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Sedro-Woolley, a tiny Skagit County town in the Cascade foothills, was formed in 1898 from a merger of two rival towns — one named for the giant cedar trees that once loomed overhead, and the other for an ambitious railroad developer.

So there’s a certain symmetry now, as some citizens unite to fight another merger — this time, one that would hand over control of their local tax-supported hospital to a multistate Catholic health-care system.

Critics say they’re not anti-Catholic or anti-religion. And they don’t underestimate the hardship and hard work of the dedicated nuns who brought health care to remote logging and mining towns in Washington before it was even a state.

But over the years, these citizens have paid hard-earned tax money to keep United General Hospital open, and they don’t want religious doctrine espoused by someone else — surely not someone in Rome or even Seattle — to govern their reproductive and end-of-life choices.

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“When a hierarchy of a religious entity is in charge of the ethics of a hospital, then they are in control — not the members of a community,” says Mary Kay Barbieri, 69, co-chairwoman of People for Healthcare Freedom, which is fighting the proposal.

Religious communities have run hospitals around the country for hundreds of years, and until recently, without much furor.

But over the last year, the furious pace of affiliations between secular hospitals and Catholic systems in Washington — one of the most unchurched areas of the country — has thrust faith into the spotlight.

No other state has so many such affiliations under way, said Sheila Reynertson, of MergerWatch, a New York-based patients’ rights advocacy nonprofit that tracks faith-based health-care mergers.

With completed, pending and possible Catholic-secular affiliations, all the hospitals and their clinics in as many as 10 Washington counties — including Whatcom, Skagit, Snohomish and Kitsap
— could be subject to faith-based restrictions on reproductive care and end-of-life options. Those medical centers account for nearly half the hospital beds statewide.

For small or financially troubled hospitals, the choice may be affiliate or die. For others, linking with a larger partner means piggybacking on a powerful, costly electronic records system, more purchasing power and better patient access to specialty care.

In all cases, Catholic system leaders say, such affiliations bring expanded care to patients in outlying areas.

But Barbieri, who’s lived near Sedro-Woolley for almost three decades, thinks there’s a steep price for patients, starting with Catholic directives barring contraception.

That means, for example, that a woman having a child by cesarean section at a Catholic hospital who wants a tubal ligation as part of that surgery would have to undergo a second, later operation at a secular hospital.

She thinks about rules that ban hospitals and the doctors they employ from prescribing lethal medication requested by a dying patient under the option approved by Washington voters.

That Barbieri doesn’t want any of those services, or that tiny, 25-bed United General doesn’t do any of those things now, isn’t the point, she says.

PeaceHealth, a Vancouver-based Catholic system, takes control, the hospital will be agreeing not to do those things for decades to come. And with three nearby hospitals also considering Catholic partners, she sees options being foreclosed along the I-5 corridor from Seattle to the Canadian border.

“Financial pressure

Like many hospitals, United General is under financial pressure to affiliate, says CEO Greg Reed. “If you look across the country, this is going on everywhere. If you are going to provide any specialty services, you have to partner with someone.”

Finances also have driven hospitals to employ formerly independent doctors, who then may be bound by hospital agreements.

Robb Miller, executive director of Compassion & Choices of Washington, which helps patients with end-of-life options, says these affiliations shift the entire perspective of health care.

“In a nutshell, what happens is that the provider’s ‘patient-centered’ policies become Catholic belief-centered policies,” he said. “Patient autonomy is replaced with provider prerogative.”

Now, critics here and around the country are questioning the legality of such faith-based deals, particularly in taxpayer-supported public hospital districts.

The American Civil Liberties Union of Washington has taken on the issue, arguing that religious restrictions on health care in public hospital districts violate the Washington Constitution and state law.

Democratic State Sen. Kevin Ranker, whose district includes San Juan Island, where PeaceHealth helped build a new hospital in a public hospital district, has asked the state attorney general whether a tax-supported hospital is obligated to provide or refer patients for legal reproductive and family-planning services.

“There are vast geographic areas covered by religious organizations that could limit critical access to women’s reproductive health-care choices,” Ranker says. “This is way bigger than just Friday Harbor — this is a statewide concern.”

Long history

It may have been inevitable that Catholic doctrine and public values would clash in Washington. In no other state have voters directly insisted on having both the right to legal abortion and to a doctor’s assistance in hastening death at the end of life — not to mention same-sex marriage, which the church also opposes.

Catholic religious communities in Washington, on the other hand, have a long history here of building hospitals, often in underserved areas, and caring for the poor. The three major systems — Renton-based Providence Health & Services, Tacoma-based Franciscan Health System and Vancouver-based PeaceHealth — together employ more than 48,000 people in the state.

“Health care in this country was initiated under the guidance of Catholic religious communities,” says Sister Kathleen Pruitt, until recently vice president for ethics at PeaceHealth. “Health care is part of our DNA.”

In Washington’s mostly rural public hospital districts, communities previously haven’t taken issue with Catholic ethics, said Jeff Mero, executive director of the Association of Washington Public Hospital Districts.

Peter Adler, PeaceHealth’s chief strategy officer, says his system always has been “completely transparent” about its values from the outset.

