SMITHVILLE, TENN. - No more surgical sterilizations, said the Catholic health system a month after it acquired the Baptist hospital. Over our dead bodies, said a group of surgeons that set out to open a surgery center where they'd be free to perform tubal ligations and vasectomies. Not so fast, said the state Health Services and Development Agency (HSDA) in denying the surgeons' application for a certificate of need (CON), a move that effectively outlawed surgical sterilizations in this rural county. Throw in charges of deception and you've got a medical turf war played out against a backdrop of surgical sterilization and Catholic canon.

"When you bring religious issues to the bedside of a patient, you step over the boundary," says Don Cripps, MD, head of the 10-physician group. "This county is mostly Protestant, but the people here are being forced to live like Catholics."

Chronology
Let's reconstruct the chain of events, based on interviews and published reports:

• In February 2002, one month after St. Thomas Health Services, part of the largest Catholic health system in the United States, purchased Baptist DeKalb Hospital, St. Thomas bans all surgical sterilizations at the hospital, citing religious doctrine.
• A 10-physician group from the hospital, where sterilizations had been performed for more than 50 years, sets out to open a surgery center where the surgeons would be free to offer the community tubal ligations and vasectomies.
• In December 2002, St. Thomas put the hospital up for sale for the first of three times in what surgeons would later say were attempts to entice them with the promise of hospital ownership in hopes that they'd forget about building an ASC.
• While negotiating to buy the hospital, the surgeons twice deferred their CON application, first for 30 days and then for 60 days. Finally, when St. Thomas took the hospital off the market, the surgeons proceeded with their CON application.
• In April 2003, the state denies the group's CON application. At the hearing, St. Thomas announces it would sell the hospital. The next week, St. Thomas retracts its intention to sell.

Empty promises
Dr. Cripps claims surgeons were repeatedly assured before the sale that St. Thomas wouldn't object to sterilizations. But a month into the new ownership, an "oral directive came down" through hospital administrators that sterilizations were no longer to be done at Baptist because of Catholic doctrine. "They said they didn't realize we did obstetrics and sterilizations," says Dr. Cripps. "That's just a bald-faced lie. I guess they didn't think anything would be done about it."

"There were no OBs on staff," says St. Thomas spokeswoman Rebecca Climer. "So it slipped under the wire in terms of [sterilizations] being done. It was only after that it became evident when financial reports stated that money was coming in from tubals."

However, Denise Dingle, MD, the OB/GYN on staff at Baptist for 11 years, says that St. Thomas officials twice interviewed her before the acquisition about what types of procedures she performed. "This information was readily available," says Sarah Cripps, the lawyer for the doctors group and Dr. Cripps' daughter.

In December 2002, when St. Thomas decided to put Baptist up for sale, Dr. Cripps' group put its ASC plans on hold, asking for a 30-day deferral on its CON application. The doctors began negotiations with St. Thomas, but "January rolled around, and they were still trying to get something together," says Ms. Cripps. So this time the doctors group asked for a 60-day deferral on the CON application. Negotiations soon broke down because St. Thomas refused to divulge a selling price, says Ms. Cripps.

The CON hearing
In voting 9-0 to deny the doctors' CON, the state said that an ASC would take too much business away from Baptist. The following week, St. Thomas said it would not sell the hospital, leaving DeKalb County without sterilizations.

"We applied for a CON hoping that the loss of service would be enough," says Dr. Cripps. "Most of us were born and raised here. We don't want to destroy our local hospital. We want to bring back a service."

Interestingly, sterilizations are still done at two of the other hospitals that St. Thomas acquired from the Baptist health system - Baptist Hospital in Nashville and Middle Tennessee Medical Center in Murfreesboro. St. Thomas "carved out" a floor at each facility, which Baptist still owns and operates, where sterilizations are performed. Such an arrangement was denied to the doctors at Baptist.