ST. AGNES HOSP. OF CITY OF BALTIMORE v. Riddick

• Decision Date: 10 September 1990
• Docket Number: Civ. No. HM-86-3071.
• Parties: ST. AGNES HOSPITAL OF THE CITY OF BALTIMORE, INC., v. Frank A. RIDDICK, Jr., M.D., etc.
• Court: U.S. District Court — District of Maryland

748 F. Supp. 319

ST. AGNES HOSPITAL OF THE CITY OF BALTIMORE, INC., v. Frank A. RIDDICK, Jr., M.D., etc.

Civ. No. HM-86-3071.

United States District Court, D. Maryland.

September 10, 1990.

John G. Kruchko, Jay R. Fries and Kathleen A. Talty, Towson, Md., for plaintiff.

Philip Jacobs and John F. King, Baltimore, Md., Douglas R. Carlson, Gary E. Dyal, Wildman, Harrold, Allen & Dixon, Chicago, Ill., for defendant.

MEMORANDUM

HERBERT F. MURRAY, Senior District Judge.

Plaintiff, St. Agnes Hospital of the City of Baltimore, Inc. ("St. Agnes" or "Hospital"), brought this action against defendant Frank A. Riddick, Jr., M.D., as Chairman of the Accreditation Council for Graduate Medical Education ("ACGME"). St. Agnes is a Roman Catholic health care institution and, as such, it adheres to the ethical and moral teachings of the Roman Catholic Church. In June of 1986, the ACGME withdrew accreditation of St. Agnes' residency training program in obstetrics and gynecology, citing deficiencies in the program relating to retropubic surgery, tubal surgery, family planning and education in the subspecialties of oncology and endocrinology. Plaintiff primarily alleges that the ACGME discriminated against and penalized St. Agnes because of its religious philosophies, specifically, its refusal to perform and to provide clinical training in elective abortions, sterilizations and artificial contraception.

In this action, the Hospital alleges violations of the First and Fourteenth Amendments to the United States Constitution, 42 U.S.C. ?? 1983 and 1985(3), common law due process rights and breach of contract, and ? 20-214 of the Maryland Health General Code. Plaintiff seeks injunctive relief, preventing withdrawal of accreditation, as well as declaratory relief, requiring the defendant to protect plaintiff's religious and due process rights during any future accreditation reviews.

This Court held a bench trial in December of 1988 and heard final arguments on July 21, 1989. The Court has carefully reviewed the evidence and testimony presented, as well as the post-trial briefs submitted by counsel. It is now prepared to rule.

I. BACKGROUND

The Plaintiff is a health care and teaching hospital that offers several medical residency training programs for graduates of medical schools, including a program in obstetrics-gynecology. A residency program is graduate medical education which follows the undergraduate period of medical education. After receiving the M.D. degree, physicians enroll in graduate medical education to develop expertise in some special branch of medicine.¹ In addition to attaining the knowledge and skills needed to be practitioners, during the graduate phase of their education, most residents seek to complete training requirements for certification by a specialty board. Each board generally requires that graduate medical education be obtained in a program reviewed and approved by the Residency Review Committee ("RRC") for that specialty, under the authority of the ACGME. In order to maintain its residency programs, each program must be accredited by the defendant ACGME. Accreditation is the process through which the ACGME assures medical students, residents, specialty boards, and the public that residency programs meet established educational standards for graduate programs in the various medical specialties.

The ACGME is a non-profit, private association sponsored by five national organizations: the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges and the Council of Medical Specialty Societies. Each sponsoring organization appoints four representatives to the twenty-three member Council. The other members are a resident representative, a public member, and a non-voting representative of the federal government. In order to accomplish the review and evaluation of residency programs, the ACGME has organized RRC's for each medical specialty. The RRC for Obstetrics-Gynecology is composed of twelve unpaid volunteers appointed by the American Board of Obstetrics and Gynecology, the American Medical Association Council on Medical Education, and the American College of Obstetricians and Gynecologists. The Executive Director of the American Board of Obstetrics and Gynecology and a staff person for the American College of Obstetricians and Gynecologists also serve on the RRC in an ex officio capacity.

