UCSF and UCSF Medical Center have
announced that they are suspending negotiations
to expand their existing relationships with four Catholic hospitals. The reversal--highly unusual for the UC medical system--came
after a public and a faculty
outcry
against more entanglement of the University with the private Dignity
medical system that declines reproductive health services,
gender-affirming surgery, and other procedures that conflict with the
teachings of the Catholic Church. This decision is a big deal: after providing some background, I'll
argue that it's an example of the power of faculty effort when it
stands on principle and in alignment with social movements--with help
from sophisticated press coverage that higher ed too often has to do
without.
Michael entitled his first draft of this post,
"Does UCSF Care about Womens' and LGTBQ Health?" It was a good
question, since UCSF Health's senior management seemed to be denying the
restrictive reality that would be imposed on UCSF personnel operating
in Dignity facilities. According to reporting by Nanette Asimov (April
26, 2019),
Dignity spokesman Chad Burns has said the Catholic hospitals require
UCSF doctors to sign God-affirming agreements that prohibit medical care
that violate the hospitals’ religious beliefs. He said these include
the “Statement of Common Values” or the more restrictive “Ethical and Religious Directives for Catholic Health Care Services,”
which characterizes certain procedures, including sterilization, as
“intrinsically evil.” Depending on the hospital, prohibited care can
include abortions, tubal ligations, hysterectomies, sterilizations,
miscarriage care, gender surgery and contraceptive counseling.
Under
the terms of the former, Dignity must deny abortions, along with
in-vitro
fertilization (which would disproportionately harm the gay and lesbian couples that depend on that procedure). Under
the latter, Dignity presumes that marriage is between a man and a
woman, forbids the prescribing of contraception as well as abortion,
and allows the morning after pill in cases of rape but not abortion (
paragraph 36).
Meanwhile, UCSF was
assuring its personnel
that it would not have to sign any such agreements or do anything that
violated their professional ethics or secular standards of care. Asimov
also reported,
UCSF spokeswoman Jennifer O’Brien said the medical center’s
physicians are not required to sign those precise documents. “But they
do commit to provide care consistent with those value statements as part
of their credentialing and privilege application to practice in Dignity
Health’s hospitals. This does not impede our physicians’ ability to
prescribe contraception medications at any Dignity Health hospital,
regardless of its Catholic sponsorship.”
The statement doesn't exactly make sense, reading from one sentence to the next, and is in any case flatly contradicted by the Dignity spokesperson.
The tacit deal seemed to have been that UCSF personnel could mention or
even advocate procedures that they could not provide at a Dignity
facility but that the patient could get elsewhere--though such counseling also
contravenes Catholic directives. UCSF seems to have carved out wiggle
room in prexisiting clinical affiliations, whose complicated policies were
the subject of a September 2017
Academic Senate report.
This was a long way from UCSF Health's original August 2017 announcement that
it was formalizing an affiliation
with Dignity. This press release represented the new stage as a
done deal that merely deepened existing affiliations between two essentially identical titans of clinical quality,
one of which, Dignity, was exemplary for its charitable medical work for
low-income patients. The announcement didn't mention that Dignity
restricted access to some kinds of health care or even that it was
Catholic. So the open debate in 2019 may well have forced the parties,
Dignity and UCSF
Health, finally to reckon with the fact that they had contradictory ideas about the
alliance, which would make it unworkable in practice.
How did the debate come to the surface? Several factors came together.
First,
advocates for reproductive and LGTBQ rights critiqued the UCSF plan and
publicized the critique. The ACLU of Northern California, the National Center for Lesbian
Rights, and the National Health Law Program
wrote a joint memorandum detailing
the various ways in which the alliance would require discriminatory
treatment of transgender patients, women, and people seeking palliative care, among others. The ACLU collected 6700 signatures on a
petition
demanding that UC reject the alliance in the name of protecting health care free
of discrimination. Word circulated about the case of Evan Minton, a
transgender man, who had sued a Dignity hospital for canceling his
hysterectomy after discovering that its purpose was gender affirmation.
The ACLU organized a protest for May 15th, calling on people to hold UC
accountable to its values of non-discrimination, equity, and inclusion.
Trans, feminist, reproductive, and other health care movements played an
important role.
Second, UCSF faculty got directly involved.
1500 staff signed a petition opposing
the alliance. They also found a channel to express individual opinions
en masse. The main agent was the Faculty Association, which decided to poll its members to confirm or deny assertions of general support. Results
ran 2 to 1 against the affiliation. When the UCSF administration
declared the results unrepresentative of the overall faculty, the FA
polled the entire faculty. They got more or less exactly the same
results: 2 to 1 against, with about 1/4th in favor.
The FA also collected
over 300 comments. Many were quite moving, both
in favor (see #1,
on experience of no restrictions in practicing at St. Marys and
reciprocal influence in caring for uninsured patients from vulnerable
populations); and
against (#8, 48, and 64, for example). The chair of the divisional Academic Senate favored the affiliation (see
his co-authored op-ed),
as apparently did much of campus Senate leadership.
