The Conscience Clause: It's Not Just About 750,000 Hospital Employees

Here's an excerpt from my latest at The Revealer regarding the recent controversy over insurance coverage of contraception by Catholic employers:

And yet the Catholic Church knows that the issue of conscience clauses is about much more than the 750,000 hospital employees who musn’t get their hands on free contraception. At stake is the autonomy of the millions of patients who are treated at Catholic institutions each year. How many? According to the USCCB, there are currently 629 Catholic hospitals serving 20% of all patients in the country (about 50 of those hospitals are sole-providers, meaning there’s no other option for miles). That’s more than 35 million admissions every year, a total that still doesn’t include patients treated in emergency rooms, elder homes, or covered by HMO networks.

These conscience clauses, initiated with the Church Amendment, passed in 1973 only months after Roe v. Wade, have overlapped and evolved to not only protect the individual conscience of health care providers but, with the passage of the Weldon Amendment in 2005, that of “health care entities.” Much as Citizens United designated corporations as people, so have these clauses granted institutions conscience rights that supersede the rights of employees and patients. Not only are services that don’t comply with the Ethical and Religious Directives (ERDs)–written and approved by the USCCB–denied at Catholic institutions, but patients aren’t informed of them as medical options, nor are they referred to other institutions where they might receive them. Informed consent and referrals are considered violation of Catholic teaching.

Of course, the level to which institutions and providers comply with the Ethical and Religious Directives varies greatly. What the church demands, as statistics regarding Catholic contraception usage show, followers and employees have a long tradition of resisting. What often determines the compliance of facilities and employees with Catholic guidelines is the amount of interest the local bishop has in the affairs of institutions in his diocese. In the past decade, we’ve witnessed the appointment of increasingly conservative bishops and the pressure of presiding bishops to pay closer attention to hospitals, in part by the conservative turn of the church leadership and in part by the pressure on health care delivery from choice movements.

Continue reading here.

The Week in EOL News

In a recent article at The Catholic Sentinel, Richard Doerflinger, Deputy Director for the Secretariat for Pro-Life Activities continues to develop the church's argument against aid in dying by conflating it with assisted suicide and by citing disregard for the ill or disabled as causes for aid in dying's increasing support and legalization. (I interviewed Doerflinger about the church's new initiative to fight legalization of aid in dying in June.) From the Sentinel article:

The Oregon law carves out a class of citizens — those diagnosed with six months or less to live — and suspends statutes that protect them from getting help to kill themselves. For Doerflinger, it's like coming across two people about to jump off a bridge, one who has a diagnosis of six months or less to live. For one, society tries persuasion, mental health treatment and emergency intervention. But to the one who has a serious physical illness, Doerflinger explained, "We say, 'Jump. Can I give you a push?'" The issue, he said, is that our culture is uncomfortable with sickness and disability. "We don't see inherent dignity in people when thy have these conditions."

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The San Francisco Examiner has been covering the story of Hong Ri Wu, who is accused of killing two of his shop-owner rivals. Wu was determined unsound for trial and then he refused to eat. Local police officials, at the direction of Sheriff Hennessey took him to the hospital but the hospital refuses to put him on a feeding tube. The Examiner writes:

Hennessey insists his department has a mandate to provide for the safety of each inmate. But hospital officials have balked at force-feeding Wu, although spokeswoman Rachael Kagan declined to discuss Wu’s case specifically, citing patient privacy laws.

“As a hospital, we respect individual self-determination and include our patients in their health care decisions,” Kagan said in a statement. “When a patient is also in custody, that patient loses some rights, but not all of them.”

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Meanwhile, thousands of California inmates have resumed a hunger strike that is meant to draw attention to their inhumane conditions in that state's facilities. Prison officials are threatening "discipline."

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"Baby Joseph" Maraachli die this week. The child, born in Canada with a terminal illness, became a "pro-life" cause when the hospital there refused the family's request for a tracheotomy. The hospital deemed the operation futile. So Father Frank Pavone of Priests for Life and other Catholic and "pro-life" groups including the Terri Schiavo Life & Hope Network, raised the funds to have the child airlifted to the US. The first US hospital they sought care from refused, but a Catholic hospital took the child in and completed the procedure. After a brief stay in the US, Priests for Life then shipped the child and his family back to Canada. Pavone said the child and his family had, "fulfilled a mission from God." The case has caused some interesting fault lines to emerge that involve denominational health care, issues of futile care, the treatment of pediatric terminal patients, and, not least, within the Catholic Church regarding the finances of Priest for Life. Father Pavone has since been called back to his home diocese; the causes remain murky.

