“Just tell them we don’t have it here.” That’s what the nurse told me in Killam Hospital, an hour east of Camrose. I’d asked what would happen if a woman came into our ER asking for the morning-after pill. The nurse wasn’t being self-righteous, but simply explaining the policy.
As a physician that locumed for weekend shifts in rural Alberta hospitals, I’d not previously worked in a public facility run by a religious institution. Unbeknownst to most people—including myself until I signed up—Alberta isn’t administered by only one health “superboard” (as Alberta Health Services is sometimes called). In fact, 23 hospitals and health facilities compose a separate board within AHS, led by the Catholic Bishops of Alberta, called Covenant Health.
In Killam the absence of emergency contraception owes to the ethical mandate prescribed by the hospital’s Catholic administration. According to Covenant Health’s corporate policy and procedures manual, “it is never permissible for Catholic healthcare providers to terminate an established pregnancy” or administer medications that have termination as their purpose. The only exception is for sexual assault—where the “assailant’s act is a violation of justice, and any semen within the woman’s body is considered a continuation of the unjust aggression.”
The morning-after pill works for up to 72 hours after unprotected sex, but the sooner it’s used, the greater its effectiveness. When there’s no pharmacy open on the weekend, and when the nearest other hospital is 40 km away, a teenager or any woman without a vehicle could be in trouble if their local hospital won’t help them.
The scenario was theoretical for me in Killam. I saw cowboys thrown from horses, an alcoholic farmer with a bleeding gut, the usual cuts and bruises—but no distressed women as I tended the ER. What was certain, though, was that the hospital, funded with public dollars, was passing judgment over private behaviour in no uncertain terms.
Covenant is now raising concerns that extend far beyond birth control. Following a Supreme Court ruling in 2015 and the federal government’s passage of Bill C-14 last year, Canada has approved physician-assisted dying. Just as it stated about emergency contraception and abortion, Covenant Health will not permit physician-assisted dying in its facilities. Their stand has many patients and physicians questioning how public hospitals can continue to be administered by Catholic agencies and operate under different medical ethics.
The Catholic Bishops of Alberta lead Covenant Health, a separate board within AHS comprising 23 hospitals and health facilities.
Covenant Health has the largest budget and covers the largest geographic area of any public Catholic health agency in Canada. Where the trend in other provinces has been to gradually absorb such agencies into the secular system, Covenant has lately been growing. Should Covenant Health continue to be protected and allowed to grow in Alberta, or is the role of the Catholic Church in administering public healthcare an anachronistic legacy that must be changed?
Hospitals in Alberta—indeed in most of Canada—began through the labour of Catholic missionaries. The first in Alberta was established in 1863 by the Sisters of Charity (Grey Nuns) in St. Albert. Dozens of others were soon created to provide care for indigenous people and the hundreds of thousands of immigrants staking out a new life on the prairies. Managed as charitable organizations, these hospitals were the only option for people without the means to pay for private doctors. They led the battle against tuberculosis and the 1919 influenza outbreak, and established the first schools of nursing.
Their role changed after the Second World War as Canada and its provinces brought in government-funded healthcare. Universal coverage of hospital and doctor services coincided with a dwindling number of Catholic missionaries—soon there simply weren’t enough to run religious hospitals. Many Catholic hospitals handed over their administration to municipal and provincial authorities; others closed their doors. Between 1969 and 1975, 20 Catholic-administered hospitals in Alberta made this transition.
In 2008 the Stelmach government embarked on an unprecedented experiment in Canadian health management, amalgamating all provincial health services under a single, arm’s length corporate body. Alberta Health Services (AHS) was meant to harmonize services and exploit economies of scale.
At the time, only a few Catholic hospitals remained in Alberta; the last one in Calgary had gone over to the government in 1969. But rather than absorb the surviving faith-administered hospitals into AHS, the province decided to bring these institutions together under their own separate administration. Covenant Health would be anchored by the high-patient-volume Misericordia and Grey Nuns hospitals in Edmonton, but would include small hospitals, long-term care facilities and hospices across the province, from Banff Mineral Springs Hospital to Killam Hospital.
