LUCKY SEVERSON, correspondent: The protesters are here each weekday morning—not a lot of them, but they are not alone. What began in Sierra Vista, a town about 80 miles southeast of Tucson, as a quiet merger between the Sierra Vista Regional Health Center and the Catholic Carondelet Health Network has turned into a religious and ethical standoff over patients’ rights.

THERESE ERICKSON (Cochise Citizens for Patients Rights): The moral issue for me is that they wish to take my moral choice away. I think I’m very capable of making my moral choices, and I’ve done pretty good for 67 years.

SEVERSON: What the merger means is that Sierra Vista, a rural, secular hospital, must now abide by the Catholic ethical and religious directives which prohibit certain procedures. So physicians can no longer do abortions, even when the mother’s life is in danger, and they can no longer perform sterilizations or provide contraception.

DOTTI WELLMAN (Cochise Citizens for Patients Rights): This county has one of the highest teen pregnancy rates in the country, not just the county. Immediately when this arrangement went in there would be no talk of birth control. If we had two hospitals, we would not be here, because there would be a choice.

SEVERSON: One doctor has quit, and others who work at Sierra Vista, like Dr. Robert Holder, an ob-gyn, are very upset. .

DR. ROBERT HOLDER (Sierra Vista Regional Health Center): I would say that the majority of the medical staff is not really happy with the fact that this is occurring and the way it came about. It was hard for us, thinking long term, how this was going to work out practically.

SEVERSON: Dr. Bruce Silva, another ob-gyn at Sierra Vista, says Catholic directives often go against health care decisions he and his patient think are best.

DR. BRUCE SILVA (Sierra Vista Regional Health Center): The person who makes that decision is not me and the woman. We can make that decision, but then it has to be okay’d by someone else who puts their belief systems and their ethics on me and on my patients, which I just don’t think is right.

SEVERSON: Right or wrong, the Catholic Church takes its directives very seriously. Last year, Bishop Thomas Olmsted of the Catholic Diocese of Phoenix cracked down on this hospital, St. Joseph’s, after a doctor terminated the pregnancy of a mother who had developed pulmonary hypertension, which has a high mortality rate among pregnant women.

DR. HOLDER: It was not an either-or case. That baby was not going to survive because the mother was not going to survive, so the decision is that you let both die or you terminate the pregnancy so the mother can live, and to me that’s a no-brainer.

SEVERSON: But Bishop Olmsted disagreed with the doctors.

BISHOP THOMAS OLMSTED (speaking at Catholic Diocese of Phoenix December 21, 2010 Press Conference): In this case, the baby was healthy and there were no problems with the pregnancy. Rather, the mother had a disease that needed to be treated. But instead of treating the disease, St. Joseph’s medical staff and ethics committee decided that the healthy eleven-week-old baby should be directly killed.

SEVERSON: Bishop Olmsted stripped St., Joseph’s of its 116-year-long Catholic affiliation and excommunicated Sister Margaret McBride, the nun who had approved the abortion.

SEVERSON: Rev. Thomas Weinandy is the executive director for the Secretariat of Doctrine at the US Conference of Catholic Bishops. He and Richard Doerflinger, who handles bioethics issues for the conference, defended the church’s ethical and religious directives which, they say, are based on Gospel teachings about the dignity of life.

SEVERSON: So you support the Bishop Olmsted’s ruling with St. Joseph’s in Phoenix?

RICHARD DOERFLINGER (Associate Director, Secretariat of Pro-Life Activities, US Conference of Catholic Bishops): Bishop Olmsted has the authority to make the right decision. Personally, I support it.

REVEREND THOMAS WEINANDY (US Conference of Catholic Bishops): If you directly said the mother could not live unless we aborted the child then that would be contrary to Gospel values and the teaching of the church.

SEVERSON: So you would not perform an abortion on a child even if it meant saving the life of the mother?

DOERFLINGER: You would try everything else to save her life except directly kill someone else. There are times when the mother needs treatment to save her life or prevent some other terrible injury that is going to lead as a side effect to risking the child’s life, maybe ending the child’s life, and that’s acceptable in Catholic teaching, because you’re intent is not to take the child’s life. It’s to treat the woman’s life.

SEVERSON: You have a child that is conceived because of incest or rape. Same?

