Complex Catholic Hospital Mergers Pose Ethics Challenge For U.S. Bishops

The network is the largest Catholic hospital chain and the second-largest nonprofit hospital system in the United States.

Dignity Health's Saint Francis Memorial Hospital and Health Center in San Francisco, Calif.
Dignity Health's Saint Francis Memorial Hospital and Health Center in San Francisco, Calif. (photo: Shutterstock)

The U.S. Conference of Catholic Bishops has asked its Committee on Doctrine to address issues such as transgender surgeries and hormone treatments for a proposed update to the bishops’ “Ethical and Religious Directives for Catholic Health Care Services” (ERDs).

But due to the complexities of Catholic health care systems today, the bishops’ directives may not be easy to enforce.

That challenge is underscored by a recent report that claims that non-Catholic hospitals within the country’s largest Catholic network of hospitals are performing transgender-affirming surgeries and possibly elective abortions.

The report on the Chicago-based CommonSpirit Health network, published by the Virginia-based Lepanto Institute, alleges “indisputable proof of gross defiance of Catholic moral teaching on the part of CommonSpirit Health.”

The 64-page report was published in May by the institute’s president, Michael Hichborn.

The health system voiced adherence to Catholic medical ethics when it was created in 2019, but its complex structure includes a “special carve-out” for non-Catholic hospitals aligned with the network, though they are barred from performing elective abortions.

CommonSpirit Health was launched in 2019 after a merger of DignityHealth and Catholic Health Initiatives health systems. It is made up of 140 hospitals and more than 1,000 health care sites in 21 states. Some hospitals aligned with the CommonSpirit network are not Catholic. The network is the largest Catholic hospital chain and the second-largest nonprofit hospital system in the United States. The merger required the approval of multiple Catholic bishops as well as state and federal regulators to proceed.

The Lepanto Institute questions the offerings of several non-Catholic hospitals in the network, including hospitals that perform transgender surgeries. The report also raises questions about CommonSpirit-aligned hospitals that provide hormone therapies and puberty blockers to children; provide contraception, abortifacients, and surgical sterilization to patients; and provide employee benefits plans that cover “gender-affirming care.”

CommonSpirit Health did not respond to requests for comment about the report.


Secular Hospital Named for St. Francis

In its report on CommonSpirit Health, the Lepanto Institute considers the actions of Saint Francis Memorial Hospital of San Francisco.

Despite its name, the hospital was founded in 1905 as a secular institution and remains so. Its description on DignityHealth’s website states: “Welcome to Saint Francis Memorial Hospital. We are a secular hospital in a Catholic organization (so we always spell out ‘Saint’).”

Doctors at Saint Francis performed the first purported transgender surgery in 1966. To serve self-identified transgender people, the hospital hosts a Gender Institute whose services include “gender-confirmation surgery.”

The hospital’s affiliated Saint Francis Foundation, which is also non-Catholic, has provided more than $7.1 million to the hospital’s Gender Institute since 2016, according to the “Health Justice” section of CommonSpirit Health Philanthropy’s 2022 annual report, which gives an overview of the health network members’ philanthropic work. The institute hosts robotic surgical equipment, including equipment used in sex-change surgeries and other “gender-affirming” care. The institute last year held a dedication ceremony for a new da Vinci surgical robot device, purchased at a cost of more than $2.6 million, to perform transgender-related procedures and other surgeries. The foundation on its website notes the importance of funding “to adequately support the transgender community” and other patients.

The Lepanto Institute describes Saint Francis Memorial as a “member” of CommonSpirit Health and cites the hospital’s self-description on its website as “part of CommonSpirit Health.” The Lepanto report pointed to CommonSpirit tax forms indicating the health system provided the hospital over $2.1 million in the 2019 and 2020 fiscal years.

A spokesman for the San Francisco Archdiocese, however, presented a different account of the relationship between the two health care organizations.

“CommonSpirit Health is a Catholic hospital system and has only Catholic hospitals in it,” said Peter Marlow, executive director for communications and media relations at the Archdiocese of San Francisco.

“It is aligned with a different system that includes the non-Catholic hospitals that were in the former Dignity Hospital system,” Marlow said.

