"The separate normative order authorized by healthcare refusal laws may take a highly institutionalized form. For example, Catholic healthcare delivery is governed by the Ethical and Religious Directives for Catholic Health Care Services (Directives), promulgated by the U.S. Conference of Catholic Bishops (USCCB). Implementation of the Directives, which ensure that healthcare is delivered in conformance with Catholic theological principles regarding cooperation and scandal, is enabled by healthcare refusal laws. According to the Catholic Health Association, one in six patients in the United States is treated by a Catholic hospital. (In Washington State, approximately half of the state’s healthcare system is now Catholic-run.) It is clear, then, that healthcare refusal laws empower a substantial segment of the healthcare industry to operate in conformity with religious principles that dictate limitations on services relating to abortion and contraception. But the Catholic hospital system is not the only organization coordinating claims on refusal laws. Religious hospitals represent nearly a fifth of the healthcare delivery system in the United States, and eight of the twenty-five largest healthcare systems are religiously owned. Even secular hospitals may act on a traditional norm widely shared in the community. And other loosely affiliated providers may act on the basis of shared convictions. For example, resistance to emergency contraception may be widespread and include both hospitals and pharmacies. In states and regions where abortion and certain forms of contraception are stigmatized, healthcare refusal laws, along with other restrictions, may create a system in which the disestablished sexual norms continue to be enforced. With widespread, cross-denominational assertion of claims for exemption, accommodation of complicity-based conscience objections can have far-reaching effects."