(Editor’s note: A proposed merger would unite Jewish Hospital & St. Mary’s HealthCare, Catholic Health Initiatives and University of Louisville Hospital into what insiders refer to as “Kentucky Statewide Network,” a statewide hospital system controlled by CHI.)
By Honi Marlene Goldman
The following includes conflicting statements by Roman Cathlolic officials and hospital executives. Further, many questions about the merger remain unanswered.
While we realize the economic benefit of this merger, we question the agreements made at the expense of health care that goes with this proposed merger.
Furthermore, because of the lack of transparency by University of Louisville officials, we do not know how this merger is being paid for and at what cost to Kentucky.
Here is what officials have said:
1. Merged entities becoming Catholic institutions/being required to follow Catholic ethical and relgious directives:
– Archbishop Kurtz: The partners have stated their commitment to respecting one another’s traditions, missions, and values, including our own Ethical and Religious Directives for Catholic Health Care Services (ERD),which give direction to those involved with Catholic Healthcare ministry.” (The Record, August 4, 2011 and The Courier Journal, August 5, 2011; paragraph 6)
– JHSMH Open Letter in “The Community”, August 26, 2011: “We recognize there are challenges to simultaneously upholding both the academic requirements of the School of Medicine and abiding by the Ethical and Religious Directives (ERDs) of the Catholic Church, but we will do both – as have similar partnerships across the country.” Emphasis added. (“Why are there so many unanswered questions?” section, paragraph 1)
-Testimony at the Frankfort Hearing on August 17, 2011 before the Interim Joint Committee on Health and Welfare: “Mr. Edgett answered a question by Senator Harper Angel by saying Catholic ERDs have only changed twice in the past 15 years and neither change impacted clinical practice or procedures. If there is a change in the ERDs, CHI would evaluate the impact, if any, on the activity within the organization and work with the university if it impacts the university’s ability to fulfill its academic mission and make adjustments. If the change impacts the university’s ability to fulfill its academic mission, the university would have cause to unwind.” (p.8)
– Joint Committee Testimony (see above): “As a Catholic health system, there is a responsibility to work with the bishop to seek his approval when entering into partnerships. His role is to assure that CHI is living up to the Catholic values as a Catholic health system.” (p.8)
– Catholic ERDs: “Catholic health care services must adopt these Directives as policy, require adherence to them within the institution as a condition for medical privileges and employment, and provide appropriate instruction regarding the Directives for administration, medical and nursing staff, and other personnel.” (Part One, #5)
– Catholic ERDs: “Catholic health care institutions have a unique relationship to both the Church and the wider community they serve. Because of the ecclesial nature of this relationship, the relevant requirement of canon law will be observed with regard to the foundation of new Catholic health care institution; the substantial revision of the mission of an institution; and the sale, sponsorship, transfer, or closure of an existing institution.” (Part One, #8)
– Catholic ERDs: “Employees of a Catholic health care institution must respect and uphold the religious mission of the institution and adhere to these Directives.” (Part One, #9)
– Catholic ERDs: “new partnerships can be viewed as opportunities for Catholic health care institutions and services to witness to their religious and ethical commitments and so influence the healing profession. For example, the new partnerships can help to implement the Church’s social teaching.” (Part Six, paragraph 2)
-Merger Partners’ Responses to the Louisville Metro Board of Health submitted questions prior to the October 19, 2011 BOH Forum: “Although UMC (University Medical Campus) is not and will not become a Catholic hospital …” (Answer to question #20)
-Merger Partners’ Responses (see above): “UMC will not become a Catholic hospital, and will not be required to follow the ERDs. By contractual agreement, elective sterilizations, elective abortions, and euthanasia will not be performed at UMC.” … ” If the University reasonably concludes that an activity that is inconsistent with the ERDs is necessary to maintain a competitive school of medicine, then the university has the right to affiliate with other facilities to conduct those activities or to unwind the transaction.” (Answer to question #23)
2. Embryonic stem cell-based research and treatment in the merged institutions (especially the Brown Cancer Center)
-Catholic ERDs: “Catholic health care ministry witnesses to the sanctity of life ‘from the moment of conception until death.’” (Part Four, paragraph 2)
-Catholic ERDs: “Nontherapeutic experiments on a living embryo or fetus are not permitted, even with the consent of the parents.” (Part Four, #51)
