A matter of integrity

Catholic healthcare providers today can live out their vision and values only if they become public policy advocates. They must learn how to shape effective public policy to help heal the ailing U.S. healthcare system. Although from a political perspective they might feel ill-equipped to advocate in the public policy arena, Catholic healthcare providers are richly endowed from the perspective of their tradition of social teaching. They must uphold the common good as a primary criterion in healthcare reform. Two important issues provide an extraordinary opportunity and challenge for Catholic healthcare leaders to demonstrate their commitment to the common good: euthanasia and healthcare reform.     

Making mission possible. A response to Rev. Richard A. McCormick's article on the preservation of Catholic hospitals

In "The Catholic Hospital Today: Mission Impossible?" (Origins, March 16, 1995, pp. 648-653), Rev. Richard A. McCormick, SJ, STD, questions whether Catholic hospitals can continue their missions in a society with so many factors and influences that seem to oppose efforts to perpetuate the healing ministry of Christ. As Fr. McCormick states, the matrix of good medicine is centered on the good of the individual. But too often, the patient has been considered an individual isolated from others. The rights of families, people who belong to the same insurance program, and the society funding much of healthcare must also be considered. Fr. McCormick points out that an obstacle to the healing mission arises because healthcare is often treated as a business instead of a service. If not-for-profit healthcare facilities come to exist for the well-being of the shareholders, as do for-profit healthcare facilities, then a perversion of values results. This should lead us to renounce for-profit healthcare and the behavior that some Catholic health organizations have borrowed from the for-profit sector. In addition, Fr. McCormick calls attention to our society's denial of death and tendency to call on medicine to cure personal, social, or economic problems. This denial-of-death phenomenon helps us realize the need for the mission of Catholic hospitals. Continuing the mission of Catholic hospitals will require the attention of all involved in them-physicians, trustees, nurses, administrators, and ancillary personnel. These healthcare providers must not be distracted from the mission by joint ventures and economic issues.     

An opportunity for positive change. We have the history, experience, and will to preserve a Catholic presence in healthcare

The charitable acts of women religious in response to the needs of the communities in which they settled is one of the great chapters in the history of the Church in America. But in the past two decades providers have had to contend with extraordinary changes in the healthcare environment. The Catholic healthcare mission was rooted in concern for the poor. Should Catholic healthcare providers withdraw from this field in which they have had such a significant presence and have contributed so much, or be driven from healthcare by the fiscal consequences of fidelity to mission? Instead, through its reform proposal, the Catholic Health Association has recommended that Catholic providers become advocates of change. However, even if change, such as universal access to healthcare, is achieved, we shall still have a society in which there will be many poor people. The challenge will be to see that healthcare for the poor does not become poor healthcare. Although the changing urban environment presents enormous challenges to providers, the Catholic healthcare ministry is a significant presence in urban areas. Widespread poverty accompanied by behavioral problems and social breakdowns are significant factors affecting healthcare and healthcare costs. Drug addiction; AIDS; teenage pregnancy; homelessness; the deterioration of the family; and generations of unemployment, anomie, abuse, and violence, which are often most acute in concentrated neighborhoods of poverty, challenge the ability of Catholic hospitals to meet their community's needs. Catholic providers today have a real opportunity to bring about positive changes in healthcare. They have the history, experience, and will to preserve a Catholic presence in the provision of healthcare.     

A dynamic force for change. The common good provides the rationale for a healthcare system for all

In advocating for a reformed healthcare system, the Catholic healthcare community has claimed that responsibility for the common good is of the highest ethical importance. Yet to many the concept of the common good remains elusive. As the common good evolved in Catholic social teaching, it grew to include its anthropological origins, the principle of subsidiarity, and the virtue of solidarity. Above all, it is characterized by justice and refers to a social order that reflects peace, unity, and harmony. As an organizing principle for civil governments, the common good calls on them to foster societies that provide spiritual, cultural, political, and economic conditions in which all persons can realize their human dignity. By viewing healthcare and the right to security in case of sickness as among the particular goods that make up the societal common good, Catholic social teaching provides the rationale for a just healthcare system on a national level. In addition to advocating for a national healthcare system designed to serve the common good, Catholic healthcare entities must evaluate their own programs and services in light of the common good and examine proposed initiatives with other providers, especially for-profit organizations, in that context, as well.     

