Surrounded by family in his Bellingham home, 88-year-old Norman Shapiro died a slow, agonizing death. "He was suffering tremendously, and we were all traumatized by watching helplessly," wrote his widow, Audrey Roll-Shapiro, following her husband's death from esophageal cancer in 2010. The staff at Whatcom Hospice, owned by the Catholic health system PeaceHealth, was attentive, Roll-Shapiro allowed, but she said they failed to inform the family of their legal rights under 2008's voter-approved Washington Death with Dignity Act, which allows physicians to prescribe lethal doses of self-­administered drugs to terminal patients.

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"Not once did any Whatcom Hospice staff mention that Norman had other options, such as palliative sedation or aid in dying," wrote Roll-Shapiro in an October 2010 guest post on the blog of Compassion & Choices of Washington, a group that helped get the Death with Dignity Act passed. (PeaceHealth responded at the time that it was exercising its own rights under the opt-out provision of the Death with Dignity Act.) Roll-­Shapiro only learned about her husband's rights the day after he died.

It's a scenario that could soon become more common in Seattle.

On October 5, Swedish Health Services announced a proposed alliance with Catholic-affiliated Providence Health & Services, which refuses to advise patients on their death with dignity options. This new alliance would be overseen by an independent board appointed by both hospital groups, but Providence, being the larger partner, would appoint more members. The alliance would affect Swedish's five hospitals, more than 70 primary-care and specialty clinics, three ambulatory-care centers, and home-care division, totaling 11,000 employees, the largest nonprofit health-care provider in the greater Seattle area. If approved by federal regulators, it would be the third such merger between Catholic and non-religious health systems in Washington State since 2010.

Economic pressures are forcing a wave of hospital mergers nationwide, and wherever Catholic-affiliated health systems expand, access to aid in dying, abortion, sterilization, and other legal services declines. An example here in Washington: The policy at Southwest Medical Center in Vancouver used to allow discussion of death with dignity before the hospital adopted PeaceHealth's restrictive policies, following their merger in 2010. Now staff are prohibited from discussing death with dignity options. It's a trend that's enabling Catholic organizations to establish through the marketplace the very same conservative end-of-life and reproductive-health policies they could not advance through the courts or at the polls.

According to the United States Conference of Catholic Bishops, 573 Catholic hospitals served 84.7 million patients in 2005, and that number is growing. MergerWatch, a patients' rights organization, has tracked more than 140 merger and affiliation agreements between religious and non-religious hospitals since 1997. The group says that 70 percent of religious-affiliated hospitals in the country are Catholic.

Catholic health systems—hospitals, hospices, clinics, and home-care providers—deliver valuable services to communities, services that will be increasingly in demand as the state continues hacking away at its social safety net (the Basic Health program will once again be on the chopping block during the legislature's upcoming special session, which begins November 28 in Olympia). But medical services from Catholic-affiliated health providers come with one very long string attached: a requirement that they follow the Conference of Catholic Bishops' "Ethical and Religious Directives for Catholic Health Care Services." These directives include prohibitions against abortion, birth control, fertility treatments, aid in dying, and even the honoring of end-of-life advance directives deemed "contrary to Catholic moral teaching."

According to a recently published Q&A, Swedish claims that after the merger it "will not be subject to the Ethical and Religious Directives that apply to Catholic health-care facilities." With the exception of its decision to shift elective abortions to a new Planned Parenthood clinic slated for its First Hill campus, the hospital insists none of its reproductive-­health policies will change. Like all Washington hospitals, Swedish has never allowed what it calls "physician-assisted suicide" on its premises, but says it will place no additional restrictions on the freedom of physicians to advise their patients about the options available: "There will be no change to current practices," the Q&A states.

But Robb Miller, the executive director of Compassion & Choices, met with representatives from Swedish on Friday, October 28, and came away concerned about the future of Swedish's hospice program, which is relatively small and unprofitable compared to the one run by Providence. The whole point of the hospital alliance is to save money through economies of scale, so it only makes business sense for Swedish to eventually close its hospice and roll it into Providence's, even though Providence's "draconian" policies concerning death with dignity "are the worst in the state," according to Miller.

Swedish currently places no restrictions on what caregivers can talk about, "including all options available to patients under the Death with Dignity Act," whereas Providence prohibits staff from even referring patients to third parties, let alone counseling them on their legal options, according to Miller. Which could mean more deaths like Norman Shapiro's—slow and agonizing, not only for patients, but for loved ones who sit by and watch, helpless and uninformed.

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Whatever the outcome, Seattle-area patients will still enjoy many more options than those in much of the rest of Washington, where most hospice services are Catholic-affiliated. But even out there the mergers continue. PeaceHealth, a near-monopoly provider in Bellingham, recently secured similar dominance in Vancouver through its merger with Southwest Washington Health System, and is in the process of acquiring United General Hospital in Sedro-Woolley.

"Death with dignity may be legal," laments Miller, "but for many Washingtonians, it's not an option." recommended

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