In Texas, a Catholic bishop made two hospitals cease doing tube-tying operations for women who are not going to have more babies. In Oregon, another bishop cast a medical center out of his diocese for refusing to discontinue the same procedure. In Arizona, a nun was excommunicated and the hospital where she works was expelled from the church after 116 years for allowing doctors to terminate a pregnancy to save a woman's life.
Such disputes between hospitals and church authorities appear to be arising because of a confluence of factors: Economic pressures are spurring greater consolidation in the hospital industry, prompting religiously affiliated institutions to take over or merge with secular ones, imposing church directives on them. At the same time, the drive to remain competitive has led some medical centers to evade the directives. Alongside those economic forces, changes in the church hierarchy have led increasingly conservative bishops to exert more influence over Catholic hospitals.
The clashes have focused attention on the limitations on care available at Catholic hospitals. In Montgomery County, concern about those constraints has emerged as an issue in the battle over whether Holy Cross Hospital, a Catholic institution in Silver Spring, or Adventist HealthCare in Rockville should be authorized to build a new hospital in the county.
A coalition of advocacy groups Wednesday urged the state to reject Holy Cross, citing concerns about access to reproductive health care, especially for poor women and teenagers. A decision in that case is expected Thursday.
Such conflicts are likely to intensify as new flash points arise, such as the spread of infertility treatments considered taboo by the church and the possible availability of therapies derived from human embryonic stem cells.
Although the issue has erupted at a variety of institutions, women's health advocates are especially alarmed about Catholic hospitals, a leading source of health care in the United States.
"Physicians are being told they must refuse to provide certain services even when they believe their refusal would harm their patient and violate established medical standards of care," said Lois Uttley, who heads MergerWatch, a New York-based group that fights the takeover of secular medical centers by religiously affiliated hospitals.
Church officials, bioethicists and hospital officials counter that the facilities are guided by directives calibrated to deliver state-of-the-art medical care without violating religious and moral beliefs. Disagreements between dioceses and hospitals, as well as cases in which patients do not receive needed care, are exceedingly rare, they say.
"We have literally hundreds of institutions that care for men, women and children every day and provide excellent care, especially to the poor," said Richard M. Doerflinger of the U.S. Conference of Catholic Bishops Secretariat for Pro-Life Activities. "We always do so with respect for each and every life in our care."
Since 1971, Catholic hospitals have been guided by the Ethical and Religious Directives , which detail religious and moral justifications for care extending from conception to death. The interpretation of those directives is the responsibility of ethics committees at the hospitals, and the final arbiter is the local bishop.
The best-known prohibition is against abortion, which led to the recent confrontation between Bishop Thomas Olmsted and St. Joseph's Hospital and Medical Center in Phoenix. In May, Olmsted declared Sister Margaret Mary McBride excommunicated after discovering that she had permitted a pregnancy to be terminated in 2009 for a mother of four who developed pulmonary hypertension in the 11th week of her pregnancy.
Doctors had concluded that the 27-year-old woman would almost certainly die without the procedure. But Olmsted demanded that the hospital acknowledge its error and take steps to comply with the directives. Hospital officials refused, leading Olmsted to announce that he was stripping St. Joseph's of its Catholic affiliation.
"I have hoped and prayed that . . . this decree would not be needed," Olmsted said at a Dec. 21 news conference. "However, the faithful of the diocese have a right to know whether institutions of this importance are indeed Catholic in identity and practice."
Although some theologians question Olmsted's ruling, a bishops' committee chaired by Cardinal Donald Wuerl of the Archdiocese of Washington issued a statement that was widely seen as supportive.
Neither the Washington archdiocese nor any of the local Catholic hospitals - Providence and Georgetown University in the District and Holy Cross - say they have experienced any similar conflicts. But some observers, including some Catholic theologians, suspect Olmsted's crackdown and the bishops' statement could embolden other dioceses.
"I can see the chilling effect of this," said the Rev. James Bretzke, a moral theologian at Boston College, who supports the directives but said he might now hesitate if a female relative sought some care at a Catholic hospital.
In addition to barring abortions, the directives prohibit tubal ligations, the surgical sterilization of women and the second leading form of contraception in the United States.