Guidance for a failing system. Catholic social teachings provide the needed principles

Catholic healthcare has traditionally relied on four major ethical principles--nonmaleficence, beneficence, autonomy, and justice--to address conflicts between various goods. However, all healthcare now finds itself facing great changes. "Principleism" is too limited to guide the Church's health ministry through the current crisis. But the Church possesses a body of social justice teachings that may provide healthcare with the necessary guidance. Eight inseparable but distinct themes are found in the social teachings: human dignity, human solidarity, the option for the poor, the common good, human rights, social justice, stewardship, and liberation. The eight themes are here applied to five critical healthcare issues: the patient-physician relationship, the right to choose, healthcare as a communal good, rationing and limits, and work and its implications. The Church's social teachings may provide us with a basis for a structural reexamination of healthcare--including Catholic healthcare. In that analysis, we may find that Catholic healthcare has developed practices and standards that are at odds with its own teachings. Such an analysis will be painful, but it must be done.     

Partners at work. Catholic social teaching demands that managers respect workers' rights

For almost 100 years Catholic social teaching has demanded that workers be treated in accord with their dignity as persons created and loved by God. Numerous papal encyclicals, a statement by the 1971 Roman Synod of Bishops, and the U.S. bishops' 1986 pastoral letter all insist on workers' rights to just wages, healthful working conditions, appropriate ways of participation and freedom to form or join unions. Throughout this century the Church has taught that a just wage should provide workers and their families "a standard of living in keeping with the dignity of the human person." Just compensation should also include provisions for adequate healthcare, security for old age or disability, unemployment compensation, and other benefits. Workers should also be able to participate as fully as possible in the enterprise they are a part of. "Each person," Pope John Paul II has written, "is fully entitled to consider himself a part owner of the great workbench at which he is working with everyone else." Finally, Catholic social teaching has consistently defended the rights of all people to form or join unions. Although the existence of this right does not oblige Catholic institutions to give up what they perceive to be their own interests, it does oblige them to avoid adopting an adversarial stance toward unions and to openly acknowledge their employees' right to unionize.     

Tradition in transition. What it means to be a Catholic healthcare facility today

Until recently we rarely questioned whether Catholic healthcare facilities would remain Catholic. New types of business ventures, however, have changed this. More important, the traditional elements that identified a facility as Catholic no longer seem enough to sustain the ministry. What are the distinct qualities that identify a healthcare facility as Catholic? Three elements are crucial to successfully defining any identity: distinctiveness, relatedness, and richness. To determine the meaning of Catholic identity, we must look at these elements from the perspective of the changes occurring in the Catholic Church and in healthcare in the United States. In light of this we can identify distinctive features that characterize U.S. Catholic healthcare. These components include understanding healthcare as a ministry, being guided by Church teachings, collaborating with others, participating in care for the world community and the poor, giving holistic care, promoting self-determination, and respecting and protecting human life while accepting suffering and death. Only in their totality, however, can these components set forth a vision rooted in our past that speaks to the realities of the present and calls us forward to a future where greater justice will reign.     

Healthcare rights: an invitation for reflection

This study focuses on changes and breaks in contemporary society relating to the right to healthcare as a universal value, in conformity with the guidelines provided by multilateral agencies and disseminated particularly since the 1990s. From the genesis of social rights and by tracing the interdependence between social and economic aspects of social citizenship in democratic capitalist countries, the study presents the two paradigms informing the approach to healthcare in the early 21st century: the full citizenship paradigm, according to which the right to healthcare is a universal value, and the paradigm of restricted social citizenship, according to which the right to healthcare is guided by the criterion of efficiency and economic rationalization. These propositions align with the health economy paradigm, which (i) defends focused resource allocation to attenuate poverty conditions, (ii) reduces the role of the state, (iii) recommends resource allocation to healthcare in association with social protection, and (iv) defines the market as the privileged regulator of healthcare actions.     

Public health policies: a Scandinavian model?

