Rules Are for Schmucks: Hospitals That Won’t Treat

I like numbers. They can’t be used to explain everything, but they can be used to explain a lot.

Consider the example of Catholic hospitals. It has always seemed jarring to me that the government licenses, protects from competition, and subsidizes hospitals that refuse to perform certain medical procedures for the most bizarre religious reasons. Now, thanks to a new study published by the National Bureau of Economic Research, we can put some hard numbers on at least part of the damage these inane religious restrictions cause.

To some extent, the task of social scientists attempting to quantify this phenomenon has been made easier by the explosion in Catholic control over hospitals in recent years. One of the many adverse effects of the Affordable Care Act has been greater concentration in hospital ownership, with a wave of hospitals being gobbled up by larger chains. There were 110 hospital mergers in 2012 alone, nearly double the rate of the pre-ACA years. The Catholic hospital empire has been an enormous beneficiary of this change, with four of the top ten healthcare systems in the country now Catholic-dominated. From the social scientist standpoint, this takeover activity presents a juicy opportunity to compare data before and after the change in ownership, to determine what if any difference it makes.

For the most part, whether a hospital is owned by Catholics, sun-worshippers, or atheists doesn’t matter in the slightest to its patients—all they want is excellent care at a fair price. And for the most part, this is exactly what the social scientists found—no significant difference in overall quality of care at hospitals that switch from Catholic ownership to non-Catholic, or vice versa. But when it comes to certain specific procedures that the Catholic Church frowns on, the researchers found some profound effects following an ownership change.

The two procedures with the sharpest statistical differences were abortion and tubal ligation. The fact that Catholic hospitals are less likely to perform abortions falls a bit short of being head-turning news, so let’s focus on the tubal ligations.

Tubal ligation, sometimes called “tube-tying,” is a procedure that effectively prevents a future pregnancy by making it impossible for sperm to reach the egg cell. Unlike certain other types of contraception, it can never result in the destruction of a newly-fertilized egg, because the process can never get that far. Tubal ligation requires a full-blown surgical operation on an in-patient basis, with all the risks that every general-anesthetic surgery carries. As a result, one of the most common circumstances of tubal ligation procedures is a difficult pregnancy and/or labor that ends with a C-section birth. The doctor tells the woman that as a result of her particular condition, trying to have another baby would involve much greater than average risk both for herself and her future child. The doctor also tells her that the incision that must be made for the tubal ligation is exactly the same incision that must already be made for the current C-section. If she wants to avoid that future risk, by far the safest time to do so is during the C-section procedure itself.

The woman then weighs her options and makes her choice. At least, that’s what she does in a hospital that cares primarily about its patients. But a Catholic hospital, which cares primarily about harebrained rules made up by elderly men, makes the choice for her. No tubal ligations are allowed, because all sexual activity must involve the possibility of procreation. (Why they don’t call sex after menopause sinful as well, you’ll have to ask them—I can’t explain it.) If the woman does die in a future pregnancy, or in a future surgery that could have been avoided, she’s just one more case of collateral damage.

After processing the mountains of ownership change data, the researchers concluded that the effect of Catholic ownership was to reduce tubal ligations by 31 percent in Catholic hospitals. Multiplying that figure by other data, they came up with a persuasive estimate that Catholic ownership “results in 9,508 fewer tubal ligations per year as a result of Catholic restrictions on reproductive care.”

That’s a lot of women put at unnecessary risk every year.

Here’s an interesting question: Why isn’t the figure higher than 31 percent? At an extreme, why aren’t all the tubal ligations done in non-Catholic hospitals? There seem to be two reasons for this—a good one, and a bad one.

The good reason is that not everyone follows the rules. Some doctors, faced with a choice between a woman’s safety and Catholic doctrine, decide that “rules are for schmucks” (or something like that!) and do what their conscience tells them is correct. (There is reason to be concerned that an unintended side effect of the publicity surrounding this study may be a crackdown against these doctors.)

The bad reason is that apparently many sales of Catholic hospitals to non-Catholic firms include a covenant to the effect that the non-Catholic firm must continue to abide by the lunatic Catholic rules even after the sale. How strictly they follow this, no one knows, but to the extent it’s followed at all, it blurs the difference between Catholic and non-Catholic hospitals the researchers were tracking.

Here’s a cool strategy for the bishops to consider: buy a hospital, then immediately flip it for the same price to a different buyer, but with the “no tubal ligations” covenant attached. Use the proceeds to buy and flip another hospital, then another, then another, until you’ve tainted the entire US hospital system. Then women will have no choice at all—God’s will be done!

Here’s an even cooler strategy for federal and state governments to consider: tell hospitals that if they want a license, if they want subsidies, if they want protection from competition, they have to treat patients based on medical criteria rather than based on what Rome says.