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Church-state issues swirl around medical school


When the University of Texas opens its medical school in 2016, most of the faculty members and the new doctors they train won’t be UT employees. Rather, the Seton Healthcare Family will sign their checks and require them to follow Catholic Church rules on birth control, abortion and end-of-life care inside Seton quarters.

The arrangement will be similar to what exists now in Austin. Seton currently works with medical schools in Galveston and Dallas to teach students and train new doctors here.

But the challenges of marrying a public medical school to a religious health care system are under growing scrutiny as the Austin flagship establishes the Dell Medical School and a national organization signals it might sue over what it sees as a breach of church-state separation.

Officials of the university and Seton — the largest health care system in Central Texas — are gingerly crafting agreements intended to ensure that medical students and doctors receive required training without breaking the Catholic Ethical and Religious Directives. They are confident both objectives will be met.

The religious restrictions have at times created challenges for faculty members, residents and patients. Some current and former residents said the rules were an occasional inconvenience in an otherwise strong program.

Others saw problems.

Jenifer Kowalik, an obstetrician-gynecologist in San Marcos who was a resident at University Medical Center Brackenridge several years ago, said she was troubled by the prohibition on tubal ligation, a sterilization procedure in which a woman’s fallopian tubes are clamped to prevent eggs from reaching the uterus.

Some women who delivered by cesarean section, a major surgical procedure, wanted to undergo a tubal ligation at the same time but could not, she said.

“It would have taken an extra three seconds to do the procedure,” Kowalik said. “Instead, we sew them up. They have to go home and heal, and six weeks later we have to go through another procedure to tie their tubes at a non-Catholic facility. That’s coming close to abuse of a patient.”

Officials of the UT Southwestern Medical Center in Dallas said they encourage trainees to raise any concern they have about care so it can be addressed. “To the best of our knowledge, this concern has never been expressed to UT Southwestern program leadership by residents in the time since we were asked to assume responsibility for oversight of residency training in Austin,” the medical center said in a written statement.

Jayme Evans, one of two chief residents in the OB-GYN program, said maternity patients requesting a tubal ligation are sent to St. David’s to deliver. Occasionally, patients have shown up in labor at UMC Brackenridge and are counseled that a requested tubal will need to be done later, at St. David’s, said Evans, who added that she is pleased with how the program works.

Seton operates the publicly owned UMC Brackenridge, but after the medical school opens, Seton will run — and own — a $295 million replacement teaching hospital opening in 2017.

In the 18 years since Seton began operating the hospital — first for the city of Austin and later for the Central Health hospital district — faculty members and residents have had to comply with changing Catholic orders. Early on, the city had to contract with a company to do sterilizations because Seton employees could not be involved in a procedure the church forbids.

Later, the Vatican’s restrictions on sterilizations prompted creation of a “hospital within a hospital” in UMC Brackenridge with a separate operator. When that operator pulled out, the service moved to the non-Catholic St. David’s Medical Center in 2011. 

One program, two payrolls

Under the current arrangement, Seton and UT Southwestern partner to provide medical education in Austin. The UT Medical Branch at Galveston sends third- and fourth-year students as well. Seton employs most of the faculty members and residents in Austin.

Medical students are not considered employees and are therefore not required to sign contracts.

Under the employment contracts, faculty members and residents agree not to engage in abortions or in vitro fertilization, the process of removing eggs from a woman and fertilizing them with sperm in a laboratory. They also must not promote or condone contraceptive practices.

“Married couples and the medical staff who counsel them” are to receive “instruction both about the Church’s teaching on responsible parenthood and in methods of natural family planning,” the Catholic directives say.

In addition, medical research must adhere to Catholic moral principles, and terminally ill patients whose suffering cannot be alleviated “should be helped to appreciate the Christian understanding of redemptive suffering,” the directives say. Those patients may forgo treatments if they “do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.”

The practices are forbidden at Seton clinics and physician office space that Seton leases, as well as its hospitals.

A master agreement creating a Seton-Central Health nonprofit to provide health care states it “will not operate in any way that would cause Seton to violate the ERDs,” meaning Ethical and Religious Directives.