AIM: To identify how public health problems are identified, explained, and addressed in Scandinavian public health programmes. METHODS: Recent public health white papers from Denmark, Norway, and Sweden have been studied asking the following questions. How are policies and activities justified? Which problems and causes are identified? What is to be done? To what extent are the interpretations and suggested interventions in accordance with liberal or social democratic political ideals? RESULTS: The programmes studied give similar reasons for dealing with public health, namely the wish to create good lives for citizens and to improve the economy of society. The health problems identified are almost the same: cancer, heart disease, diabetes, musculoskeletal diseases, and mental illness. The Danish programme differs from its Norwegian and Swedish counterparts with regard to explanations and suggested solutions to the problems. It may be characterized as more liberal. While the Danish programme stresses the importance of individual behaviour, responsibility, and autonomy, the two others emphasize social relations, living conditions, and participation in addition to behavioural factors. Political responsibility for the health of the population is emphasized in the Norwegian and Swedish programmes. The Swedish programme, in particular, stresses common values such as equality and equal rights, and the significance of the welfare state. The Norwegian programme underlines the importance of empowering the individual, an ambition that could also be seen as a social liberal ambition to increase the self-determination of citizens. CONCLUSION: There is not one Scandinavian model in public health policy but several: a Danish model mainly adhering to liberal ideals, a Norwegian one that could tentatively be labelled social liberal, and a Swedish model adhering to more social democratic ideals.     

Healthcare reform's moral, spiritual issues. The problems are not just political

Although President Clinton's proposals were defeated in 1994, healthcare reform is an issue that will not go away. But it is an especially complex issue because it is moral and spiritual as well as political. Catholic social teaching could help free us Americans from our confusion on the topic. For example, the Catholic ideas of justice, subsidiarity, and the common good could help us address the crux of the healthcare reform debate, which questions the fairness of forcing more fortunate people to provide healthcare for those who are sick and poor. Catholic social teaching tells us that our healthcare decisions must be made not only on the basis of what is good for me but what is good for us as a community. By the same token, we might find that several specifically spiritual ideas are helpful. Christianity says, for example, that sickness can be a gift because it is a window on immortality for us; that we should not prize life above all other values; and that friendship--including the civic friendship involved in healthcare--is a way we can enter full friendship with God. These moral and spiritual ideas lead us to certain political conclusions: Healthcare reform should be politically realistic, relatively simple. and inclusive. Because healthcare is a good like no other, it can be a powerful occasion for realizing God's own compassion, healing, and justice.     

Preserving the mission. Sponsors and lay leaders must collaborate to maintain the Church's presence in healthcare

As the number of women and men religious involved in healthcare decreases, the Church faces the task of sustaining and expanding its institutional presence in the healthcare world. Both the Gospels and Church teaching support the claim that the Church should be involved in social institutions such as healthcare. Documents such as the Second Vatican Council's Pastoral Constitution on the Church in the Modern World stress the Church's concern with the impact of God's kingdom on all dimensions of human life. Pope Paul VI's Evangelization in the Modern World clearly affirms that the Gospel cannot be complete until it is interrelated with social life. Jesus' ministries of teaching and humble service are also paradigmatic for Catholic healthcare. To preserve and extend its institutional presence, Catholic healthcare will have to meet a number of challenges in the coming years. Catholic healthcare facilities must be prepared to relinquish their autonomy and work with others, providers will have to become attuned to what is distinctively Catholic about their facilities, and the Church must commit itself to preparing lay leaders for the Catholic healthcare ministry.     

Shaping public policy: a challenge in faith

Religious health care's involvement in public policy is an essential part of Christian life. The most important way in which Catholic hospitals and health care systems can contribute to public policy is through faith-reflection upon their identity and calling. To guide the shaping of public policy, several theological models have been set forth. The theology of democratic capitalism is based on individual human creativity. As a system of political economy organized to prevent the centralization of government power, it thrives on free competition. Well- intentioned social programs that seek to equalize results, according to democratic capitalists , inevitably lead to greater government control and should be avoided. Inequality, in fact, according to this theory, can create incentive for individuals and industry to be more productive. The stewardship approach to theological reflection calls for a distribution of goods and services based on need. The right to health care, for example, is founded in God's gift of creation to all inhabitants. The resources of creation are allotted to individuals as property in a sense of cooperation and sharing. Thus, according to this notion, government programs that help society steward its resources wisely should be promoted. The U.S. bishops ' 1981 pastoral letter on health and health care presents a third model, which reflects on the dignity of human beings as images of God to guide public policy. Models, however, must not replace personal theological reflection. Catholic health care providers share a responsibility to evaluate social issues from their perspective as members of the healing ministry and to participate in public policy development.     