“When this alignment was set up, a special carve-out was made for the non-Catholic hospitals that would continue to do direct sterilizations,” Marlow said. “It is run by a separate oversight board, and the revenues stay separate. The non-Catholic hospitals agreed to a ‘Statement of Common Values’ with the Catholic hospitals; therefore, the non-Catholic hospitals do not perform abortions, physician-assisted suicide, or IVF.”

“Transgender surgeries are a new issue not originally conceived in the ERDs,” Marlow continued. “The agreement provided that other ethical and religious issues in the future could be included in the ERDs among those that the non-Catholic hospitals do not perform. This has just now come to light, so it has to be looked into.”

Lepanto Institute President Hichborn, author of the report on CommonSpirit Health, criticized that explanation.

“One cannot create legal barriers that grant license to commit grave moral evil. Any entity that is a part of a Catholic system must abide by Catholic moral laws, or else the system of which it is a member cannot remain Catholic,” Hichborn told CNA. “Would the Church create similar carve-out clauses for Planned Parenthood in the interest of partnering with them for mammogram screenings or STD treatments?”

“The structure of CommonSpirit Health is somewhat convoluted, but what is absolutely clear from the organizational chart published in March of 2018 in Modern Healthcare magazine is that regardless of whatever legal barriers have been carved out for non-Catholic hospitals, the entire structure of CommonSpirit falls under the Catholic Health Care Federation,” Hichborn said.

He said that the hospitals identify themselves as members of CommonSpirit Health on their website, and CommonSpirit’s Form 990, a nonprofit tax document, shows that the health system funds the non-Catholic hospitals.

Hichborn also said that transgender surgeries should not have to be in the bishops’ “Ethical and Religious Directives” to be proscribed.


Enforcement Hinges on Local Bishop

As the U.S. bishops embark on the path to update their “Ethical and Religious Directives” along the lines of their doctrinal note on the gender issue, each bishop will continue to have a responsibility to ensure the ERDs are being enforced in the hospitals and health systems in their diocese.

Dr. Steven White, president of the Catholic Health Care Leadership Alliance (CHCLA), said that it is important to remember that Catholic health care “is a ministry of the Church and falls under the authority of the shepherds, the bishops.” When it comes to enforcing the ERDs, a bishop within his diocese “not only has the authority but has the responsibility to ensure that his hospital systems and health care professionals are acting in accord with the moral, ethical teachings of the Church.”

In extreme circumstances, when an institution is violating Church teaching, the bishop can “require that the name Catholic be removed from the hospital or system.”

To assist the bishops in their responsibility of ensuring the Catholic identity of health care institutions in their dioceses, the National Catholic Bioethics Center offers a “Catholic Identity and Ethics Review” that examines a particular health care institution at the local bishop’s behest to see if it is in conformity with the ERDs.

John Brehany, executive vice president and director of institutional relations at the bioethics center, said that the bishops’ directives “outline the responsibilities of Catholic health care institutions to assess the potential for scandal, to consult with the local bishop, and to respect his resolution regarding the need to avoid or resolve any theological scandal given.”

“If this work was not done before taking some of the actions reported upon in the Lepanto report, then it should be done in a timely manner,” he said.

“Catholic identity, and Church teachings, and the principles of the Catholic moral tradition should provide ultimate guidance for Catholic health care institutions,” Brehany added. “By that I mean that Catholic health care institutions should follow all laws and regulations unless they conflict with Catholic teachings. Ascertaining when they conflict or not can be complex.”

Michael Vacca, director of ministry, bioethics, and member experience at the Christ Medicus Foundation, a Catholic health-sharing network, said that while all Catholic health care facilities are supposed to comply with the ERDs, “there are Catholic institutions that struggle to apply them.”

As transgender procedures become more common, Vacca feels that the bishops have seen the need to be “more specific and clarify that this is a violation of the natural moral law, and it’s a violation of the teaching of the Church, which says that sexual identity is good and willed by God.”

In their March doctrinal note, the bishops wrote that “any technological intervention that does not accord with the fundamental order of the human person as a unity of body and soul, including the sexual difference inscribed in the body, ultimately does not help but, rather, harms the human person.”

Regarding Catholic hospitals joining with secular hospitals, Vacca said that if the secular institutions are openly providing abortions and transgender procedures, then the Catholic institution “would have a moral obligation not to partner with a secular institution that was going to be harming the human person.”

