Questions of Church-State Separation at Dell Seton Medical Center

Illustration by Jason Stout

Driving down 15th Street near Red River, passersby have grown accustomed to the parking cones, forklifts, and sounds of rapid construction. But in Feb­ru­ary, that clatter should end, and by May give way to a sleek, state-of-the-art teaching hospital: The Dell Seton Medical Center will stand alongside the University of Texas at Austin Dell Medical School, which opened its doors last June, welcoming in its inaugural class. Moving forward, Dell Seton will serve as UT's primary hands-on training institution for Austin's medical students.

Aspirations for a local medical center have been a long time coming: After heavy lobbying and public outreach from key community figures like state Sen. Kirk Watson, D-Austin, voters passed Proposition 1 in 2012, leading the way to a local partnership between Catholic-based Seton Health­care Family and Travis County's Central Health. The two entities joined forces to create the Community Care Collaborative. Seton would in turn own and operate the $310 million teaching hospital slated to replace longstanding University Medical Center Brackenridge, which, since 1884, has provided care to Austinites just across 15th Street from the new center. (The 14 acres Brackenridge sits on will become a mixed-use development, likely including medical offices, housing, and a public market.)

Prop. 1 increased property taxes by five cents per $100 property valuation to partially fund the Dell School, at $35 million a year. The UT System also pledged $334 million to the school, while the Dell Foundation pledged $50 million. Seton kicked in $260 million. Despite a substantial tax bump, the public resoundingly endorsed the investment in growing a medical center, seeing the value of creating a model health care hub in a city long starved for such a designation.

While a monumental step for health care delivery and education in Austin, the union of a public medical school and Seton, a Catholic hospital, renews questions of church-state separation. Bound to religious directives that forbid basic reproductive health procedures – even beyond abortion care – Seton's relationship with the new venture also calls into question possible limitations on women's reproductive health care education.

Bound by the Church

Seton, the largest health care system in Central Texas, is subject to religious doctrines referred to as the "Ethical and Religious Directives for Catholic Health Care Services," issued by the United States Conference of Catholic Bishops. The hospital adheres to the 2009 version of the ERDs, which lists, amid the teachings in the Bible, a lengthy set of restrictions related to abortion, sterilization, contraception, artificial fertilization, and end-of-life care, including prohibition of euthanasia and using fetal tissue for research. "Reproductive technologies that substitute for the marriage act are not consistent with human dignity," the directives explain in summary.

For years, these ERDs have created local conflicts: Since 1995, through a lease agreement with the city, Seton has run the now aging and soon-to-be-replaced Brackenridge hospital. The agreement allowed doctors to function outside of Catholic directives (with the exception of abortion care) until 2001, when the Vatican objected, forcing the creation of a fifth-floor "hospital within a hospital" to provide those reproductive health services not allowed in Catholic-run facilities. (UT Medical Branch ran the floor and constructed a separate elevator so patients could sidestep the Seton reception desk.) The city transferred the agreement to the Travis County Central Health District in 2004. In 2012, the University of Texas Med­ical Branch lost funding for the women's health floor, moving services to St. David's.

Seton is far from the only hospital that is bound by the ERDs. One in six U.S. hospital beds sit in a facility that abides by the Catholic directives, which prohibit a range of reproductive health care and family planning services, even when a woman's life or health is at risk, a May 2016 report from the American Civil Liberties Union found. The 40-page report documents women across the country who have been denied reproductive health services – from emergency tubal ligation to termination of pregnancy due to health risk – because of strict religious policies.

Texas lays claim to the second most Catholic hospitals – 42, just behind the leader California, which has 46 – and more than 6,500 beds. A total of 548 hospitals in the U.S. adhere to the ERDs. That number's up 22% since 2001. A 2016 analysis from Merger Watch, a group that tracks Catholic hospital consolidation, partly attributed the jump to a national trend of mergers and affiliations with, or purchases of, secular community hospitals. Today, four of the top 10 hospital systems in the U.S. are Catholic (due to a merger of the two largest systems, Trinity and Catholic Health East). Ascension Health – Seton's parent company – remains the largest nonprofit Catholic health care system in the country and the world's largest Catholic health care system.