"Pro-life" groups have said that their objective was to allow the child to die at home, a statement that echoes both home hospice and aid in dying advocates, perhaps signaling broader acceptance that a home death is preferable to a hospital death.

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The death of Troy Davis was not the act of a faceless state against a potentially innocent man. Amsterdam News writes about the company that was contracted to oversee the execution, the same company that is contracted to provide health care services to inmates in prisons. For-profit companies are increasingly called in to provide inmates with care in prison settings, in part because the incarceration industry is just that, an industry, with states spending big money to manage their prison populations and high-powered lobbyists pressuring local law makers to "protect" their state citizens by being strong on crime. As well, particularly in the South, prison populations are growing exponentially older and require more health care services. But the challenges for CorrectHealth and other such health care companies operating in prisons is that they are increasingly under fire for unethical and illegal activities, including the use of illegally-acquired execution drugs. Drugs like sodium thiopental, which is part of a three drug series used to execute inmates. It's no longer in easy supply because Abbot Laboratories, its sole US manufacturer, has stopped making the drug. For a while states were purchasing sodium thiopental from the UK but drug officials there have cracked down on it's international export. This scarcity has forced US prisons to beg and barter with each other or to find illegal sources. Writes the Amsterdam:

It was Dr. Carlo Musso, who owns CorrectHealth, a for-profit company that provides what they call "cost effective" health care to prisoners, who managed the process. He does this work under the umbrella of another company he owns, Rainbow Medical Associates, which, according to the American Civil Liberties Union, is contracted by the Georgia Department of Corrections to do its executions.

While some may defend Rainbow Medical Associates as capitalism in action, Musso might find himself in a heap of trouble-of the legal kind-that could do more damage than the backlash from the Davis execution.

Earlier this year, the Southern Center for Human Rights filed a complaint against CorrectHealth, accusing them of illegally importing and distributing sodium thiopental, the drug they use in carrying out the execution of convicted felons.

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The Atlantic this week wrote about a new documentary that examines the "unique subculture of hospice volunteers as they contemplate their own philosophies of life and death." (h/t Scott Korb)

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The Guardian reports on a case in the UK that was brought by the family of a minimally conscious patient to remove her feeding tube. The family of "M" held that she would not want to be kept alive with a feeding tube, but the court did not decide in their favor, stating that her level of consciousness allowed that she may feel discomfort if removed. From the article:

The case raises deep existential and moral questions – questions that law is not well equipped to answer. The Mental Capacity Act does at least, provide a framework for discussion but it offers no guidance on how each factor should be weighted. For the family, the key factor was that M's continued existence was not what she would have wanted. For Mr Justice Baker, the decisive factor was the preservation of life.

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As with abortion, the language used to discuss end of life and patients' rights continues to be muddied up, with each side claiming to stand for the patient. Wesley J. Smith's recent scree against futile care is telling. He's taken up the rubric of patients' rights, claiming that a patient who wants just one more chance at beating cancer should be able to make that decision for themselves, regardless of limited health care resources, the doctor's recommendations, or that of the hospitals where the patients are treated. I've said very much the same thing myself, here, repeatedly. But what Smith and others fail to miss -- and this is a conservative blind spot that we see exploited often -- systems and culture affect how patient's view their health care choices. Those concerned with futile care recognize that a culture of "do everything" is responsible for the increase of treatments and services that won't save lives and often prolong death. Those of us who stand for patient's rights -- a person's right to choose what their best path of treatment may be -- must be careful to recognize that cultural influences and not just the individual's ideas about their fate can play a role in the patient's choice. If you want to stand for choice in all cases, abortion advocates have long known, you have to stand for even the choices you don't agree with.

Don't miss Smith's knock of the Veteran's Administration, the largest provider of health care in the US and conservative's primary example, after medicare, of how the government mismanages health care.

Patient's rights is a term I use often but independence and individual rights are only half the conversation. We're also members of a community and creators of a culture that establishes values even as we espouse them. Simple calls for patients' rights (or women's rights, etc.) are only part of the challenge those who wish to address the vagaries of our health care system (or it's absence) must consider.

