Not Here: Catholic Hospital Systems and the Restriction Against Transgender Healthcare

Abstract

Not Here: Catholic Hospital Systems and the Restriction Against Transgender Healthcare Eric Plemons Surgical interventions to facilitate transgender people's medical transitions were excluded from most private health insurance policies in the United States beginning in 1979, and from Medicare and Medicaid coverage beginning in 1981. For decades, Americans seeking transition‐related surgical care either paid for that care out of pocket or, more frequently, went without it. Over the past five years, however, public and private health insurance coverage for transition‐related surgery has increased exponentially. As available funds have increased, so has demand for services. American institutions are now struggling to meet a growing demand for competent, efficient, and effective transgender healthcare that they had denied for decades. At the same time that demand and funding for transgender healthcare is expanding across the country, the number and market share of Catholic‐owned hospitals is also growing. Between 2001 and 2016, the number of U.S. hospitals affiliated with the Catholic Church increased by 22 percent (Uttley & Khaikin ). By 2016, one in six acute care beds in the United States was in a Catholic hospital, and in some states, more than 35 percent of all hospitals were affiliated with the Catholic Church (ibid). Multibillion‐dollar hospital system mergers led one recent commentator to ask if 2018 would be “the year of Catholic hospital dominance (Fig. ).” Click for larger view View full resolution Percentage of hospital beds in Catholic hospitals by U.S. state. Source: ACLU : 24. [Color figure can be viewed at http://wileyonlinelibrary.com] The rapid expansion of Catholic hospitals is a concern for transgender people, their advocates, and the insurers who provide their health coverage because Catholic hospitals do not provide transition‐related care. A recent commentary on “Insurance Coverage and Transgender Care” in the Catholic Health Association magazine, Healthcare Ethics USA, put the matter plainly: “The fact that insurance companies are providing coverage [for transition‐related procedures] certainly does not mean that these treatments, or even the diagnosis, are clinically appropriate or morally acceptable” (HCE : 34). The conflict between patients’ demand for procedures that are recognized as medical best practice among numerous American medical organizations but are identified as religiously unacceptable among conservative Catholics has resulted in several legal actions against the church in recent years. Law suits have provoked theological and ethical debates that make Catholic rationales for refusing transgender care explicit. In this article, I examine how the liceity of transgender surgical procedures has been discussed by contemporary American Catholic bioethicists, with attention to how they justify and explain ongoing denials of care. As I will show, Catholic debates about the ethical status of transgender healthcare contribute to the surging American discourse of “religious liberty,” in which it is “freedom of conscience” that exempts Catholic institutions from the duty of providing best‐practice medicine. This line of argumentation, well rehearsed with regard to reproductive and end‐of‐life care, is being newly and somewhat differently applied in the case of transgender medicine. I argue that within this discourse, the contentious status of the transgender body is used as a moral lever to expand the penumbra of “conscience‐based” exemptions beyond the issues of life and death that have dominated Catholic healthcare debates for decades. The Ethical and Religious Directives for Catholic Healthcare Services The United States Conference of Catholic Bishops (USCCB) delimits the services provided in Catholic hospitals through a set of guidelines called the Ethical and Religious Directives for Catholic Healthcare Services (ERD). First published in 1948, the fifth edition and the most recent edition of the ERD published in 2009 state that they are a set of “theological principles that guide the Church's vision of healthcare” (UCCB : 3). Variously interpreted and inconsistently applied in their early iterations, the promulgation of ERD began in earnest in 1973, following two pivotal events. The first was the decision in Roe v. Wade in which the U.S. Supreme Court affirmed a woman's right to have an abortion within the first two trimesters of pregnancy. Immediately following Roe, the U.S. Congress passed the Church Amendment into law, the first American “conscience clause” exempting private hospitals from requirements to provide abortion or sterilization services...