In Texas, a Catholic bishop made two hospitals cease doing tube-tying operations for women who are not going to have more babies. In Oregon, another bishop cast a medical center out of his diocese for refusing to discontinue the same procedure. In Arizona, a nun was excommunicated and the hospital where she works was expelled from the church after 116 years for allowing doctors to terminate a pregnancy to save a woman's life.

Such disputes between hospitals and church authorities appear to be arising because of a confluence of factors: Economic pressures are spurring greater consolidation in the hospital industry, prompting religiously affiliated institutions to take over or merge with secular ones, imposing church directives on them. At the same time, the drive to remain competitive has led some medical centers to evade the directives. Alongside those economic forces, changes in the church hierarchy have led increasingly conservative bishops to exert more influence over Catholic hospitals.

The clashes have focused attention on the limitations on care available at Catholic hospitals. In Montgomery County, concern about those constraints has emerged as an issue in the battle over whether Holy Cross Hospital, a Catholic institution in Silver Spring, or Adventist HealthCare in Rockville should be authorized to build a new hospital in the county.

A coalition of advocacy groups Wednesday urged the state to reject Holy Cross, citing concerns about access to reproductive health care, especially for poor women and teenagers. A decision in that case is expected Thursday.

Such conflicts are likely to intensify as new flash points arise, such as the spread of infertility treatments considered taboo by the church and the possible availability of therapies derived from human embryonic stem cells.

Although the issue has erupted at a variety of institutions, women's health advocates are especially alarmed about Catholic hospitals, a leading source of health care in the United States.

"Physicians are being told they must refuse to provide certain services even when they believe their refusal would harm their patient and violate established medical standards of care," said Lois Uttley, who heads MergerWatch, a New York-based group that fights the takeover of secular medical centers by religiously affiliated hospitals.

Church officials, bioethicists and hospital officials counter that the facilities are guided by directives calibrated to deliver state-of-the-art medical care without violating religious and moral beliefs. Disagreements between dioceses and hospitals, as well as cases in which patients do not receive needed care, are exceedingly rare, they say.

"We have literally hundreds of institutions that care for men, women and children every day and provide excellent care, especially to the poor," said Richard M. Doerflinger of the U.S. Conference of Catholic Bishops Secretariat for Pro-Life Activities. "We always do so with respect for each and every life in our care."

Religious directives



Since 1971, Catholic hospitals have been guided by the Ethical and Religious Directives , which detail religious and moral justifications for care extending from conception to death. The interpretation of those directives is the responsibility of ethics committees at the hospitals, and the final arbiter is the local bishop.

The best-known prohibition is against abortion, which led to the recent confrontation between Bishop Thomas Olmsted and St. Joseph's Hospital and Medical Center in Phoenix. In May, Olmsted declared Sister Margaret Mary McBride excommunicated after discovering that she had permitted a pregnancy to be terminated in 2009 for a mother of four who developed pulmonary hypertension in the 11th week of her pregnancy.

Doctors had concluded that the 27-year-old woman would almost certainly die without the procedure. But Olmsted demanded that the hospital acknowledge its error and take steps to comply with the directives. Hospital officials refused, leading Olmsted to announce that he was stripping St. Joseph's of its Catholic affiliation.