Smith, who claims to be a bioethicist, often blames greed for what he says is a pervasive "culture of death." With many issues like pentagon spending, incarceration, and social services, I've said pretty much the same thing. But what Smith misses is the responsibility that society has to the patient to prepare them for death and to do no unjust harm. Futile care often stymies both. And it's preventing us from talking about death and health care in practical, dignified ways.

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Read Catholics for Choice's recent open letter to Kathleen Sebelius, posted at Politico, here. The group is fighting The Catholic Church's heavy lobbying for less restrictive conscience laws in the new insurance coverage guidelines. The Church claims that allowing insurance programs to cover contraception is an offense to their religious conscience and that clauses in the new regulations are far too narrow for their health care providers to work according to their faith. In other words, Catholics for Choice wishes to remind the government that the influential priests who have mobilized against the regulations do not speak for the US's Catholic community but for the Vatican. Or rather, their male dictatorial selves.

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Funny how long it took the Wall Street Journal to pick up this study about the public's views of those in persistent vegetative states.

I Told You So: Catholic Church Comes After Catholic Bioethicists

Cross-posted from The Revealer, a publication of The Center for Religion and Media, NYU.

I shouldn’t take any credit for predicting the actions of the most predictable institution on the globe, but I’ll take it anyway. I made the case at The Nation last week that the USCCB’s recent statement on aid in dying would lead to broader crack-downs on end of life rights, privacy, and awareness. I was right. According to a new report at Crisis Magazine and a press releasefrom the bishops today, they’ve targeted Catholic professors at four universities: Georgetown, Marquette, Santa Clara and Boston College. How did the bishops identify the academics they wanted to discredit? Writes Patrick J. Reilly at Crisis:

The professors’ efforts came to light during a Cardinal Newman Society investigation in 2005, following news reports of a legal brief filed by 55 bioethicists in opposition to “Terri’s Law,” a Florida measure that empowered Gov. Jeb Bush to ensure that the comatose Terri Schiavo received water and nutrition. As reported in “Teaching Euthanasia,” an exclusive report in the June 2005 issue of Crisis, multiple professors at Catholic universities had taken positions on end-of-life issues that seemed to conflict with Vatican teaching.

That’s right. Conscience aside, if you don’t exactly teach–or even in your personal life espouse– the Vatican line, you’re not Catholic. And it’s a seething mission among Catholic Church leadership to reign in not only Catholic bioethicists and professors but also Catholic hospitals. Only two years ago, the USCCB changed the Ethical and Religious Directives that are used to manage all 625 of their hospitals to limit a patient’s ability to be removed from artificial nutrition and hydration.

These actions are a direct response to the Terri Schiavo fiasco — which I’ve written about at Religion Dispatches and AltNet — and the Church’s desire to more directly guide health care policy in the US. The USCCB is still smarting over dissent of nuns and the Catholic Health Association during the recent health care debate. By rooting out dissenters, they hope to present a more unified voice on issues of the body.

Who’s their next target? It’s hard to say. While the church cleans out universities, hospitals, agencies and schools, “pro-Life” organizations prepare their on-the-ground election-time efforts and renewed pressure.

The Catholic Church well knows that even a statement addressing “assisted suicide” will serve as a political map for “pro-life” activists and their allies who have long seen “euthanasia” as one item on their platform. Think legislation governing advanced directives (already moot at Catholic hospitals if you’ve got a feeding tube, where a webwork of conscience clauses prevents them from complying with state and federal laws), hospice and palliative care regulations, inheritance laws for families of suicides, drug regulations….

I hope Church leadership is overreaching. While their fight against abortion is aided by the fact that women’s reproductive rights have been shamed and ghetto-ized since time began, seniors vote. And the US population resoundingly supported the Florida decision in 2005 to remove Terri Schiavo’s feeding tube.

Yet, the Church is particularly skilled at over-representing its influence and voting base. Again and again, health care rights for women have been bargained away with deference to the Church. Why not seniors’? Neither party seems willing to press for a meaningful Patients’ Bill of Rights or real health care reform. And the obstacles to nuanced conversation about death are myriad; they include an uninterested, misinformed, or easily-distracted press.

Whether you think aid in dying should be legal or not, whether you abide by Catholic doctrine or the light of the moon, you should still question the health of a democracy where a church’s laws dictate the actions of the pluralistic societal body.