But the FA persisted,
which is important in itself; generated empirical evidence, which is
equally important as a check on spin; and gathered a large set of
individual comments, which allows personal experience and care to be
expressed in a way that helps collective thinking, and that serves as a
displaced form of democratic deliberation. The faculty, so often
inexpressive on university policy, were brought on line.
On
the systemwide level, Academic Council chair Robert May opposed the affiliation on principle. Although he sees the business logic, he told
some of us in April, the alliance would compromise the
fundamental values of the university, not unlike the
McCarthy-era
loyalty oath
of 1949. We can debate what UC's fundamental values really are, but
May articulated a support for absolutely equal access to health care
regardless of any aspect of personal identity, one that allowed for no
splitting the difference between UCSF and Dignity. I think it made a
difference to see a faculty member in May's position stating quite
clearly what the university is for, and standing up for that.
Third,
press coverage rendered the alliance as a public concern. In addition
to Asimov's reporting, Michael Hiltzik wrote a pair of columns in April (
here and
here)
describing how the details were not public, the Regents were confused,
the defenses were not convincing, and the ethics were disastrous. The
first column said early on:
Dignity’s adherence to Catholic Church directives affecting medical
care, including a near-total ban on abortion, is hopelessly at odds with
the values of a public institution such as UCSF. What’s worse, UCSF, by
implicitly accepting Dignity’s model discriminating against women and
LGBTQ patients, would empower that model’s expansion.
and built up from there. For the LA
Times's business columnist --and author of a
history of UC science--to deliver to UC a set of cogent criticisms helped
stop the train that has always already left the station so that people
could think again about where the train was going.
There
are at least two issues to keep analyzing and pushing, given the
possibility that UCSF and Dignity will come back later with a
restructured deal. The first is now widely discussed--how to develop
fundamentally egalitarian health care in our Handmaid moment of
coordinated assaults
on Roe v. Wade, and more muted but pervasive opposition to transgender
rights. UCSF's position was the kind of moderation that has made
reproductive healthcare vulnerable (see
Rebecca Traister on Democrat triangulation with abortion).
The
second is the UC medical center business model. UCSF argued that it
needed Dignity to solve a capacity crisis. But why does it have one after
it spent 10 years building a whole second campus at Mission Bay? We've
commented before
on the planning problems there. After all that building, where are the beds to handle
projected growth? Were too many new buildings devoted to targeted projects
of interest to donors? I don't know the answers to these questions, but somebody should answer them. It
seems like something has gone very wrong with planning when two entire UCSFs, one
brand-new, can't handle the clinical load.
There is also another possibility, which is that UCSF doesn't have a capacity crisis, but a monopoly crisis. There isn't actually an overall shortage of hospital beds in the Bay Area (Dignity has many empty ones), but only a shortage of beds controlled by UCSF. This raises the thorny question of whether the UC medical enterprise is financially viable without a quasi-monopoly share of the local market that, among other things, would make it easier to raise prices on patients. The question should be of
burning interest to the UC system, since the US health care system is in a state of turbulent uncertainty and UC it is on the hook for its medical center losses.
But
for the moment, we should see the suspended Dignity deal as a real success for faculty-staff engagement in tandem with social movements and an intellectually active
press.
ADDENDUM, JUNE 1ST (from Ed Yelin, Professor of Medicine, UCSF)
Re: the UCSF capacity issue: the Mission Bay hospital
provides different services than the Parnassus one, by design. Mission Bay covers oncology, Ob/Gyn, and pediatrics while Parnassus does the rest. That may make sense from a faculty
perspective, so a pediatrician doesn’t have to schlep across the city to see
patients in two places, but it means any errors of prediction in demand bump up
against the lack of flexibility and lack of redundancy. If the Ob wards are full at Mission Bay,
Parnassus can’t help.
Another issue is that they may have overbuilt lab space
(this gets to the issue of who among the donors gets to have their names on
buildings) and under-built clinical capacity at Mission Bay. Just guessing based on rumors about the lab
and clinical buildings. The predictions
about how much lab space would be supported by indirect cost returns from NIH
grants were probably off when the Mission Bay campus was planned; they were
projecting increases in real value based on the Clinton years. The rest is history, even though from some
perspectives NIH has fared better than much of the Federal government. Better
to say things got bad at a slower pace!
Oh, one last thing, about the Faculty Association role. Like to take credit for some part in this
movement, but we were late to the game.
We may be more than the straw, but definitively weren’t the anvil that
broke the camel’s back. Maybe a
mid-weight rider on the camel. Faculty
in Ob/Gyn and reproductive health were ahead on this. Glad that we contributed a lot at the end. As to the survey: we made the call to extend
it to the entire faculty to head off the accusation about not being fully
representative rather than reacting ex post facto to the administration’s claim
about that.
ADDENDUM 2, JUNE 7
Here is a
link to the Interim Report of the Academic Senate Task Force on Non-Discrimination in Health Care. It recommends what has happened, which is the suspension of the affiliation pending an reconciliation of fundamental principles, which is unlikely to say the least.
