This piece is published in collaboration with Echoing Ida, a Strong Families project.
I am a fat Black woman from the South. I exist at the intersection of multiple identities that medical research labels “vulnerable populations.” The label “vulnerable population” describes people who are frequently excluded from involvement in medical research, including clinical trials, because they are perceived as difficult to reach by the research community. Despite acknowledging that their research is not inclusive of all groups, the medical industry has a long exploitive history of attributing health disparities to patient behavior and economic inequality rather than admitting that their own prejudices also lead to differential outcomes for “vulnerable populations.” So when it was reported recently that French drug manufacturer HRA Pharma had found that the emergency contraceptive Norlevo, which has a similar chemical makeup to Plan B One-Step, is ineffective for women over 176 pounds, I was not surprised. Medical research, researchers, and commentary do not exist in a vacuum of objectivity; they are shaped by social assumptions and stereotypes that often end up having harmful consequences for “vulnerable populations.”
The labeling of one’s size and obesity status is not objective, nor are the factors isolated. Body mass index (BMI) has long been a magnet for fat-shaming and does not take into account differences in body composition between genders and racial and ethnic groups, and people of color are still disproportionately considered “obese.” Poverty exacerbates barriers to quality health care, thereby increasing the potential for obesity in these communities. With Black and Latino/a populations disproportionately living in poverty, they are at a much higher risk for obesity and more likely to be overweight, especially those living in the South. Poverty not only restricts access to nutrition and health care, but also appropriate reproductive health services and information. This means women of color are less likely to have access to appropriate emergency contraceptives.
According to Princeton’s emergency contraceptive web page, obese women (with a BMI of 30 or greater) became pregnant more than three times as often as non-obese women when using emergency contraceptives like Plan B. For women with a BMI greater than 26, the site recommends they contact a health-care provider for a copper intrauterine device (IUD) within five days after intercourse to prevent pregnancy. Confusion and misinformation already surround emergency contraceptives, especially more popular types like Plan B, but barriers mount depending on one’s race, body type, and class, resulting in often dire consequences for women of color seeking emergency contraceptives.
These findings raise concerns about whether fat women are given adequate knowledge about the proper emergency contraceptives. The medical industry assumes that “obese” women know that a copper IUD would be a more effective alternative to oral emergency contraceptives, can find a physician, and have the device implanted. Though a copper IUD is among the most inexpensive long-term (lasting up to 12 years) and reversible forms of birth control, upfront cost can range from $500 to $900. This presents a potential hardship for these women, who are often unable to acquire such a large lump sum of money. Even with Planned Parenthood’s prorated costs based on income, or even Medicaid, cost is still a barrier for women in rural communities who lack access to health-care professionals and women living in red states that have rejected Medicaid expansion. Even when they gain access to a health-care provider, they may not receive accurate contraceptive information about weight and may encounter poor medical advice that is rooted in the provider’s own racial, gender, class, and fat biases. Additionally, despite the perceived long-term convenience of an IUD, it cannot be inserted or removed without medical assistance. This leaves the judgment to remove the device up to the medical provider, stripping women of their reproductive agency. Lack of adequate access to health care and medical information compounds disadvantage resulting in limited reproductive health options for many women who happen to be considered “obese”—a de facto determination of who is and isn’t deserving of various reproductive health options.
Though over a third of U.S. women are “obese,” they remain underrepresented in contraceptive clinical trials, and at this point there are no clinical trials for an emergency contraceptive scheduled for “obese” women. It is painfully obvious that the medical industry has yet to account for how “vulnerable populations” intersect with one another. “Obese” women included in clinical trials will likely represent the health concerns and needs of white women even though poor women of color are more likely to be “obese” and need to be accounted for, if the medical industry plans to be inclusive. But they seem to have no plans to be inclusive. For example, human papillomavirus (HPV) vaccine medical trials under-represent Black women, meaning the vaccine on the market is designed to fight HPV strands that are common in white women, rendering it less effective for Black women whose common strands differ. We see this happening in clinical trials for contraceptives as well. Historically, contraceptive research excluded “obese” and overweight women from clinical trials, resulting in a limited body of evidence regarding contraceptive effectiveness and safety in “obese” and overweight women. This means that overweight and “obese” women are prone to receiving improper birth control information largely because their under-representation results in a lack of accurate information about how they are affected. The problems of this lack of information fall disproportionately on the shoulders of women living at the intersections of Blackness, poverty, and Southerness.