Cross-posted from The Revealer, a publication of The Center for Religion and Media, NYU.

What the USCCB's New Focus on Aid in Dying Could Mean

I have a new piece at The Nation that you can read in its entirety here. Here's an excerpt, below. It was posted Wednesday night but I'm still waiting for Kevin Drum and Ezra Klein to call....

A focus on aid in dying should illuminate failures in end of life care, of which the US has many. In our current state of crisis—52 million people are uninsured; the United States spends twice as much on healthcare than other developed nations, with inferior results; the population is growing older; the dying are often subject to debilitating futile care in their last days—we can hardly afford ideological diversion. As with the issue of abortion, when the Catholic Church shines a spotlight, Americans get blinding orders, not illumination.

Even typically astute writers miss the point on end-of life care. While Ezra Klein, the Washington Post's healthcare expert, didn't endorse Catholic pundit Ross Douthat's contention that aid in dying should be illegal (though Klein failed to acknowledge that it is legal in three states), he bought the same "slippery slope" argument "pro-life" groups have used for years to oppose and restrict abortion. While Mother Jones's Kevin Drum refuted Douthat’s religious arguments and Klein’s sources and logic, he too failed to connect the conversation on assisted suicide to the larger crisis in end-of-life care. Neither took meaningful issue with the outsized role the Catholic Church—which operates one-fifth of all hospital beds in the United States according to their own guidelines—plays in this or the healthcare debate.

USCCB and Catholic Health Association Under Fire From Ultra-Conservative Catholics.

Yesterday, Deal Hudson wrote at the Catholic Advocate that the US Conference of Catholic Bishops has failed to effectively strategize it's opposition to the health care bill.

He also criticizes the USCCB for allowing the Catholic Health Association (CHA) to voice support for the bill. CHA represents the more than 600 Catholic hospitals, hundreds of long-term care and hospice facilities, and three of the top 10 HMOs (health management organizations) in the country. Hudson writes:

At present, the USCCB has not issued any statement directly opposing the Catholic Health Association or any of the Catholic groups supporting the Senate bill such as Catholics United and Catholics in Alliance for the Common Good.

The lack of such a statement allows the press, the White House, and the Congress to hold up these groups as providing official Catholic support to a public which largely does not know any better.

A direct rebuke from the USCCB towards the Catholic Health Association would not be in keeping with what I have termed its strategy of qualified support, but it would certainly keep wavering members of Congress from finding political cover from these groups willing to accept abortion funding.

With a vote on the bill coming as soon as Friday or Saturday, the USCCB is running out of time to get tough. The parish bulletin program emailed last Friday by the USCCB comes too late to have any serious impact on a vote this week.

The willingness of such an intimate partner with the USCCB to break with the bishops on the health care bill is just another aspect of its failure to negotiate powerfully with Congress and speak loudly and clearly to the media on this legislation. Its strategy of qualified support has put the USCCB in a weakened position and allowed the initiative to be taken over by groups with vested interests. CHA wants federal money for its hospitals, while Catholics United and Catholics in Alliance for the Common Good were created precisely to keep Democrats in power, even if it means further endangering the lives of the unborn.

It’s common sense that you can’t win a negotiation if you aren’t willing to walk away from the table. Thus far, the USCCB hasn’t shown that willingness. Bishop Thomas Wenski of Orlando understood this when he wrote a few days ago, “No health-care legislation is better than bad health-care legislation.”

Despite recent and vocal debunking of the accusation that the current bill provides federal funding for abortion, Hudson and Catholic Advocate, along with other Catholic-right organizations, have worked hard to push the conservative USCCB even farther to the right on health care. That the composers of both the Stupak and Nelson amendments deserve criticism for not being right enough and that they are allowing CHA to misrepresent Catholic opinion on health care is a blatant falsehood.

An October poll shows that a full 56% of Catholics think the USCCB should not take a position on health care reform and a majority support both the public option and funding for abortion (again, even though the latter is not included in the existing bill.)

While I'll agree that public opinion is too often falsely touted as the best way to achieve individual rights (historically, meaningful minority rights legislation has required both strong executive or legislative leadership AND public support) Hudson is asking the church hierarchy to take a much more conservative stance than it's parishioners. As we've seen throughout the debate, they certainly have. But that's not enough for Deal Hudson - and he's not alone; he is so far right of Catholic opinion on this issue that he makes the USCCB look more liberal than they really are.