– Catholic ERDs: “A Catholic health care institution, especially a teaching hospital, will promote research consistent with its mission of providing health care and with concern for the responsible stewardship of health care resources. Such medical research must adhere to Catholic moral principles.” Emphasis added. (Part One, #4)
– Merger Partners’ Responses to the Louisville Metro Board of Health submitted questions prior to the October 19, 2011 BOH Forum: “The merger will have no effect on academic research. University faculty, physicians and researchers are not part of the merged entity. Clinical trials involving adult stem cell therapies can continue.” Emphasis added. (Answer to question #21)
– Testimony at the Frankfort Hearing on August 17, 2011 before the Interim Joint Committee on Health and Welfare: “Mr. Edgett answered a question by Senator Denton by saying that the $200 million from CHI would focus on advancing academic and research activities at UMC.” Emphasis added. (p. 7)
3. End of life patient advance directives in the merged institutions
-Catholic ERDs: “The institution, however, will not honor an advance directive that is contrary to Catholic teaching.” (Part Three, #24)
-Catholic ERDs: “Decisions by the designated surrogate should be faithful to Catholic moral principles and to the person’s intentions and values …” (Part Three, #23)
-Catholic ERDs: “The free and informed health care decision of the person or person’s surrogate is to be followed so long as it does not contradict Catholic principles.” (Part Three, #28)
-Catholic ERDs: “While medically assisted nutrition and hydration are not morally obligatory in certain cases, these forms of basic care should in principle be provided to all patients who need them, including patients diagnosed as being in a “persistent vegetative state” (PVS), because even the most severely debilitated and helpless patient retains the full dignity of human person and must receive ordinary and proportionate care.” (Part Five, Introduction)
-Catholic ERDs: “In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (eg PVS) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot be expected to prolong life or when they would be “excessively burdensome for the patient or (would) cause significant physical discomfort…” (Part Five, #58)
– JHSMH Open Letter in “The Community”, August 26, 2011: “Advance Directives can be honored, consistent with ERDs.” (“Will health care delivery be changed?” paragraph 4)
– Testimony at the Frankfort Hearing on August 17, 2011 before the Interim Joint Committee on Health and Welfare: “All advance directives and organ donations can be honored consistent with the Catholic Ethical and Religious Directives (ERDs) with rare exceptions.” (p. 6)
– Merger Partners’ Responses to the Louisville Metro Board of Health submitted questions prior to the October 19, 2011 BOH Forum: “Physicians will continue to inform patients and families of all available options for end-of-life care …” “Advance directives are honored, with a singular clinical exception for patients in a persistent vegetative state, a condition not typically treated at an acute-care hospital.” Emphasis added. (Answer to question #14)
4. Counseling on birth control or other subjects that go beyond that allowed under Catholic doctrine in the merged institutions
-Catholic ERDs: “When the health care professional and the patient use institutional Catholic health care, they also accept its public commitment to the Church’s understanding of and witness to the dignity of the human person.” … “This professional-patient relationship is never separated, then, from the Catholic identity of the health care institution.” (Part Three, Introduction)
-Catholic ERDs: “Catholic health institutions may not promote or condone contraceptive practices, but should provide, for married couples and the medical staff who counsel them, instruction both about the Church’s teaching on responsible parenthood and in methods of natural family planning.” (Part Four, #52)
– JHSMH Open Letter in “The Community”, August 26, 2011: “The sanctity of the doctor-patient relationship will remain unchanged with physicians providing patients with a full array of clinical options and assisting with their decision-making regardless of where services are provided.” (“Will heath care delivery be changed?” paragraph 1)
-JHSMH Open Letter (see above): “Emergency contraception and family planning will continue in an office setting.” (“Will health care delivery be changed?” paragraph 8)
– Testimony at the Frankfort Hearing on August 17, 2011 before the Interim Joint Committee on Health and Welfare: “Dr. Dan Varga, CMO, St. Joseph Healthcare System, stated that the most important component of the clinical aspect of the merger is the sanctity of the doctor-patient relationship, as it exists today, remains unchanged. The agreements ensure the physician will be able to discuss with patients the full array of clinical options to inform their decision-making regardless of where the services are provided.”
