One year ago, the University of California Board of Regents voted to approve an uncompromising policy governing the terms of partnerships between UC's medical schools and Catholic hospital systems.
The policy led UC doctors to believe that they would be permitted to provide any care they judged warranted for their patients, including performing abortions and contraceptive implants that are otherwise forbidden at Catholic healthcare facilities.
They couldn't be required to transfer or refer those patients to non-religious hospitals if moving them or delaying treatment would be "detrimental to the patient's care," as is often the case.
But somehow the policy language changed when the regents' vote was translated into a formal UC policy. The policy now fails to guarantee that UC doctors can perform any procedure they deem necessary, only that they can prescribe and counsel patients about their options.
And it now says doctors can refuse to transfer a patient only if the move would "risk material deterioration to the patient's condition." That's a stricter standard that doctors say deprives them of significant discretion to direct patient treatment.
Many UC doctors say the policy, as it's now written, is not a significant improvement over the situation that prevailed before the regents' vote, when affiliation contracts often subjected UC doctors to religious restrictions on care when they practiced in faith-based institutions.
"We are taken back to where we started," Amy Autry, an OB/GYN professor at UC San Francisco's regional campus in Fresno, told the regent's health services committee last month.
Although the policy approved by the regents last year formally applied to UC's affiliations with hospitals with "policy-based restrictions on care," in practice it mainly applied to Catholic hospitals and their religious strictures on contraceptives, abortion, and gender-affirming procedures.
As passed almost unanimously by the regents on June 23, 2021, (there was one abstention), the new policy — drafted by then-board Chair John A. Pérez — was designed to settle the contentious issue of how the restrictions at Catholic healthcare systems conformed to UC's goal of providing "evidence-based, medically indicated care" to all patients, as the regents' policy statement put it. Affiliating institutions and systems would have until Dec. 31, 2023, to come into compliance with UC standards.
Instead, buried in the version written by the office of UC President Michael V. Drake, which is now codified as Policy 4405, is an enormous loophole that leaves them still subject to church-imposed restrictions.
Put simply, although the policy guarantees that UC providers can "advise, refer, prescribe, or provide emergency items and services without restrictions," it fails to guarantee that UC providers can perform any procedures they deem advisable or necessary.
The differences in language between Pérez's version and the final policy are subtle and may be opaque to laypersons. But not to medical providers, for whom they're tantamount to the difference between night and day.
"As currently written, Policy 4405 betrays our values by requiring us to limit the care we provide patients and by harming trainees and their future patients," Jody Steinauer, professor of obstetrics, gynecology and reproductive sciences at UC San Francisco, the system's preeminent medical school, told the regents committee on health services at its meeting June 15.
The policy could deprive UC medical students of the training they need to provide the full spectrum of medical care for their patients, Steinauer said. "We know that people trained in restrictive hospitals do not actually learn the basic skills they should," she told the regents committee.
"Many OB/GYN residents trained in hospitals that restrict their practice graduate not feeling comfortable in important contraceptive and abortion skills," Steinauer said. "They are not prepared to place an IUD, do post-partum sterilizations [that is, tubal ligations], offer comprehensive early pregnancy loss care or do an abortion to save someone's life."
Some background may be useful. UC health administrators have long said that affiliations with outside healthcare system are crucial because the university and its medical centers don't have the room they need to fit all their patients and provide clinical training to all their medical and other healthcare students.
UC aims to provide treatment and inculcate its students at the highest level of medical science. Catholic hospitals, however, generally adhere to the Ethical and Religious Directives for Catholic Health Care Services, a set of guidelines issued by the U.S. Conference of Catholic Bishops.
The ERDs label abortions, euthanasia, assisted suicide and direct sterilization "intrinsically evil" and prohibit them at Catholic facilities. They also bar such gender-affirming procedures as hysterectomies for transgender patients. They place the ultimate judgment about medical practices in the hands of local bishops.
The ERDs place the ultimate judgment about medical practices in the hands of local bishops. They label abortions, euthanasia, assisted suicide and direct sterilization "intrinsically evil" and prohibit them at Catholic facilities.
That means, for example, that the standard of care applicable to tubal ligations, which is that they should be performed as part of the same procedure as a Caesarian section, can't be met at Catholic hospitals. Instead, women desiring the procedure would have to undergo two surgeries, not just one — increasing their health risks. The ERDs bar such gender-affirming procedures as hysterectomies for transgender patients.
UC's affiliations with Catholic hospitals became a flashpoint in 2019, when UCSF sought to expand its professional affiliation with four hospitals owned by the Catholic chain Dignity Health. After an uproar by UCSF personnel, the proposal was abandoned.
It soon became clear that other affiliation contracts bound personnel connected to almost every UC medical center to limitations on care when they were working at locations that had restrictive policies, chiefly Catholic hospitals.
Pérez's policy was designed to inoculate UC personnel and students from the imposition of the ERDs when they were practicing or training at Catholic facilities. The regents' vote last year was praised by many, including myself, as a significant counterstrike — indeed, one of the first in recent memory — against the steady encroachment of church restrictions into American healthcare.