Catholic Hospitals Falling Away.

A fantastically telling article from Sue Ellen Browder at the National Catholic Register on Catholic hospitals not really telling the whole truth to their bishops. There are more than 600 Catholic hospitals in the U.S., making them the second largest deliverer of health care in the country. In order to be "Catholic" a hospital has to abide by the 72 Ethical and Religious Directives the Catholic church imposes.

But some keep the Catholic only in name - perhaps for the seemingly good reputation that such an affiliation brings? Dissent is not a new thing to the Catholic hierarchy, they've been battling misbehaving parishioners for centuries. And when their discriminatory dictates overlap with modern medicine, doctors, patients, and nurses all chafe.

Another sign that the hyper-right current leadership of the Catholic church are out of touch? Of course. Can we start calling for Vatican III? Who's stopped calling for it since Vatican II?

St. Charles Medical Center in Bend lost the title “Catholic” on Feb. 15 due to its refusal to stop doing tubal ligations to sterilize women. Founded by the Sisters of St. Joseph in 1918 but no longer run by them, St. Charles is Oregon’s only Level II trauma center in the central and eastern part of the state.

“The crux of the conflict was the hospital and ethics board’s intentional misinterpretation of ‘direct’ and ‘indirect’ sterilizations,” said Diocese of Baker Bishop Robert Vasa. After several years of negotiations with St. Charles, Bishop Vasa made the difficult decision to strip the hospital of its “Catholic” status.

Tubal ligation, informally known as “getting one’s tubes tied,” is always a direct form of female sterilization not permitted in Catholic health-care institutions. But, based on the Catholic principle of double effect, other procedures that indirectly induce sterility — the removal of cancerous fallopian tubes or ovaries, for example — are permitted in situations where no simpler remedy is available.

“The heart of my conflict here is that the hospital and the ethics board identified all of these 200 to 250 sterilizations they do a year as indirect,” Bishop Vasa said.

A typical case at issue would be that of a mother with three children. A doctor may decide it could be “dangerous” for her to get pregnant again. In such a circumstance, St. Charles’ hospital and ethics board claimed it was permissible under the directives for a surgeon to sterilize the mother with the “indirect” intention of keeping her healthy.

“Clearly, that’s a direct sterilization with the secondary hope of preserving her health,” Bishop Vasa said. “So it was in my mind an intentional misrepresentation and misinterpretation of that teaching.”

Further, the bishop stated, “It is possible that this teaching about sterilization may be misunderstood and misrepresented in a number of Catholic hospitals nationwide.”

To be called “Catholic,” a health-care institution must follow the “Ethical and Religious Directives for Catholic Health Care Services” issued by the U.S. Conference of Catholic Bishops. Paragraph 53 of the directives states: “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health-care institution.” A second sentence reads: “Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.”

This second sentence is often made the illegitimate pretext for sterilizations at Catholic hospitals.

Don't miss this bit on the new directive regarding artificial nutrition and hydration:

Nevertheless, Hamel is executive editor of the quarterly CHA publication Health Care Ethics USA: A resource for the Catholic health ministry, which until Feb. 24, 2010, was posted on CHA’s website. In one article, Hamel posed the question, “The CDF Statement on Artificial Nutrition and Hydration: What Should We Make of It?” in which he personally interpreted the Vatican’s position on the matter.

Speaking as CHA’s senior director of ethics, Hamel wrote that there are “questions about the accuracy of the medical assumptions in the CDF statement and commentary.” An unsigned “primer” on the Vatican’s statement published in the same issue stated that if a patient has “objective discomfort that a reasonable person would describe as unacceptable subjective discomfort, the withdrawal of [artificial nutrition and hydration] would appear to be permissible.”

Another Health Care Ethics USA article, not authored by Hamel, stated, “The ethical distinction between allowing-to-die and euthanasia depends, for the most part, on the medical condition of the patient,” while a third article noted that the “autopsy after [Terri Schiavo’s] death belied any thought that she would have recovered.”

The fall 2007 issue of Health Care Ethics USA published “A Resource for Evaluating Levels of Authority in Church Teaching,” with the “pope’s [sic] ordering of a document’s publication” by the Congregation for the Doctrine of the Faith said to carry the least “theological weight.”