5. Ectopic pregnancy in the merged institutions
-Catholic ERDs: “In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.” (Part Four, #48)
-Catholic ERDs: “Abortion (that is, the directly intended termination or pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted.” (Part Four, #45)
– Testimony at the Frankfort Hearing on August 17, 2011 before the Interim Joint Committee on Health and Welfare: “The life of the mother always takes priority over the life of her unborn child.”
– JHSMH Open Letter in “The Community”, August 26, 2011: “The vast majority of reproductive services, including miscarriage management and treatment for ectopic pregnancy can be provided consistent with ERDs as can medically indicated abortion treatment and emergency contraception.” (“Will health care delivery by changed?” paragraph 6)
– Testimony at the Frankfort Hearing on August 17, 2011 before the Interim Joint Committee on Health and Welfare: “Dr. Sharmila Makhija, Chair, Department of Obstetrics, Gynecology, and Women’s Care, University of Louisville, stated that miscarriage management, ectopic pregnancy, medically indicated abortion, and emergency contraception of alleged victim of rape will be provided consistent with ERDs.” Emphasis added. (p. 6)
– Merger Partners’ Responses to the Louisville Metro Board of Health submitted questions prior to the October 19, 2011 BOH Forum: “There will be no change in manner of treating ectopic pregnancies at UMC. The medical and surgical management of ectopic pregnancy, including tubal preservation, will be determined on a case-by-case basis.” (Answer to question #1)
6. Rape victim treatment in the merged institutions
-Catholic ERDs: “Abortion (that is, the directly intended termination or pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted.” (Part Four, #45)
-Catholic ERDs: “A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization. It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum.” (Part Three, #36)
– Merger Partners’ Responses to the Louisville Metro Board of Health submitted questions prior to the October 19, 2011 BOH Forum: “Physicians and Sexual Assault Nurse Examiners (SANE) program nurses will continue to provide counseling, care and emergency contraception to victims of rape. Sexual assault victims may receive emergency contraception after appropriate testing to rule out pre-existing pregnancy.” … “There will be no change in UMC’s current policies and procedures, which provide that the morning after pill will be available and the prescription may be filled at UMC.” (Answers to questions #4 and #5)
– JHSMH Open Letter in “The Community”, August 26, 2011: “Emergency contraception and family planning will continue in an office setting.” Emphasis added. (“Will health care delivery be changed?” paragraph 8)
7. In vitro fertilization, vasectomy, or tubal ligation
-Catholic ERDs: “Homologous artificial fertilization (that is, any technique used to achieve conception using the gametes of the two spouses joined in marriage) is prohibited when it separates procreation from the marital act in its unitive significance (e.g. any technique used to achieve extracorporeal conception).” (Part Four, #41)
-Catholic ERDs: “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution.” (Part Four, #53)
– JHSMH Open Letter in “The Community”, August 26, 2011: “Procedures such as vasectomy and in vitro fertilization can be provided consistent with ERDs.” (“Will health care delivery be changed?” paragraph 7)
“Questions and Answers About the Hospital Merger” and “Merger Partners’ Responses”, Louisville Metro Board of Health Community Forum, October 19, 2011.
Open Letter to the Jewish Community by Dr. Gerald Temes (Jewish Hospital HealthCare Services Board Chair), Louis Waterman (JHSMS Board Chair), and David Laird (Jewish Hospital President and CEO), dated August 26, 2011.
Interim Joint Committee on Health and Welfare, Minutes of the 2nd Meeting of the 2011 Interim, Frankfort Hearing, August 17, 2011.
Archbishop Joseph Kurtz’s Column in The Record, August 4, 2011, and reprinted in the Courier-Journal, August 5, 2011.
