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.     

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.     

The rights debate

To date, no proposal for systemic healthcare reform directly addresses whether healthcare is a right for all Americans. In fact, some proposals have avoided the issue altogether. Typically, proponents of reform have been more comfortable approaching healthcare services as something society has a moral obligation to provide rather than something individuals have a right to. Such an approach is consistent with the liberal democratic tradition's understanding of rights, which stresses individual freedom and autonomy. According to the Catholic social teaching of the past century, however, the right to participate in society takes precedence over the right to be free of governmental intrusions. From the Catholic perspective, furthermore, lack of access to healthcare is tantamount to being denied full involvement in social life. This tradition has stressed repeatedly that each individual achieves dignity and fulfillment only by being actively involved in the social world. In debates over systemic healthcare reform, it is imperative that advocates of the Catholic perspective recognize the difference between the meaning of "rights" as it has developed in their tradition and the meaning that has emerged from the context of the liberal democratic tradition. Their challenge will be to give the debate's key term a meaning that better reflects the tradition of Catholic social teaching.     

Preserving Catholic identity in mergers--an ethical and Canon Law perspective

A merger or joint venture between a Catholic healthcare facility and a non-Catholic healthcare facility that provides procedures the Catholic Church believes to violate moral principles raises a number of issues to be considered by diocesan bishops. The 1983 Code of Canon Law provides bishops with guidelines to help establish the Catholicity of a Catholic hospital that has affiliated with a non-Catholic hospital. The diocesan bishop exercises his authority through a threefold ministry of teaching, sanctifying, and governing. These ministries stand as a reminder of his decision-making authority in matters that affect the spiritual state and growth of those entrusted to his care. Catholic identity, as it is presented in the Code of Canon Law, can be determined through the presence of a relationship between an institution and ecclesiastical authorities, the legal establishment of the entity, and a degree of control that the Church exercises over the institution. When evaluating a possible merger of joint venture between a Catholic hospital and a non-Catholic hospital that is performing procedures not in accord with Catholic Church teaching, the diocesan bishop must consider what limits must be observed. The good effects of the affiliation must be intended and direct, and the harmful effects must be perceived as unintended and indirect. The difficulties in determining and protecting the identity of Catholic hospitals in possible mergers or joint ventures should not prevent facilities from considering alternative forms of corporate structures. The Code of Canon Law and the Church's ethical teachings provide guidelines to ensure these possibilities.     

Working for the common good. Catholic healthcare's opportunity to shape values-based managed care

Managed care has come under fire lately, and states and the federal government have stepped in to regulate some plans' deficiencies. Some say regulation is not enough; managed care is morally flawed. But the evils of managed care are the result of letting it be shaped solely by market-driven forces rather than mission-driven values. In the Catholic tradition, healthcare is part of the common good. Viewed in this light, managed care becomes more than just a way to control costs. For managed care to serve the common good, we will have to collaborate with other providers that demonstrate a commitment to human life and dignity that is similar to our own. Such collaborations may force us to negotiate (without compromising) our values, but this gives us the opportunity to recognize a hierarchy of goods to be pursued and evils to be avoided. Through our involvement in managed care, we can help shape the greater culture, as well as the culture of healthcare. But we must prioritize our commitments according to values and principles grounded in the Catholic moral tradition. Without these values to guide us, Catholic healthcare will lose its identity and fade away.     

Catholic Identity and Charity Care in the Era of Health Reform

Catholic healthcare institutions live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all, and financially sustainability. Within this tension, the question sometimes arises as to whether it is ever justifiable, i.e., consistent with Catholic identity, to place limits on charity care. In this article we will argue that the health reform measures of the Affordable Care Act do not eliminate this tension but actually increase the urgency of addressing it. Moreover, we will conclude that the question of limiting charity care in a manner that is consistent with the obligations of Catholic identity around serving the poor and vulnerable, promoting the common good, and remaining financially sustainable is not a question of if, but of how such limits are established. Such limits, however, cannot be established in light of one overriding moral consideration or principle, but must be established in light of a multitude of principles guiding us to a holistic understanding of the interrelatedness of the moral dimensions of Catholic identity.     