Louis Brown, executive director of the Christ Medicus Foundation, believes there should be a “wholesale reevaluation of the manner in which these mergers between Catholic health care systems and secular institutions are done, such that they can be consistent with the Gospel and the teaching of the Church on faith and morals.”

While not speaking to any specific merger, he said “it is clear that, at least some of these mergers between Catholic health institutions and secular health care systems” have not been done in a manner based on Catholic teaching, and there is a risk for scandal.


What is the Lepanto Institute?

The Lepanto Institute presents itself as a fact-finder that scrutinizes Catholic organizations that act contrary to Catholic teaching and ethics. It has produced reports critical of Catholic institutions and apostolates, but it has not escaped criticism itself.

In 2016, Catholic Relief Services corrected a Lepanto report that it said wrongly claimed that the U.S. bishops’ international relief organization was involved in contraceptive distribution in the Democratic Republic of the Congo.

In August 2015, the Lepanto Institute reported that a member of the World Meeting of Families organizing team had made political donations to pro-abortion political candidates.

This drew a critical response from the event host, the Archdiocese of Philadelphia, which said the Lepanto Institute showed “that it is not interested in presenting information in any useful way” and suggested that its reports are “not to be taken seriously.” Then-Philadelphia Archbishop Charles Chaput described the group as “sincere, but also destructive.”

Hichborn said the Lepanto Institute stood by its research on the World Meeting of Families. He said the Philadelphia Archdiocese “ignored our concerns” about political figures on the event’s leadership committee who rejected Catholic teaching on abortion and LGBT issues. He referred to a Sept. 24, 2015, blog post on the Lepanto Institute website for background. He also defended its reports critical of Catholic Relief Services.

The Lepanto Institute’s latest report charges that since the 2019 merger, distinctions between Catholic and non-Catholic hospitals have been “blurred to the point of obscurity.”

The Lepanto Institute said it was motivated to look at the health system after its unnamed sources indicated that CommonSpirit was opposed to the U.S. Conference of Catholic Bishops’ March 2023 “Doctrinal Note on the Moral Limits to Technological Manipulation of the Human Body,” which rejects surgical or chemical techniques that purport to change a patient’s sex.

Thirteen of the CommonSpirit-aligned non-Catholic hospitals in Washington and California scored a perfect 100/100 rating from the LGBT advocacy group Human Rights Campaign’s (HRC) Healthcare Equality index, which rates health care organizations’ compliance with LGBT goals. This designation requires employers to provide employee health plans that are fully “transgender-inclusive,” the report says. This includes hormone therapies and puberty blockers and also coverage for “gender-reassignment” or “sex-change” surgeries and related reconstructive procedures for the chest and genitals.

Another 14 Catholic hospitals in the CommonSpirit network fell short of a perfect score on the HRC’s index but still achieve LGBT-complaint health plan coverage, including purported transgender drugs and procedures. The Lepanto Institute says it confirmed the HRC evaluation through its own review of health plan documentation. Other covered services include elective sterilization for women.

One hospital, Mercy San Juan Medical Center in Carmichael, California, was deducted 25 points on the HRC index for unspecified “large-scale official or public anti-LGBTQ blemish on their recent records.” The Catholic hospital is being sued for declining to perform a hysterectomy on a woman who identifies as a transgender man because doing so would violate Catholic ethics. The plaintiff’s attorneys argue that refusal to perform a hysterectomy on a self-identified transgender man constitutes illegal discrimination based on sex. The lawsuit is seeking a court order that would force the hospital to perform elective hysterectomies in the future.


Bishops Looked at Mergers in 2018

At their spring 2018 general assembly, the U.S. bishops approved updates concerning hospital mergers to their “Ethical and Religious Directives.”

“Assessing material cooperation can be complex, and legitimate disagreements may arise over which factors are most relevant in a given case. Reliable theological experts should be consulted in interpreting and applying the principles governing cooperation,” the directives say. 

They also note the “danger of scandal.” For Catholics, scandal does not mean simply controversy. Rather, it means that one does or says something that leads others into sin.

The 2018 directives bar Catholic health organizations from engaging in “immediate material cooperation” with “intrinsically immoral actions,” including abortion, euthanasia, and direct sterilization. They also bar referring for procedures considered immoral by the Church and establishing another entity to oversee immoral procedures.

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