The title page of Health Care Ethics USA grants permission to Catholic Health Association members “to copy and distribute” the publication free “for educational purposes.”

Thanks Compassion & Choices for Profiling Me!

I'm flattered and humbled this Sunday morning by receipt of the latest Compassion & Choices newsletter which has, among other fantastic news items, a profile of little old me! You can read the profile here.

And you can find great information about end of life care and C&C at their homepage.

Here's a clip from the article by Blaine Palmer:

Compassion & Choices’ President Barbara Coombs Lee first wrote in November about the directive from United States Conference of Catholic Bishops (USCCB) to Catholic health care facilities regarding feeding tubes. Compassion & Choices is concerned whenever patients’ choices for end-of-life treatment are blocked, whether it is by the government, by providers and certainly by a religious institution with control of nearly a quarter of American health care facilities.

Traditional media showed little initial interest in the change to Ethical and Religious Directive 58, and we feared we would be a voice crying alone in the wilderness. But the alternative journalists on blogs have been much better at reporting the story. One of the first, and most consistent is author and hospice volunteer Ann Neumann who, as she puts it, writes “primarily about the nexus of death and religion.” Her December blog at otherspoon explained the Bishops action:

The new guideline, instituted last month, determines that artificial nutrition and hydration (ANH, delivery of food and water via surgically applied feeding tubes) is "obligatory" care.

The USCCB has reached into an area of settled law in the US - it is now legal for patients or their proxies to deny ANH in all 50 states) - and created a scenario where patients lose autonomy over their own care.

Governments, churches and the medical profession, Ann says, have all worked to limit choices in end-of-life care because choice is a threat to their power. She cites a 2005 Garret Keizer article in Harpers to explain why these authorities are invested in protecting their control over pain:

. . . the belief that pain is fundamental to justice, which makes perfect sense if justice is conceived as nothing more than a system of punishments and rewards. The essence of punishment is pain. Whoever owns pain owns power.

“I would like to encourage various rights groups to work together to push a patient bill of rights. Many of the opponents pushing against end-of-life care rights are also opposed to women’s reproductive rights as well,” Ann said in a recent interview. “They are powerful and well-organized. The only way to counter that force would be for all groups working for patients’ rights to come together.” Her blog in January,What the Aid in Dying Movement Must Learn from Abortion Advocates, explains why.

Finally, Legacy Media Picks Up On New Catholic Directive.

While the US Conference of Catholic Bishops changed their Ethical and Religious Directives in November to now consider artificial nutrition and hydration "obligatory" care, few major media outlets have picked up the story. Yesterday, the Chicago Tribune finally ran a long article covering the issue.

They do the usual two-sides-to-every-story bit, primarily citing Catholic "experts" but slip in a quote from Barbara Coombs Lee of Compassion & Choices. My concerns with the story are many, including: the down-play of who ultimately gets to make decisions (the good-intentioned doctors at your friendly local Catholic hospital); little is made of why Catholic hospitals are allowed to make these decisions for patients; and the writer make no mention of how large the Catholic health care system is in the US - second only to Veterans' Affairs and serving 1 in 5 patients annually.

The comments from readers are resoundingly opposed to this imposition. We can only hope that this article and others like it will begin to spread. The more light shed on this draconian, paternalistic, authoritative new directive the better. And the more people aware of the Catholic Church's heavy grasp of health care delivery in this country - via provider refusal laws - the better a chance that elders and the public at large will fight it.

Here's a clip on PVS patients:

People in a persistent vegetative state, the bishops say, must be given food and water indefinitely by natural or artificial means as long as they are otherwise healthy. The new directive, which is more definitive than previous church teachings, also appears to apply broadly to any patient with a chronic illness who has lost the ability to eat or drink, including victims of strokes and people with advanced dementia.

Catholic medical institutions — including 46 hospitals and 49 nursing homes in Illinois — are bound to honor the bishops' directive, issued late last year, as they do church teachings on abortion and birth control. Officials are weighing how to interpret the guideline in various circumstances.

What happens, for example, if a patient's advance directive, which expresses that individual's end-of-life wishes, conflicts with a Catholic medical center's religious obligations?

Gaetjens, 65, said she did not know of the bishops' position until recently and finds it difficult to accept.

"It seems very authoritarian," said the Evanston resident. "I believe people's autonomy to make decisions about their own health care should be respected."

