"What angers me the most is they made up this farcical explanation," says Merle Robboy, a veteran Hoag OB/GYN. "They claimed M.D.s don't do counseling — I've been doing this for 41 years, and I spend a lot of time counseling patients."
The truth, as Braithwaite acknowledged to me and my colleague Anna Gorman in an interview, is that St. Joseph's unhappiness with abortions at Hoag emerged early in the partnership talks. Braithwaite's sugar-coated version is that during those talks "we recognized that there was sensitivity on the women's reproductive health issue to our partner." Consequently, around the end of last year the Hoag board undertook a "very comprehensive, clinically led evaluation process of women's health services."
The conclusion of that study, Braithwaite said, was that "the continuation of elective abortions at Hoag was not the optimal solution to maintain the highest-quality family planning services for women in our community."
Braithwaite seems to consider it something of a victory that Hoag managed to preserve the right to keep performing sterilizations and offer contraceptive consultations and other reproductive health services that "are not typically found inside Catholic hospitals."
His point appears to be that Hoag sacrificed abortions to St. Joseph in order to keep doing the rest — as though Hoag had no choice but to capitulate, if only partially, to Catholic practice. Does that amount to St. Joseph pressuring Hoag to end abortions? Of course it does.
Harris' Feb. 8 statement approving the deal, and a December 2012 report by a consultant she hired to examine the proposal, both acknowledge that abortions would be ended at Hoag under the terms of the deal. No such provision appears in the text of the Oct. 15 affiliation agreement that Covenant provided to me, but according to the attorney general's office that's not the complete document. In any case, Richard Afable, who negotiated the agreement as Hoag CEO and subsequently became CEO of Covenant and a St. Joseph executive, made it plain in an interview that ending Hoag's "direct abortions" — the Catholic term for terminating a pregnancy by destroying a developing fetus any time after conception — was a fundamental condition for St. Joseph.
Speaking for St. Joseph, where he is now an executive vice president, he said that adherence to the institution's own ban on abortions was "sacrosanct … required of ourselves and anyone that we [St. Joseph] would work with."
That implies that Hoag's "evaluation" of its women's services was window-dressing designed to validate an agreement already reached between the partners.
The legal standard governing Harris' authority to reject a hospital transaction requires her to find that it would "significantly" erode the availability or accessibility of healthcare in the community. Defining "significant" is a judgment call, but it's hard to see how Hoag's abortion ban fails to qualify.
Unlike women living in areas where abortion rights are under full-scale assault and where there may be a lone abortion clinic for hundreds of miles around, women in Orange County obviously don't lack for options for reproductive healthcare. But that doesn't mean Hoag's action is not "significant."
The Hoag and St. Joseph affiliation aims to serve fully one-third of Orange County's 3 million residents. Hoag has the highest market share in obstetrics of any hospital in its area, at 26%. The seven partnering hospitals are linchpins of charity and community care in the county. That's a significant chunk of healthcare capacity closed to women seeking a legal medical procedure.
There's no evidence that Harris considered the basic complications that arise when any medical treatment is compromised by non-medical considerations, especially when they're suddenly imposed on a facility boasting a tradition of full-service healthcare dating to 1952. Hoag physicians are wrestling with these complexities already, with little guidance from the administration.
For example, Catholic doctrine allows abortions under some conditions where the mother's life is at stake — but "who's going to decide if it's for the health of the mother?" asks Illeck.
In oncology, doctors and patients sometimes choose to terminate a pregnancy because it can compromise the effectiveness of cancer treatment. "For me to say, 'My hospital won't allow that' makes a bad situation so much worse," says Lisa Abaid, a gynecological oncologist at Hoag and a signer of the open letter. "It would be a terrible thing for me to say that I can't provide my patients a safe and legal and simple procedure."
One impression that comes across from talking with Hoag executives is their disdain for such concerns. Their position is that this partnership is a business arrangement that will benefit all healthcare users in Orange County, and if the doctors aren't down with that, tough. Brooks says, "When strategic decisions are made at the level of an organization and their vision and their mission … they don't go to physicians and their at-will medical staff to ask their permission."
That mindset explains how Hoag's administrators could assure their doctors that "nothing would change" even though a controversial change was preordained, and why the doctors weren't kept in the loop as the new policy developed.
And it surely raises the question of what other women's services might be getting lopped off at Hoag in the future, for the sake of a religion-based restriction masquerading as a "strategic decision."