REV. WEINANDY: Well, sure. You don’t just kill somebody because of their—how it happened. That doesn’t make their life any less worthy of living.

SEVERSON: Dr. Holder tells of a mother who had miscarried one of her twins and was about to lose the other.

DR. HOLDER: We were advised to send that person 80 miles away to another hospital because there was a heartbeat, and that was a very difficult situation for me to manage.

DR. SILVA: Some people will define abortion if a baby has a heart rate, and you terminate that pregnancy—it’s an abortion. But there are times, for instance, with a pregnancy in the fallopian tube, where babies will have heart rates but that baby can’t survive there. It’s impossible. So there are some places where they do not allow you to terminate that baby. This is the real problem is that it’s defined differently by different bishops, who are the ones that decide how your hospital is going to run.

SEVERSON: Officials at the Sierra Vista Regional Health Center declined to be interviewed, but the circumstances here are not unique. Catholic hospitals have become the largest nonprofit health care provider in the US, with over 600 hospitals. This year, one in six patients will be cared for in a Catholic hospital.

DR. SILVA: I have worked at Catholic hospitals before, and I have no problems with that. I think Catholic hospitals do great care. But it was in a larger city where there was another hospital there, so women had a choice. Here we are very rural.

JESSICA GRAHAM: I’m Jessica Graham to see Dr. Silva, okay?

SEVERSON: Sierra Vista’s new directives posed a very real problem for Jessica Graham, who was going to have her second baby by c-section at Sierra Vista and then get a tubal ligation, or have her tubes tied. She and her husband didn’t want any more children.

GRAHAM: So I said, can you tie my tubes while I’m in surgery for a c-section? And when I got pregnant that was the option and that was the plan. Then it changed during my pregnancy when they did the merger here.

DR. SILVA: When I do a cesarean section, the woman is open already, and so if I do the tubal ligation it adds nothing to the risk that she has. But I can’t do them here.

SEVERSON: So Jessica was forced to have a second surgery in another city, which could have created problems.

DR. SILVA: People get infected, people can get bowel injuries. You can have a reaction to the anesthetic that can kill people. People die from tubal ligations every year—now very, very, very rarely, but why undergo that risk?

REV. WEINANDY: The fact that they can’t get, receive sterilization or abortions at a Catholic health care facility is not a form of suffering at all. It’s a matter of fact that we are protecting them from evil things that could happen to them.

SEVERSON: Doctor Silva says his Sierra Vista patients can’t get the standard of care they deserve and that some simply can’t afford a second operation at another hospital. He says when he worked at a Catholic Hospital 20 years ago, tubal ligations were permitted.

DR. SILVA: But politically things change. You get someone who is a little more conservative in, and they now stop you from doing that.

DOERFLINGER: I don’t think it has anything to do with politics. It has to do with the language of the directives, which are a reflection of Catholic teaching and the bishops’ theological understanding of what that requires.

SEVERSON: Another concern for the protesters outside Sierra Vista is what happens with their end-of-life wishes if the Catholic Church doesn’t agree with them.

CHARLES GORDON (Cochise Citizens for Patients Rights): If I’m in a bad place I want to be able to direct them, “Hey pull those tubes.” They won’t kill me, I know that.

DR. SILVA: They talk about the fact that all of your end-of-life wishes will be observed unless they go against Catholic teaching. The problem is what does that last line mean?

DOERFLINGER: They are not going to stand back and watch if you are doing something they think is basically just trying to make yourself dead, but they are also going to respect your decisions about how burdensome a treatment to accept, how far to go in terms of prolonging your life when you know that you are on a course toward the dying process.

SEVERSON: Dr. Holder says in these hard economic times he understands the need for smaller hospitals like Sierra Vista to hook up with a larger health care service. But he thinks there are more suitable non-Catholic partners out there, and he’s hopeful that one will come along.

DR. HOLDER: I don’t think they quite expected the push-back from the community, and I think it’s at least opened their eyes to think that maybe we need to re-look at this and look at some alternatives.

SEVERSON: The merger process is not completed and won’t be for months. Doctors hope for a compromise, but they realize that the Catholic Church won’t be changing its directives.

For Religion & Ethics NewsWeekly, I’m Lucky Severson in Sierra Vista, Arizona.

