Robert Ullman
These are the places that have Catholic hospital mergers completed or in the works, which means that residents may soon be receiving health care according to the moral dictates of the Catholic Church—whether they agree with it or not.

I'm sitting in a crowded coffee shop and I'm making a woman cry. At least, that's how it looks. Tears are slipping down the laugh lines in her cheeks, and one hand rests on her small belly. People around us are covertly staring.

But we're not discussing her pregnancy, not yet. We're talking about Savita Halappanavar, the Ireland resident who died from pregnancy complications four months ago, in a country that doesn't believe in abortion. "Except, of course, when a woman's life is in danger—they all add that caveat," the woman across from me says. "Like your pregnancy is a game of chicken they can play."

When Halappanavar was told that she was miscarrying, the 31-year-old dentist and her husband mourned the loss of what would have been their firstborn child. According to reports, they were eager to start a family. But, as there was nothing Halappanavar or doctors could do to save her 17-week-old fetus, she asked for an abortion to speed up the heart-wrenching process.

And she was denied.

According to Halappanavar's husband, they were told, "This is a Catholic country." Even though abortion wasn't against the Hindu couple's religious beliefs, they were told that her fetus still had a heartbeat, and as long as that tiny heart kept beating, doctors would do nothing to speed up her body's inevitable miscarriage.

Still, she asked, day after day, according to her husband, as her body grew weaker, her blood pressure dropped and her fever spiked, and she became disoriented and afraid. Doctors and nurses monitored her for infections but told her husband there was nothing more they could do, even as she vomited and her breathing became irregular. Finally, on October 24, three days after being admitted to the hospital, the fetal heartbeat stopped. Doctors snapped into action, and within hours, Halappanavar delivered a dead fetus. But it was too late for the aspiring mother: Despite the steady stream of antibiotics being administered to her, infection set in, then septic shock. As Halappanavar lost consciousness, her now-empty womb bloated with infection and her skin turned blue, according to her husband's reports. Doctors assured him that she was young and she'd bounce back, even as her body shut down, even as she could no longer breathe on her own and her body wouldn't respond to dialysis. One week after being admitted to the hospital, Halappanavar died.

If one good can be taken from Halappanavar's slow and likely avoidable death, it's that the world witnessed it and an important dialogue began: Whose ethical or religious conscience reigns supreme in hospitals—the patients whose health is at stake or the institutions caring for them?

The hospital where Halappanavar was a patient has announced that it is investigating the circumstances that led to her death. Meanwhile, officials within the Irish government announced their intentions to draft new regulations clarifying when doctors can perform abortions.

Here in Washington, 4,500 miles from Ireland and a world away from that country's Catholic-driven politics, it's easy to clutch your pearls and dismiss Halappanavar's death as a horror story. After all, Washington residents voted to legalize abortion in 1970, three years before Roe v. Wade, and we've consistently upheld a woman's right to access abortion services since then.

But cases like Halappanavar's exist in Washington State. In fact, they've happened right here in Seattle. "I was past 24 weeks when doctors at Swedish told me I was miscarrying," explains the woman sitting across from me at the coffee shop. We'll call her Mary. She's asked to remain anonymous to maintain her privacy, but like Halappanavar, Mary is a thirtysomething professional who was eager to start a family with her husband. So they got pregnant the old-fashioned, church- approved way: missionary style, after marriage. Life was swell, and the ultrasounds looked good. And then Mary awoke in pain last year; there was blood. She was checked into Swedish Medical Center, Seattle's largest nonprofit health-care provider. But unbeknownst to Mary, last year the hospital formed an alliance with Providence, a Washington-based Catholic institution that operates 32 hospitals in Alaska, California, Montana, Oregon, and Washington. Per their new relationship, Swedish agreed to stop performing abortions except in emergency situations—you know, like when a woman's life is at risk. Its website now advertises OB "speed dating" events to new mothers: Choose the OB who will deliver your baby! But for expectant mothers whose pregnancies don't make it that far, and whose health hasn't yet deteriorated to "emergency" status, a grim set of entirely different choices await.

During Mary's Swedish visit last year, "They said that they couldn't save the fetus but it still had a heartbeat, so there was nothing they could do. They had to wait for the heartbeat to stop."

Mary says she demanded an abortion but was basically told her options were to "wait for nature to take its course" or unhook herself, crawl out of bed, and find another hospital. "It was a nightmare," she says. "It still is."

Miscarriages are common, and complications can be deadly. The American Pregnancy Association estimates that between 10 and 25 percent of all clinically recognized pregnancies end in miscarriage, and the chance that a woman will suffer a miscarriage during her pregnancy rises with age.

