The U.S. Conference of Catholic Bishops has tightened restrictions on reproductive health care for the one in six hospital beds nationwide that operate under its directives.

The directives ban abortion, sterilization, and most forms of contraception in Catholic facilities. Hospitals seeking to keep their doors open have found workarounds: allowing contraceptive prescriptions under the guise of a medical diagnosis, permitting tubal ligations after a Cesarean section if patients meet medical criteria, or even sectioning off an operating room where the directives don’t apply.

But reproductive health advocates worry changes approved this month will inspire a crackdown on such workarounds by local bishops charged with interpreting the rules.

“I’m anticipating that many of the arrangements we hear about will come under greater scrutiny and may not be allowed to proceed,” Dr. Debra Stulberg, associate professor at the University of Chicago, who researches Catholic hospitals, told Rewire.News. “And that will really leave patients with no options.”

The new language requires a Catholic institution that affiliates with another health-care entity to “ensure that neither its administrators nor its employees will manage, carry out, assist in carrying out, make its facilities available for, make referrals for, or benefit from the revenue generated by immoral procedures.”

“In any kind of collaboration, whatever comes under the control of the Catholic institution—whether by acquisition, governance, or management—must be operated in full accord with the moral teaching of the Catholic Church, including these Directives,” the document states.

This is particularly significant because Catholic hospitals have expanded their dominance of the health-care market through such acquisitions. From 2001 to 2016, the number of Catholic-owned or -affiliated hospital beds grew by 22 percent in the United States, even as the overall number of these hospitals dropped. A pending merger between Catholic Health Initiatives and Dignity Health would create the largest nonprofit health system in the United States, bumping fellow Catholic behemoth Ascension Health to number two. Catholic hospitals are the only accessible option in many parts of the United States.

“The rule of thumb is a Catholic hospital in partnership with a non-Catholic hospital cannot formally cooperate with doing evil,” Bishop Robert McManus of Worcester, Massachusetts, chair of the subcommittee that crafted the new directives, told the Catholic News Agency.

The new directives cite Pope John Paul II’s definition of “formal cooperation” as directly participating in an action or “sharing in the immoral intention of the person committing it.”

This policing of “intention” could have a chilling effect on many arrangements whereby providers try to help patients get around the Catholic directives to obtain care, Stulberg said.

The Trump administration has moved to grant Catholic hospitals and other religious objectors—like the pharmacist who refused to fill a prescription for a miscarrying woman—even broader leeway to impose their religious beliefs on patients. Justice Anthony Kennedy’s retirement has placed at risk U.S. Supreme Court rulings protecting abortion, contraception, and LGBTQ rights.

Catholic hospitals, under the directives, have turned away bleeding patients in the process of miscarrying, forced people to sicken before they induce labor to save their lives, refused to provide gender-affirming care to trans patients, and denied tubal ligations and contraception.

In other words, Catholic hospitals may offer a preview of what life could be like with a second Trump appointee on the Court.

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