Today Covenant Health accounts for 10 per cent of ER visits in the province, 20 per cent of deliveries and 12 per cent of acute care beds. Its 2015 budget was $895-million, or roughly 5 per cent of the provincial health budget. Covenant remains largely dependent on public funding—88 per cent of its revenue in 2015 came from the government. Its budget has grown over the past few years as Covenant builds long-term care facilities.
CEO Patrick Dumelie says Covenant works under “dual accountability.” Its board has a commitment to AHS, which sets annual targets for quality and cost. But Covenant must also adhere to policies set by the Catholic Bishops of Alberta. These men, the leaders of the seven dioceses spanning Alberta and the Northwest Territories, approve appointments to an intermediary board entitled Catholic Health of Alberta, which appoints Covenant’s 11-person board. The Most Reverend Richard Smith, Archbishop of Edmonton, also holds one of the Covenant Health board positions. (Smith was appointed archbishop by Pope Benedict XVI in 2007.)
The bishops, says Dumelie, ensure that Covenant fulfills its “thousands-of-years-old calling to serve others… through protecting the sanctity of life from conception to natural death.” This includes guiding the policies adopted by Covenant on, among other things, birth control, pregnancy termination and end-of-life care. But the continuation of Catholic administration of hospitals in Alberta is entirely at the discretion of the government in power.
Alberta isn’t the only province to permit faith-based groups to manage health facilities. Across the country, 124 hospitals, hospices and long-term care facilities are affiliated with the Catholic Church. They’ve gone from covering 35 per cent of national healthcare needs in 1968 to just over 5 per cent today. A handful of other faith-based providers exist, with affiliations to the United Church, Seventh Day Adventists and the Jewish faith.
Ironically the only province with no Catholic health providers is the one with by far the largest Catholic population—Quebec. Church control of hospitals in Quebec was ceded in the 1960s Quiet Revolution, when a conscious effort was made to throw off what was seen as oppressive clerical meddling over many aspects of social policy. Elsewhere in Canada the process of secularizing health administration has been gradual and conciliatory. Catholic management hasn’t been forced to cede control, but little effort has been made to preserve it. When provinces restructure services or build new facilities, they tend to close religious facilities at a pragmatic pace that honours Catholics’ historic contributions but affirms the importance of secular administration.
As with emergency contraception and abortion, Covenant Health will not permit physician-assisted dying in its facilities.
Such was the pattern in Ontario between 1996 and 2000 under the Ontario Hospital Restructuring Commission, when 43 hospitals were shut down or amalgamated. It was briefly the pattern in Alberta prior to 2008, when several religiously administered hospitals were closed. It is the pattern in BC, where Comox’s St. Joseph’s Hospital will be replaced with a facility without Catholic administration.
But this isn’t the case for Covenant Health, which is expanding. Covenant Care, created in 2014, brought into the organization’s purview a number of new long-term care facilities with a combined budget of $56-million. Covenant is also distinguished by its geographic reach. In other provinces, the few remaining Catholic hospitals tend to be free-standing structures under regional health jurisdiction. Covenant spans a province, including urban hospitals and rural hospitals that are often residents’ only nearby practical option.
In February 2015 the Supreme Court handed down the Carter decision, recognizing a Charter right for medical personnel to assist in dying when patients are mentally competent and suffering a severe and incurable condition. On June 16, 2016, after lengthy debate, the federal government passed Bill C-14, giving legislative permission for what became known as medical assistance in dying.
Although the change had support from 85 per cent of Canadians and 88 per cent of Albertans, according to a 2015 Ipsos survey on behalf of Dying With Dignity Canada, the ruling and the law faced opposition. The question of whether individual doctors should be compelled to perform the procedure—or at a minimum refer patients for it—was challenged by the Christian Medical and Dental Society.
But the question of whether public institutions—hospitals, hospices, long-term care facilities—should be able to deny assistance has raised the most concern.
