On Thursday the Sixth Circuit Court of Appeals dismissed the case of Tamesha Means, a Michigan woman who had argued a Catholic-affiliated hospital was negligent in following religious directives in treating her miscarriage.

Approximately one in six hospital beds in the United States are in a facility where health-care delivery is governed by the Catholic directives. In some states, more than 40 percent of all beds fall into that category, with those hospitals routinely refusing to provide comprehensive reproductive health care to patients.

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In 2010, when Tamesha Means showed up at Mercy Health Partners in Muskegon, Michigan, while having a miscarriage, she had every reason to expect the hospital doctors and staff would treat her emergency medical condition. Instead, the Catholic-affiliated health-care entity turned her away twice, effectively telling her to just “wait and see” what would happen.

Means filed suit against Mercy Health Partners and the United Conference of Catholic Bishops (USCCB) in 2013. On Thursday, the Sixth Circuit Court of Appeals ruled that she had failed to state a viable legal claim.

Thursday’s ruling is a narrow one. It does not prevent other patients who have faced similar denials of care from Catholic-affiliated health care facilities from suing based on those denials. But it does suggest those claims will be very difficult to win.

Means’ case is, in some ways, the perfect example of conservative federal courts’ reluctance to second-guess the medical decisions made at religiously affiliated hospitals. When Means first showed up at Mercy, the only hospital in her county, she was 18 weeks pregnant. Her water had broken, and she was beginning to miscarry. Doctors and staff at Mercy Health—which is operated by Trinity Health, a multi-billion dollar network of Catholic-run hospitals—told Means there was no medical care they could offer her. That was because treatment would mean the termination of her pregnancy: a violation of Catholic directives preventing any care resulting in the death of a fetus, even a non-viable one.

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So instead, they sent Means home.

Means came back the next day, in pain and this time bleeding vaginally. As detailed in court documents, doctors and staff at Mercy again told Means the only thing they could do was to wait and see how the miscarriage progressed.

Means returned to Mercy Health a third time just days later. Now, she was suffering from a significant infection from her untreated miscarriage. This time, instead of telling Means to just wait it out, hospital staff gave Means some aspirin to treat her fever and prepared to send her home yet again. But before the hospital discharge process for Means was complete, she started to deliver her dying fetus. It wasn’t until then that the hospital agreed to admit her; she delivered a baby who died within hours of birth.

Means eventually sued, claiming the Catholic directives followed by the hospital amount to the provision of negligent care.

These “Ethical and Religious Directives” are not the same thing as professional standards of care, which dictate when a hospital or doctor has committed an act of medical negligence. Rather, they are expressions of religious beliefs. Still, Mercy deferred to them as a defense for its actions, saying its doctors and staff did nothing wrong in relying on those directives, rather than medical standards, when they turned away Means and refused to treat her.

And both a lower court and, now, the Sixth Circuit Court of Appeals have ruled Means’ case could not go forward. This was, in part, because the court felt it was not its job to judge the directives and decide whether or not following them amounted to negligence in the delivery of health care by Mercy and its doctors and staff.

Part of these decisions rests in a legal doctrine dating back more than 100 years called “ecclesiastical abstention.” Both the federal district court and the court of appeals ruled in part that this doctrine prevents courts from reviewing cases like Means’.

According to the doctrine of ecclesiastical abstention, civil courts should be limited in their role in deciding matters of religious controversy. The idea behind the ecclesiastical abstention doctrine is that courts should not settle what would amount to disputes about religious doctrine, which Catholic-affiliated hospitals like Mercy claim their refusal to provide health care to patients like Means amounts to. Specifically in Means’ case, the defendants claimed the directives offer “a statement of the Roman Catholic Church’s moral and religious postures as it relates to health care issues” and are in place “to provide authoritative guidance on certain moral issues that face Catholic health care today.” That means, the bishops and Mercy argued, that interpreting the directives in the context of whether or not carrying out those directives amounts to medical malpractice means interpreting Catholic theology. And according to the bishops and Mercy Health, that is exactly the kind of thing which the ecclesiastical abstention doctrine prohibits.

Thursday’s ruling did not decide definitively whether or not the directives are insulated from judicial review in cases of medical negligence. Instead the court ruled that the USCCB could not be sued in Michigan in this case. According to the court, USCCB’s action of publishing the directives does not “create a substantial connection” between USCCB and Michigan hospitals sufficient to justify bringing the bishops into court to respond to claims like Means’.

But the court used topsy-turvy logic to justify refusing to allow Means to sue the USCCB. According to the court, “Michigan—like every state—does have Catholic hospitals, and USCCB does intend the Directives to be implemented by all Catholic healthcare institutions. USCCB may even have known that Trinity Health is a Catholic hospital network operating in Michigan,” the court wrote. But this is not a “substantial connection” enough that USCCB could expect to be sued when following those directives results in medical negligence, according to the court. Similarly, Mercy cannot be sued in this case for following those national directives.

Approximately one in six hospital beds in the United States are in a facility where health-care delivery is governed by the Catholic directives. In some states, more than 40 percent of all beds fall into that category, with those hospitals routinely refusing to provide comprehensive reproductive health care to patients. As Means’ case illustrates, some patients’ only choice is to seek care at a Catholic-affiliated hospital. If courts are unwilling to hold those institutions accountable for delivering to their patients shoddy and substandard care, in part on the grounds that those hospitals have a religious imperative that courts cannot second-guess, where does that leave patients like Means, whose lives are being put at risk in the name of religiously driven health care?