Physicians for Human Rights: a foreign observer at three trials against physicians in Turkey

Physicians have a professional obligation to be among the first to defend human rights. Accordingly they have established organisations in many countries to that aim, which are united in the International Federation of Health and Human Rights Organisations (IFHHRO). The author was invited by this federation to attend several trials against members of the Turkish sister organisation. In one of them the doctor's duty to protect his patients' privacy was at stake. This physician has since been acquitted because of insufficient evidence. In Turkish society there are opposed conservative and liberal democratic forces: on the one hand people try to maintain the democratic and constitutional state, on the other some circles hold the opinion that undemocratic and inhuman measures are necessary to counter the dangers of terrorist movements. Even in the Netherlands the right of physicians not to reveal confidential information regarding 'illegal immigrants' has recently been challenged, and until now the medical organisations have not protested.     

Capitalism ex cathedra. Sources of hope in tough economic times

Pope John Paul II's encyclical Centesimus Annus--written in honor of the centennial anniversary of Rerum Novarum, the first papal social encyclical--examines the present world socioeconomic situation in light of traditional Catholic social teaching. The pope warns the West not to be too quick to celebrate the demise of communism as a victory for capitalism. Capitalism has some good points, the pope acknowledges, but by themselves, market mechanisms do not ensure the just distribution of food and other goods that fulfill essential human needs. When capitalism relies on market forces alone, it creates a culture of consumerism that promotes selfishness and greed. Capitalism has been in flux for decades. After World War II, developed Western societies began moving toward "Keynesian capitalism," which subjects the mechanisms of the free market to public control. After Keynesian capitalism's apparent failure in the United States in the 1970s came the "monetarist" theory and a return to an earlier, liberal form of capitalism in which society relies on market mechanisms alone to revitalize the economy and regulate the production and distribution of goods. The monetarist policies of the 1980s turned out to be part of a global plan to reorganize the economy around the giant multinational corporations. This forced individual countries to compete for capital investment and led to unemployment and neglect of low-income people. Structural adjustment policies have been adopted by governments all over the world, in poor countries as well as developed. All are moving toward the form of capitalism that is repudiated by Catholic social teaching in general and Centesimus Annus in particular.     

The political divide in health care: a liberal perspective

U.S. health policy has been consumed by an ideological divide between conservative and liberal viewpoints. The liberal philosophy, based on both moral principles and utilitarian arguments, attempts to balance the needs of the individual with the concerns of the entire population. Elements of the liberal health care perspective include a belief that health care is an equal right of all people, the implementation of that right through a social insurance system that provides universal health coverage, equitable financing of health care, and a commitment to equality in health care.     

Protecting children's health. CHA's immunization program helps organizations increase vaccination rates in their communities

In response to the increasing outbreaks of vaccine-preventable diseases in the United States, the Catholic Health Association (CHA) has developed a new resource to help its members launch programs that will increase immunization rates among children in their service area. Vaccines are the building blocks of basic primary care. But society and the healthcare system have erected barriers that prevent children from being fully immunized. Impediments include missed opportunities, cost barriers, and facility and resource barriers. Catholic healthcare providers can help eliminate these barriers and ensure that all children in their service areas are vaccinated by assessing their immunization resources, seeking out unvaccinated children, and collaborating with community organizations and agencies. CHA's immunization campaign will guide Catholic healthcare providers as they protect children from preventable diseases. Immunization may help reduce the costs of emergency and acute care for conditions that could have been prevented.     

