How a Catholic code of ethics is influencing women's healthcare at Australian public hospitals

There's a little-known religious code governing some public hospitals — but its implications are far-reaching. 

It began with a simple request from a patient: an intra-uterine device (IUD).

"I wrote up the report for her GP," recounts that patient's doctor, who worked at one of Australia's public Catholic hospitals.

"But then I was called over by my supervisor."

The doctor does not wish to be identified out of fear of speaking out against a major hospital.

"[My supervisor] asked me to change the wording to say that we had supplied [the IUD] for acne, rather than birth control."

The doctor was shocked.

"That was the first time in my practice I'd had to change my management."

That hospital is, on the surface, an ordinary public hospital in a big city. But like 20 other public hospitals around the country, it runs by a Catholic code of ethics.

This code, which applies to both public and private hospitals, advises against contraception, pregnancy termination, IVF, voluntary-assisted dying, and even the provision of abortion medication to rape victims.

"In sexual and reproductive health matters, the responsibility of Catholic health care is to give counsel which is both medically accurate and a witness to the teachings of Christ and his Church," the code of ethics states.

Workers from other public Catholic hospitals — speaking anonymously for fear of losing work — confirm that workarounds are widespread.

One worker at a second public Catholic hospital said how time consuming and embarrassing it was having to ask GPs to rewrite IUD referrals to pretend the woman had a heavy period. 

Another, currently employed by a third major public Catholic hospital, said "there's so much fudging of documentation that it's really difficult to accurately see what's going on in the health system. It means that data is meaningless."

Clinicians also said that creativity can mean the type of contraception supplied is based more on what doctors can get away with, than what the patient needs.

Melbourne woman Lesley, who asked that we only use her first name, was referred to the public Mercy Hospital for Women to have precancerous cells lasered off her cervix last year. That meant removing her copper IUD, but when she asked for it to be replaced, the hospital could only offer a hormonal IUD, as they can use it to treat heavy periods.

Lesley didn't want a hormonal IUD. She'd had a bad reaction in the past. Ultimately, she says the hospital agreed to insert a copper IUD if she brought it herself on another day. While it was hard for her to get medical leave, she says she "had no choice, because it's very hard to find an appointment for IUD insertion in the northern suburbs".

While contraceptives can be found elsewhere, many procedures can't be done outside these hospitals. Around 10 per cent of the hospitals in Australia are Catholic-run, but for maternity and gynaecological care, they're some of the most influential players.

'Willing to put my safety at risk'

Melbourne mum Jessica Leonard had tried everything. The excruciating menstrual periods which had plagued her since her teenage years were now coming closer and closer together, until she felt she had her period "12 days out of 18".

"I would be in too much pain to look after my children. I would be in too much pain to go out of the house. Some days I would just be in bed crying for 24 hours."

So when her doctor proposed a procedure called an "endometrial ablation" that could end her period forever, it seemed too good to be true.

There was just one catch: if she happened to fall pregnant again, it would be extremely dangerous, and could even kill her.

Jessica's GP recommended she get her tubes tied as a precaution, and having finished having children, she was "happy and confident" to make that decision.

Normally, that would all be one operation. But The Mercy Hospital for Women, which had the specialised staff and equipment to perform Jess's procedure, were unwilling to tie her tubes.

She was told she'd need two surgeries, through two different hospitals.

As a single mum, she'd need to find care for her children while she recovered — twice. It also meant double the risk.

"Double the risk from things like anaesthetics, double the risk of infections, double the risk of my organs being punctured, double the recovery time. And just a massive increase in time until the treatment that I was having would become effective.

But behind the scenes, a doctor was fighting for Jessica. Eventually, she says they convinced The Mercy to let a surgeon from another hospital tie her tubes during the operation. Two surgeons, one surgery.

For Jessica, it was a lucky escape.

But many women don't get this eleventh hour miracle. Brisbane woman Stephanie wanted the same procedure as Jessica, but says she had to settle for an inferior procedure that only offered a temporary reprieve from her debilitating endometriosis, because The Mater Hospital would not tie her tubes.

"I was shocked that a public hospital was allowed to not offer a full range of services," she says.

