Quick — is your nearest hospital affiliated with the Catholic Church?
This is a question I would not have been able to answer during my two pregnancies. It never occurred to me that it was relevant. But in fact, for a woman who has a pregnancy complication that sends her to the emergency room, it can make the difference between timely, effective care and callous treatment that leaves her with permanent damage to her health and fertility.
In 2016 the American Civil Liberties Union published a sobering report, Health Care Denied: Patients and Physicians Speak Out about Catholic Hospitals and the Threat to Women’s Health and Lives. It describes how the Catholic Church’s top-down directives tie doctors’ hands in ways that go far beyond a ban on elective abortion, forcing them to withhold standard, mainstream treatment sanctioned by medical schools and professional medical organizations.1
Given the Catholic Church’s well-known stance opposing abortion and contraception, most people would probably not be surprised that Catholic hospitals do not offer these services. But what I suspect would surprise many is that standard medical treatment for miscarriages and ectopic pregnancies are regarded as “abortions” and are also tightly restricted.
According to the Ethical and Religious Directives for Catholic Health Care Services, guidelines the Catholic Church requires its hospitals to follow, any action a doctor takes to remove a fetus that still has a heartbeat is considered an “abortion,” even if the miscarriage is inevitable and the fetus is too young to possibly survive. A woman who goes to the emergency room bleeding and scared, sad to be losing her pregnancy, will be told to wait for care until either the baby’s heart stops or she develops complications that could endanger her health or life. Until the hospital ethics committee deems the risk to the woman to be equal to the risk to the fetus (i.e, risk of death), the medical staff is not allowed to evacuate her uterus.
This is counterintuitive to me: when there is no chance the baby will live, how could it possibly make sense to compound the tragedy by risking the woman’s life too? It also contradicts what I understand about the history of medical practice: historically, women’s families and the doctors they summoned to help at complicated births prioritized the life of the woman over the baby. And yet, the Catholic Church justifies its rules partly by claiming that it has consistently represented the Christian approach since early Christian times.
As I began thinking more carefully about this as a historian, I realized that the foundational scholarship in the history of reproduction in the United States, such as James Mohr’s Abortion in America and Leslie Reagan’s When Abortion Was a Crime, only tangentially touches upon the influence of the Catholic Church as an institution and a cultural influence. I wondered if it was possible that we historians have traced out the dominant Anglo-Saxon Protestant narrative and failed to take note of the opinions and practices of a substantial minority. Was I missing something? Do the rules at Catholic hospitals, so at odds with standard medical practices promulgated by organizations such as the American College of Obstetricians and Gynecologists, reflect a separate, longstanding Catholic cultural tradition in which women and their families expected doctors to refrain from accelerating the death of a fetus, even if it meant leaving a woman to suffer and risk death? In criticizing the Church’s imposition of its rules on the doctors and patients in Church-affiliated hospitals, was I failing to do justice to large numbers of Catholic women who preferred to be treated according to Church rules? I set out to investigate.
What I found was a story not so much about Protestant vs. Catholic culture, but about the shifting relationship between Catholic authority and medical practice in Europe and its former colonies.
Until quite recently, most women gave birth at home, where they and their families had control over the process. Until the twentieth century, hospitals were for the desperate and abandoned poor. From the middle ages through the nineteenth century, women and their families brought medical practitioners into their homes for care they deemed necessary, and doctors and midwives performed their skills in service of their clients. When a birth or a pregnancy grew complicated, families generally expected doctors to put the well being of the woman ahead of her fetus, and doctors obliged. The calculus was practical as much as emotional: a woman could have another baby if she lived.
Everyone understood that it was not much use to just save the child: babies rarely survived if their mothers died. Babies did not fare well in pregnancies complicated by eclamptic seizures or disastrous births impeded by rickets-damaged pelvises, and after birth they relied on mother’s milk to keep them alive and healthy. The consensus between patients and doctors was that when a pregnancy or birth was complicated and threatened the mother, her life and health took priority over the fetus.2
Many theologians had a different view. Starting in the twelfth century, as part of the development of the field of criminal law, scholastic theologians defined abortion as homicide. From the late twelfth century to the mid-nineteenth century, a prominent strand of Christian theology held that any action taken against a living fetus that had a recognizable human form (i.e., a few months into gestation) is an act of homicide. In the late nineteenth century that definition of abortion as homicide was extended earlier in pregnancy, all the way to conception.