Some UC professionals say they were surprised by the change in the policy's language between the regents vote and publication of the formal policy in April. "I was unhappy when I saw the wordsmithing right away," sociologist Lori Freedman, an expert on the influence of abortion politics on medical practice at UCSF, told me. "I was very concerned that the new language was not going to change practice."
Freedman and others have asked UC officials to explain whether the policy would allow UC professionals working at faith-based institutions with healthcare restrictions to perform procedures such as implanting an intrauterine device or other implantable contraceptive. "We never really got answers," Freedman says.
The same issue was raised at the regents' monthly meeting Wednesday by Vanessa Jacoby, an associate professor of obstetrics, gynecology and reproductive sciences at UCSF and a leading critic of UC affiliations with Catholic health systems.
"Providing an abortion or an implantable contraceptive are procedures that don't fit the 'advise, refer, prescribe' phrasing of the current policy," Jacoby told the board. "These procedures can't be prescribed and picked up at a pharmacy."
Jacoby called the policy's suggestion that UC doctors could simply refer patients to another facility "highly concerning" because referrals and transfers "create unnecessary delays in care that worsen health outcomes for our patients."
One reason that UC professionals are so sensitive about the language of the policy is that it's not hard for religious institutions to interfere with doctors' judgments without seeming to do so.
A Catholic hospital might not stock contraceptives in its drug formularies, so that doctors prescribing an implantable drug or device can't obtain it for their patients on site. Hospitals can assert that staffing problems make the prompt scheduling of an abortion impossible. Explicit language allowing doctors to perform the procedures they prescribe would reduce the prospects of that happening.
It should go without saying that ensuring that preserving UC's professional values is more important today than ever, thanks to the Supreme Court's eradication of the constitutional right to abortion through its June 24 decision in Dobbs vs. Jackson Women's Health Organization.
The Dobbs decision has thrown the whole landscape of reproductive healthcare into turmoil. In the more than 20 states imposing or planning severe restrictions on abortion, patients and doctors are unsure what medically urgent procedures can be performed or drugs prescribed without running afoul of state laws.
The decision has made California, with its liberal abortion policies, a sanctuary state for women seeking abortions or other reproductive health services. That in turn places UC at the center of reproductive healthcare policy. Indeed, much of Wednesday's regents meeting was occupied by a presentation on the impact that Dobbs will have on the university's services and training.
The Guttmacher Institute, an abortion advocacy organization, calculates that the number of women of reproductive age for which California will have the nearest abortion clinics will increase 30-fold, to 1.3 million, the regents were told by Anne Foster, chief clinical officer of UC Health, which administers UC's health professional schools and medical centers.
As many as 16,000 patients per year may travel to the state for care, Foster said, straining facilities that are already over capacity.
Drake, a physician who previously served as chancellor of UC Irvine and as UC's vice president for health affairs, told the regents that the Dobbs decision is "antithetical to the university's mission and values."
Drake said UC "will continue to provide the full range of healthcare options possible in California, including reproductive health services and to steadfastly advocate for the needs of our patients, students, staff and the communities that we serve. We will also continue to offer comprehensive training to the next generation of healthcare providers."
Yet that doesn't seem consonant with the gaps inherent in UC's affiliation policy with institutions that don't meet those standards, such as faith-based hospitals that don't offer comprehensive services to their patients or comprehensive training to students taking clinical rotations on their premises.
Drake's office told me that affiliation contracts subject to the new policy "expressly require that UC providers, using their independent professional judgment, are able to counsel on options, transfer or refer a patient to a facility that provides abortion services." The office also said UC doctors are able to "provide any care they deem necessary and appropriate in an emergency." But the latter authority would be guaranteed by federal law, even without the UC policy.
I sought comment from Pérez, who wasn't in attendance at Wednesday's regents meeting during its discussion of the Supreme Court's abortion decision. At the June meeting of the health services committee, which he chairs, he expressed skepticism about how well UC was prepared to hold its Catholic affiliates to the university's standards.
He asked the system's health officials to report, for example, on whether in the case of implantable contraceptives, UC providers at Catholic hospitals would have "the ability not only to prescribe but to implant."
He acknowledged the concerns raised by UC doctors about their "being able to engage in the practice of medicine the way one would at a facility that did not have restrictions. What I want to make sure is that changes that we're putting in our agreements are real and that they're not a veneer."
Pérez noted that, according to UC's figures, of 97 new contracts and renewals subject to negotiations between the university and affiliates over the last year, only one resulted in the contract's termination.
Pérez wondered aloud whether that meant that UC contract officials were not being firm enough about the university's standards when they negotiated agreements. "I don't know whether to be elated," he said, "or to be suspect."
There is an easy fix to the confusion produced by what Freedman called the "wordsmithing" of the regents policy. A light tweak of the language would suffice.
Freedman told the regents committee that it should add three words to the policy: "and perform procedures" so that it read, "Clinicians should have the right to make clinical decisions and perform procedures consistent with the standard of care."
The key question is who is really in charge of medical practice when UC professionals and trainees are on site at Catholic hospitals — or any other institutions that impose non-scientific strictures on healthcare: the church or the university?
The only suitable and responsible answer is the university. UC needs to make that unmistakably clear.