The Mater and Mercy hospitals declined an interview with Background Briefing. The Mater confirmed in a statement that it only performs tubal ligations in "certain exceptional circumstances". The Mercy said that "Consistent with our Catholic beliefs, we do not provide termination of pregnancy or direct contraceptive procedures. At all times we are dedicated to providing compassionate care for all those who use our services, and to working to improve the quality and safety of the care we provide."

Jessica and Stephanie's stories underscore a cruel irony. There are major Catholic-run tertiary hospitals for women in Australia that offer specialised obstetric and gynaecological care that nearby public hospitals can't. But once women get there, they can find out too late that the basic services of contraception and pregnancy termination aren't available to them.

For the healthcare workers who spoke with Background Briefing, not being able to tie women's tubes is heartbreaking — particularly for women who request it after multiple caesareans.

One current Catholic hospital worker said in a previous role in a disadvantaged area, she'd see women "come in for their eighth baby and maybe fourth caesarean, which is potentially very dangerous".

"There'd be lots of frowning at them, as another caesarean puts their life at risk, but if they requested a tubal ligation we'd say 'No, you have to wait until you've healed and then go on the waitlist for another hospital'. Pretty often, they'd come back with another pregnancy in the meantime.

"These were refugee or migrant women with very limited social and financial support, often parenting completely on their own. I felt really ashamed of having to do that."

Another clinician who worked at that same public hospital told Background Briefing when they booked a patient having their third caesarean in for a tubal ligation, "All hell broke loose".

"It was a big incident. I was taken to the Director's office, told, 'Did I realise this was not allowed in the hospital?' And I was like, 'Why is it not allowed? I'm not Catholic, the patient is not Catholic, why should it matter what I do?'"

James Cook University Professor of Obstetrics and Gynaecology Caroline de Costa says these situations are "unreasonable".

"It shouldn't be that what happens to a woman in the operating theatre is dictated by the principles of the administrators, and not by the best medical recommendations for the woman herself."

She says while there has been objection to the Catholic code of ethics for decades, few health care workers want to rock the boat.

"Certainly many junior doctors do not support [the limits] but they are very much bound by the rules of the hospital, and they will be very hesitant to break those rules because they will be on short-term contracts and they will want to progress in their training."

Professor de Costa says while Catholic hospitals, "especially large ones like The Mater", are important teaching hospitals, they are "not fulfilling their obligations" to RANZCOG or the colleges of nursing and midwifery when "they don't allow students and junior staff to participate in contraceptive and abortion care".

"I know that this is a constant problem for staff involved in supervising teaching and training who often have to make covert arrangements so students and junior doctors get some experience in these areas."

The heartbeat rule

Under Catholic Health Australia's code of ethics, doctors can't remove a pregnancy while there's still a heartbeat — unless there's a "grave risk" to the woman's health.

But one clinician told Background Briefing that "grave risk" is a grey area, and if they wait too long, the patient could die.

There's one case that haunts this worker.

A woman came to the Catholic public hospital with her waters broken at 17 or 18 weeks.

In Ireland, a woman had died in that same situation when doctors failed to remove the pregnancy because there was a heartbeat.

That death paved the way for the decriminalisation of abortion in Ireland, and this clinician couldn't get it out of their mind.

"In any other hospital, I would say 'You've broken your waters, there's a small, very small chance the baby will live, but the bigger risk is an infection that's life threatening to you, so the best option is to terminate this pregnancy'.

"But in a Catholic hospital I couldn't have this discussion, which was mind-boggling, because I knew of this Irish woman who'd passed away," the clinician said.

The clinician says the patient, who had poor English, was so confused that they continued with the pregnancy, and began developing an infection.

"So finally at the end of 48 hours, I said my sincere advice is to leave without telling anyone, get in your car and drive down to the emergency department at [another, secular hospital]. Because if I called that hospital, they would say 'Well the treatment is termination, so do it'. And I can understand that, as they're equally busy and not able to take transfers from places with all the doctors and theatres necessary to provide that care.

"But what my hospital would probably have said is, 'Well she's well right now, there is no risk of her dying in 24 hours'. The whole point of medicine is to prevent people getting to that point."

"To this day, I honestly believe I saved that woman's life."

Background Briefing put this incident to Bernadette Tobin, who chaired the drafting of the Catholic Health Australia code of ethics.

"Our code of ethics says we don't intentionally terminate the life of a fetus or an unborn child," says Dr Tobin.