The RRC is responsible for reviewing and evaluating all residency programs within its area of specialty pursuant to the Manual of Structure and Functions. The standards for accreditation of obstetrics-gynecology residency programs consist of the "General Requirements," which are applicable to residency programs in every specialty, and the "Special Requirements for Residency Training in Obstetrics-Gynecology" ("Special Requirements"). The Special Requirements state that the program must offer training in high-risk obstetrics, immediate care of the newborn, the full range of gynecologic surgery, gynecologic oncology including the use of radioactive materials, gynecologic surgical pathology, reproductive endocrinology and infertility, family planning, emergency medicine, psychosexual and psychosomatic counseling, genetics, medical jurisprudence, and the full range of commonly accepted diagnostic procedures.

The evaluation process consists of the submission by the residency program director of a lengthy and detailed report. In addition, an on-site inspection is made by a surveyor designated by the RRC, in order to verify the information provided. The surveyor collects data and information on the program and submits a report to the RRC. The material is reviewed by the RRC, which then recommends full accreditation, probation or withdrawal of accreditation.

Once the RRC makes its preliminary determination, a program found to be deficient may request reconsideration by the RRC and submit further information in an attempt to establish that it is not deficient. If the RRC sustains its prior determination, the program director may request a hearing before a board of appeals, consisting of three directors of accredited residency programs in obstetrics-gynecology. The program chooses one panelist, the RRC chooses one and they in turn select the third. The Board of Appeals reviews all of the submitted material, and conducts a hearing at which the program, represented by counsel, may submit further evidence, including witnesses, in order to establish that it is in substantial compliance with the general and special requirements. The decision of the Board of Appeals is then submitted to the ACGME for a final determination as to the status of the program.

St. Agnes, a Roman Catholic hospital sponsored by the Daughters of Charity of St. Vincent de Paul, adheres to the ethical and moral principles of the Roman Catholic Church, which are set forth in the "Ethical and Religious Directives for Catholic Health Facilities" ("Directives").² The Directives proscribe elective prevention of conception and elective termination of pregnancy.³ Sister Mary Louise Lyons, President of St. Agnes and Chairman of the Board of Directors, testified that "the effect of the Directives is just to simply clarify what St. Agnes Hospital has always held, that is its basic religious beliefs." Tr. 81.

In view of the Hospital's Catholic sponsorship and adherence to the tenets of the Catholic Directives, St. Agnes does not provide residents in the obstetrics-gynecology program with clinical training in procedures which are directly intended to prevent conception or are directly intended to terminate the life of a fetus. Furthermore, St. Agnes follows the doctrine of "material cooperation,"⁴ which Sister Lyons interpreted as "... what the residents do, we participate in materially." Tr. 85. Extending that principle, St. Agnes forbids its residents from indirectly acquiring clinical experience that cannot be directly obtained within the hospital. Thus, St. Agnes does not allow its residents to acquire clinical experience in sterilization, abortion, or artificial contraception in a rotation outside of the hospital.⁵ Plaintiff believes that allowing its residents to have outside clinical training in the forbidden procedures, while they are under contract and being paid by St. Agnes, would amount to material cooperation in those procedures.

Prior to commencing a residency in obstetrics-gynecology at St. Agnes, each resident is advised of the hospital's religious beliefs and agrees to abide by them during the residency period. Specifically, before beginning the residency, each resident receives a residency agreement as well as a letter from the president of St. Agnes. The agreement provides:

Acceptance of this appointment indicates agreement to comply with the rules and regulations of the hospital and of the department of obstetrics-gynecology and its teaching as well as the philosophical and ethical directives and policies upheld and practiced by the Hospital.

Plaintiff's Ex. 255. The letter expresses the hospital's moral and religious beliefs and makes clear that its training does not include "the actual clinical experience in contraception, sterilization and abortion or pregnancy termination," although it does include didactic instruction. Tr. 76, 77; Plaintiff's Ex. 255.⁶ It also provides that outside electives in artificial contraception, sterilization and pregnancy termination will not be permitted while the resident is under contract with St. Agnes.⁷

St. Agnes' graduate residency program in obstetrics-gynecology was fully accredited until 1981. In October of 1981, the RRC for Obstetrics-Gynecology placed the program on probation because of three stated deficiencies: inadequate supervision of the residents, inadequate total responsibility for a sufficient number of patients, and an inadequate number of faculty.

In 1983, the program was resurveyed by the...