CATHOLIC hospitals have been a force in American medicine since the Industrial Revolution, when nuns arrived from Europe to tend to immigrant communities. They are still flourishing. The total number of Catholic acute-care hospitals, where patients receive short-term treatment for urgent health conditions, increased by 8% from 2001 to 2016. In the same period, the number of beds in such hospitals grew by 18%. One in six acute-care beds lies within a Catholic hospital. Over the past two decades, economic pressures have driven health-care providers to consolidate. To achieve scale and increase their bargaining power with insurance companies, independent hospitals have merged to form larger systems. Catholic hospitals look to each other for potential partnerships first, says Lois Uttley, the director of MergerWatch, an advocacy group. Of the ten largest non-profit health systems in America, six are Catholic. To ensure their survival, Catholic hospitals have also overhauled their leadership. While in 1968 there were 770 religious officials—often nuns—running hospitals, today there are only four; the rest are laypeople.

Catholic hospitals generally follow the health-care directives laid out by the Conference of Catholic Bishops, which ban “contraceptive intervention” of any sort. Abortions are rarely administered in any sort of hospital, but secular hospitals usually provide emergency abortions in cases where pregnancies go awry. When future pregnancies are undesired, or would carry health risks, women also rely on hospitals to tie their Fallopian tubes, a process called “tubal ligation”. Catholic hospitals seldom provide either of these services. In Arizona in 2010, a nurse at a Catholic hospital was demoted after she approved an emergency abortion for a woman suffering from perilously high blood pressure.

Some hospitals have found creative ways to reconcile religious interests and reproductive emergencies. In Austin, Texas, the fifth floor of Brackenridge Hospital, which is affiliated with the Catholic Ascension Health system, operates as a women’s hospital, which is separately incorporated and managed. It provides maternity services, sterilisations, emergency contraception for rape victims and family planning services. A Catholic hospital in Troy, New York, has carved out a similar facility.

But most Catholic hospitals have not made such accommodations. The American Civil Liberties Union (ACLU) tells the stories of several women with pregnancy complications who were denied emergency abortions at Catholic hospitals. One, Mindy Swank of Illinois, recalls how she was refused an abortion when her waters broke prematurely at 20 weeks and testing showed her fetus had a very low probability of survival. It was only when she began rapidly losing blood seven weeks later that the hospital induced labour. Her baby died shortly after. The Catholic Health Association called the report’s claims “unsubstantiated and irresponsible”.

In some rural areas patients have little choice over hospitals. According to MergerWatch, almost 50 Catholic facilities are at least 35 miles or 45 minutes away from a competitor. This worries Douglas Laycock of the University of Virginia. “One has a presumptive right to live by one’s own moral commitments,” he says. “One does not have a right to use a monopoly position to block others from exercising the same liberty.” Kevin Fitzgerald of the Centre for Clinical Bioethics at Georgetown University retorts that Catholic hospitals are prominent in many rural areas because nuns were once the only carers intrepid enough to hunker down there. “To those who complain ‘Well, it shouldn’t be that way’, I say: no one is keeping you from starting a hospital there.”