Editor’s Note: According to local media, on March 29, 2010 the president of Sierra Vista Regional Health Center announced that its agreement with the Catholic Carondelet Health Network is expected to be canceled in early April.

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Originally broadcast July 3,2009.

FRED DE SAM LAZARO: Aravind is the world’s largest eye care center, a one-stop shop that even makes many of the lenses and instruments used by its surgeons. It looks like any of India’s high tech centers where rich Indians and medical tourists can get first-world care at third-world prices. The surgical error rate is as low here as any place in America. The big difference at Aravind is that its patients are among the world’s poorest people.

Twenty years ago, I visited Aravind’s founder, Dr. Govindappa Venkatswamy. Everybody called him Dr. V. He had retired from a government hospital in 1976 and set out to tackle “needless blindness.” Worldwide, 45 million people still suffer from preventable or reversible blindness. Twelve million are in India alone, where the extreme sun and a genetic predisposition are blamed. Many people lose their sight—and livelihood—by their early 50s.

Dr. GOVINDAPPA VENKATASWAMY (Aravind Founder, speaking in 1988): There is nothing which disables a man more than cataract and poor eyesight, and there is nothing more easier than to mend it. You just do a small operation.

DE SAM LAZARO: Dr. V began with a simple idea in a sparse 11-bed hospital with four doctors, three from his own family. It would serve patients who could pay, but the profits would afford free care to the many more people who couldn’t afford even the bus fare. So Aravind set out to find patients, mainly through screening camps in surrounding rural areas. For those needing surgery, groups like the Lions Club provided buses to the hospital, where they entered a brisk assembly line operating room. Dr. V’s business role model was the American chain store.

Dr. VENKATASWAMY: In America you have models, whether it is Sears stores or McDonald’s hamburgers. You are able to open a chain of stores, restaurants, hotels, and you are able to organize them efficiently.

Dr. ARAVIND SRINIVASAN (Aravind Hospital Administrator): You spoke to him here. You were sitting here, and he was sitting there and talking about McDonald’s.

DE SAM LAZARO: Dr. V died in 2005, but his office is left untouched as a shrine to him. His nephew, ophthalmologist Aravind Srinivasan, manages a system that’s grown to five regional hospitals and 25 satellite clinics. This was the first one.

Dr. ARAVIND: This is a 32-year-old hospital, so we are probably geared to see about 700 patients a day. Today we are seeing about 1500 to 2000 patients a day.

DE SAM LAZARO: Each pays about one dollar for a doctor’s appointment. That helps fund an equal number of patients who go next door to a free eye hospital. There’s not much profit margin, so a heavy volume of paying patients—satisfied patients—is critical. Efficiency is also critical.

Dr. ARAVIND: We call this a clinic scoring sheet.

DE SAM LAZARO: Dr Aravind, who also has an MBA from the University of Michigan, has continuous productivity reports at his fingertips.

Dr. ARAVIND: This statistic talks about service time, what percentage were seen within two hours.

DE SAM LAZARO: Patients are promised a completed appointment in two hours. A brochure details what they can expect.

Dr. ARAVIND: Registration takes about 5 minutes, vision test about 10 minutes, refraction check about 10 minutes.

DE SAM LAZARO: This is sort of a patients bill of rights almost?

Dr. ARAVIND: Exactly. So they understand what’s happening.

DE SAM LAZARO: Aravind’s reputation is drawing patients from farther and farther away.

K.G. ANGENEYULU (Aravind Patient/Voice of Translator): Whenever you say eye operations everyone says go to Madurai.

DE SAM LAZARO: Fifty-five-year-old K.G. Angeneyulu had been in a three-year depression that started when cataracts began clouding his vision. He became completely blind three months ago. Angeneyulu and his wife Shobha endured a two-day train journey to get here.

Mr. ANGENEYULU (Voice of Translator): I was a sportsman. I used to swim. After the cataract, I could no longer move around. I got stuck at home, and I started eating. Then a leg injury made me even more immobile. I had problems being overweight, and I developed high blood pressure.

DE SAM LAZARO: By nine o’clock the morning after arriving here he was being prepared for surgery. Already dozens of patients had gone ahead of him

(to Dr. Aravind): So you’ve been going for two hours and done 16 surgeries?

Dr. ARAVIND: Yes.

DE SAM LAZARO: Dr, Aravind and surgeons in several other operating theaters or OTs were first working the routine—mostly cataract—cases.