"It also says, 'nor do we stand by and let the life or the health of the mother be under grave risk'. Now, after that, it's a matter of a case-by-case judgement. And a good doctor will know when she should act."

Catholic Health Australia, which represents the Catholic-run hospitals across Australia, declined an interview but echoed this stance in a statement.

'I trusted them'

Catholic hospitals won't terminate a pregnancy while there's still a heartbeat. But for women with a pregnancy with no chance of survival, that can feel like an extremely arbitrary line.

Nina Crawley fell pregnant in August, but tragically, at her 10-week scan, the doctor revealed the baby could not live.

She assumed she'd be able to access a termination as quickly as she'd accessed care at The Mercy during an earlier miscarriage in June.

After all, it was the same procedure to perform a termination as to remove that miscarriage ... same equipment, same staff … it even shared a Medicare Item Number.

Instead, she says The Mercy told her she'd need to go elsewhere as the baby still had a heartbeat.

It felt like a betrayal.

"I was really, really mad. Like, I gave birth there — it's kind of part of my identity. It's an important institution in my life. I trusted them."

It would be two weeks at the earliest until she could get into another public hospital.

"I was just going to look more and more pregnant and I was already finding it hard to hide at work," she says.

After calling around Melbourne, Nina found a fluke appointment at a private clinic a few days away, which cost her $650 out of pocket.

Another patient at The Mercy that week shows what would have happened if she'd left it to the hospital to sort her care through the public system.

Peta, who asked to use a pseudonym, was told by The Mercy that she could miscarry at any minute — but the wait time for a termination at another public hospital was nine days. She felt unable to leave the house, but terrified she would miscarry at home, in front of her young children.

"They didn't know that I was pregnant and it was difficult for them because they knew that I was sad and they were worried about my heart being broken."

Compounding the grief and fear, she says she felt "guilty and ashamed", having "asked for something the hospital doesn't believe in".

Counsellors told Background Briefing that women choosing to terminate a baby with a severe defect can already feel extreme guilt, and being turned away by Catholic hospitals compounds that shame. As one patient described it, "It made me believe the small voice in my head that said I was a murderer."

Peta says every day of those nine days she had to wait for her termination felt like a year, and that she could imagine someone with mental health issues contemplating suicide.

So, she wrote a letter to the executives of The Mercy Hospital.

Within 24 hours, a reply popped up in her inbox. But when she opened it, her mood changed.

The Mercy acknowledged her distress and offered their condolences, but said it took "pride [in] providing care in accordance with the teachings of Jesus Christ".

"In all cases, we adhere to the Catholic practice of the utmost respect for human life and the recognition that human life comes into being at conception."

For Peta, it felt like a slap in the face.

"They say that they respect life, but where was the respect for our lives, and our decision making, and our grief and ability to move forward?"

Both Melbourne's The Mercy and Brisbane's Mater hospitals have cutting-edge maternal fetal medicine units, meaning women are referred there when an abnormality is picked up during early scans.

"You'd have to ask, why are they going to the trouble of running the diagnostic service if they cannot provide the solution to the woman?" asks Professor Caroline de Costa.

The Mater said in its statement, "Mater Mothers' Hospitals have established a world-leading Centre for Maternal Fetal Medicine, which provides expert diagnosis and management of complex pregnancy problems ... However, not all clinical services are provided at all hospitals. Where Mater is unable to provide a requested service we will facilitate an on-referral to an appropriate hospital or doctor."

Mercy Health said in its statement that it "values the dignity of life from conception to death. We provide a comprehensive and highly regarded range of women's health, pregnancy and birthing services. However, consistent with our Catholic beliefs, we do not provide termination of pregnancy."

'Wrong side of the river'

Nicole Huig deals daily with the limitations imposed by the Mater hospitals.

Her counselling team at Children by Choice take calls from women all over Queensland desperate to find a termination. But often it's most complicated for those living on what she describes as "the wrong side of the river" in Brisbane.

That would be South Brisbane. And while there's another option for women there besides The Mater — Logan Hospital — Nicole says access is hampered by "conscientious objection".

That's where individual health workers object to providing terminations or contraceptive procedures. And that's not limited to Logan Hospital — "it would be most hospitals in Queensland", says Nicole.

Those hospitals are meant to refer on, and many have partnerships with private clinics. But for some women, by the time they jump through the hoops to get an appointment, it's too late, and they're forced to carry through with the pregnancy. Nicole is aware of six women in this situation this year — "but that's only the women who've actually accessed our service."

