The growing presence of religious extremism in the political arena, coupled with years of legislation chipping away at Roe v. Wade, has increasingly impeded the work of reproductive healthcare providers and blocked patients’ access to comprehensive healthcare. Though Roe legalized abortion in 1973, abortion did not, as expected, become part of comprehensive reproductive healthcare services; rather, it became a specialized, outpatient procedure that has been increasingly stigmatized, marginalized and politicized by anti-choice forces.

Faith and religious practice play a key role in the lives of many patients and physicians, serving as a support system, a means of coping with life’s obstacles and a force for healing. Yet extremist religious ideology has played a pivotal role in limiting access to comprehensive reproductive healthcare. How does religion affect medical education in a Catholic medical college? How does it affect patients’ access to reproductive healthcare services when their insurance companies are religiously affiliated? How does it affect the doctor-patient relationship when a pharmacist refuses to dispense a birth control pill as prescribed?

These are the troubling questions that have compelled PRCH to educate providers about the religious forces that interfere with the delivery of comprehensive reproductive healthcare.

The Consequences of Hospital Mergers

According to Modern Healthcare, a leading trade magazine, half of the 20 largest health systems in the United States, as measured by net patient revenue, are Catholic.¹ There were 171 mergers between Catholic and non-Catholic hospitals between 1990-2001.² According to a study published by Catholics for a Free Choice in 1998, reproductive healthcare was either reduced or eliminated in 50 percent of cases in which Catholic and non-Catholic hospitals merged.³ As part of the negotiation of the mergers, the secular partners upheld the religious doctrine of the religiously affiliated hospitals in half the cases, maintaining the status quo of limiting access to reproductive healthcare, unbeknownst to patients.

Legislative Attacks on Reproductive Healthcare

On the state level, policymakers have continued to introduce legislation that would allow individuals and institutional entities to opt out of providing certain reproductive healthcare services based on religious or moral objections. According to the Guttmacher Institute, 46 states allow individual healthcare providers to refuse to participate in abortion procedures.⁴ In response to the increase in refusal cases being reported at pharmacies, states are pushing to expand rights to individual pharmacists who refuse to dispense medication such as birth control. Likewise, on the federal level, Congress has supported initiatives to allow for refusals by individuals and institutions.

Since 1973, when abortion became legal throughout the United States, a number of significant laws have been instituted relating to issues of religion and medicine that directly affect reproductive healthcare providers:

• Church Amendment
  As a reaction to the U.S. Supreme Court’s 1973 decision to legalize abortion in Roe v. Wade, Congress started the chain reaction of religiously influenced interference in medicine by passing the Church Amendment. This established that federally funded public health institutions could not require individuals to perform or assist in sterilization or abortion procedures to which they had moral or religious objections. The Amendment protects both those who choose to participate in and those who opt out of these procedures.

  Many states followed suit and passed similar legislation, but omitted the clause that protects individuals who choose to participate in abortion services. The Church Amendment was a precursor to what is often referred to today as the “refusal clause.”

• Coats Amendment
  The Coats Amendment, which protects individual refusals, was introduced after the Accreditation of Council for Graduate Medical Education (ACGME) adopted professional standards requiring obstetrics and gynecology residency programs to provide abortion training. The Coats Amendment, passed by Congress in 1996, maintains the federal funding and legal status of medical institutions that do not offer abortion training or provide referrals for individuals seeking abortion training at another institution. It also prohibits discrimination against institutions and individuals who refuse to provide the training. Though the ACGME standard exempted programs or individuals with moral objections from participating in the training, under the Coats Amendment institutions and/or individuals no longer had to claim moral objections for their noncompliance.

• Weldon Amendment
  The Weldon Amendment, formally known as the Abortion Non-Discrimination Act, was signed into law in 2004 as part of the Departments of Labor, Health and Human Services and Education and Related Agencies Appropriation Act 2005 spending bill. The Weldon Amendment prohibits federal agencies and programs, and state and local governments, from discriminating against healthcare entities because they do not offer abortion services, or provide coverage or referral for abortions. The Weldon Amendment covers a diverse group of healthcare entities, including physicians and other healthcare providers, hospitals, provider-sponsored organizations, HMOs, insurance plans and any kind of healthcare facility, organization or plan. Any law or regulation mandating these entities to require such action would be considered discriminatory and they could be at risk of losing federal funding under the Labor-HHS-Education bill. As of September 2006, the Weldon Amendment continues to be part of the Appropriations bill. For an up-to-date status report, contact advocacymail@prch.org or visit the Library of Congress website.

  This amendment directly conflicts with the federal regulation of Title X–funded family planning clinics that are required to provide referrals for abortion services if requested by a patient. At this point, the impact of the Weldon Amendment is not yet known.

• Individual Refusal Clause
  An individual refusal clause, also known as a conscience clause, is a law that allows an individual to refuse to provide certain reproductive healthcare services based on his or her religious and/or moral beliefs. Currently, 46 states have refusal clauses that allow individuals to refuse to participate in abortion-related services.

• Institutional Refusal Clause
  An institutional refusal clause, also known as institutional restrictions on reproductive healthcare, involves healthcare service limitations based on the religious beliefs or ideology of an institution. Examples of these restrictions include, but are not limited to, prohibiting contraceptive counseling (including emergency contraception for survivors of sexual assault) or assisted reproductive technologies within religious hospitals, refusing insurance coverage for family planning services, forbidding physicians affiliated with religious hospitals to perform sterilizations within their private offices, and denying contraception to students at religiously affiliated colleges or universities.

If you are a physician and would like more information on how you can advocate against religious restrictions and refusal clauses, please contact prchpolicy@prch.org or contact 646-366-1890.

If you are not a physician, but would like more information on how you can support physician advocacy, please contact prchpolicy@prch.org or contact 646-366-1890.

1 Modern Healthcare. Profitability a Matter of Ownership Status. June 12, 2000.
2 Catholics for a Free Choice. Catholic Health Care Update. July 2002.
3 Catholics for a Free Choice. When Catholic and Non-Catholic Hospitals Merge: Reproductive Health Compromised. 1998.
4 Guttmacher Institute, State Policies in Brief: Refusing to Provide Health Services. September 2006. Available at: http://www.guttmacher.org/statecenter/spibs/spib_RPHS.pdf. Accessed October 4, 2006.