There has never been complete consensus, except as officially enforced by the Church; over the centuries many theologians attempted to challenge and modify this way of understanding pregnancy and treatment of pregnancy complications. They looked for ways to justify standard medical and popular views about saving mothers when pregnancies and births went awry. While scholastic theologians maintained a consistent viewpoint, dissenters could see that it did not conform to accepted common sense.3
In practical terms, while laws that defined abortion as homicide nominally supported the scholastic point of view, they were not aimed at doctors. They were used in two ways: first, when a woman was assaulted by someone outside her family and she miscarried because of it, her family might demand compensation and justice. Second, authorities sometimes prosecuted women who were caught burying a miscarried child from a secret pregnancy and birth, charging her with infanticide. Authorities did not try to interfere with medical decisions made within families.4
During the late nineteenth century, physicians and Catholic theologians conducted international debates about the morality of treating pregnancy complications in their respective professional publications and meetings. Physicians argued about whether caesarean section, a new and risky operation, could be safe enough to be substituted for craniotomy, which involved dismembering a fetus to take it out in pieces when a woman’s pelvic opening was too small to allow her to give birth. Physicians generally prioritized the woman, and were reluctant to perform a caesarean section if it could possibly be construed as sacrificing the mother for the sake of the infant (a reasonable interpretation given the appallingly high fatality rate of the operation at the time).
Theologians more commonly proposed a different calculus, interpreting craniotomy as a form of homicide, and therefore regarding a risky caesarean section as preferable to waiting and hoping that the woman would outlive the fetus, at which point craniotomy would be permitted. These international debates included physicians and theologians from majority-Protestant and majority-Catholic countries alike; the difference in perspective was based on profession, not national culture and religion.5
As medical training became more centralized and formalized in medical schools, and medical practice became more concentrated in hospitals, the Catholic theological perspective gained more formal authority, if not more popularity. The Church could make rules about what would be taught in their medical schools, and how physicians would be allowed to practice in their hospitals. In the US, Catholic physicians’ guilds brought together physicians who were interested in establishing medical practice based on Catholic moral guidelines, and facilitated a network among the Catholic hierarchy, Catholic medical schools, and Catholic physicians.6
Catholic institutions and networks were originally created to support Catholic physicians and patients, who faced discrimination and evangelization in traditionally Protestant American institutions.7 They were also intended to keep Catholics in the faith and to enforce Catholic moral discipline.8 For instance, Dr. Austin O’Malley, a founding member of Philadelphia’s Catholic physicians’ guild, thought that physicians were being seduced by secular values. They were too sentimental in their regard for women, all too ready to perform an abortion when a pregnant woman had “fits,” or what we now call eclampsia, because they were thinking of their own mothers and they did not have proper moral training. Doctors knew that eclampsia commonly killed both woman and fetus. O’Malley believed that doctors needed the Catholic moral discipline to prevent them from taking mercy on the suffering woman and performing an abortion to protect her life.9
As birth moved into the hospital over the first half of the twentieth century, that discipline would come in the form of a hospital bureaucracy that constrained physicians’ practices, and physicians who were increasingly held accountable to the institution rather than to the pregnant or birthing woman and her family.
Today, one in six hospital beds in the United States is in a facility governed by the Church’s Ethical and Religious Directives, and that number has been steadily growing as hospital networks consolidate. A substantial proportion of American women are exposed to the risk of receiving inadequate reproductive care in a Catholic hospital. Catholic restrictions on care have the potential to affect any woman, but they have fallen particularly hard on women outside the urban and suburban middle class. Women who live in rural areas served by a single regional hospital, or who are otherwise restricted by their health insurance or their transportation options, are particularly likely to be trapped into inadequate medical care.