Fortunately for Mary, the fetal heartbeat stopped soon after she was admitted. But the emotional damage she sustained runs deep. "That experience left me mistrustful of doctors. I still feel helpless about it. My husband and I want to have a baby, but frankly I'm afraid of getting pregnant again."

Patient confidentiality prevents Swedish from commenting on Mary's case, but I contacted both Swedish and Providence to find out what specific guidelines or protocols the hospitals have in place for dealing with pregnant women in crisis. (Swedish has pledged to continue providing abortions when a mother's health is at risk, as has Providence.) Both hospitals stress that each case is unique but that the health of every mother is their priority.

"Our commitment at Providence is to provide the highest quality, compassionate care to women and babies," says spokesperson Colleen Wadden. When pressed for details on what turns a prohibited, elective abortion into an allowable, necessary abortion, her answer is vague. "It wouldn't be appropriate to speculate on a hypothetical patient scenario," she says. (A spokesperson for Swedish echoed this position.)

Unofficially, Swedish may have chalked up Mary's case to a training error.

At least that's the theory offered by Chris Charbonneau, CEO of Planned Parenthood of the Great Northwest: "We heard of a case like that at Swedish. We heard that it was a training problem." Charbonneau explains, "In the wake of the hospital alliance, there was a lot of confusion and fear among staff about what was permissible and what wasn't."

Charbonneau says she's confident that this particular "training problem" has been fixed. In fact, she's staking her reputation on it. When Swedish entered into its new partnership with Providence and agreed to stop providing abortion services except in emergency instances, the administration took a proactive and somewhat admirable step: They pushed Planned Parenthood to open a clinic in an adjoining medical tower. That clinic, which is accessible by a breezeway, functions like any other Planned Parenthood clinic, offering everything from STD testing, abortion services, and sexual education to in-office female sterilization and vasectomies. "It was important to us that women continue to have the same access to services and not feel ostracized," Charbonneau says. "But we wouldn't enter into any deal with Swedish that would leave women coming into the ER in any kind of trouble. They have a commitment to me, in writing, that there will be no women getting hurt and no women dying."

Charbonneau says that Swedish has kept its word and has performed emergency abortions in its hospital.

This partnership with Planned Parenthood makes Swedish one of the most progressive Catholic hospital partnerships in the state. But there are a lot of other partnerships under way that would be far less progressive—partnerships involving organizations that aren't urging Planned Parenthood to open offices in the building next door. Catholic hospitals account for more than 12 percent of health-care institutions in the United States, according to the Catholic Health Association of the United States, which means that roughly one in eight Americans seeks treatment at one, whether they realize it or not. Here in the Northwest, our percentage of Catholic hospitals is much higher—44 percent and growing.

Catholic institutions across the nation are merging with secular hospitals, clinics, and even small private practices at an unprecedented rate. Optimists explain that the consolidation and shared infrastructure help reduce costs. Pessimists point out that the aggressive mergers come at a time when Catholic bishops are exerting and expanding their authority. "I see it as a conscious effort to achieve through the private market what they failed to achieve through the courts or at the ballot box," says Monica Harrington, a San Juan Island resident who's spent the last year fighting a Catholic hospital in her town.

Three of the largest health-care systems in the Northwest—PeaceHealth, Providence Health & Services, and Franciscan Health System—are Catholic entities, and they're busy making new deals in our state. According to MergerWatch, a nonprofit that tracks Catholic hospital mergers across the nation, there was a record-breaking 10 mergers announced in Washington State in 2012.

"In the 15 years we have been tracking religious/secular hospital mergers, we have never seen so many active cases in one state—until now," says Lois Uttley, the founder and director of MergerWatch. Compounding the problem: All 10 mergers would happen in Western Washington, which means that in the space of a few years, patients with needs that go against Catholic teaching could be forced to drive hundreds of miles to access the health services they need.

The mergers wouldn't just affect women's health care, they would affect end-of-life care for everyone and, potentially, compassionate medical care for members of the LGBT community.

"One merger is worrisome enough. There's no adequate oversight of the impact of all these individual cases," explains Sheila Reynertson, a six-year advocacy coordinator with MergerWatch. "Look at them all on a map—if they all come under Catholic rule, it wipes out a huge geographical area for all reproductive health care and the full range of end-of-life choices." The end result? The Catholic Church effectively controls medical care in Skagit, Whatcom, and San Juan Counties. "People living in Western Washington should be worrying."