Toward that end, faculty members and residents work off the Seton clock, for another employer, when performing procedures outside Seton facilities that the church forbids, said Greg Hartman, Seton’s president of external affairs.

For example, abortions are done at Planned Parenthood, and while there, faculty members and residents are not on Seton’s payroll, Hartman said. The same goes for training on sterilizations or emergency contraception for rape victims at St. David’s.

UT, Seton and Central Health officials expect those relationships to continue when the Austin school opens.

Residents who do not want to take part in abortions may opt out, but they still must learn how to manage complications of abortion, according to the Accreditation Council for Graduate Medical Education. Discussions of performing an abortion and handling complications can be held inside Seton facilities, just as physicians are allowed to talk to Seton patients about contraception and abortion.

Seton supports those guidelines, said John Gianopoulous, vice president for women’s health and president and CEO of perinatal programs and services. “By the ethics of medicine, all the options need to be given” to the patient, he said.

Seton hired Gianopoulous last year from Loyola University Chicago, where he worked for more than 30 years at the Catholic institution’s medical school.

When employees are not in a facility owned or leased by Seton, “they can do what their conscience dictates,” he said. They can even give speeches favoring abortion rights, as long as they don’t put forth those opinions as Seton employees, he said.

“In no way is their education hindered … in a Catholic medical school environment,” Gianopoulous said. “I’ve never had any problem having … residencies accredited.”

It also would be “very rare” for a clinical trial to be forbidden based on Catholic directives, and if that happened, the medical school could find another partner, said Steven Warach, executive director of the Seton/UT Southwestern Clinical Research Institute.

Restrictions no secret

Two graduates of the obstetrics-gynecology residency program praised the training.

“I felt free to do what we needed to do to care for our patients,” said Allison Urrutia, a 2011 graduate.

Doctors could counsel patients on birth control and care for those who came to Seton with complications from an abortion, said Lori Stafford, who finished her residency in June. Traveling to St. David’s wasn’t convenient, but it was valuable to learn how another hospital works, she said.

If she could change one thing, she would make the system easier for patients, especially non-English speakers. “It can be an interesting system to navigate,” Stafford said.

Programs like Seton’s must publicize restrictions to prospective residents. Current and former residents said they were told before signing up.

Right now, Seton employs 249 residents and fellows, 132 faculty members and 148 support staff members, spokeswoman Adrienne Lallo said. Seton even reimburses UT Southwestern for the salary of its regional dean in Austin.

Seton spends about $45 million a year on faculty salaries and resident stipends, Hartman said. That is expected to increase in future years. In addition, Central Health plans to use $35 million a year from a Travis County voter-approved property tax increase to pay for services provided by medical school faculty members and residents.

Ian Smith, a lawyer with Washington-based Americans United for Separation of Church and State, finds the partnership troubling. A government entity, such as UT or Central Health, “cannot legally bind itself to those religious rules,” he said.

It doesn’t matter that residents, faculty members and others can engage in church-banned procedures elsewhere, Smith said.

That “glosses over the central problem,” he said. “If they are teaching in a medical school, they are a government actor. Restricting their behavior and their presentation under the Ethical and Religious Directives is problematic.”

Americans United sent a letter last month to UT-Austin and Central Health charging that an agreement between Seton and Central Health is unconstitutional because of religious restrictions. The letter asked that the agreement be reworked or scrapped. The university is researching the legal issues raised in the letter, said spokesman Robert Cullick.

The current agreement between Seton and UT Southwestern intertwines the two with the UT System Board of Regents when it comes to public relations, marketing and advertising. It says they will agree in advance on announcements and media communications about their relationship and the medical services provided.

In addition to the doctors on Seton’s payroll, about 180 physicians who are self-employed or in separate doctor groups have faculty appointments, said Sue Cox, UT Southwestern’s regional dean for Austin programs. They, too, are required to comply with the Catholic directives in Seton facilities, as are some residents not employed by Seton.

Employment details, funding and governance for the Dell Medical School are in the fourth month of negotiations, but Cox didn’t sound as if she expected major changes.

“I think it’s safe to say we’ve been very happy with the arrangement,” Cox said.



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