Ethical and Religious Directives for Catholic Health Care Services, Fifth Edition, United States Conference of Catholic Bishops, issued November 17, 2009.
Further Questions, Still Unanswered:
What is the structure of the merger between CHI, UMC and Jewish-St. Mary’s? Is CHI purchasing U of L Hospital as part of the merger deal, or is University Medical Center, Inc. (“UMC”) assigning its interest in its lease with the Commonwealth to operate U of L Hospital? What is the price that CHI has agreed to pay for purchasing the Hospital (or assuming the lease)? Is the amount CHI is paying for the purchase or lease of U of L Hospital separate from the $320 million that CHI has stated it will be investing in the university academic medical center and in community and state-wide programs?
How specifically will the $200 million that CHI says it will invest in the university academic medical center be used? Why has the university medical faculty already being asked to compile their own wish lists of how to spend the money?
When you produce the documents (including power points, etc.) that CHI is providing to investment banks and other financing sources to obtain financing of this merger?
Financial and Legal Issues
In the merger agreement/stipulations, how much money (dollars or percentage) will be paid yearly to CHI for administrative fees and/or franchise fees?
Where is the money coming from? CHI reserves, investment banker or broker, a private equity firm, and/or a loan or bond? If loan, what are the terms of the loan and who is responsible for the loan?
Because UofL is a public entity per the recent Attorney General’s ruling, in this situation do the procurement procedures apply, i.e. requiring RFPs (request for proposals) and bids? When will the University Hospital also release its financial data showing that it is not financially viable?
What will happen to the University Hospital’s assets, which are currently owned by the Commonwealth, after the merger? Is CHI paying additional amounts to lease or purchase the assets? Who will own the assets like the CT scans, MRI, robotic surgery equipment, etc.
Will the Jewish Foundation continue to exist after the merger? What will happen to the Jewish Foundation and the foundation money after the merger? Will donors to UL and Jewish Foundations that have earmarked their contributions be able to get their money back?
Medical and Clinical Issues
How is it possible to reconcile the ERDs with AMA Code of Medical Ethics Opinion 9.11 for Ethics Committees, Opinion 10.02 for Patient Responsibilities and Rights, Opinion 8.08 for Informed Consent, Opinion 10.015 for Patient-Physician Relationship, Principles of Medical Ethics Preamble, Opinion 8.021 for Ethical Obligations of Medical Directors?
Will all employees, and the medical staff who are not employees, be given a form to read and sign informing them that their continued employment is contingent upon their agreeing to abide by the ERDs? If so, when and under what circumstances? (SEE: ERDs #5, #8, #9 for example.) Will an employee actually have to sign something or pledge in some way to “respect and uphold” the Catholic doctrine as stated in the ERD’s? If not, what is the standard by which an employee will be judged on respecting and upholding the Catholic doctrine?
What impact will the merger have on health insurance for Hospital employees, particularly employee health insurance benefits for contraception and sterilizations? What impact will the merger have on employee health insurance and other benefits for its employees and their partners who are homosexual?
Reproductive and Women’s Health Issues
Rape victim who are taken to ULH because of their injuries – how will they be given emergency contraceptives within the prescribed window and without further traumatizing the patient? Also Mr. Laird and Dr. Temes in an Open Letter to the Jewish Community stated that emergency contraception can be provided “consistent with ERDs.” Even though the ERDs state that a rape victim should be able to defend against a pregnancy as a result of rape, many Catholic hospitals still do not dispense emergency contraception pills to rape victims and some Catholic hospitals only dispense emergency contraception pills once medical tests have shown that the victim is not ovulating. How will you guarantee the Louisville community that, after the merger, emergency contraception pills will continue to be prescribed and dispensed to rape victims at the University of Louisville Hospital and Jewish Hospital, that the Hospitals will not use an ovulation test before determining whether to prescribe emergency contraception, and that these rape victims will not simply be referred to another hospital or clinic for emergency contraception services?
About Honi Marleen Goldman. Honi Goldman is a media relations executive, owner of HMG Media Relations and a longtime Kentucky activist.