Ethical and Religious Directives for Catholic Health Care Services

In the 19th and early 20th centuries, religious rules for Catholic hospitals were published by various local and regional entities in America. An early example was published by the Archdiocese of Detroit in 1921, prohibiting abortion and sterilization. This document was a single-page poster. It was copied by other archdioceses, sometimes with modifications. These posters hung on operating room walls in American and Canadian Catholic hospitals in the early 20th century. Cardinal John Krol persuaded most American bishops to adopt the controversial 1971 document because of the legalization of abortion in Roe v. Wade in 1973 and ''Taylor v. St. Vincent's Hospital'', a lawsuit by a woman seeking tubal ligation, in 1975. The Catholic Bishops voted to begin the process of banning gender-affirming care in 2023. They view the transgender medical treatments as "not morally justified." Editions The document's seven editions are as follows: == Directives ==

The Ethical and Religious Directives contains 49 directives within the document's six sections, many of which lay out rules that Catholic healthcare providers must follow. Notable rules include the following: Allowed or required • Service and advocacy in particular to "people whose social condition puts them at the margins of our society" including the poor, the uninsured, and "the unborn". • Equal opportunity employment. Employees must be treated "respectfully and justly." • Canon law of the Church must be followed by Catholic healthcare providers. • Eucharist and other Catholic sacraments must be available to, and only to, Catholic patients. Prohibited A number of the directives that prohibit medical procedures namely abortion, euthanasia, and sterilization specify that the procedure is prohibited only when "directly intended." This is because of the principle of double effect, a Catholic teaching. • Abortion is "never permitted." Health care providers are directed to council women who have suffered "the trauma of abortion." The document reiterates that abortion is prohibited in the case of extrauterine pregnancy. Nor may a victim of sexual assault get an abortion, nor may she interfere "with the implantation of a fertilized ovum." • Sterilization is prohibited. This prohibits tubal ligation and vasectomies. • Euthanasia or assisted suicide are not allowed. A person has a moral obligation to keep on living, though they "may forgo extraordinary or disproportionate means of preserving life." • Advance directives that are contrary to Catholic teaching are prohibited. Catholic institutions must make information about advance directives available in compliance with federal law. • Infertility treatment is permitted only within marriage, and only as long as it does not "substitute for the marriage act." For example, fertilization via sperm donor and in vitro fertilization are prohibited, as is surrogate motherhood. == Impact ==

The ERDs apply in 600 Catholic general hospitals across the United States. Approximately 100 more hospitals are managed by Catholic chains that place religious limits on care. They have had more impact over time as the healthcare industry consolidates and Catholic hospitals expand. The Directives state that "whatever comes under control of the Catholic institution — whether by acquisition, governance, or management — must be operated in full accord with the moral teaching of the Catholic Church." A number employ workarounds to provide patient care. Enforcement Within each hospital, the directives are enforced by ethics committees made up of clinical, religious, legal, and administrative members. Hospital ethics committees consult on medical questions, act as gatekeepers of ERD-restricted treatments, and sometimes perform surveillance of medical practices. Bishops have some power to enforce the prohibitions in the ERDs, but they lack the power to enforce the guarantees of care in the ERDs. For example, the ERDs statement that "a Catholic health care institution should provide prenatal, obstetric, and postnatal services" proved unenforceable when the largest Catholic hospital chain, Ascension, closed down many of its obstetric facilities. Charles Bouchard, a former director of the Catholic Health Association and vice president of theological education at Ascension, explained this limitation of the bishops' power: "They can keep hospitals from doing something if it's seen as at odds with Catholic teaching. But they can't, unless they're going to pay for it, they can't go out and say, 'you've got to keep this hospital open.'" == Fit with medical standards ==

The Ethical and Religious Directives are often at odds with accepted medical standards, especially in areas of reproductive health. For example, guidelines of American College of Obstetricians and Gynecologists (ACOG) specify conditions under which women should be offered the option of an abortion. In national study of obstetrician-gynecologists in 2012, 5.5% of respondents at Catholic institutions reported that their options for treating ectopic pregnancy are constrained by their hospitals. Sexual assault Emergency contraceptives are the standard of care for rape victims. Whether the ERDs contradict this standard is subject to different interpretations by different diocesan bishops. Some Catholic hospitals have policies prohibiting emergency room physicians from prescribing emergency contraceptives, or even from discussing them, while others do not. Some staff use "creative solutions" to circumvent emergency contraception prohibitions and meet the standard of care. The interpretation of the Catholic Medical Association rejects all emergency contraception after sexual assault, totally prohibiting Levonorgestrel (Plan B), Ulipristal acetate (Ella), insertion of an IUD, and all other measures a woman might use to avoid pregnancy after rape. == References ==