Bishops and Politicians in the Delivery Room: A Review of Bishops and Bodies: Reproductive Care in American Catholic Hospitals

Lara Freidenfelds

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“There are some situations where the mother may in fact die along with her child. But—and this is the Catholic perspective—you can’t do evil to bring about good. The end does not justify the means.”^[1]

These are the chilling words of Rev. John Ehrich, who served as the medical ethics director for the Diocese of Phoenix. He was defending Phoenix Bishop Thomas Olmsted’s decision to discipline a hospital administrator (and nun) who gave permission for a life-saving abortion in 2009.

A group of scholars and activists has been working for decades to expose how Catholic hospitals endanger their patients by withholding reproductive health care when it conflicts with Catholic principles. For too long, these critics have been shouting into the wind as hospitals tiptoe up to the line of faith-based malpractice, compromising Catholic principles just enough to save the lives of women from absolutists like Bishop Olmsted, while leaving many women damaged and traumatized.

Sociologist Lori Freeman, a member of the Advancing New Standards in Reproductive Health research program at the University of California at San Francisco, is among these scholars. Her brilliant new book, Bishops and Bodies: Reproductive Care in American Catholic Hospitals, has arrived at a moment when we should all finally be listening.

In the past two years, new anti-abortion laws have borrowed extensively from the Ethical and Religious Directives (ERDs) that have governed American Catholic hospitals, with the imprimatur of the United States Conference of Catholic Bishops, since 1954. The results have been appalling. In Texas in July 2023, a group of women who suffered trauma and tragedy in childbirth publicly revisited their trauma in an attempt to press for laws that will prevent more women suffering the same in the future. Samantha Casiano had carried an anencephalic fetus, but was denied an abortion. “She delivered her baby, then watched her slowly die: she was ‘gasping for air’ and turning from pink to red to purple. Her eyeballs started bleeding. ‘I watched my baby suffer for four hours,’ Casiano sobbed. ‘I told her, I am so sorry I couldn’t release you to heaven sooner… There was no mercy for her.’”

Amanda Zurawski’s water broke at 18 weeks, long before viability, but because there was a fetal heartbeat, her doctors waited until she was close to septic shock to treat her. She almost died and was left with damage to her uterus and one fallopian tube, severely compromising her future fertility. Ashley Brandt was carrying twins, one of which was diagnosed with anencephaly. She was forced to deplete her savings to travel out of state to abort the non-viable twin in order to save the healthy twin. “I don’t feel safe to have children in Texas anymore,” she testified. “I knew it was very clear my health didn’t matter, but my daughter’s health didn’t really matter either.”^[2]

These same situations have been playing out at Catholic hospitals for decades. As several of Freedman’s subject’s stories indicate, they can be difficult to document, because patients often can’t tell the difference between unavoidable harm and what Freedman calls “doctrinal iatrogenesis”: doctor-caused harm based in Catholic doctrine. Did a nurse monitor a threatened miscarriage because there was a chance of saving the baby, or because the ERDs mandated that the hospital withhold care until the heartbeat stopped? Did a doctor truly do everything she could to prevent hemorrhage, or did she wait longer than medically recommended because she was waiting for approval from the ethics committee? And patients may feel reluctant to share their trauma publicly, or may blame themselves for their reproductive difficulties. Nevertheless, work such as Civia Tamarkin’s documentary Birthright: A War Story have revealed examples of these lapses in care.

Bishops and Bodies delves much deeper. Freedman has led research on abortion access and on reproductive care at Catholics hospitals over a number of years at UCSF Medical School’s Advancing New Standards in Reproductive Health program (AHSIRH). The trust Freedman built with her numerous interviewees is crucial, and readers are lucky they are willing to share their experiences. The book is full of compelling stories from patients and doctors, grounding Freedman’s nuanced insights about the workings of Catholic health care.