When you enter a hospital seeking care, you carry with you a set of assumptions: You trust your doctors will explain all of your medical options to you after a thorough examination. You trust your doctors will recommend a treatment based on those options. You trust that they will help you make an informed decision about your treatment. You trust that they will treat you.

But what happens when religious restrictions interfere with that trust? To understand Catholic health care, it's important to know the rules that guide Catholic hospitals, otherwise known as Ethical and Religious Directives (ERDs). These directives are drafted and tweaked by the rotating cast of mostly white, mostly celibate bishops couch-surfing at the Vatican. ERDs operate like a code of conduct that medical staff in Catholic hospitals agree to abide by, regardless of whether or not a particular staffer is Catholic. For the most part, the directives aren't suggestions—they're prescriptive.

"Any partnership... must respect church teaching and discipline," one directive states. The church monitors the implementation of these directives through hospital ethic committees overseen by regional bishops like our very own Archbishop Peter Sartain.

Sure, in 43 pages of Ethical and Religious Directives, there's some common-sense guidance to be found. But they're also flush with horrifying detail. As you'd expect, the directives pertaining to women's fertility read like a misogynist romance novel or found art from the Middle Ages: "Catholic health institutions may not promote or condone contraceptive practices." Emergency contraception can only be given to rape victims, and even then only "if, after appropriate testing, there is no evidence that conception has occurred already." Vasectomies and tubal ligations are also prohibited. Egg and sperm donors are deemed "contrary to the covenant of marriage," surrogate motherhood is prohibited because it denigrates "the dignity of the child and marriage," and doctors at Catholic hospitals can't help infertile couples conceive artificially—using their own eggs and sperm—because test-tube babies "separate procreation from the marital act in its unitive significance."

Then there's this: "Abortion... is never permitted."

Not even when the egg attaches outside the uterus and puts a mother's life in danger: "In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion."

Vasectomies, sperm donation, abortions, surrogacy—these are all perfectly legal, mundane procedures that married couples and single people of all faiths utilize (as recent statistics show, even 98 percent of Catholic women admit to using birth control). And yet, according to the Catholic institutions conquering our medical ones, these are options patients should not have.

In 2008, 59 percent of Washington voters approved a statewide "Death with Dignity" initiative, making our state the second (of only three) in the country to embrace physician-assisted suicide for people with terminal illnesses. In San Juan County, the initiative's approval rate was much higher—an overwhelming 72 percent.

Acquiring the drugs to end your life is a predictably onerous process. Nonetheless, the law is serving its purpose. According to the most recent status report from the Washington State Department of Health, 103 people received life-ending medication in 2011, 98 of whom lived west of the Cascade Mountains. These terminal patients cited fears of losing their autonomy, their dignity, and their joy in life as their main reasons for wanting to die in peace at their own pace.

But residents of Friday Harbor can't even acquire the life-ending drugs they voted to legalize four years ago. The island's only hospital, PeaceHealth's Peace Island Medical Center, is Catholic affiliated.

PeaceHealth operates nine hospitals and 73 medical centers in the Northwest. Its newest hospital opened last November with all the medical gadgetry a small island population could desire: an expanded primary care and specialty clinic, a shiny new diagnostic services center, a cancer care suite for on-island chemotherapy, a 24-hour emergency room, even 10 hospital beds reserved for short-term care. Even though it is not owned by the church—just affiliated with it—PeaceHealth still chooses to "manifest" the Catholic ERDs in its own ethical policies, CEO Nancy Steiger tells me. They also keep "on-staff ethicists."

Not being a direct arm of the Catholic Church theoretically gives the hospital more flexibility. "We don't allow abortion or physician-assisted suicide on our property," Steiger says, but physicians can prescribe birth control if it's deemed "a medical necessity." And physicians can talk about physician-assisted suicide with patients (even if they can't administer it) because conversations are considered "private and protected."

But these concessions sound more generous than they are, considering that Peace Island is located on an island. Sure, a physician could theoretically refer a terminal patient to a doctor on the mainland for help acquiring life-ending drugs, but hopping a ferry for a road trip isn't practical for someone who already feels so awful they want to end their life. On San Juan Island, Death with Dignity is functionally useless.

By default, islanders are instead forced to die the Catholic way. And if living by the church's ethical directives is hard, dying by them is hell. For example, let's say that an accident leaves you comatose and brain-dead in the nearest Catholic hospital. You would be faithfully fed and watered so that you may "reasonably be expected to live indefinitely," regardless of your last wishes, according to the ERDs. If you're cognizant and dying, your options aren't much better: "Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering."

"We're essentially paying a Catholic institution to deny us care," explains island resident Monica Harrington, a soft-spoken blond with steely eyes. "It isn't right."

