The contribution of religious orders to the provision of hospital services in Ireland extends back to 1834 when the Religious Sisters of Charity founded St. Vincent’s Hospital in Dublin. Generally, the role of religious orders was seen in a positive light by Irish Catholics but over the last two decades public opinion has changed radically.
This was clearly evident in 2017 when plans to relocate the National Maternity Hospital from Holles St. to the St Vincent’s site provoked an outcry. Why such a change in attitude? To answer this question, it will be necessary to make some reference to historical developments.
When the Irish Free State was set up in 1922, religious management of health services was well established. Church involvement in healthcare, education, and social welfare services gave the Catholic Church enormous power in matters of public policy and the practice of medicine in Ireland.
The Catholic ethos prevailed. The Our Lady of Lourdes Hospital (Drogheda), under the control of the Medical Missionaries of Mary up to 1997, prohibited all forms of artificial contraception - in common with all other Catholic hospitals. The only approved birth control method within the hospital was the highly unreliable Billings method based on calculations of the infertile phase of the menstrual cycle.
Tubal ligations (female sterilization procedures) were prohibited – even in circumstances where another pregnancy was dangerous. However, Catholic ethical guidelines did permit “indirect sterilisation.” It was permissible to remove a diseased organ such as a uterus although the woman would then be incapable of having a baby. In such cases, the intention was to preserve the health of the patient - not to prevent future pregnancies.
In her Lourdes Hospital Inquiry report (2006) Judge Maureen Harding Clark found “much evidence” that the prohibition on sterilisations gave rise to the practice of “compassionate hysterectomies” in hospitals with a Catholic ethos – “an unspoken Irish solution to an Irish question.” The clinical judgement of surgeons was not questioned in such cases.
Tubal ligations were a different matter. A rigid adherence to conservative Catholic doctrine gave rise to the performance of sterilisations by hysterectomy when tubal ligations would have been more appropriate. Hysterectomy was far more invasive and traumatic for the patient. Even so, religious ideology over-ruled clinical judgement and best medical practice - the welfare of women was of secondary importance.
The issue of symphysiotomies also caused reputational damage to Catholic moral teaching. Pubic symphysiotomy is a surgical procedure to enlarge the delivery capacity of the mother’s pelvis when the baby is too large to pass through. This procedure was sometimes considered as an alternative to caesarean section but it was rarely chosen. When it was chosen, some patients suffered adverse effects.
Irish obstetrical practice was constrained by a legislative framework which in turn was influenced by Catholic values. Pope Pius XI’s encyclical, Casti Connubii (1930), condemned artificial contraception, abortion and sterilization, and almost certainly influenced Irish legislators to pass the Criminal Law Amendment Act 1935 which banned the importation and sale of contraceptives. Artificial contraception was illegal up to the Health (Family Planning) Act 1979 and was even then limited to married couples on prescription.
The frequency of symphysiotomy procedures needs to be seen against a background where multiple births were the norm and repeat caesarean sections presented grave dangers to maternal health (especially up to the early 1960s). Symphysiotomy seemed to offer the possibility of safe repeat deliveries for some mothers and was undertaken more frequently than would otherwise have been the case.
In recent years, an awareness of the symphysiotomy issue served to stiffen opposition to any extension of Catholic moral teaching that might obstruct access to healthcare services relating to reproductive medicine.
In a broader context, the moral authority of the Church was undermined by a relentless stream of scandals.
In parallel with all this, public opinion about reproductive choice and sexual morality had changed radically, as indicated by referendums on divorce (1995), same-sex marriage (2015), and abortion (2018). The law changed, reflecting radical shifts in public opinion, but Catholic doctrine remained the same. A conspicuous rift emerged between the institutional Church and the Church as a community of believers.
In the late twentieth century, the decline of Church influence in healthcare services became increasingly evident. Falling vocations meant that the Church was unable to place brothers and nuns in key positions to influence policy and the training of doctors and nurses. Sterilisation procedures (tubal ligations and vasectomies) became available in the 1980s.
The power of the institutional Church was not what it once was – yet it was not negligible. Hundreds of millions of euros worth of health-service assets in Ireland were controlled by religious orders, especially by the Sisters of Bon Secours, the Religious Sisters of Charity, and the Sisters of Mercy. Ireland was not unusual in this context.
The Roman Catholic Church was the largest non-governmental provider of healthcare services internationally and issues of public concern were sometimes raised when decisions had to be made about institutions against the background of ageing and shrinking memberships. Religious orders were less and less able to directly manage the hospitals their predecessors had founded. New managerial structures were required.
Dr Peter Boylan, a former Master of the National Maternity Hospital, observed that, in recent years, Catholic religious orders worldwide transferred their assets to charities approved by the Vatican and with the intention of preserving the Catholic ethos. Transfers in Ireland include the Mater Hospital group (2016), the Mercy Hospital in Cork (2016), the Bon Secours group (2017), and St John of God’s (2019).
The Religious Sisters of Charity also felt compelled to adapt to changing conditions. In 2003 St. Vincent’s Healthcare Group Limited (SVHG) was formed and St Vincent’s University Hospital was transferred to the company. The Religious Sisters of Charity became the shareholders and the SVHG Constitution required the hospital to function in compliance with the Catholic ethos.
Government plans to relocate the National Maternity Hospital (NMH) provoked angry protests in 2017 - not only because a hospital built at taxpayers’ expense would be privately owned, but also because some services such as tubal ligations, would not be provided due to Catholic ethical principles.
Further to this, the historical legacy of the Religious Sisters of Charity was tainted by the scandalous abuse and exploitation of women in the Magdalene Laundries. This was exacerbated by the refusal of the religious order, and three others, to contribute to a redress scheme for several hundred survivors.
In May 2017 the Religious Sisters of Charity announced that they were transferring their ownership of SVHG, which would now become St Vincent’s Holdings CLG – a private company. They would not have a role in the new NMH. This failed to address concerns that religious influence might interfere with the governance of the new NMH.
Hospitals built on Church land are owned by the Church and are subject to canon law and Catholic ethics. The Constitution of St. Vincent’s Holdings CLG did not refer to Catholic ethics or canon law and undertook to provide healthcare services in compliance with international best practice on medical ethics and the laws of the State.
On 27 May 2020 the company, through its solicitors, assured the Department of Health that canon law “shall have no impact on the Company.”
Yet it remains to be seen if the Catholic ethos will be set aside so that contraception services, tubal ligations, abortions, and assisted fertility treatment will be provided consistent with secular law and women’s welfare. Even if such services are provided, there is still a question of fundamental importance to be addressed.
Why should a hospital, funded by the State at enormous cost (at least €500 million), be 100% owned by a private company?
- Dr Don O’Leary is the author of Biomedical Controversies in Catholic Ireland (Eryn Press, 2020), available through Amazon, paperback and Kindle ebook; or directly from www.erynpress.com