The irony here is that modern contraceptive knowledge is based on experimentation and forced sterilization of Black women and other women of color during the eugenics movement and its aftermath. Now, when we actually stand to benefit from our inclusion in these trials, the medical industry ignores us. Though “vulnerable population” should imply the increased likelihood of being exploited or mistreated by medical professionals and researchers as it has in the past, it has now come to signify our invisibility and negligent disregard by the medical industry.
On Monday, the American Civil Liberties Union (ACLU) and the ACLU of Michigan announced they had filed a lawsuit against the United States Conference of Catholic Bishops (USCCB) “on behalf of a pregnant woman who miscarried and was denied appropriate medical treatment because the only hospital in her county is required to abide by religious directives.” Written by the USCCB, the directives “prohibited that hospital from complying with the applicable standard of care in this case.”
The ACLU is taking the USCCB to task for requiring that all Catholic health-care facilities abide by the “Ethical and Religious Directives for Catholic Health Care Services,” which prevent Catholic hospitals from, among other things, offering an abortion under any circumstances, even when a fetus has little to no chance of survival and the woman’s life or health are at risk.
A recent Catholics for Choice/ACLU poll found that when it comes to abortion, nearly all respondents say doctors should not be allowed to withhold information about a fetus’ health for fear the woman may have an abortion, and majorities say doctors should not be allowed to refuse to make a referral for an abortion and that Catholic hospitals should not be allowed to refuse to provide medically necessary abortions. Nonetheless, we know that at least in the case of Tamesha Means, the woman the ACLU is representing, this made little difference.
Unfortunately, we also know that in Catholic hospitals in Michigan and across the country medical decisions are often derailed by the bishops’ directives.
Catholic health care is big business, especially in Michigan, where Catholic health care is health care for many people. Of all hospital admissions that occur in the state, between 20 and 29 percent occur in a Catholic-run facility. In total, Michigan’s 23 Catholic hospitals care for 5,142,006 patients each year. The state’s eight Catholic health-care centers attend to 517,084 patients annually. Not all of the individuals treated by the Catholic health system are Catholic, but there are 2,008,445 Catholics in Michigan—21 percent of the state’s population. Only 17 of them are bishops. Mercy Health Partners, the hospital where the above case took place is the only one in the county.
It is worth noting that a significant percentage of the health care delivered in the United States comes from the country’s 630 Catholic hospitals, which make up 12.6 percent of the nation’s total. People in certain areas may rely upon Catholic health care because there are few other options—nearly one-third (32 percent) of all Catholic hospitals are located in rural areas. The economically vulnerable individuals served by Medicaid are often treated at Catholic hospitals, which account for 13.7 percent of all Medicaid discharges in the United States (nearly one million patients, at 978,842).
In addition, there are 56 Catholic health systems, which are enormous conglomerations made up of many separate Catholic-run hospitals. Catholic hospital systems are among the largest in the country—among the top five biggest nonprofit systems, four (80 percent) are Catholic, and all of the top three are Catholic. These three largest entities alone comprise 268 hospitals. Looking at the nation’s ten largest nonprofit health systems, six of the ten (60 percent) are Catholic. Of the group of the 25 largest nonprofit health-care systems, 11 (44 percent) are Catholic-run. When one considers the 868 hospitals affiliated with the top 25 largest hospital systems in the country, 493 of these are Catholic. All of those operate under the bishops’ directives.