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.     

Social justice in a time of crisis. Catholic tradition offers creative ideas for solving the problems of healthcare costs and access

In this moment of crisis, Catholic healthcare leaders must seek root causes and thorough solutions to the pressures of rising costs and the grave question of access to healthcare. The first question is whether the system can be fixed or if a more radical approach is needed. To reach a solution, government, business, hospitals, and physicians must sit down at a common table to debate the issue. In 1981 the bishops outlined a series of values or principles that should characterize the U.S. healthcare system, including treating the whole person and providing access for all. These values have characterized Catholic healthcare facilities in the past decades and should not be lost in the present crisis and in the decisions being made for the future. Today, Catholic healthcare leaders have a broadened understanding of Catholic identity and the need to continually probe what that means. They realize Catholic identity is more than a few moral codes; it is a broader concern about the way in which healing takes place. Another gain is the development of lay vocations, but these are often restricted and should be more fully developed. In conjunction with this concept, we need to see hospitals as belonging to the whole Church in terms of its mission and thus the responsibility of the entire body of believers. Finally, a new image is needed concerning how care is provided. We need to bring prevention and care closer together, preventing duplication of major services and making certain basic services available to all.     

Who really wants health care justice?

U.S. health care is at a crossroads. It faces many challenges--the most evident being unsustainable cost increases and diminishing access. For decades, attempts at reform have been unsuccessful. One reason our traditional approaches have not worked is that we who serve the ministry have not brought to those efforts sufficient reflection concerning the deeper, values-level attitudes concerning reform. Instead, the reform movement has concentrated on promoting particular policy solutions. Ultimately, of course, we must agree on a delivery and financing system if we are to redress the situation. But first we must recognize that U.S. health care's fundamental challenge is moral and social in nature. Stakeholders will not let go of the status quo until a critical mass of people becomes convinced that there is a serious moral and social imperative to do so. Social change of this magnitude is not simply a matter of comprehensive new policy. To be effective, it must be accompanied by sustained individual and public conscience work that grounds a significant social movement comprising a critical mass of each of those stakeholders. Several principles from the Catholic tradition--the common good, solidarity, and stewardship--are particularly relevant to the individual and public conscience work necessary in the health care reform movement. Health care professionals and organizations are simultaneously part of the solution and part of the problem. By keeping this interior dialogue alive, in ourselves and in our work communities, we are much more likely to get at the root causes of our unjust health system and to contribute to the larger social movement that brings about more health care justice. This article contains a "conscience work exercise" that will help individuals and organizations examine and identify the values, attitudes, and dispositions that contribute to health care justice and those that keep us mired in the status quo.     

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.     

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.     

Catholic theology and the "right to die"

Catholic moral theology teaches that life is sacred but not absolute. Because life and all activities are subordinated to spiritual ends, it is moral to allow oneself to die when efforts to prolong life will bring no significant benefit and may even make it more difficult to finish life in peace, composure, and union with God. This is not the moral equivalent of suicide, but rather an acceptance of the human condition. In making such a decision, the distinction between morally ordinary and extraordinary means is crucial and based on the patient's total good. Ordinary means are those which offer a reasonable hope of benefit without excessive expense, pain, or other inconvenience. Extraordinary means are those which cannot be obtained without excessive burden or which, if used, would not offer a reasonable hope of benefit. Whether a medical procedure is standard or experimental does not, from a moral viewpoint, affect whether it is ordinary or extraordinary. In Catholic teaching, the patient has the paramount right to decide whether life-preserving measures will be used. If the patient is unable to make this decision, then the family should make it as the patient's representative.     

