BEND, Ore. — It might be the tip of an iceberg. Repeated ethical violations at an Oregon hospital led its bishop to revoke the hospital’s privilege to call itself “Catholic” and to warn that the same moral error could already have infected Catholic health-care systems nationwide.

St. Charles Medical Center in Bend lost the title “Catholic” on Feb. 15 due to its refusal to stop doing tubal ligations to sterilize women. Founded by the Sisters of St. Joseph in 1918 but no longer run by them, St. Charles is Oregon’s only Level II trauma center in the central and eastern part of the state.

“The crux of the conflict was the hospital and ethics board’s intentional misinterpretation of ‘direct’ and ‘indirect’ sterilizations,” said Diocese of Baker Bishop Robert Vasa. After several years of negotiations with St. Charles, Bishop Vasa made the difficult decision to strip the hospital of its “Catholic” status.

Tubal ligation, informally known as “getting one’s tubes tied,” is always a direct form of female sterilization not permitted in Catholic health-care institutions. But, based on the Catholic principle of double effect, other procedures that indirectly induce sterility — the removal of cancerous fallopian tubes or ovaries, for example — are permitted in situations where no simpler remedy is available.

“The heart of my conflict here is that the hospital and the ethics board identified all of these 200 to 250 sterilizations they do a year as indirect,” Bishop Vasa said.

A typical case at issue would be that of a mother with three children. A doctor may decide it could be “dangerous” for her to get pregnant again. In such a circumstance, St. Charles’ hospital and ethics board claimed it was permissible under the directives for a surgeon to sterilize the mother with the “indirect” intention of keeping her healthy.

“Clearly, that’s a direct sterilization with the secondary hope of preserving her health,” Bishop Vasa said. “So it was in my mind an intentional misrepresentation and misinterpretation of that teaching.”

Further, the bishop stated, “It is possible that this teaching about sterilization may be misunderstood and misrepresented in a number of Catholic hospitals nationwide.”

To be called “Catholic,” a health-care institution must follow the “Ethical and Religious Directives for Catholic Health Care Services” issued by the U.S. Conference of Catholic Bishops. Paragraph 53 of the directives states: “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health-care institution.” A second sentence reads: “Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.”

This second sentence is often made the illegitimate pretext for sterilizations at Catholic hospitals.

A Covert Practice

Bishop Vasa noted that during the course of his negotiations with St. Charles, the hospital’s chief executive officer had been in contact with two or three very large Catholic health-care systems, and their question to him was: “Why did you tell the bishop you were doing this?”

The bishop was told that administrators in other Catholic health systems said, in essence, “This information should not have been shared so openly with the bishop.”

“It appears that hospitals may be pleading that their interpretation of the directive is correct,” Bishop Vasa said. “But it may also be that they are not being as transparent with their bishops as they should be. Thus, when the bishops ask the question, ‘Are you following the Ethical and Religious Directives?’ they will answer with a straight face, ‘Yes we are.’

“But if you ask, ‘Are you doing tubal ligations?’ they will say, ‘Yes, but always in accord with the directives as an ‘indirect sterilization.’”

It’s that code word “indirect” that’s the tip-off to evasion of ethical guidelines.

“If a bishop trustingly accepts that Catholic hospitals in his jurisdiction are following the directives in accord with his proper interpretation of those directives, he may be surprised to learn this may not be the case,” Bishop Vasa said.

According to an article, “In the Name of God and Truth: The Catholic Ban on Sterilization,” in the January 1994 issue of the bioethics journal Second Opinion, eticist Ronald Hamel writes, “Most Catholic hospitals that permit tubal ligations do so without the knowledge of local Church authorities. Their practice is in some ways covert.”

Hamel took the Church to task for cautioning against the “scandal that might result from Catholic hospitals’ performing tubal ligations” and stated, “the scandal really lies in the Catholic church’s [sic] refusal to permit direct sterilizations in the face of human tragedy and suffering.”

During his negotiations in Bend, Bishop Vasa learned it was Hamel’s article that convinced St. Charles’ board that sterilizations in Catholic hospitals were okay.

“Having read Hamel’s 1994 article, it is even more explicit and damning than I could ever have imagined. It is shocking in its one-sided and biased condemnation of the Church’s teaching about the evil of sterilization,” Bishop Vasa said. “No wonder Catholic hospitals are conflicted.”

Hamel is now senior ethicist at the Catholic Health Association of the U.S., a major Catholic health-care lobbying organization in Washington, D.C., which represents more than 2,000 Catholic health-care sponsors, systems, hospitals, long-term care facilities and related organizations.