“We do not provide elective abortions or participate in physician-assisted suicide,” and communities know that, he says. PeaceHealth has always been invited in, he adds, and in exchange, “we have always expanded services.”

On San Juan Island, before PeaceHealth built Peace Island Medical Center, patients needing chemotherapy, overnight stays or emergency care had to leave the island. PeaceHealth paid two-thirds of the hospital’s $30-million cost; taxpayers footed the rest and will continue contributing taxes.

Pruitt, who now sits on Peace Island’s board, says people have a right to basic health care, but institutions also have a right to set policies.

“I think we have to work to bring them into alignment.”

Wide directives

Most of the time, patients aren’t worrying about whether their rights as a patient align with religious principles. Scans and heart surgery haven’t prompted directives from Catholic, Jewish or Lutheran leaders.

Reproductive and end-of-life issues in Catholic health-care systems, though, are subject to ethical and religious directives (ERDs) outlined
by the United States Conference of Catholic Bishops. The rules ban elective abortions, contraception — including sterilization for birth control — artificial reproduction assistance and participation in Washington’s Death with Dignity law, and bar hospitals from honoring advance directives that conflict with church teaching.

The wide-ranging directives also say hospitals must serve the poor and pay staff a living wage.

Catholic health-care systems answer to the local bishop, who in turn answers to Rome.

PeaceHealth considers any doctor-patient conversation sacred and confidential, Pruitt says — even if it’s about contraception or end-of-life options — and defers to doctors about whether a procedure is “medically necessary.”

Late last year, PeaceHealth unveiled a plan to partner with Franciscan’s giant national parent, Colorado-based Catholic Health Initiatives (CHI), which requires partners to adhere to the ERDs.

The plan mobilized a new wave of critics such as San Juan Island’s Monica Harrington, who created, where she tracks the growing clash between secular and religious values in health care.

Although the partnership plan recently was suspended, the two systems said they will continue discussions about working together.

Meanwhile, CHI’s local subsidiary, Franciscan, has been busy.

Franciscan has just acquired
269-bed Highline Medical Center
and its clinics, and has filed
plans to operate 347-bed Harrison Medical Center in Bremerton, Kitsap County’s largest private employer.

Harrison CEO Scott Bosch says Franciscan will become Harrison’s corporate parent, and negotiations over sterilization policy are still under way.

Highline CEO Mark Benedum says his hospital will remain secular but will align its policies with Franciscan’s: “We can’t do anything at Highline that would cause the Franciscans to fall out of compliance with the ethical agreement.”

The fine print

Wait, did he say the hospital would remain “secular” but comply with the Catholic bishops’ ethical and religious directives? Isn’t that what Catholic hospitals do?

For patients, decoding secular-religious “affiliations” and “alignments” is tough. Much depends on an agreement’s fine print.

At Swedish Medical Center, which affiliated with much-larger Providence Health & Services last year but calls itself secular, negotiations pared the religious directives issue to a ban on “elective terminations.”

Even that term isn’t as simple as it seems. An abortion is not “elective” if the mother’s life is at stake, or if the fetus has a fatal anomaly. But the rules ban selective reduction of multiple embryos, terminations of fetuses with nonfatal genetic conditions or abortion for patients with dangerous pre-existing conditions.

Are patients clear on where the line is? Dr. Jane Uhlir, an obstetric specialist and top manager at Swedish who met with Providence to work out details, says that discussion is “between the physician and the patient.”

But not everywhere, it seems.

In a controversial 2009 Arizona case, a local bishop excommunicated a nun who participated in a Catholic hospital ethics-committee decision approving an abortion for a woman with a possibly fatal disease.

“The difficult cases are very complicated,” Uhlir concedes, but at Swedish, doctors — not religious authorities — make the decisions.

At Swedish, doctors also remain free to prescribe lethal medication to terminally ill patients under state law.

But doctors at other Catholic-affiliated hospitals may not be able to do that.

Dr. Deborah North, a Skagit Valley internist who says she’s committed to giving terminally ill patients the option of hastening death, is now employed by Skagit Valley Hospital, which bought her clinic in 2010. It’s among three hospital district facilities in Skagit and Snohomish asking PeaceHealth and Providence, and two secular systems, for affiliation proposals.

People say that PeaceHealth and Providence do “damn good medicine,” North says. And it’s great they bring that to small communities, she adds.

“It’s just that I don’t agree that it has to be tied to a religious issue,” she says. “I’m sort of surprised the state allows that.”

The state’s Certificate of Need program, which reviews proposed affiliations, doesn’t consider the religious aspect, says Director Janis Sigman, but does look at whether current services would be discontinued. “That doesn’t mean we would require the facility to maintain those services,” she adds.

State Sen. Karen Keiser, D-Kent, says the state should take a sweeping look at affiliations, mergers and takeovers of nonprofit hospitals, particularly those in public hospital districts with taxing authority.

These arrangements not only can bring taxpayer dollars under religious control, they raise issues of monopoly power and accountability, she says.

“But nobody has oversight of the industry,” she says. “Not at the federal level, not at the state level, not at the local level. And it’s a huge industry.”

Carol M. Ostrom: or 206-464-2249. On Twitter @costrom

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