Faith-Based Barriers to Access

A women's health champion and registered nurse, Rep. Donna Howard, D-Austin, has fought to expand access to reproductive health care during her time at the Lege. She says the limitations of women's health care at Seton have become an ongoing discussion.

"There have been efforts to make sure women will not be denied services – they can go to [non-Catholic] St. David's for what's not allowed at Seton – but I don't think that has totally been worked out. I'm not convinced that there aren't still gaps in service," said Howard. "And the fact that we have public dollars involved makes it even more imperative that women are receiving the services they need."

One of those possible gaps in service is the ability to access long-term contraception at a time when the local demand for that method is high.

When the state radically defunded family planning in 2011, cutting $74 million from its budget, and later excluded Planned Parenthood from a preventative Medicaid program, women in Texas were left with fewer contraceptive options – inevitably, Med­icaid births began increasing. From 2011-14, there were 35% fewer claims for long-acting, reversible contraceptives (LARCs) such as IUDs, according to a 2016 study by the UT-Austin based Texas Policy Eval­u­a­tion Project in the New England Journal of Medicine. There was also a 31% drop in claims for injectable contraceptives, and a decrease in the rate of continuation of their use. Yet the research group had previously discovered that postpartum women in Austin have a strong preference for LARC and permanent contraceptive methods after they give birth. More than half the women surveyed at Austin hospitals wanted a LARC or sterilization after giving birth. There exists a "substantial unmet demand" for those highly effective methods of contraception, TxPEP researchers concluded in their study.

The new Dell Seton Medical Center

Those findings come at time when the American Congress of Obstetricians and Gyne­cologists have made IUD post-delivery a priority. The medical organization's Committee on Obstetric Practice strongly recommends doctors offer a LARC to women immediately after delivery (10-15 minutes after giving birth), as it can significantly reduce unintended pregnancy and abortion. Women with the highest risk of quickly becoming pregnant again have low postpartum follow-up rates; having women obtain an IUD right after they deliver efficiently addresses that problem. Consider that half of women in Texas face at least one barrier to reproductive health care and the recommendation becomes more sensible. "It's very important for hospitals to offer this because it has shown to make a big difference in unintended pregnancy," says Dr. Joseph Potter, lead investigator for TxPEP. "There are so many barriers when the woman steps out of the hospital after delivery, so it's a real problem to think she'll easily find a way to get this long-acting contraception when she leaves."

At the start of 2016, the Texas Health and Human Services Commission attempted to at least get on board with encouraging LARC use postpartum by changing the state Medicaid policy to allow hospitals to receive reimbursements for the insertion – a positive step in a state that has extensively shredded the family planning safety net. But for local women seeking care at Seton Hospital, that option is unavailable – due to the Catholic health care provider's faith-based rules. So is the option of sterilization, or tubal ligation, the technical term for "getting tubes tied," unless it's a side effect of a medical procedure required for the woman's health (such as reducing the risk of ovarian cancer).

Dr. Ted Held, a local OB-GYN of two decades and an advocate of contraception, says that he's in early talks with the state health commission and community stakeholders like Central Health to widen access to LARCs in Travis County. "There's probably not much state conservatives and liberals agree on, but there's consensus from both sides that offering this type of contraception to poor women who want it is a good idea," says Held. "From the conservative side, it prevents unwanted pregnancies, which means fewer Medicaid taxpayer-paid births and fewer abortions. For the left, data shows when women have control over their reproductive lives they will be in a better place economically and socially."

Held continues: "But here locally, we have a disjunction because Seton, as a Catholic health care provider, views contraception as 'intrinsically evil' and [doctors there] aren't able to place these devices."

Even more troubling is the fact that Seton employs and credentials Sexual Assault Nurse Examiners yet bars emergency contraception for survivors of sexual assault if they are ovulating because of its religious practices. "The area emergency medical services providers' default protocol is to transport sexual assault victims to a facility other than one operated by Seton," states Seton ERD guidelines.

An Unholy Marriage?

Church-state separation groups have cast a skeptical eye on the local merger.

"We've been monitoring this issue of public entities merging with Catholic hospitals all across the country, and there have been a number of situations that have given us concern," says Alex Luchenitser, associate legal director with Americans United for Separation of Church and State.

