, the physician’s recommendation is not always the chosen course. When a
physician has recommended termination because waiting until the
fetus is dead carries a high risk, a
woman might decline intervention
because of her personal beliefs.
When possible, the course of
treatment must be the patient’s
decision, but it is important that
the physician is able to offer patients pregnancy termination
when he or she considers it a
necessary treatment without having to defy hospital policy or risk
job loss.
Our findings bring into question
the ethics of an institution’s right
to refuse care as granted by ‘‘conscience clauses.’’12,19 Should a religiously owned institution have a
right to a legally protected ‘‘conscience’’ in the same way an individual physician does? These are
questions that members of the
medical profession, ethicists, and
lawmakers must continue to grapple with. The case histories we
described indicate that, in some
Catholic-owned hospitals, the private patient–physician relationship, patient safety, and patient
comfort are compromised by religious mandates that require physicians to act contrary to the

1778   Government, Politics, and Law   Peer Reviewed   Freedman et al.

current standard of care in miscarriage management. j

5. Brooks P. Merge talk under way for
Kingston’s two hospitals. [Kingston, NY]
Times Herald-Record. December 30, 2006.

About the Authors

6. Catholic Health Care in the United
States. Washington, DC: Catholic Health
Association; 2007.

The authors are with the Department of
Obstetrics, Gynecology and Reproductive
Sciences and the Bixby Center for Reproductive Health Global, University of California, San Francisco.
Requests for reprints should be sent to
Lori R. Freedman, PhD, UCSF Bixby Center
for Global Reproductive Health, 1330
Broadway Street, Ste 1100, San Francisco,
CA 94110 (e-mail: freedmanl@obgyn.
ucsf.edu).
This article was accepted January 17,
2008.

Contributors
L. R. Freedman conducted the research,
did preliminary analysis, and led the
writing. U. Landy and J. Steinauer conceptualized and supervised the study,
contributed to analysis, and assisted in
the writing.

Acknowledgments
This research was sponsored by the
Kenneth J. Ryan Residency Training Program in Abortion and Family Planning at
the Bixby Center, University of California,
San Francisco.
Carole Joffe, Felisa Preskill, Joy Singleton, Ori Tzvieli, and Tracy A. Weitz
provided support and helpful feedback.

Human Participant Protection
This study was approved by the institutional review board of the University of
California, San Francisco.

References
1. Vitello P. Used to big losses, Schenectady is hit hard by plan for hospitals.
New York Times. December 4, 2006:B1.
2. Sloboda M. The high cost of merging
with a religiously controlled hospital.
Berkeley Womens Law J. 2001;16:140–
156.
3. Labi N. Holy owned. Is it fair for a
Catholic hospital to impose its morals on
patients? Time. 1999;154(20):85–86.
4. Fogel SB, Rivera LA. Saving Roe is not
enough: when religion controls healthcare. Fordham Urban Law J. 2004;
31(3):725–749.

7. Uttley L, Pawelko R. No strings attached: public funding of religiously
sponsored hospitals in the United States.
In: The Merger Watch Project. New York,
NY: Family Planning Advocates of New
York State; 2002:11–12.
8. Catholic Health Association. Ethical and religious directives for Catholic
health care services. Origins. 2001;31(9):
153, 155–163.
9. Cataldo PJ, Moraczewski AS. Catholic
Health Care Ethics: A Manual for Ethics
Committees. Boston, MA: National Catholic Bioethics Center; 2002.
10. Charo RA. The celestial fire of
conscience—refusing to deliver medical
care. N Engl J Med. 2005;352(24):2471–
2473.
11. Curlin FA, Lawrence RE, Chin MH,
Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med.
2007;356(6):593–600.
12. Dickens BM, Cook RJ. The scope and
limits of conscientious objection. Int J
Gynaecol Obstet. 2000;71(1):71–77.
13. Gallagher J. Religious freedom, reproductive health care, and hospital
mergers. J Am Med Womens Assoc. 1997;
52(2):65–68.
14. Bellandi D. Access declines. Reproductive services fall with hospital consolidation. Mod Healthc. 1998;28(16):26.
15. Raghavan R. A piece of my mind. A
question of faith. JAMA. 2007;297(13):
1412.
16. Dickens BM, Cook RJ. Dimensions
of informed consent to treatment. Int J
Gynaecol Obstet. 2004;85(3):309–314.
17. O’Rourke KD, Kopfen-Steiner T,
Hamel R. A brief history. A summary of
the development of the Ethical and Religious Directives for Catholic Health Care
Services. Health Prog. 2001;82(6):18–
21.
18. deBlois J, O’Rourke KD. Care for the
beginning of life. The revised Ethical and
Religious Directives discuss abortion,
contraception, and assisted reproduction.
Health Prog. 1995;76(7):36–40.
19. Fogel SB, Weitz TA. Health Care
Refusals: Undermining Medical Standards
of Care for Women. Los Angeles, CA:
National Health Law Program. In press.

American Journal of Public Health   October 2008, Vol 98, No. 10