CARRINGTON, N.D. — The Carrington Health Center in North Dakota is run by a Catholic health firm, Catholic Health Initiatives, so one might assume that everyone working there would understand and comply with Church teachings regarding medical practices.

But in fact, until last November the health center was performing sterilizations on women. Sister Paula Ringuette, a board member of the hospital, told Associated Press that she thought the practice complied with Catholic health care rules.

Eventually, Bishop James Sullivan of Fargo was forced to order the hospital to stop. “Direct sterilization is an intrinsically evil act and, as such, is always and without exception forbidden,” he said in a November 2000 letter to Catholic Health Initiatives.

What happened in North Dakota is anything but unique. Catholic and Catholic-managed hospitals across the country have offered sterilizations, contraceptives and abortifacients to their customers, according to the Linacre Institute-Catholic Medical Association, a nationwide group that dedicates itself to upholding Catholic principles in medicine.

In order to try to stop the widespread abuses, the U.S. bishops in June adopted a revised fourth edition of their Ethical and Religious Directives for Health Care Services. Some “applications [of the old rules] were not acceptable,” said Bishop Donald Wuerl of Pittsburgh, who directed the revisions along with Archbishop Daniel Pilarczyk of Cincinnati.

The previous directives “seemingly were misapplied, “ Archbishop Pilarczyk agreed, adding that they “seemed to be an invitation to trouble. “

The revised rules, specifically those detailed in Part Six, entitled “Forming New Partnerships with Health Care Organizations and Providers,” are designed to prevent Catholic hospitals — and Catholic hospitals that have merged with secular firms — from engaging in “intrinsically immoral” acts.

Such actions include abortion, euthanasia, assisted suicide, and direct sterilization.

“The goal of the revisions is to ensure sufficient distance between the Catholic entity in arrangements with other-than-Catholic organizations and wrongdoing, particularly direct sterilizations,” said Fred Caeser, senior public affairs director of the Catholic Health Association.

Vatican Involved

The revisions were made after the Congregation for the Doctrine of the Faith ordered changes be made to the old directives, particularly to a four-paragraph appendix that appeared to contain loopholes allowing Catholic hospitals and merged hospitals to be involved in sterilization, contraception and related matters.

The revisions were the result of a yearlong consultation between a working group of the bishops’ conference, Vatican officials, theologians and Catholic health care representatives. An introduction to the revised directives says that efforts in the original appendix to explain the principles of cooperation “did not sufficiently forestall certain possible misinterpretations and in practice gave rise to problems in concrete applications of the principles.”

The key change was the deletion of the appendix. “How the appendix was interpreted was the problem,” Bishop Wuerl stressed. “Now, the bishops are clarifying exactly where things are not allowed. It is practical, not theological.”

According to the revised directives, decisions that may lead to serious consequences for the identity or reputation of Catholic health care services, or entail the high risk of scandal, should be made in consultation with the diocesan bishop. Any partnership that could affect the mission or religious and ethical identity of Catholic health care institutions must respect Church teaching and discipline, and diocesan bishops and other Church authorities should authorize the final agreements on such partnerships.

As well, if a Catholic health care organization is considering entering into an arrangement with another organization that may be involved in activities judged morally wrong by the Church, participation in such activities must be limited to what is in accord with the moral principles governing cooperation. Catholic health care organizations are forbidden to engage in immediate material cooperation in actions that are intrinsically immoral, such as abortion, euthanasia, assisted suicide, and direct sterilization.

Still, some observers remain skeptical that the bishops’ conference or the Catholic Health Association, which represents more than 2,000 organizations working in the not-for-profit health care sector, are fully committed to the new guidelines.

“I think the loopholes have been tightened,” said Dr. Eugene Diamond, director of the Linacre Institute-Catholic Medical Association. But, he added, some firms “are still going to try to make abortifacients available, and they are going to continue to want the Catholic hospitals to forfeit their beliefs in order to get mergers and contracts.”

The Catholic health care ministry runs nearly 600 hospitals and more than 700 nursing homes in the United States. Four of the country's 10 largest health care firms are Catholic, and between 1994 and 1997, 17% of hospital and health care mergers involved Catholic institutions. Of those mergers, 93% were with secular hospital partners that commonly provide sterilizations contraceptives and other services prohibited by the Church.

Merger Problems

The problem is how to maintain those mergers and enter new ones without violating Church teaching. The problem is compounded by the fact that nearly all health insurance provides “family planning” services that can include abortions and contraceptives.

In addition, 13 states now require health insurers to provide “family planning” services.

“I know that the bishops are trying to tighten up on this stuff,” said Michael O‘Dea, director of Christus Medicus, a Bloomfield, Mich.-based organization dedicated to promoting health care coverage that complies with Catholic teaching. “But I'm not sure they understand the problem. Are they going to rewrite the health plans? They have to be rewritten and then approved at the state level.”

Concerning the new directives, O‘Dea said he “hopes” that they close the loopholes that have allowed sterilizations and other immoral actions to occur at Catholic hospitals.

To avoid seeming directly complicit in such actions, O‘Dea explained, the merged firms have taken to moving certain operations to another site.

As well, some Catholic hospitals have used a third party to collect fees, with any money collected from a site offering “reproductive services” not being sent to the Catholic hospital.

The bishops’ revised policy clarifies that “not only can't you do it but you can't help others do it,” Archbishop Pilarczyk told Catholic World News in June.

Asked what sort of cooperation was allowable between a Catholic institution and an institution offering prohibited services, he said that the two institutions might share a driveway.

Father Michael Place, director of the Catholic Health Association and former health care advisor to Cardinal Joseph Bernardin, said that the new guidelines are “the best we have right now,” although experience may reveal the need for further refinements.

“I believe the new directives respond to the Congregation's concerns,” said Father Place.

“But it's like reading a book on swinging a golf club.” He explained that this meant there are many variables to the issue and no single application of the rules can work in every case.

Local Bishop Decides

So, how will the new directives be enforced?

“The ultimate responsibility is with the diocesan bishop,” said Father Place, whose organization has more than 2,000 members working in the not-for-profit health care sector. “What we're doing is providing our members with the resources they need.”

When asked whether individual bishops would comply with the new rules, Archbishop Pilarczyk said, “They are supposed to.” He added, however, that these are directives and “they can't guarantee compliance.”

Added the archbishop, “No document, no directive can solve every problem in advance … I think we did what was asked of us, in accord with what the Holy See wanted. But not everyone is deliriously happy.”

Christus Medicus’ O‘Dea predicts it will remain a diocese-by diocese battle to ensure that Catholic institutions remain faithful to Church teachings. “I don't think the U.S. bishops [as a group] will do much of anything to enforce the directives,” he said. “It will come down to individual bishops taking action.”

Michael Chapman writes from Washington, D.C.