Dr. ARAVIND: The other OTs are not primarily cataract surgeons. They are primarily doing either glaucoma or cornea, and they also do some cataract to contribute to the main volume, so we are able to identify those cases that need a little extra attention are segregated from the pool.

DE SAM LAZARO: Angeneyulu was a high-risk case, given his hypertension and obesity.

Dr. ARAVIND: You just have a margin is about five to10 minutes to get the surgery done.

DE SAM LAZARO: About 10 nervous minutes later, Dr. Aravind had removed a particularly tough, leathery cataract.

Dr. ARAVIND: The cataract was a little obstinate, but things went on well. He’ll get about 95 percent vision tomorrow, so when you see him tomorrow you’ll see a very different man—more confident.

DE SAM LAZARO: By the end of this day, Dr. Aravind and his colleagues did about 300 surgeries, about half of them free of charge. Increasingly, however, patients are seen outside the hospital. Telemedicine connects doctors to satellite clinics, and today’s eye camps offer much more on site—from grinding eye glass lenses to digital scans. Near the camp a satellite truck beamed high resolution images to specialists at the hospital. Technology has improved care, and it has also brought down costs—notably for the intraocular lenses which are implanted during cataract surgery. They used to be imported.

Aravind began making its own intraocular lenses back in the early 1990s. They used to cost between $50 and $100 each. Today they are made in this factory for as little as two dollars a piece. Aravind lenses are exported to 120 countries, and they own eight percent of the global market in intraocular lenses. This factory is an example of how Aravind turned a supply problem into an opportunity.

It’s not just business acumen that drives the mission, but also a firm spiritual basis, inspired by the teachings of Sri Aurobindo, a mid-20th century spiritual leader. He believed that good work and good ideas are a manifestation of the divine.

R.D. THULASIRAJ (Aravind Executive): Part of that is to recognize that whatever ideas you get, it’s not really your ideas. They are divine ideas. So how do you kind of act on it but are not taking the egoistic ownership to those ideas, like “I have don it?” So how do you train yourself to open up?

DE SAM LAZARO: One way Aravind has opened up, or shared its ideas, is by training some 250 hospitals in 40 nations to adopt its methods.

Mr. THULASIRAJ: In this institution we train organizations to become more efficient. We completely give our intellectual property or our store away. We open up our systems, processes, how we charge the patients, our records.

DE SAM LAZARO: It’s the ethos set by his uncle. Dr. V, who was single, never took a salary. In fact, he mortgaged his home to start Aravind, and he also coaxed or inspired 34 members of his extended family to work here, starting in 1976 with his sister Natchiar and her husband. Both left surgical careers in America to work here for about $20 a month.

Dr. G. NATCHIAR: Today, oh my God, we are very, very happy. In fact, at that time in ’80s we were not happy, even though Dr. V was happy. In the family, like me and my husband, two children, it was not easy for us. We could not even buy a cycle. At that time, we didn’t appreciate his far vision.

Mr. ANGENEYULU: God bless you, Madam.

Dr. NATCHIAR: God bless me? God bless the surgeon.

DE SAM LAZARO: She says the satisfaction of seeing patients like Angeneyulu restored to full lives makes up for any material privation, although over the years salaries have greatly improved for the 220 doctors and some 2500 other Aravind staff.

Mr. ANGENEYULU: My children are starting school on the first, so I want to get going.

Dr. NATCHIAR: We’ll give you some dark glasses just like a Hollywood actor.

DE SAM LAZARO: He’s one of 27 million patients who’ve been treated at Aravind and 3.4 million who’ve had surgery.

Over the next 20 years the goal is to raise that number ten-fold. That’s a measure of how ambitious the Aravind people are. It’s also a measure of how many people remain blind in the world whose vision can easily be restored.

For Religion & Ethics NewsWeekly, this is Fred de Sam Lazaro in Madurai, India.

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We have a story today about doctors and medical students at a famous Texas hospital who are facing those questions and their painful answers. Lucky Severson reports.

LUCKY SEVERSON: Baptist pastor Kevin McBryde knew something was very wrong when he got such a debilitating headache he was bedridden for several days.

Pastor KEVIN MCBRYDE: I laid in the dark and I groaned and griped and finally my wife talked me into getting up and going to the hospital when my face went numb.