"Women's health can be greatly harmed or endangered by these religious directives. And when the government is involved in propping up these restrictions – whether it's through a joint venture or through public funds – it's even worse, because government shouldn't support religious-based discrimination in any way," says Luchenitser.

On July, 9, 2013, Americans United sent a letter to the Central Health Board of Managers and former UT President Bill Powers, indicating they received a complaint regarding the contractual relationship between Seton and Central Health. (AU told the Chronicle the complainant has chosen to keep her identity confidential.) Because the Master Agreement between the two entities "requires the government to restrict healthcare services at a government-run hospital based on religious doctrine, it violates the Establishment Clause of the First Amendment to the U.S. Consti­tu­tion. The same would be true for any agreement by the University of Texas that forces its medical school students and employees to conform to religious dogma while at the proposed teaching hospital," the letter reads. "Accordingly, we request that you either terminate the agreement or that you rework it so that services provided at the hospital are not restricted by the religious directives."

Among its legal citations, AU references a 1968 U.S. Supreme Court case out of Arkansas that found the state had violated the Establishment Clause by prohibiting teachers from teaching evolution due to religious beliefs.

On Sept. 10, 2013, attorneys at local firm Husch Blackwell representing Central Health responded to AU's three-page letter with two paragraphs defending the medical collaboration's practices. AU's depiction of its services was not "fully representative" of the actual services delivered; Central Health has "always provided and continues to provide comprehensive" women's health care, wrote attorney David Hilgers. AU's claims are "both factually inaccurate and legally incorrect," he wrote.

Luchenitser says AU has had discussions with officials involved, and while some concerns were allayed, not all were put to rest. However, AU did not further pursue the matter, in part because it's often difficult to find someone to serve as a plaintiff in a lawsuit of this kind.

Civil liberties and church-state separation groups aren't the only organizations critical of the public-private partnership. Catholics for Choice, a four decades-old advocacy organization that works to ensure the voice of Catholics who disagree with the Bishops' and Vatican's interpretation of health care is reflected in public policy, were part of talks when the idea of the local alliance was taken to the community. The group heard concerns from both Seton faculty and Central Health regarding how the ERDs would fit into the picture.

"We believe very strongly that there's a lack of knowledge and awareness about these ERDs from both the health professionals who might teach at a Catholic hospital and the general public who show up in an emergency situation," says Sara Hutch­in­son Ratcliffe, Catholics for Choice domestic program director. The organization commends Seton for its dedicated mission to provide health care to the low-income community in Travis County, but remains disappointed that poor women cannot access a full range of reproductive health care services there. Ratcliffe's group say the majority of the 7 million Catholics in Texas don't agree with the ERDs. "To impede someone's conscience-based decision is actually against Catholic teaching," she says. "So health providers who try to care for patients in the best medical way possible and are forced to adhere to non-medical ERDs is not only concerning, it isn't really Catholic."

A national survey reported in the American Journal of Obstetrics & Gynecology found more than half of obstetrician-gynecologists at Catholic hospitals had a conflict with their institution over religiously based policies. When the patient's health was at risk, and/or the fetus was no longer viable, physicians surveyed considered the restrictions imposed by Catholic bioethics to be "unacceptable" and were shown to cause "distress."

Both Catholics for Choice and the AU worry that education at the Dell Medical School will be curtailed due to the ERDs. For AU, it's a matter of a constitutional violation. For Catholics for Choice, it's a social justice issue.

A Delicate Balance

Patricia Young Brown, founding president and outgoing CEO of Central Health, says the Travis County district is "very aware" of Seton's ERD restrictions and work "proactively" to ensure women obtain the services they need, even if that means directing them to St. David's or federally qualified health centers. Young Brown says that while working around the restrictions is "not an easy pill to swallow," the district must balance the financial value of the Catholic hospital's involvement. When Seton took over in 1995, it also subsumed full monetary risk from the struggling public hospital. "But with that came the challenge of those ethical and religious directives, and so there's a tension that exists and has existed for the city and now for Central Health," said Young Brown.