The guideline addresses the cases of people like Terri Schiavo, a Catholic woman who lived in a persistent vegetative state for 15 years, without consciousness of her surroundings. In a case that inspired a national uproar, Schiavo died five years ago, after her husband won a court battle to have her feeding tube removed, over the objections of her parents.

The directive's goal is to respect human life, but some bioethicists are skeptical.

"I think many (people) will have difficulty understanding how prolonging the life of someone in a persistent or permanent vegetative state respects the patient's dignity," said Dr. Joel Frader, head of academic pediatrics at Children's Memorial Hospital in Chicago and professor of medical humanities atNorthwestern University's Feinberg School of Medicine.

On the various interpretations of the new directive:

There are several important exceptions. For one, if a person is actively dying of an underlying medical condition, such as advanced diabetes or cancer, inserting a feeding tube is not required.

"When a patient is drawing close to death from an underlying progressive and fatal condition, sometimes measures that provide artificial nutrition and hydration become excessively burdensome," said Erica Laethem, a director of clinical ethics at Resurrection Health Care, Chicago's largest Catholic health care system.

Some ethicists are interpreting that exception strictly. The Rev. William Grogan, a key health care adviser to Cardinal Francis George and an ethicist at Provena Health, based in Mokena, said death must be expected in no more than two weeks — about the time it would take someone deprived of food and water to die.

But Joseph Piccione, senior vice president of mission and ethics at OSF Health Care in Peoria, said that if a patient knows she is dying of, say, incurable metastasized ovarian cancer but is several months from death, she can decline to have a feeding tube inserted if she anticipates significant physical or emotional distress from doing so.

Of course the Catholic media have done their job in spreading the over-dramatized Rom Houben story and the new study of PVS patients that suggests few are able to hear and experience brain waves that respond to questions from researchers. Both cases have been repeated and spread in an effort to promote the Church's - and Fundamentalist and Evangelical fellow-travelers' - "pro-life" stance. A commenter brings up Houben's case as justification for the new policy.

And a clip of the questions that follow the article:

Q. What inspired the change?

A. Church leaders oppose assisted suicide and euthanasia and wanted to affirm strongly that the lives of severely disabled people have value.

Q. Does it apply to Catholics only?

A. The guideline affects all patients who seek care at Catholic medical centers, regardless of their religion, said Stan Kedzior, director of mission integration at Alexian Brothers Health System.

Q. Who decides if a feeding tube is "excessively burdensome" and therefore not warranted?

A. That's up to the patient, but it isn't as simple as, "I don't like it and I don't want it." There have to be discernible physical, emotional or financial hardships for the patient, according to Joseph Piccione of OSF Health Care. Those hardships must outweigh the potential benefits.

For the record: the decision is now not up to the patient. That should scare the hell out of us all.

Calls to Include Coverage of Immigrants in Health Care Bill

From The New York Times blog:

The leader of New York City’s massive public hospital system warned this week that the health care bills in Congress would burden safety net hospitals by failing to provide coverage for uninsured immigrants while also reducing federal payments for indigent care.

In a conference call with reporters on Wednesday, Alan D. Aviles, president of the city’s Health and Hospitals Corporation, called for congressional conferees to lift the existing five-year ban on federal health benefits for legal immigrants. Neither the Senate bill nor the House bill currently do so. Mr. Aviles also encouraged the Senate to accept House language to allow illegal immigrants to buy health coverage on new government exchanges at full cost.

To do otherwise, he said, “makes no practical sense and is needlessly punitive.”The call was hosted by National Council of La Raza, a Hispanic civil rights group, and included the United States Catholic Conference of Bishops, which also supports extending benefits to immigrants.

“These exclusions do not eliminate the cost of care for these individuals and families,” Mr. Aviles said. “They merely transfer the costs to providers. And often the uncompensated care burden will be shouldered disproportionately by safety net systems like ours simply because we will not turn these uninsured immigrant patients away.” He added: “We will necessarily have to divert resources meant to support many of the essential services we provide to the community at large.”

Under both bills, federal payments to hospitals that handle large numbers of uninsured patients would decline gradually as more Americans gained coverage. The bills would make insurance mandatory for most people, and the government would subsidize the cost of policies for those with low incomes. Illegal immigrants would not be eligible for the subsidies, just as they typically are not now eligible for Medicare and Medicaid.