SEVERSON: Because he had a pre-existing condition, Hodgkin’s disease, when he was a teenager, the pastor was rejected by three health insurance companies. So he ended up here at UTMB, the University of Texas Medical Branch. Now, with no insurance and no money, he’s receiving very costly treatments at no charge for an aggressive form of lymphoma.

Dr. AVI MARKOWITZ (Chief of Oncology & Hematology, UTMB, speaking to Pastor McBryde): And it’s the five days of Prednisone, the one day of the Rituxin and chemotherapy, and then we will repeat that for three or four cycles.

SEVERSON: UTMB is legendary in Texas. It’s the oldest teaching hospital west of the Mississippi, a huge 795-bed complex centered in Galveston. The bulk of UTMB’s funding comes from Medicare, Medicaid, and the Texas legislature. The hospital attracts doctors and medical students for whom treating everyone, regardless of their ability to pay, is a solemn duty.

Dr. Kirk Smith

Dr. KIRK SMITH (Founder, Frontera de Salud, UTMB): We take an oath. We actually stand up, raise our hands, and take an oath to be here for the health of all. Are we going to live up to that or not?

SEVERSON: If Doctor Smith seems upset, he’s not alone. UTMB finds itself in an untenable position. Because of dwindling funding and ever more patients who can’t pay, the hospital has been forced to ration health care. It’s a situation that has left doctors and students here deeply conflicted.

This was a meeting to debate the morality and justice of the latest rationing plan to deny treatment to cancer patients who are illegal or undocumented immigrants.

LAURA HERMER (Attorney, UTMB): We cannot ration, for example, based on someone’s race, someone’s ethnicity, someone’s gender, someone’s religion.

KATRINA LEONARD (Second Year Medical Student, UTMB, speaking at hearing): We are convinced that it is unjust and immoral to exclude a population of patients on the basis of their citizenship status.

Dr. JOHN STOBO (Former President, UTMB, speaking at hearing): It’s been a painful process and nobody has liked it. Many of the people who came to UTMB because of our mission were very upset when we had to do this.

SEVERSON: Dr. John Stobo is the former president of UTMB. He says like public hospitals nationwide, UTMB has been caught in a perfect storm.

Dr. STOBO: You had several things happening: an increase in the uninsured, decreasing in the rolls of people covered by federal and state programs, and closure of emergency rooms. So it became a real challenge to UTMB to take on the health care of an increasing number of people with the cost of health care continuing to increase.

Treating a patient

SEVERSON: To reduce costs, the hospital system laid off almost 400 employees and curtailed some costly procedures altogether like cochlear ear implants, as well as some expensive high- tech drugs. Two years ago, the hospital simply ran out of funding for indigent care and was forced to turn patients away.

Dr. MARKOWITZ: That, in fact, was the worst thing that’s ever happened to me in my career.

SEVERSON: Dr Avi Markowitz is the chief of oncology and hematology at UTMB. He is convinced that denying cancer treatment to undocumented patients is the most ethical way, under the circumstances, to ration care.

Dr. MARKOWITZ: Shortly after I got here, because we had run out of money I was forced to close the medical oncology clinic to all unfunded patients for over four months, and that was a horrible situation to be put in. We can’t simply say we’ll go ahead without any forethought and treat until the money runs out and then close the doors. That, to me, that’s the least ethical way to take care of people with cancer.

SEVERSON: If James Halbert had come to UTMB when the hospital was forced to withhold care for patients without the means to pay, he might not have survived. Halbert has acute myeloid leukemia, and he lost his insurance when the mortgage company he worked for went broke. He says no one at UTMB has talked to him about money, and he’s grateful. But he wonders why such a rich country can’t take care of its own.

JAMES HALBERT (Patient, UTMB): When are you going to start taking care of the people of the United States and quit worrying about everybody else? You know, why aren’t we spending money on us?

SEVERSON: Of all the states, Texas has the highest percentage of residents without insurance — about one in four. Eighty percent of them are employed by small companies that don’t have to offer health insurance. It’s one of the reasons that students and doctors here are being forced to make painful human calculations.

Dr. Kirk Smith is the founder of Frontera de Salud, which offers free health care along the Mexican border. Volunteer students and doctors work out of a privately funded clinic, and when the patients can’t come to them, they go to the patients. Dr. Smith is extremely proud of Frontera’s work and bly opposed to limiting health care for undocumented patients.