Covenant Health stated in May of 2016 that it has an “ethical and moral opposition to medical assistance in dying” and that the organization’s “unequivocal position to not provide or explicitly refer” must be recognized. Functionally, this means that any assessment of capacity, any answering of technical questions, and the act of assistance in dying itself would require a transfer away from a Covenant facility.
The Alberta government thus far has accommodated this objection through the creation of AHS’s Medical Assistance in Dying Resource Team. Team members are patient “navigators” brought in for all requests for medical assistance in dying—whether from patients or from facilities that object to the procedure.
CEO Dumelie believes this team ensures a seamless experience for patients. “We organize transfers for all sorts of reasons every day,” he says. “There’s no reason why we can’t do this well.” By February of this year, 85 Albertans had received medical assistance in dying. Ten of these people had been transferred from Covenant facilities, Dumelie says, “without concern.”
Others aren’t convinced the transfer plan is adequate—or that it ever could be. Dr. David Reggler is a family physician in Comox who conducts physician-assisted dying and has participated in five procedures. He recently resigned from the ethics committee of his Catholic hospital because it decided that all patients who opt for medical assistance in dying must be transferred to a community 45 minutes away.
“The process of medical assistance in dying involves first confirming that a patient has capacity, then waiting a minimum of 10 days, and then confirming on the desired day of the procedure that the patient has capacity and continues to seek the procedure,” he says. “Realistically, these patients are frequently in an extremely fragile situation. To move them at any point during this process can be a tremendous burden. It can undermine the entire intention of dying with dignity.”
Dr. Reggler says that if Canada follows the model of physician-assisted dying adopted in the Netherlands, where 85 per cent of procedures are conducted by the patient’s own family doctor, more such deaths will occur in rural areas. “It’s not an overly complicated process [and] can easily be brought into the training of a GP. It can be done at any facility where patients can stay overnight—an acute care centre, a hospice, a residential care centre.”
He predicts a problem if Covenant Health’s nine rural Alberta hospitals continue to refuse medical assistance in dying, because they’re often a patient’s only choice. But even Edmonton presents a challenge. There, Covenant is responsible for 71 of the available palliative and hospice beds—or 90 per cent of the regionally available spots.
The case of Ian Shearer, an 84-year-old Calgary man living in Vancouver with palliative heart and kidney disease and severe chronic pain, brought attention to how transfers can do harm. Shearer was denied a request for medical assistance in dying from St. Paul’s Hospital, a Catholic facility near where he lived and where he’d been admitted for care. On the day he chose to die, his ambulance was delayed three hours and his medications were withheld to allow him to confirm consent. The ordeal, last August, was described by his daughter as “unnecessary… excruciating suffering.”
To understand Covenant Health is to consider much more than its perspective on medical assistance in dying. Advocates suggest Catholic healthcare has a special “ethos” of compassionate care, emphasizing those who are neglected, that is worth preserving. Outside of the morning-after pill, only a few practical inconveniences are created by Covenant when it comes to women’s health. Early-term abortions are not regularly provided in any Edmonton hospital. And although elective tubal ligation isn’t typically provided at Covenant, it will be if a woman seeks it and is having a C-section delivery anyway—thus avoiding a second surgery.
“It’s just like working at any other hospital,” says a colleague of mine who works in the Misericordia ER. “The only difference was I had to fill out a different form for getting hospital privileges.”
But if the benign effect is an argument for maintaining Catholic-administered healthcare, it’s an even more powerful argument for ending the extra administration. If the care is essentially no different, Covenant Health merely represents an added layer of senior management in a system already top-heavy with administration. With Alberta spending the second-highest amount per capita among the provinces on healthcare, streamlining bureaucracy can’t be overlooked.
Dr. David Swann, leader of the Alberta Liberals, calls the senior management of Covenant Health “redundant.” Rather, he suggests, “more primary healthcare out in the community is what’s needed. Not higher salaries for unnecessary leadership in Covenant Health.”