In an e-mail response to the Register, Hamel said, “I do think there is validity to many of the points I make in the [Second Opinion] article, although I would probably word things differently today. The article, however, does not reflect the teaching of the Church nor the position of the Catholic Health Association.”

“Catholic hospitals are bound to follow the ‘Ethical and Religious Directives’ put out by the bishops’ conference,” Hamel said. “CHA adheres to the ‘Ethical and Religious Directives.’ The directives prohibit direct sterilization in Catholic hospitals.”

Hamel said he wrote the Second Opinion piece when he “was with another organization. It has no connection with CHA.”

Nevertheless, Hamel is executive editor of the quarterly CHA publication Health Care Ethics USA: A resource for the Catholic health ministry, which until Feb. 24, 2010, was posted on CHA’s website. In one article, Hamel posed the question, “The CDF Statement on Artificial Nutrition and Hydration: What Should We Make of It?” in which he personally interpreted the Vatican’s position on the matter.

Speaking as CHA’s senior director of ethics, Hamel wrote that there are “questions about the accuracy of the medical assumptions in the CDF statement and commentary.” An unsigned “primer” on the Vatican’s statement published in the same issue stated that if a patient has “objective discomfort that a reasonable person would describe as unacceptable subjective discomfort, the withdrawal of [artificial nutrition and hydration] would appear to be permissible.”

Another Health Care Ethics USA article, not authored by Hamel, stated, “The ethical distinction between allowing-to-die and euthanasia depends, for the most part, on the medical condition of the patient,” while a third article noted that the “autopsy after [Terri Schiavo’s] death belied any thought that she would have recovered.”

The fall 2007 issue of Health Care Ethics USA published “A Resource for Evaluating Levels of Authority in Church Teaching,” with the “pope’s [sic] ordering of a document’s publication” by the Congregation for the Doctrine of the Faith said to carry the least “theological weight.”

Moral Error Erupts in Texas

The title page of Health Care Ethics USA grants permission to Catholic Health Association members “to copy and distribute” the publication free “for educational purposes.”

It may be no mere coincidence that the same confusion between “direct” and “indirect” sterilizations that caused St. Charles to fall also erupted in Texas.

In 2008, a whistle-blower report by anonymous researchers looked at detailed data available from the state of Texas and found that 9,684 instances of allegedly unequivocal “sterilization for contraceptive purpose” had taken place in 23 of the state’s Catholic hospitals between 2000 and 2003. The whistle-blowers’ report, “U.S. Catholic Hospitals Betray Mission,” was posted on a website called Wikileaks.

Many questioned a report posted on the Internet by anonymous researchers. But when Bishop Alvaro Corrada of Tyler, Texas, asked tough questions, he unearthed trouble. Two Catholic hospitals in his diocese, Trinity Mother Frances in Tyler and Christus St. Michael in Texarkana, were indeed doing immoral sterilizations.

Both hospitals had relied on a misinterpretation of the directives, which led them to believe their policies and practices were in compliance with Church teachings on sterilization.

The erroneous contrast between “indirect” vs. “direct” sterilizations was at the heart of the confusion in Texas, just as it was at St. Charles in Oregon.

When Bishop Corrada clarified the authentic teaching of the magisterium, the Texas hospitals almost immediately changed their protocols and stopped doing sterilizations.

“There is no such thing as a tubal ligation that’s an indirect sterilization,” said Father Gavin Vaverek, promoter of justice for the Diocese of Tyler. “If the tube is bad — if it’s cancerous — you remove the tube. You don’t tie it. Tying it is always a direct sterilization. But it’s hard to get anyone [in the medical field] to admit this.”

Chooses Not to Change

Although the hospitals in the Tyler Diocese quickly altered their practices to retain their Catholic standing, St. Charles didn’t. The hospital had done sterilizations for years, and “the board did not see how it could now align the medical practices of the hospital with the [‘Ethical and Religious Directives’] to a degree that would justify an ongoing sponsorship relationship between the Diocese of Baker and St. Charles,” Bishop Vasa wrote in the Catholic Sentinel, the diocesan newspaper.

St. Charles had been only tenuously “Catholic” since about 1992, when the Sisters of St. Joseph no longer had a strong presence there. Only one Catholic remained on the hospital board of directors.

Although the bishop called the stripping of St. Charles of its Catholic name “sad” and the decision “difficult,” he said, “It just reached the point where the title of Catholic, which I was providing for them, no longer made sense.”

But the moral errors infecting St. Charles could be just a small foreshadowing of what Bishop Vasa predicted may be “a ballooning problem” in Catholic health care nationwide.

Sue Ellin Browder writes from Ukiah, California.