The right to healthcare: integrity, diversity, and territoriality

Examining some issues and challenges for ensuring the universal right to healthcare in Brazil, this paper explores the findings of a government project conducted in 2003 to broaden the approach to healthcare problems in Brazil, based on dialogs between government and society that supplement institutionalized approaches to social participation in healthcare management. Starting with an overview of the complex international backdrop against which government actions take place for implementing social rights, this paper highlights three issues among the problems listed that are rated as crucial for drawing up public policies: integrity and dignity as pillars for the organization and regulation of public interventions; recognition and respect for difference as a condition for achieving the right to healthcare; and territorialization of problems and policies for the production of responses to new realities. Finally, it lists some aspects that challenge Brazilian government and society in their efforts to guarantee the right to healthcare, affirming the timeliness of the steps taken by the government administration, moving steadily ahead towards effective universal access to this right through an appreciation of aspects related to human rights and citizenship.     

Public policy analysis]

This article presents to public health professionals concepts and perspectives from political science relevant for creating a healthier public policy. Currently, there is no uniform vision of what constitutes public interest and the decisions of public administrations tend to be based on compromise. In public debate, what is paramount is the capacity to persuade. From the perspective of public policy analysis, the crucial issue is definition: the final decision depends on the definition of the problem that has emerged triumphant in the public debate among competing actors with different definitions of the problem. From a policy analysis perspective, the problems entering the agenda of public administration does not necessarily correspond to their severity, as competing actors try to impose their point of view. Because of its historical evolution, the Spanish political system has specific traits. The relatively weak democratic tradition tends to make the decision process less visibles, with strong technocratic elements and weaker social articulation. Both the juridical tradition and liberal rhetoric portray lobbying as contrary to public interest, when in fact it is constantly performed by powerful vested interest groups, through both personal contacts and economic connections. Regulatory policies, with concentrated costs and diffuse benefits, seem to be moving from Spain to the European Union. To promote healthier public policies, the development of civil society initiatives and the building of coalitions will play an increasingly greater role in the future.     

Values and vision--CHA's plan for healthcare reform is based on two unique perspectives

The Catholic Health Association (CHA) Leadership Task Force on National Health Policy Reform has offered a proposal that, if enacted by Congress, would result in profound changes in the way providers deliver healthcare in the United States. The proposal would result in fewer acute healthcare facilities, challenge some acute care facilities to provide additional services and require each Catholic healthcare provider to collaborate with Catholic providers and others. Two features distinguish CHA's plan from the many other healthcare proposals that have been offered. First, CHA's plan is rooted in six tenets of Catholic healthcare. Second, the plan primarily focuses on client-centered delivery reform rather than on financing issues as other proposals have done. The task force believed it first had to create a vision of what the nation's future healthcare delivery system should look like. The task force decided that providers must do a better job of meeting clients' healthcare needs. To be a credible leader in the healthcare reform debate, the task force believes that CHA must offer a plan that primarily focuses on the needs of people and, second, controls costs effectively.     

Meeting mission challenges in IDNs. Through integrated delivery networks, organizations can continue their ministry and extend its reach

Whatever the final shape of healthcare reform, providers and sponsors are already collaborating with each other in various network arrangements. As they pursue these arrangements, they are asking questions about their role in a reformed system and whether the networks they participate in will strengthen their mission and ministry. Documents published about five years ago by the Catholic Health Association (CHA) and the Commission on Catholic Health Care Ministry provided the rationale for CHA's proposal to form integrated delivery networks (IDNs) as part of a national healthcare reform plan. The documents called for a continuum of care with comprehensive community- and institution-based services and challenged Catholic healthcare leaders to work for a healthcare system that guarantees access to the needy and most vulnerable in society. The central task for administrators today is to determine whether participating in an IDN enables Catholic healthcare providers to fulfill their original mission and purpose. To determine this, organizations must clarify their mission and evaluate their beliefs. They must also develop a shared vision of motives and goals among everyone with whom they collaborate. IDNs' success in furthering the healthcare ministry will depend on leaders' ability to ensure that new corporate cultures which arise in cooperative ventures and arrangements support Catholic values and mission. In making the transition to a new environment, leaders should remember that aspects of IDNs support many of the goals of the Catholic healthcare ministry.