When it comes to matters of individual conscience, Washington State voters have a don’t-mess-with-us attitude that makes Texans look like cattle—and it goes way back.

In 2012 Washington voters flexed their muscle by legalizing recreational marijuana use and marriage for same-sex couples. In 2008, death with dignity passed some counties by as much as 75 percent. In 2006, Washington lawmakers outlawed discrimination based on sexual orientation and gender identity. In 1991 a citizen initiative established that “every individual has the fundamental right to choose or refuse birth control” and “every woman has the fundamental right to choose or refuse abortion.” It also guaranteed an absolute right to privacy around mental health and reproductive issues for teens aged 13 and up. Washington state’s constitution includes an Equal Rights Amendment and (from the get-go) a stronger wall of separation between church and state than the U.S. Constitution.

In other words, west of Moscow, Idaho, and north of Portland, any bishops who want to control what they think of as their sacramental turf –birth, coming of age, sex, marriage, trippy transcendent experiences, and death—haven’t got a chance in hell at the ballot box. Washington even has extended statutes of limitations on child sex abuse—something Archbishop Timothy Dolan successfully fended off in New York and Pennsylvania. The Archdiocese of Spokane declared bankruptcy.

But the Vatican hasn’t survived for 1,500 years by being stupid. And as my devout family members like to say, “Where God closes a door, he opens a window.” The window the bishops found open in Washington takes the form of independent hospitals with financial problems.

Thanks to changes in healthcare delivery, more and more independent hospitals are being forced to merge with large healthcare corporations. The pressures include expensive equipment, complex electronic record keeping technologies, and an Obamacare-driven push for greater administrative efficiency. Rather like mom-and-pop hardware stores that survived by becoming Ace franchisees with standardized, streamlined supply and distribution systems, independent health facilities are surviving through acquisitions and mergers with other hospitals and healthcare corporations.

Of the largest healthcare corporations in the country, five of six are administered by the Catholic Church including the famously conservative Catholic Health Initiatives which operates the Franciscan brand and has $15 billion in assets. By the end of 2013, if all proposed mergers go through, 45 percent of Washington hospital beds will be religiously affiliated. In 10 counties, 100 percent of hospital facilities will be accountable to religious corporations, which are rapidly buying up outpatient clinics, laboratories and physician practices as well.

In the words of the U.S. Conference of Bishops, Catholic hospitals and healthcare corporations are “healthcare ministries” and “opportunities:”

New partnerships can be viewed as opportunities for Catholic healthcare institutions and services to witness to their religious and ethical commitments and so influence the healing profession. . . . For example, new partnerships can help to implement the Church’s social teaching.

Here is the diabolical stroke of genius. In any merger between a secular and Catholic care system, fiscal health comes with a poison pill. One condition of the merger is that the whole system becomes subject to a set of theological agreements call the “Ethical and Religious Directives for Catholic Health Care Services” or ERDs. Rather than care being dictated by medical science and patient preference, a set of religious doctrines place restrictions on what treatment options can be offered to (or even discussed with) patients.

Under these agreements, the patient-doctor relationship becomes a patient-doctor-church relationship: “The Church’s moral teaching on healthcare nurtures a truly interpersonal professional-patient relationship. This professional-patient relationship is never separated, then, from the Catholic identity of the healthcare institution.” Furthermore providers who work in these systems are required to sign binding contractual agreements to adhere to the religious directives, whether or not they are Catholic: “Catholic healthcare services must adopt these Directives as policy, require adherence to them within the institution as a condition for medical privileges and employment, and provide appropriate instruction regarding the Directives . . . .”

The ERDs in full are readily available to public, but here are some key samples and implications:

Fertility Treatment: “Reproductive technologies that substitute for the marriage act are not consistent with human dignity.” This provision excludes in vitro fertilization and related treatments. It especially affects same-sex couples, who may rely on surrogacy or insemination for childbearing, but it also affects the 10 percent of American couples who have fertility problems.

Contraception: “Catholic health institutions may not promote or condone contraceptive practices.” . . . “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution.” While we don’t typically associate contraception with hospitals, state-of-the-art long acting methods like IUD’s increasingly are provided at the time of delivery, because postpartum insertion improves health outcomes. Under ERD guidelines, a woman who delivers a baby at a Catholic hospital and wants an IUD or to have her tubes tied has to have a second, separate procedure at a secular facility—if she can find one.

Abnormal Pregnancies: “In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.” Catholic practice encourages the removal of the entire fallopian tube to end an ectopic pregnancy, rather than the standard practice which simply ablates the developing fetus. That is because the standard treatment is considered abortion, while in the invasive and fertility-destroying surgery, death of the embryo is simply a side effect. More broadly, Catholic “ethics” forbid abortion even to save the life of a mother carrying a nonviable fetus. The battle to save a young woman named Beatriz in El Salvador exemplifies this very situation.

Advance Directives: “A Catholic health care institution . . . will not honor an advance directive that is contrary to Catholic teaching.” Where patient directives and bishop directives conflict, the directives of the bishops take precedence regardless of a patient’s own religious or conscience obligations.

DNR: “The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.” Since this battle heated up, stories are emerging in which Catholic hospitals have force-fed incapacitated patients whose advance directives specifically forbid this.

Death with Dignity: “Catholic healthcare institutions may never condone or participate in [Death With Dignity] in any way.” Physicians are prohibited even from discussing options that exist in other institutions or making referrals.

To many non-Catholics, the most shocking statement in the ERDs is the suggested alternative to death with dignity: “Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering." Redemptive suffering is a theological notion that derives from the crucifixion story—the idea that the blood sacrifice of a perfect being could redeem harm done. (Theories about how this works have varied over the course of Christian history.) By extension, suffering itself has redemptive value, which is why Mother Teresa’s order, for example, practiced self-flagellation and glorified suffering of the poor, ill and dying.

Given the clash between Washington State’s independence streak and the top-down approach of the Catholic bishops, Washington citizens are pushing back. After Catholic Peace Health got an exclusive contract near her home in the San Juan Islands, advocate Monica Harrington created a website, Catholicwatch.org to complement the efforts of the national Merger Watch. Merger Watch has been fighting the religious takeover of secular systems across the country for over a decade, and sometimes winning, but describes a recent surge that overwhelms their resources. The ACLU of Washington is ramping up and aggregating funds to fight for a state-wide solution, the first in the country, and is soliciting stories (confidentiality protected) from patients and providers anywhere in the U.S. who have experienced religious interference in medical decisions.

Even so, on May 20, the Seattle Times announced an affiliation agreement between the University of Washington system and Peace Health. Even within Catholic-controlled hospitals, less than five percent of revenues come from the Catholic Church. Most are tax payer funds in the form of Medicaid, Medicare and capital grants for public services—and insurance reimbursement. So, the thought of the bishops influencing a public owned and funded institution adds insult to injury. In response, Columnist Danny Westneat, of the Times, framed a pointed question. “Most of us aren’t Catholic, so I’m guessing we’d never go along with letting the creeds of that one faith run something as universal as education [even if ‘the Catholics have a good record of running quality schools’]. So why are we allowing it with healthcare?”

Why indeed.