She notes that without Seton, county taxpayers – already struggling with rising property valuations – would be footing a much higher bill. By outsourcing hospital operations to Seton, taxpayers see one of the lowest burdens of any urban hospital district and manage to avoid massive debt, saving residents millions a year. Taxpayers now pay roughly 11 cents per $100 of property value, amounting to an annual price tag of around $315 for the average home valued at $285,152, still lower than the five comparable Texas hospital districts. A portion of those funds go toward uncompensated health care at Brackenridge. "If we had to run a hospital every day we would be totally consumed by that – our funding and energy," said Young Brown.

Patricia Young Brown (l) and Dr. Amy Young

Instead, Central Health is freed up to make those investments in primary care clinics, specialty care in the community, disease management, and building up a behavioral health system. According to Central Health's 2016 calculations, forgoing Seton's partnership would cost approximately an additional 13 cents per $100 of property value a year, amounting to roughly $170 million annually, $10 million more than the public currently pays. Average homeowners would need to pay an additional $600 per year. The tax rate would effectively double if Seton were out of the picture, says Young Brown.

"I don't think that's a fiscal burden this community would sign up for," she said, underscoring the tension. "People want us to provide more services but don't want us to tax any higher, so I don't really think there's an appetite for that financial responsibility."

Limits on Teaching?

The Dell Medical School administration contends that its medical education is not hampered by the ethical and religious directives. To meet medical education accreditation standards, the school must offer a full spectrum of educational experiences. In other words, students must learn about reproductive health care if their degree requires – they just have to go elsewhere. So while Seton is the primary provider of clinical teaching sites, some procedures are taught at other facilities, including non-Catholic St. David's Hospital and CommUnityCare clinics. "Seton recognizes that UT Austin/UT Dell Medical School, UT System Institutions, and DMS faculty, residents, and fellows are not bound by the ERDs and are not prohibited from performing ERD non-compliant procedures outside of Seton facilities without involvement, participation, or support of Seton," the affiliation agreement between the UT-System, UT-Austin, and Seton Healthcare reads.

Dr. Amy Young, the Women's Health Department chair at Dell Medical School, echoes the argument. "There are currently no limitations on women's health education, as the University of Texas has responsibility for that education and is not under those restrictions," says Young. "Moreover, if ERDs preclude certain educational experiences through direct clinical care, those experiences are obtained for residents outside of Seton facilities."

Claire Sellers, now an OB-GYN physician in North Carolina, completed her residency through a partnership between UT-South­west­ern Medical School and Seton in Austin. For four years, Sellers worked at UMC Brackenridge, Seton Medical Center Austin, and other clinics for her OB-GYN residency training – all on Seton's payroll. She says some reproductive health care services like tubal ligation weren't allowed at Seton, so patients interested in the procedure would have to deliver at St. David's instead. "Because of Seton's religious and ethical directives, we were unable to perform those procedures for patients," said Sellers. "At times it was really frustrating.

"Ultimately, having some space from it, I see that I was well-trained in all forms of contraception, but it was just very logistically challenging to ensure that training was obtained," said Sellers. "Just coming up against these ethical and religious directives was pretty much a challenge for everyone."

Katie Hansen is among the first crop of Dell Medical School students. She and her cohort won't begin clinical training until their second year. While she doesn't need to make an official decision until her residency begins in four years, Hansen is considering specializing in women's health, OB-GYN, or internal medicine. The new student praised Seton's service to the Travis County community and expressed her trust in Dell's commitment to providing a full education, but concedes there will likely be some roadblocks due to the ERDs.

"There are obvious challenges for us as medical students as we go on to get our clinical training in women's health and I think our faculty is aware of those challenges," said Hansen. "There may be areas of potential conflict while training at a Catholic hospital, but at this stage, I'm not anticipating – or at least hoping – it will be too many barriers."

Hansen helped co-found the Dell School's chapter of the international Medical Students for Choice, a group dedicated to ensuring that reproductive health care, including abortion, is standard in medical education and training. The disconnect between her pro-choice views and the affiliation with a Catholic hospital bound to religious directives is one she considers thoughtfully. Living in an anti-choice state, Hansen realizes navigating her career will at times be difficult. "It's an interesting potential conflict that I will likely have to struggle with my entire career," she says.