Nicole says when her team gets a call from a woman in South Brisbane, "your heart just sinks".

"You can get better access in Toowoomba."

She says access is so complicated that "quite regularly" her team help women change their addresses.

While that might sound drastic, she says the women denied care are exceptionally vulnerable.

The health network that manages Logan Hospital declined an interview but said in a statement, "Metro South Health is committed to providing termination of pregnancy services in a timely, sensitive and caring manner … at Logan Hospital and through a partnership with a contracted private provider … To assist with this, we have employed a Nurse Navigator for Termination of Pregnancy to ensure women who are accessing this service receive timely care."

'A deep respect for our staff'

The code of ethics governing Catholic hospitals is about to get an update.

But when it comes to reproductive healthcare, nothing is going to change, according to Dr Tobin, who chaired its drafting.

In fact, she disputes the suggestion that contraception and abortion are "health care", which she says is "to do with making people better and keeping them better".

Dr Tobin says contraception being prescribed under false pretences is "not a real problem", despite Professor de Costa saying it has been happening in Catholic hospitals since she started out there as a junior doctor in the 80s and 90s.

But there are areas where Dr Tobin agrees with the patients and healthcare workers who've expressed concerns with the code of ethics she drafted.

She agrees that public patients should be able to choose whether to attend a Catholic hospital, and that the limitations must be well advertised.

She believes those limits are well known, while others say they're not — especially among migrant populations.

She says doctors who don't support the code should not choose to work in Catholic hospitals, but that "any good institution will have a robust respect for the consciences of its individual staff members."

"And certainly in our own code of ethics, we say no staff member may be required to participate in an activity that in conscience, the person considers to be wrong. So we have a very deep respect for the consciences of our staff."

While there may be no changes forecast to the code's stance on reproductive healthcare, ultimately, governments decide where Catholic hospitals fit in the public system.

And one state politician has been advocating for change.

'A new urgency'

Fiona Patten started the Sex Party, now rebranded the Reason Party.

For the past eight years, she's represented the northern suburbs of Melbourne — home to the St Vincent's hospitals and many of the women zoned to The Mercy Hospital for Women.

Earlier this year, she introduced a bill that would stop Victorian public hospitals from refusing procedures on religious grounds.

Ms Patten says she was spurred to act after hearing "more and more stories" from constituents, but when the US Supreme Court overturned the right to abortion, her work "took on a new urgency".

Her bill did not affect the right for individual healthcare workers to refuse to provide services if it went against their consciences. It just stopped hospitals having blanket bans.

But it was voted down by the Dan Andrews government. Ms Patten believes the government did not want to attract controversy so close to an election.

"But this is a government that says they believe in equity, and that they believe in women's reproductive health rights," she says.

Dr Tobin, the Catholic ethicist, says Fiona's bill was "undemocratic" and "undesirable".

"I think that in a liberal, pluralist, democratic society, we want both diversity of opinions and diversity of practices.

"And it's very valuable to a society like our own to have a range of different kinds of public hospitals."

Catholic Health Australia, which represents the hospitals, said in a statement: "Most providers of public health and aged care will have services they do not provide ... For our members, this includes the intentional termination of pregnancy. These limits are well known, given our members have been looking after the Australian community for more than 150 years."

For Bonney Corbin, head of policy at MSI Australia, the solution is clear: redirect some of the funding from the hospitals not providing these services to the places that are.

"It's looking at every single region at where their capacity is, and then funding those smaller providers accordingly."

Ultimately, Ms Corbin says, it's about bang for buck.

"If that region is serious about efficient expenditure of health funds, they'll realise that investing in contraception and abortion can reduce other health costs over the long term."

Advocates are hopeful change could come from a federal senate inquiry into access to reproductive health care, with submissions closing this month.

"Some of us think if we just got together and protested things would change, but people who've been fighting it a lot longer are of the opinion we need to be quiet for now, that it might cause more problems. They are aware of the intricacies of the conversations that happen behind closed doors.

"Making the change from the inside jeopardises our positions, and then who will be there to care for these women if we're gone?"

Credits

• Reporter: Annika Blau
• Executive producer: Fanou Filali
• Photographer: Danielle Bonica
• Illustration and design: Teresa Tan
• Digital producer: Sam Nichols