Covenant CEO Dumelie dismisses these criticisms. “People like to focus on the smallest of pieces but it depends on the overall context. We perform well in terms of accreditation and are good value for money.”
But it’s difficult to square how Dumelie’s 2015 salary of $560,000 can be justified when AHS CEO Dr. Verna Yiu earned about $575,000 in the same year to oversee a budget nearly 20 times bigger. Nor is it clear how critical each of the 12 members of Covenant’s senior leadership team are when their job descriptions match similar positions in AHS.
As for the claim of compassionate care disproportionately directed towards society’s most vulnerable, there are certainly signs of this. Alberta has a rapidly aging population and disappearing patient-centred care. Covenant Health fills many of the gaps, from its geriatric mental health program in northern Alberta to its new long-term beds and palliative care.
Meanwhile many of Canada’s most progressive healthcare programs have emerged from Catholic facilities. St. Michael’s Hospital in Toronto and St. Paul’s Hospital in Vancouver are known internationally for the work they do on injection drug use, HIV and the urban poor.
Bud James, mayor of Killam, is a 50-something small-business owner born and raised in his prairie hometown. He’s adamant that Covenant Health has a unique ethos that leads to high-quality care, crediting Covenant with, for example, a recent extraordinary effort to keep an elderly couple together in assisted living. And James says his attachment to Covenant is premised on general, not religious, terms. He believes that in contrast to AHS, Covenant considers “holistic care” and “understands the unique needs of a rural health facility.”
But Steven Lewis, a Saskatchewan health policy expert, has a more dispassionate view of the alleged superiority of Catholic-administered care. “We hear this all the time—that there’s a different vibe at Catholic facilities,” he says. “Yet no one to my knowledge has ever demonstrated that with research. But let’s say it’s true—good, then we should all learn from it. It is good for elderly couples to stay together regardless.
“But the argument that [such care] can’t possibly take place in a secular system is ridiculous. We have examples all over the world of great care provided in non-religious facilities. The argument that it’s necessary in even a small way to impose a particular religious view of healthcare in order to make this happen has no defence.”
Alberta is not a particularly Catholic province—Statistics Canada reports that 23 per cent of Albertans are adherents to the faith, the second-lowest rate in the country and well below the national average of 44 per cent. But religious pockets—a number of French-Catholic communities, and Edmonton’s sizeable Ukrainian Catholic community—create important local constituencies.
The appointment of former Premier Stelmach—himself a Ukrainian Catholic—in 2016 as chairman of the board of Covenant, which was created during his tenure, undoubtedly brings a level of political heft.
There may be other benefits for Covenant Health aside from maintaining the privileged role of the Catholic Church. Given Covenant’s separate budget from AHS, any cutbacks to its facilities will be more transparent—and likely more scrutinized. This gives local administrators an incentive to maintain the special attention they receive in being outside AHS.
The clearest reason for Covenant’s continued role, however, is the absence of any challenge to it. The potential backlash is presumably too fierce for the government to make an issue of the arrangement.
But the time has come, says Lewis. “If we were to redesign the healthcare system today, we wouldn’t allow Catholic administration to continue… When Canada consisted of two religious groups, Catholic and Protestant, it was a simpler world. We now have a much cleaner separation of church and state… It’s the political norm that state institutions be even-handed about religions.
“Frankly it’s reprehensible that government doesn’t go to the wall on this. They say [to patients], ‘Well you can go somewhere else.’ Well, sorry, then you’re accepting the imposition of a religious view on people who have no choice.… It takes principle to raise [this issue] and stand up, and governments are basically cowards.”
So far, the province has settled for a workaround when it comes to medical assistance in dying. It’s time to change course. Alberta should have a transparent and comprehensive review of why in 2017 nearly $1-billion in healthcare funding is under the administration of the Catholic Church. And an answer of “because it’s always been that way” isn’t good enough.
Ryan Hoskins is a GP and emergency room physician based in BC who regularly locums in rural Alberta.
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