Freedom of Conscience in a Catholic Hospital

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My mother, at 89, lives with a sound mind in a failing and frail body. She has had a living will for decades, and it specifies that no extraordinary medical measures — including artificial feeding — be used to prolong her life if there is no hope of recovery. She has explicitly told my brother and me, who have the legal power to make her health-care decisions if she is no longer able to do so, that she wants nothing done to keep her alive if her mind is gone. You can’t get much clearer than that.

In spite of the advance planning for which my mother is legendary, she might be in real trouble if she were unfortunate enough to be taken in an unconscious state to an emergency room at a Roman Catholic hospital. The moral values of the U.S. Conference of Catholic Bishops — not her own values — could dictate her care.

The bishops’ most recent health-care directives, issued near the end of 2009, make it clear that they consider it the duty of Catholic health-care providers to impose artificial nutrition and hydration on patients in persistent vegetative states. My brother and I would, of course, take immediate steps to have our mother removed from a setting where her wishes would be ignored. But what if she had no living children or, like some two-thirds of Americans, had procrastinated about putting her instructions in writing? 

Here is an issue involving the separation of church and state that is, at its core, a question of whether individual liberty of conscience really means liberty for all. In recent years, much of the debate over religion in the public square has revolved around symbolic issues such as reciting “under God” in the Pledge of Allegiance, installing monuments of the Ten Commandments in courthouses, or, most recently, maintaining a cross as a World War I memorial on public land. As an atheist, I do not dismiss the importance of such issues. After all, they are called symbolic precisely because they stand for something larger than practical concerns. The truth is, however, that these symbols may sometimes offend my constitutional sensibilities, but they have zero impact on my personal life.

Health care is something else entirely — literally a matter of life and death. At a time when the government plays an ever-expanding role in paying for individual care — and is almost solely responsible for the medical expenses of those over 65 — “conscience clauses” are concerned only with the right of religious health-care providers, on an individual and institutional level, to refuse to offer services that conflict with their faith. These clauses have nothing to do with the right of Americans, whatever their beliefs, to receive legal medical care consistent with their consciences.

The issue arises not only at Catholic hospitals, which at least have written directives from a governing body. The beliefs of health-care administrators also play an unwritten role in many institutions that are ostensibly nonsectarian and secular. The American College of Emergency Physicians, for example, has issued guidelines stating that rape victims should be counseled about how to prevent pregnancy — a position with which I daresay most Americans, whatever their faith, would agree. Yet in the state of Missouri, with a strong Catholic and conservative Protestant presence, only half of hospital emergency rooms stock the “morning after” pill or require pregnancy counseling for rape victims. It need hardly be said that victims of sexual assault, like the terminally ill, are not in the best position to go hospital-shopping.

It is past time for a fundamental redefinition of what freedom of conscience means in a pluralistic society. Since Roe v. Wade galvanized the religious Right in 1973 in opposition to the legalization of abortion, there has been unremitting pressure to protect health-care workers from doing anything they consider immoral in treating patients. I have no quarrel with that half of the equation — as long as it is made clear to patients and their relatives, in advance, exactly what services the provider will refuse on religious grounds, exactly how the patient can obtain legal care elsewhere, and who will pay for the change of venue. A patient should not have to foot the bill for respecting the conscience of others.

That some providers claim the right not only to refuse services on religious grounds but to deny information about other choices seems utterly incompatible with respect for the consciences of the vulnerable, which we all are when we need medical care. Redressing this morally untenable balance will be complicated, not only because Americans have become accustomed to thinking and talking only about the “rights” of providers but because the discussion has usually focused on positions taken by the most vocal and extreme elements within any religious group.

There is vast disagreement among Catholics themselves, for instance, about health-care issues extending from conception to the end of life. Consider the case of Sister Margaret McBride, the administrator of a Catholic hospital in Phoenix, who was excommunicated by the local Catholic bishop for giving her approval to a therapeutic abortion for a mother of four — a woman who had been told by her doctors that she would die of heart disease if she continued her pregnancy. Such conflicts are more visible among Catholics because of the hierarchical structure of the Church, but they surely exist within most large religious groups in the United States.

We cannot hide behind the false assumption that every patient has a free choice of health-care providers. What “choice” does a woman have if she is not told about the existence of emergency contraception until three days have passed — and the pill will no longer work? What choice would a dying patient — one less prepared than my mother — have if she found herself in a hospital where, for religious or any other reasons, she was denied the knowledge that she did not have to consent to being hooked up to machines that can only prolong death?

The basic principle for a legal solution to this moral problem seems to me as clear and straightforward as the three opening words of the Constitution. If the phrase “we the people” means anything, it means that my mother’s conscience counts just as much as the conscience of a bishop.

Susan Jacoby is the author of Freethinkers: A History of American Secularism and The Age of American Unreason.