Under the directives, the reality for women who find themselves at a Catholic hospital means they have:
The sole exception to the ban on contraception falls under Directive 36, which only allows the provision of emergency contraception (EC) in cases of sexual assault when it can be proven that pregnancy has not occurred. This creates an unnecessary restriction, as EC does not interfere with the implantation of a fertilized egg. Evidence also suggests that many Catholic hospitals rarely provide EC even under the circumstances approved by the directives. A 2006 study found that 35 percent of Catholic hospitals did not provide EC under any circumstances, while 47 percent refused to provide referrals to hospitals that did. Of those that provided referrals, only 47 percent of these led to a hospital that actually provided EC.
The Misinformation Campaign
The bishops who claim that Catholic institutions care for the poor and underserved in a fashion that surpasses other nonprofit hospitals are engaging in a public relations campaign that is more myth than fact. Here are several claims you can expect to hear from the bishops—followed by the truth about what health care under the Ethical and Religious Directives means for people who need care at a Catholic hospital.
Claim: Catholics support the directives and do not want or expect their hospitals to provide services that are forbidden. “With the support of the faith community, Catholic organizations and agencies provide pastoral services and care for pregnant women, especially those who are vulnerable to abortion and who would otherwise find it difficult or impossible to obtain high-quality medical care.” – USCCB, “Pastoral Plan for Pro-Life Activities: A Campaign in Support of Life,” 2011.
In Fact: Many Catholics do not even know about the directives and are shocked when they find out that Catholic hospitals do not provide a full range of medical services. Catholics throughout the United States rely upon their individual consciences when making decisions about which reproductive health-care services they use and want their hospitals to provide. In 2009, more than six in ten Catholic voters (62 percent) indicated that hospitals and clinics that take taxpayer dollars should not be allowed to refuse to provide medical procedures or medications based on religious beliefs, and most Catholic voters (78 percent) oppose allowing pharmacists to refuse to fill prescriptions for birth control.
Catholics use and obtain contraception and abortion at rates similar to the rest of the U.S. population and support access to these services. Sexually active Catholic women above the age of 18 are just as likely (98 percent) to have used some form of contraception banned by the hierarchy as women in the general population (99 percent), and less than 2 percent of sexually active Catholic women use the bishops’ preferred method (natural family planning) as their primary form of birth control. In 2008, a study of almost 9,500 women showed that Catholic women have abortions at the same rate as other women: 28 percent of women who had an abortion self-identified as Catholic, while 27 percent of all women of reproductive age identified as such. The facts tell the story—the majority of Catholics have rejected the USCCB’s hard-line stance, as outlined in the directives, and instead support access to comprehensive reproductive health care and need their hospitals to provide these services.
Claim: “Catholic health care does not offend the rights of individual conscience by refusing to provide or permit medical procedures that are judged morally wrong by the teaching authority of the Church.” – USCCB, The Ethical and Religious Directives for Health Services, 2011.
In Fact: The reverse is true. Catholics throughout the United States rely on their consciences to use services that are banned under the directives. Last year, Catholic hospitals employed over 600,000 full-time staff, accounting for 16.7 percent of all full-time hospital staff in the United States. Time and time again, medical professionals employed by Catholic hospitals have reported that, out of fear of theopolitical retribution or out of sincere adherence to the draconian measures imposed by directives, their institutions have forced them to endanger women’s lives by denying timely and necessary reproductive health care. Catholic medical professionals have described situations in which, due to these strictures, they have provided substandard care to women seeking treatment for miscarriage or ectopic pregnancy.
While it serves neither the patient seeking care nor the dictates of conscience to force individual medical professionals to provide services they consider immoral, it goes too far to grant such blanket rights to an institution. Catholicism requires deference to the conscience of others in making one’s own decisions. Its intellectual tradition emphasizes that conscience can be guided but not forced in any direction. The directives, in their rigidity and their enforcement by the bishops, dictate to people what services they may provide and access rather than respecting the individual capacities of women and their doctors to form their own decisions.
When a young pregnant woman with pulmonary hypertension finds her life in danger and decides that it is best to defend herself by discontinuing her pregnancy, as happened in the case of St. Joseph’s, the hospital where she is treated has an ethical obligation to respect her decision. When an unemployed mother of five decides that she cannot have more children and seeks a tubal ligation, she should not have to worry about whether her right to follow her conscience will be denied. When a doctor has made the choice to save a woman on her operating table rather than waiting to perform unnecessary tests and waste precious minutes, that provider should have the ability to provide rapid, life-saving care without fear of retribution from administrators or the local bishop.
