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One in six hospital patients in America are treated at a Catholic hospital, and in the last three years at least 20 Catholic hospitals have merged with secular ones. Catholic-affiliated hospitals must abide by the United States Council of Bishops' Ethical and Religious Directives, and merged hospitals are frequently required to follow these directives. One of the core set of directives, having to do with "the beginning of life," do not allow any Catholic-affiliated hospitals to offer a range of reproductive services, including abortions, contraceptives, and sterilizations. As a result of mergers, formerly secular hospitals frequently have to adopt the directives. However, the directives are often applied in an ad hoc manner, and hospital administrators and doctors sometimes attempt to circumvent them in confusing and roundabout ways. Ultimately, Catholic-secular hospital mergers lead to a variety of legal challenges, most of which are successful on the basis of medical malpractice laws.