Dr. SMITH: We’re taking a segment of the population, of the human community, and saying because you have this attribute, in this case you are undocumented, you don’t count.

SEVERSON: They are not even citizens.

Dr. SMITH: I’m a physician. I don’t look at citizens. I look at human beings.

Dr. Avi Markowitz

Dr. MARKOWITZ: I have had that discussion with Dr. Smith, and I respectfully disagree with both his characterization and his conclusions. Personally, I don’t have a problem saying that it’s OK to turn away undocumented patients and treat U.S. citizens. I have said to Dr. Smith and to the students who take umbrage with that that that’s OK. If you want me to do that then you are going to have to come down and look at the 10 U.S. citizens or more who are gong to be denied access to care for each one of those undocumented patients that you treat.

SEVERSON: Dr. Markowitz says of the 190 patients he’s turned away in the last 18 months, about 14 percent — no more than 25 — have been undocumented. Even at that, he says, the savings in costly cancer treatments like chemotherapy can be substantial.

Dr. MARKOWITZ: We have patients who are often getting drug treatments that cost us — costs not charged by us — but cost us in excess of $30,000 a month. You don’t need too many of those patients to drain your entire resources program, and then you are turning away everybody else.

SEVERSON: Facing the hard reality of health care has come as a jolt to students like Katrina Leonard, a second year med student who came here full of idealism.

Ms. LEONARD: I look at the reasons why we were turning away the 14 percent, and if it’s something that’s unethical or unjust or immoral, then regardless of how many people that you are able to serve at the expense of that 14 percent, it shouldn’t be done.

Dr. SMITH: We’ve told them you’re unique, your profession stands aside because of this high moral relationship you stand in with regard to the patient, and then they get into the reality of practice and find its often profit-driven, or the willingness with which we deny some patients some access to care. And we have to lay this at the feet of the citizens. It’s a decision we’ve made as a society.

SEVERSON: Dr. Smith says he is not opposed to rationing. He simply wants a more equitable distribution.

Dr. SMITH: Before you put together whatever the rationing plan is, you make sure that you’re blinded to who that rationing plan is going to apply to. That’s how you can ensure that it’s going to be fair, unbiased, ethical. You make sure that, ahead of the game, you don’t know whether it’s going to apply to your worst enemy or your mother.

SEVERSON: He says that one problem is that patients want the best care money can buy — tests, for instance, they may not need like MRIs and CAT scans. Dr. Markowitz agrees that hospitals and doctors need to rethink the tradeoffs of prescribing expensive tests and drugs.

Dr. MARKOWITZ: We see patients referred to us with very advanced disease who, in fact, are likely to only live a few weeks or perhaps a few months, and it will be an enormous drain on the resources. And then you have to ask yourself, is it reasonable to do that when you know you’re not going to accomplish anything good, or take that same amount of money and be able to help a half of dozen women newly diagnosed with early stage breast cancer and offer them curative therapy?

SEVERSON: Pastor McBryde believes the compassionate care he has received at UTMB underscores one of Christianity’s greatest commandments: to love your neighbor as yourself. But he draws a line if the neighbor is undocumented.

Pastor Kevin McBryde

Pastor MCBRYDE: They’re breaking the law when they come into this country. I don’t know. It’s just a big part of me that has a real problem with someone who breaks the law, knowingly breaks the law, and then demands privileges.

SEVERSON: Calculating the cost versus the benefit of patient care has taken a toll not only on patients but on the doctors who make the hard choices, none more than Dr. John Stobo.

Dr. STOBO: It’s time for this country to take this issue on, and seriously take it on. We’ve got a health care system which denies health care to 47 million Americans simply and solely because they don’t have health insurance and can’t afford to pay for the health care. So this is an abomination, and we as a country have got to say this is totally irresponsible. We’ve got to do something about it.

SEVERSON: Doing something about it, of course, means increased funding from the federal government and the Texas legislature, and that’s a challenge. President Bush has proposed budget cuts in both Medicaid and Medicare, and the Texas legislature has yet to fully reinstate $50 million that was cut from UTMB’s budget.

For RELIGION & ETHICS NEWSWEEKLY, I’m Lucky Severson in Galveston, Texas.

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