In addition, Catholic hospitals in the United States are part of a pluralistic society and have a moral obligation to respect the religious beliefs and denominations of all those whom they treat and employ, and whose taxpayer dollars they utilize, including many non-Catholics. Ultimately, when the bishops stop writing prescriptions for both individuals’ consciences and their medical care, all of us will benefit.
Claim: “Whether young or old, rich or poor, insured or uninsured, people in the US find the care they need—care always respectful of their dignity as human persons—at Catholic-sponsored health care facilities … [Catholic hospitals are] a passionate voice for compassionate care.” –Sr. Carol Keehan, CHA President and CEO, “Catholic Health Association Brochure,” 2010.
In Fact: Catholic hospitals routinely deny basic reproductive health-care services, leaving women without the respectful care that the CHA claims to provide. The Catholic health-care system indeed provides some important services in communities across the United States. The reality is, however, that the CHA and USCCB aim to highlight their commitment to human dignity and the poor while simultaneously refusing to meet the health needs of the people they serve.
By banning most services for women experiencing miscarriages, seeking to avoid pregnancy, or in need of abortion care, and turning away couples attempting to conceive a child through new reproductive technologies, Catholic hospitals in fact demonstrate a lack of compassionate understanding of peoples’ lives.
Even in instances in which the directives allow some reproductive health-care services, such as the emergency contraception provision for rape survivors included in Directive 36, many Catholic hospitals still refuse to comply with basic standards of medical care. In a 1999 survey of 589 Catholic hospitals, 82 percent stated that they did not provide EC under any circumstances. In a 2002 study, 328 of the 597 Catholic hospital emergency rooms surveyed refused to dispense EC under any circumstances.[xii] In 2006, only 37 percent of Catholic hospitals surveyed stated that EC was available for sexual assault patients at their hospital, while 35 percent stated that EC was not available under any circumstances. For the sexual assault survivor who turns to a Catholic emergency room during her time of crisis and is denied emergency contraception, the CHA’s dedication to “compassionate care” may ring false. In addition, a recent study examined the impact that the directives have on the care pregnant women receive at Catholic hospitals and concluded that women presenting with symptoms related to ectopic pregnancies were denied information about, and access to, possible treatments.
Claim: “[Catholic hospitals] operate not out of a profit motive but out of charity. In 1998, for example, the nation’s 637 Catholic hospitals’ service to the poor resulted in a $2.8 billion financial loss.” –Maureen Kramlich, US Conference of Catholic Bishops’ Secretariat for Pro-Life Activities, “The Assault on Catholic Health Care,” 2002.
In Fact: Catholic hospitals operate under the same tax laws as other nonprofit hospitals, charge market rates for health care services, receive the same government funding as non-Catholic hospitals and do not provide any more charity than other health care systems. In 2002, a MergerWatch study found that public hospitals provided twice as much free care as Catholic hospitals, based on charity write-offs.
Furthermore, directly following the “merger mania” of the mid-1990’s, some Catholic health systems actually saw double-digit revenue surges compared to previous years. In 2004, Ascension Health, the largest Catholic system and sixth-largest health-care system overall based on its number of acute-care hospitals in 2003, achieved a $10.04 billion, or 11 percent, revenue growth in the fiscal year ending in 2004.
U.S. tax dollars continue to fund Catholic hospitals, which do not provide the full range of health services. A 2002 study of over 600 religiously affiliated hospitals found that they received more than $45 billion in public funds. Approximately half of this revenue was received from Medicare, Medicaid and other government programs.
As a 501(c)(3) nonprofit organization, the CHA itself also benefits from tax breaks similar to those provided to charitable, religious, educational, literary, scientific, public safety, amateur sports, children’s and animal rights organizations such as the American Cancer Society, the Poetry Foundation and American Society for the Prevention of Cruelty to Animals. By the conclusion of the fiscal year ending on June 30, 2010, CHA had garnered over $26 million in assets.