The impact of the Directives has also been racially discriminatory: earlier this year the Columbia Law School’s Public Rights/Private Conscience Project documented the lopsided impact of religious restrictions on women of color, who are disproportionately likely to give birth at Catholic hospitals.10
When a woman has a miscarriage, she ought to have access to standard medical care and the opportunity to make her own choices about her body. Of course, doctors and hospitals should also respect a woman’s right to refuse care based on her medical beliefs; no one who wants to follow conservative Catholic theology should be forced to accept miscarriage care that she does not want. But it is unacceptable that when a woman arrives at a hospital in the midst of a miscarriage, the hospital, under the mandate of the Church, is allowed to compound her physical and emotional distress by withholding care that she has requested.
Laura Briggs, Reproducing Empire: Race, Sex, Science, and U.S. Imperialism in Puerto Rico (University of California Press, 2002).
Jadwiga E. Pieper Mooney, The Politics of Motherhood: Maternity and Women’s Rights in Twentieth-Century Chile (University of Pittsburgh Press, 2009).
Mala Htun, Sex and the State: Abortion, Divorce, and the Family under Latin American Dictatorships and Democracies (Cambridge University Press, 2003).
Barbra Mann Wall, American Catholic Hospitals: A Century of Changing Markets and Missions (Rutgers University Press, 2011).
- Julia Kaye et. al., “Health Care Denied: Patients and Physicians Speak Out about Catholic Hospitals and the Threat to Women’s Health and Lives” (New York: American Civil Liberties Union, 2016). Return to text.
- Katharine Park, “Managing Childbirth and Fertility in Medieval Europe,” in Reproduction: Antiquity to the Present Day, ed. Nick Hopwood (Cambridge University Press, 2018); Jacqueline Wolf, Cesarean Section: An American History of Risk, Technology, and Consequence (Johns Hopkins University Press, 2018), 43-44. Return to text.
- Wolfgang P. Muller, The Criminalization of Abortion in the West: Its Origins in Medieval Law (Ithaca, NY: Cornell University Press, 2012); John Connery, Abortion: The Development of the Roman Catholic Perspective (Chicago: Loyola University Press, 1977). Return to text.
- Muller, The Criminalization of Abortion in the West, 2-3, 10, 15-16, 220-23. Return to text.
- Joseph G. Ryan, “The Chapel and the Operating Room: The Struggle of Roman Catholic Clergy, Physicians, and Believers with the Dilemmas of Obstetric Surgery, 1800-1900,” Bulletin of the History of Medicine 76, no. 3 (2002). Return to text.
- Jessica Martucci, “Religion, Medicine, and Politics: Catholic Physicians’ Guilds in America, 1909–32,” Bulletin of the History of Medicine 92, no. 2 (2018). Return to text.
- Martucci, “Religion, Medicine, and Politics,”, 294-99. Return to text.
- Ryan, “The Chapel and the Operating Room,” 463. Return to text.
- Martucci, “Religion, Medicine, and Politics,”307. Return to text.
- Kira Shepherd et al., “Bearing Faith: The Limits of Catholic Health Care for Women of Color,” (New York: Public Rights/Private Conscience Project, Columbia Law School, 2018), 8. Return to text.
Really important article; thank you Lara. I hope you’ll consider writing about the “abortion reversal” offered by some catholic physicians and pushed by the anti-choice movement. This consists of progesterone injections that can leave a dead fetus that cannot be expelled and can lead to sepsis. Your article puts this latest “medical” treatment in context.
Thanks, Janet. I totally agree, and “abortion reversal” is not the only other medical mistreatment a woman might get at a Catholic hospital. She may receive treatment for an ectopic pregnancy that unnecessarily leaves her infertile. Preterm birth management may be inappropriate. She may need a tubal ligation after c-section to prevent future pregnancies but be unable to get one. I think I need to write a whole series.