One of the most important insights Freedman offers about the current moment is that doctors at Catholic hospitals habitually pursue what they term “work-arounds” to get necessary care for their patients, and to avoid the worst of the scenarios shared by the Texas women. She writes that they may transfer miscarrying patients to hospitals that will deliver them promptly regardless of heart tones on the ultrasound; direct them to alternative hospitals if they want a tubal ligation following a cesarean section (since Catholic hospitals do not provide birth control or sterilization); prescribe birth control under false pretenses, for period pain or heavy bleeding; take care to use terminology with the ethics committee that will allow a delivery before a birthing person’s life is actually immediately at risk; and so on.

At times, this means sending women to Planned Parenthood for services. As Freedman notes, since the legalization of abortion in Roe v. Wade Catholic hospitals have frequently systematically relied upon abortion and contraception providers so that they can avoid providing these services in their own hospitals. Sometimes this can mean, for example, transferring unstable patients at risk of bleeding out, just so they can get medically necessary abortions to complete complicated miscarriages. It isn’t the best care by any means. But this strategy allows a Catholic hospital to insist that it never does abortions, while also avoiding the scenario Rev. Ehrich evoked, where doctors and nurses would be expected to sit on their hands and watch a woman die rather than perform an abortion. The Ethical and Religious Directives were written to be quite strict while not purist, avoiding absolutist policies that would get hospitals shut down for malpractice or shunned entirely by their communities.

Why is this an especially crucial point right now? The flexibility that allows Catholic hospitals to push medically-necessary but theologically-forbidden care onto non-Catholic hospitals and clinics will not apply in states with strict anti-abortion laws, except to the extent that doctors manage to send patients out of state. Anti-abortion activists have tried to insist that Catholic hospitals provide models of safe care without abortion, but this ignores the systemically necessary role of abortion and contraception providers to Catholic hospital functioning. In states with anti-abortion laws, many of the work-arounds that doctors use to mitigate the harms of the Ethical and Religious Directives will no longer be viable in Catholic and non-Catholic hospitals.

In surveys that Freedman and her colleagues conducted, as well as in the interviews for Bishops and Bodies, the large majority of patients did not know that they were delivering at a Catholic hospital. Even when they did realize it, did not understand how it might dangerously compromise their care. While a substantial minority of Americans self-identify as “pro-life” and oppose elective abortion, many fewer understand that the Church and the Republican Party construe “pro-life” to mean that a woman must sustain a futile pregnancy that is threatening her health or fertility. Pro-life groups’ insistence that therapeutic abortion is never necessary adds to the confusion. Women are shocked and hurt when they discover that their own lives seem to count for so little, just when they most need care.

In the same way, those who live in liberal states might assume that they are safe—after all, they elected politicians who passed laws protecting their rights to reproductive care. But as Freedman explains, a 2009 federal law called the Weldon Amendment protects hospitals that refuse to provide abortion and sterilization, regarding any requirement to provide those services as a form of discrimination and withholding Health and Human Services funding from any state or agency that tries to impose a requirement. In other words, if you live in a blue state, your local hospital still may deny you critical reproductive care. And as Freedman shows, that hospital is unlikely to advertise that limitation, given how unpopular it is. Doctors’ work-arounds are likely to work better than in red states, but as Freedman notes, work-arounds are at the whim and will of providers who have to take it upon themselves to bend or break rules for their patients.

Bishops and Bodies contains far more insight than I can stuff into one book review. I filled the margins of my copy with highlights and stars. It’s all important. It’s not a long book, and it is well worth the time spent. In nuanced detail, Freedman shows the dangers to pregnant and birthing people of a world in which medical care comes second to theology and politics, and those who carry pregnancies are treated as vessels. Many more Americans live in that world now, and all of us should be concerned about the consequences.

Notes

1. Quoted in Lori Freedman, Bishops and Bodies: Reproductive Care in American Catholic Hospitals (Rutgers University Press, 2023), p. 132. ↑
2. (https://theintercept.com/2023/07/21/texas-abortion-zurawski-lawsuit/) ↑

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Featured image caption: Saint Agnes Medical Center, a Catholic hospital in Fresno, California. (Courtesy David Prasad)