Tax breaks and government funding to organizations that do not provide the full range of reproductive health do not bode well for the health of U.S. Catholic and non-Catholic taxpayers. During the 2009 health-care reform debate, the majority of Catholic voters (65 percent) indicated that hospitals and clinics that receive taxpayer dollars should not be allowed to refuse to provide medical procedures or medications based on religious beliefs. A majority of Catholic voters (60 percent) also believe that hospitals and clinics that take taxpayer dollars should be required to include condoms as part of HIV prevention.[xx]Women, meanwhile, disapprove of circumstances in which a Catholic hospital would become the only medical institution in their community (68 percent), while 85 percent reject the idea that Catholic hospitals receiving government money should be allowed to ban procedures because of religious beliefs.
Claim: Patients can go to another hospital if they need procedures that Catholic hospitals do not provide. “Those who have decided to be critical of Catholic healthcare apparently work hard to find some of those few cases in which one or more elective procedure [sic] may have been eliminated within a community. But we fail to see how they can jump to the conclusion that women have ‘no access’ to the elective procedures.” –Rev. Michael D. Place letter to Redbook Editor in Chief Lesley Jane Seymour, 2000.
In Fact: More than one third (32 percent) of U.S. Catholic hospitals are located in rural areas, and they are often the only local health-care providers in these communities. For the men and women who depend on these hospitals, however, their right to even basic reproductive health services is severely compromised. If the hospital is Catholic and will not fulfill the needs of the community it serves, then the hospital is frankly not helping people who have no other choice in health care.
In areas where Catholic hospitals are often the only health-care providers, those without the means or, in the case of emergency situations, the time to travel cannot access alternative care. In the span of one year, Catholic hospitals accounted for more than 2 million Medicare discharges (16.7 percent of the national total) and more than 900,000 Medicaid discharges. These patients, some of them the poorest of the poor, were left without access to their basic health-care needs. For example, a Medicaid patient in eastern New Orleans arriving at a hospital in the Franciscan Missionaries of Our Lady Health System and hoping to prevent an unplanned pregnancy with modern contraception will not get the care she needs. A woman in rural Nebraska who cannot take time off from work to travel many miles to a non-Catholic hospital after a potentially life-threatening diagnosis of ectopic pregnancy will also find that most treatment options are closed to her.
Even those individuals whose financial status or location may normally enable them to travel to a non-Catholic facility can find themselves reliant upon Catholic hospitals. More than 19 million emergency room visits occurred in Catholic facilities during 2009. Women experiencing medical duress due to ectopic pregnancies, miscarriages or rape may not have the time or the luxury of choosing another hospital. A woman in this situation will not have her medical wishes honored, but may instead find herself in a hospital that will allow her condition to dangerously deteriorate out of a strict adherence to the directives.
Many people are also not aware of the restrictions imposed by the directives until they are in need of the services that are banned. Often, patients believe the name of the hospital to be a name only and are unaware that it indicates a different standard of health care. Even non-Catholics who seek care at a Catholic institution are subject to the directives, and many will be surprised to learn that the care they require is unavailable.
Catholic hospitals are, first and foremost, health-care facilities—they all receive taxpayer money and they must adhere to standards of health care. This means providing comprehensive care for all patients. The USCCB and CHA aim to highlight the importance and commitment of Catholic services to the community, while at the same time downplaying the reproductive health needs of the people they serve and whose tax dollars they continue to utilize. A health-care institution should primarily provide care with a focus on its responsibility to the patients, employees and community it serves.
Catholics and non-Catholics recognize this and consistently exercise their own judgment when making decisions about which reproductive health services they want to use and want their hospitals to provide.
Catholics for Choice remains convinced of the moral capacity of men and women to make their own decisions regarding their reproductive lives. We are committed to the idea that access to reproductive health care is a matter of social justice, and that all people, Catholic or not, should be able to walk into a hospital without fear that their medical needs will not be met.
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