I’m not sure it’s possible to consider the consolidation of Church power in healthcare (two-thirds of hospital beds in my state are in Catholic-affiliated facilities subject to the Directives) without also addressing the marginalization of midwifery and of midwives in the same era. Without a community-based healthcare system for reproductive health, women were vulnerable to the abuses of Church authority within the formal healthcare system as their sole option. As a healthcare provider who has experienced inappropriate treatment delay during an incomplete miscarriage in the ER of a Catholic hospital — the only local hospital — that structural power has been made extraordinarily clear, and the resistance by physicians and physician groups to independent practice by APRNs, including CNMs, in states like Michigan continues to argue that this is at least as much an issue of consolidation of power as it is about Church doctrine. After all, Ireland, a far more Catholic country than the US, successfully repealed an abortion ban in May 2018. This is not only about doctrine.
Meghan, thanks for your comment. I absolutely agree that pushing midwives out of health care was part of consolidating obstetric authority and moving birth to hospitals. These days, midwives who practice in Catholic hospitals face the same restrictions as physicians, so as you say, a legal and medical structure that allows for home birth and birth centers would make a big difference in opening up women’s options. I think we’d still have an issue, though, for example with ectopic pregnancy. What do you think? To what degree can community-based reproductive care be a substitute for Catholic institutions?
Yet the Irish ban was only possible after decades of fairly severe abuses and several well-publicized deaths resulting from these practices. Irish women have only more recently begun to discuss some of these abuses, like the hospitals promoting the practice of breaking women’s pelvises to deliver in a complicated delivery over caesarians, since good practice doesn’t allow unlimited caesarian operations and might require a future sterilization to avoid a ruptured uterus.
Add in the church child sex abuse scandals and Magdalene laundries and the Irish were much more disposed of late to question the church’s say on secular law regarding abortion.
The US has its own relationship with the Catholic Church and women’s bodies which is thorny in its own right and still indebted to a period in the early twentieth century when the Church had more pull in many city governments and some states’ political governance. It seems at present the US government doesn’t have the will or support to press the issues of women’s health in Catholic hospitals (or health insurance supplied by Catholic employers) further yet.
Very important article, thank you. Gives us an opportunity to remember the awful case in Ireland and it’s impact in the recent abortion referendum there too – https://www.thejournal.ie/eighth-amendment-4-3977441-Apr2018/
excellent aticle. There is, I think another issue that your article raises. You say “The impact of the Directives has also been racially discriminatory: earlier this year the Columbia Law School’s Public Rights/Private Conscience Project documented the lopsided impact of religious restrictions on women of color, who are disproportionately likely to give birth at Catholic hospitals.”
Why are women of color disproportionately likely to give birth at Catholic hospitals? What is going on with our structure of charitable provision that we leave it in the hands of the Catholic church? I would love to see as smart and spirited an article addressing this question, as the one you have published here.
Thanks for your comment, Alice! You are right that this is a question deserving full treatment. It turns out to be more complicated than it might appear on the surface: while Catholic hospitals used to deliver a disproportionate amount of charitable care, they no longer do. So that is not the reason women of color disproportionately deliver at Catholic hospitals, at least presently. I suspect that Catholic hospitals are still more likely to operate in low-income neighborhoods in cities, which is probably what accounts for why they disproportionately serve women of color, but I have not yet come across research demonstrating this. This report contains a certain amount of detail, and indicates that the pattern differs by state, in terms of which groups of women are affected and to what degree: https://www.law.columbia.edu/sites/default/files/microsites/gender-sexuality/PRPCP/bearingfaith.pdf. For example, in New Jersey, it is Hispanic women who disproportionately give birth in Catholic hospitals; in Connecticut it is black women. I would love to trace out the history and figure out when and how these patterns emerged, and why they have persisted.
Thanks for shedding light on Catholic Hospitals. Having worked in a number of them, I’ve been witness to examples you described and have seen the devastating effects of delay. Add to that the insanity of transferring a woman who has just given birth to another hospital for tubal ligation. Most of these women were among the working poor, choosing sterilization to prevent adding to the burden of providing adequate care [basic food clothing and shelter].