In Texas, CHRISTUS St. Michael's and Trinity Mother Frances Hospital agreed in 2009 to a request by Bishop Alvaro Carrada to discontinue the practice. But St. Charles Medical Center in Bend, Ore., refused a similar request, prompting Bishop Robert F. Vasa in February to sever ties with the 92-year-old institution, which was founded by nuns.
"Sterilization has the direct effect of destroying a properly functioning part of the human body," Vasa said in a telephone interview.
As was the case at St. Joseph's in Phoenix, the decision meant that Mass could no longer be celebrated in the hospital's chapel, and the hospital had to return religious objects to the church.
Several doctors interviewed across the country, particularly in rural areas, described frustration over being barred from taking a few extra minutes during a Caesarean delivery to tie the tubes of women who no longer want children or face complications if they become pregnant again.
"I feel very stuck," said a doctor at a hospital in an isolated town in a western mountain state whose institution barred the procedures after the Phoenix case. "I don't know where to turn."
Jessica Graham, 33, delivered her second child through a Caesarean in September at the Sierra Vista Regional Health Center in Arizona, but she had to schedule a second operation to have her tubes tied after the hospital decided to become part of a Catholic hospital group and ordered a stop to all tubal ligations.
"It's very unsettling," said Graham, whose kidney problems increase the risk of another pregnancy or another surgery. "Now they are going to have to back inside my body again and cut me open again."
Of even greater concern to many doctors and advocates are conflicts over treatments for women who have miscarriages and ectopic pregnancies.
Standard care for ectopic pregnancies, which are life-threatening, is to inject the drug methotrexate or to remove the embryo surgically while leaving the fallopian tube intact, both procedures that are intended to preserve fertility. But some Catholic hospitals refuse to perform either and will extract the embryo only by taking out the fallopian tube.
For miscarriages in which the fetus is not expelled quickly, doctors often use drugs or surgical procedures to protect the woman from potentially fatal infections and bleeding. But if the fetus still has a heartbeat, some Catholic hospitals refuse to intervene. And the patient has to go to another hospital, sometimes hours away, or wait for the heart to stop.
"The fact that this happens is simply outrageous and inexcusable," said Jill Morrison of the National Women's Law Center, which is releasing a 30-page report documenting the impact of the directives through interviews with 25 physicians and administrators at 16 hospitals in 10 states .
Morrison and other critics cite cases such as one in which a woman 15-weeks pregnant with twins sought help at Sierra Vista in November after miscarrying one twin at home. After doctors concluded there was no hope for the second twin, the woman and her husband agreed to terminate the pregnancy. But the hospital refused, requiring the couple to travel more than 70 miles to Tuscon for the procedure.
"There's always grieving when you lose a pregnancy," said Robert Holder, an obstetrician gynecologist who treated the patient. "But then to have an entity questioning your decision, that compounds that trauma."
"We can respect that everyone has different beliefs, but if you take federal dollars you have to follow federal law that requires access to emergency care," said Brigitte Amiri, an ACLU senior staff attorney.
Last month, Marilyn Moon, chair of the Maryland Health Care Commission, recommended that Holy Cross be authorized to build Montgomery's new hospital, arguing that the county offered women enough alternatives to obtain the restricted services.
But Marissa Valeri, senior associate for domestic programs at Catholics for Choice, said Moon's recommendation "ignores the reality that for poor women, this will not be an option" to seek services elsewhere.
A spokeswoman for Holy Cross said that the "largest access problem in the county by far" is to prenatal and primary care services for uninsured women and that Holy Cross is the largest provider of care to uninsured pregnant women.
John M. Haas, president of the National Catholic Bioethics Center in Philadelphia, said that although there is some debate over treatments for miscarriages and ectopic pregnancies, the church's guidance should not have prevented care in any of the cases cited by critics. He blamed failures to fully understand the directives.
"I don't know any case where legal action or a malpractice case has been brought against a Catholic hospital because a conflict situation had arisen between the life of a mother or the life of a child," Haas said.
Doerflinger said the moral and ethical concepts that underlie the directives also are integral to Catholic hospitals' emphasis on caring for the needy and attending to the spiritual needs of patients and families.
"If we want to give up all that and say the Catholic health-care system should be officially secularized, then that's a position people can take," Doerflinger said. "But they should not pretend that you can remove that core conviction and still have Catholic health care."
Staff writer Lena Sun contributed to this report.