As the eighth child of devout Catholic parents, Harrington grew up loving the church she now finds herself battling. Despite her parents' religious beliefs, they were equally devout believers that abortions saved women's lives. Now, fighting San Juan Island's Catholic hospital monopoly has become Harrington's unofficial full-time job. Last year, she spearheaded a 300-person petition to kill the deal before contracts were signed. She helped pack public meetings with skeptical, angry locals. More importantly, when the county's hospital district commissioners finalized a 50-year lease agreement with PeaceHealth last year, she didn't stop talking about inequity. Island property owners are now paying $1 million in annual property taxes to support the hospital. Proponents of the agreement argue that there's no law dictating what entities hospital districts can and can't contract with. Undeterred, Harrington continues to push for the agreement to be renegotiated: She thinks PeaceHealth should only be contracted and paid for the specific services it offers. She thinks PeaceHealth should have to disclose what services it doesn't provide, preferably in bold, red, 16-point type on the door. She thinks PeaceHealth should be held accountable for masquerading as a comprehensive health-care institution, taking taxpayer money, and then refusing care based on religious standards its patients may not agree with. She's contacted her legislators, the state attorney general's office, and the ACLU.

And she's getting their attention.

In February, state senator Kevin Ranker (D-San Juan Islands) introduced a bill that would require new or expanding hospitals in the state to prove that they would provide for, or at the very least refer for, all women's health care, family planning, and end-of-life services. "In rural areas, there aren't many options," Ranker says. "We shouldn't allow the sole health-care provider to limit the legal medical choices you have available."

Especially when these Catholic hospitals are financed by taxpayers, private insurance companies, Medicare, Medicaid, and federal and state tax breaks.

Which might not even be legal. After all, the Washington Constitution forbids any use of public dollars for the establishment of religion.

Kathleen Taylor, executive director of the ACLU of Washington, agrees. "We are deeply concerned that PeaceHealth's religiously based policy of restricting access to reproductive and end-of-life services violates the Washington Constitution and state law," Taylor wrote on January 3 in a three-page letter addressed to the San Juan County Public Hospital District #1. "The County must insist that, in order to receive public funds, PeaceHealth or other medical facilities provide access to contraceptive services and abortion and that their policies be based on medical ethics and state law, not religious doctrine."

A week later, the hospital commission "respectfully disagreed" with the conclusions drawn by Taylor, but from their wording, it seemed like they were sweating it: "However, we are considering what, if any, action is necessary on our part," their response said.

It is the second Monday in January, and four neat rows of church chairs stand arranged at the United Methodist Church in Sedro-Woolley. A sign on the door advertises adult Sunday school, but that's not what's attracted the small crowd of 20 people. This is a Skagit PFLAG meeting. At the front of the room are a gently wafting rainbow flag and other flags that read "peace" in six languages. A man passes me a "Be Yourself!" booklet.

Kathy Reim, proud president of Skagit PFLAG, welcomes everyone and introduces her daughter and daughter-in-law, drawing them each in for a hug. "It's all about popcorn and hugs here, that's what we're about," she says. Reim and her husband have missed only two monthly meetings in the 12 years she's been president.

This isn't a typical PFLAG support group. This is a brainstorming session on how to stop PeaceHealth from leasing and operating the local United General Hospital—yet another pending Western Washington hospital merger.

"I'll come right out and say it—I worry that gays and lesbians will also be affected," Reim says. "The church is very clear on their opposition to gays and lesbians, and I don't know if we can trust them with our health care." Heads nod in unison.

For the last year, PeaceHealth has been raising hackles in Western Washington. One reason is that it is considering merging with another Catholic hospital entity called Catholic Health Initiatives, which, unlike PeaceHealth, is infamous for its strict adherence to the ethical directives, and has taken a more hard-line position on reproductive issues in other states. And last March, PeaceHealth cold-called Planned Parenthood's regional Mt. Baker office and said it wanted to stop processing Planned Parenthood's blood tests, under advisement from Archbishop Sartain.

"They weren't controversial tests we're talking about," says Linda McCarthy, executive director of Mt. Baker Planned Parenthood. One test ruled out ectopic pregnancy, which can affect 1 in 100 women and can be life-threatening without immediate care. Another was a simple culture test, and the third was a semen analysis for post- vasectomies. The semen test is time- sensitive. "PeaceHealth is our closest lab, and we only have an hour limit to get the samples in," says McCarthy.

Mt. Baker Planned Parenthood has filled the gap that every Catholic hospital merger in the northwestern corner of the state has created. It now serves more than 15,000 people in Whatcom, Skagit, and San Juan Counties. One in 17 locals last year used its services. Given Planned Parenthood's vital role in the community, "We sent a letter back saying we rejected that request to stop doing our labs," says McCarthy. After three months, PeaceHealth backed down.

Asked about this confrontation, PeaceHealth CEO Nancy Steiger said, defensively, "I'd like you to check the facts—that was never stopped. We were asked by the bishop to stop providing some services to Planned Parenthood, and we met with them. We talked about options. They were not happy with those options. I don't remember the details. It was only a request... It was never a discontinuation of services. It was just a conversation."

"We don't have a written commitment from them to keep processing the labs, but we're staying vigilant," McCarthy says. "But we can't do it alone. It's time for the general public to wake up and pay attention to what these mergers mean."

You might be wondering: What do the doctors, nurses, hospice workers, and social workers who are innocently subsumed in these Catholic mergers think?

Broadly speaking, many of them are stressed and afraid. Like patients, doctors come from all religious backgrounds and don't appreciate having laypeople dictate how to do their jobs. No one I contacted would speak with me on the record about working for a Catholic hospital. A handful agreed to speak anonymously, but then half of them decided that even speaking anonymously was too dangerous. I heard excuses like "retaliation," "career killer," "patterns of revenge," "ostracization," and "it would ruin me."

Three physicians working in Whatcom County eventually agreed to speak with me. PeaceHealth bought out the secular hospital in 2008. Since then, PeaceHealth has systematically bought up nearly every specialty clinic in the area, from cardiologists to pediatricians, hospice to oncology. The physicians who agreed to meet me for coffee talked about the mindfuck of being raised Catholic, turning to atheism, and excelling in medicine—only to wake up one day with the church as your boss. The first physician joked grimly about the religious directives being "medieval torture porn." He talked about the struggle of trying to balance his duty to patients with the edicts of a Catholic hospital.

"Physicians who sign on [to the hospital] are explicitly enjoined from participating in or referring for physician-assisted suicide. You can't even talk about it," the second physician explains to me. "In Whatcom County, the only people who can take advantage of [Death with Dignity] are the people who have a computer, know how to use it, and know how to find Compassion & Choices. It's utterly preposterous."

"This is a problem with some Catholic hospitals more than others," says Robb Miller, Washington executive director of Compassion & Choices, a nonprofit advocating for end-of-life choices. He describes Seattle's Providence Hospital and Tacoma's Franciscan Hospital as having a "very poor" record on talking about or referring for physician-assisted suicide. In comparison, PeaceHealth is "not so bad—they're willing to refer to an intermediary." He says that despite these barriers, what makes the system sing are the nurses and social workers at these Catholic institutions who break the rules. "They quietly and covertly inform patients about Death with Dignity and Compassion & Choices, but they do so at the risk of losing their job," Miller explains.

Providence spokeswoman Colleen Wadden says, "We respect the rights of patients and physicians to have confidential conversations, but Providence cannot participate in any way in a patient's suicide," in response to Miller's "very poor" rating. A spokesperson for Franciscan didn't return calls for comment.

The worry about hospital retribution extends to Whatcom physicians who aren't even technically employed by PeaceHealth. Doctors who have private practices often have to admit patients to the hospital for advanced blood tests, X-rays, or surgeries. If they do, "they have to have medical staff privileges, and that means they have to agree with the hospital bylaws," the second Whatcom County physician explains. "You must read them and sign them. Once you've done that, you're bound by whatever they say."

I ask about the repercussions of not following the edicts. What happens if you're caught talking to patients about physician-assisted suicide in your private practice, or performing abortions, or, the trifecta of theoretical sins, assisting a fetal suicide on God's day of rest?

"Well, your staff privileges would certainly be revoked," the second physician tells me.

"You'd have to move out of the county," the third physician quietly says. "You couldn't get work. Every route ends at the church."

I ask about loopholes—like doctors prescribing birth control for an "acne problem" instead of for contraception.

"You put your license at risk by doing that," the third physician tells me. "You also put your patient at risk—what if she changes doctors, and they decide her skin is just fine and take her off the medication?"

"It's incredibly unethical," the second physician tells me. "You're falsifying diagnoses."

The third physician says, "And the point isn't that patients should be aware that there are loopholes. It's that patients should trust that physicians, in good conscience and faith, are working for their best interests."

Should patients trust that physicians, in good conscience and faith, are working for their best interests at Catholic hospitals? Should women? Should the LGBT community? Should terminally ill patients?

"That's a tough question," the first physician answers. "I think the answer is yes?" recommended

This article has been updated since its original publication.