The virtuous manager. Renewing the experience of work

In healthcare, as in any other field, work can become dehumanizing, meaningless drudgery. But good managers can transform their organizations and renew the experience of work. Good management demands not only good business skills, but character, rooted in truthfulness and vision. Three virtues are particularly important: prudence, justice and fortitude. The moral skill of prudence enables healthcare managers to know what is to be done; justice creates honest relationships; and fortitude enables managers to seek a good that is difficult to achieve--to do the right thing. Businesses must also explore their potential for sacramentality and find ways in which employees--and employers--can become better, holier people through their work. Organizations should strive to achieve subsidiarity and keep employees well-informed of their missions. Establishing a sense of connectedness is important, as is open and honest communication. Finally, managers-and healthcare organizations-must always work for the common good.     

A new role for the Church. Dioceses should do more in providing care for dependent and dying persons

In 1988, with the publication of Catholic Health Ministry: A New Vision for a New Century, the Commission on Catholic Health Care Ministry called on the Church to redefine its healing mission in society. Unfortunately, despite various efforts, the Church has not yet fully articulated a shared vision of Catholic healthcare, healing, and support. Healing human brokenness has always been the Church's work in the world, whether the brokenness be physical, emotional, intellectual, moral, or spiritual. The Church, having a broader definition of brokenness than that of the larger healthcare system, must sometimes act as a countercultural critic of that system. Two of the great challenges facing healthcare today are providing care for dependent persons (people with chronic illnesses and older people) and for dying persons. In both cases, much more coordination of the various actors is needed. The Church could ensure that this coordination is carried out. In each diocese, the bishop should organize a pastoral health and social service planning group to assess community needs and apply Church resources to them. Local Catholic healthcare providers and social service agencies should develop a corporate culture of healing and support. Parishes should accept the idea that healing and supporting frail people are integral parts of parish life.     

Persistence and pain. Women and healing in the Gospel offer insights to Catholic healthcare providers

Scripture can enlighten us on the difficult times Catholic healthcare providers face today. Two stories from Mark's Gospel offer helpful insights to persons engaged in the institutional context of healing. These stories are of the woman with the "flow of blood" (Mk 5:25-34) and of the Syro-Phoenician woman (Mk 7:24-30). The women were determined to receive the healing they needed. They went for it, and got it, despite considerable obstacles. I suggest five insights we might draw from these two narratives of healing. These women were persistent. Sometimes it takes a great deal of persistence to find God in all the ordinariness, the numbing everydayness we encounter in our daily work. Like these women, the healing you seek for those you care for takes place in a hostile world. Catholic healthcare institutions themselves face some hostility from other institutions. The stories remind us that we must feel our own pain and that of others. The capacity to hurt and to feel the hurt of others helps us persevere in the face of this hostile world. Both women did what others could--and should--have done for them. Each of these women found in herself a place of strength she could draw on. This place of strength is the presence of God. I hope that Catholic healthcare providers are aware of God's presence in them and in those to whom they minister. I hope they work against the "quick-fix" mentality of much of modern healthcare and modern consumerism. Catholic healthcare recognizes the sacramentality of life on earth, struggling always to find the God who is revealed where we least expect her.     

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.     

Workplace diversity: a leadership challenge. Managing diversity is a social, financial, and moral imperative

Fostering workplace diversity is about building an organizational culture that embraces personal differences and encourages heterogeneous persons to work together toward a common end. Setting in motion the transition to a more inclusive and productive workplace is an uncommon challenge and the primary responsibility of leaders, especially in Catholic healthcare. The origins of diversity can be found in creation itself. Not only are we united as a people of God and as members of the body of Christ, we are bound together through our shared humanity. Three values are especially relevant to promoting diversity in the workplace: respect for human dignity, the common good, and distributive justice as participation in the common good. Economic incentives strengthen the theological and moral motives for developing a diverse work force. Organizations' financial success will depend ultimately on how well diversity is integrated into the organizational culture. As a process, managing diversity enables healthcare leaders to discover new ways to develop the potential of all employees and at the same time improve performance and production. At the heart of managing diversity lies the reform of internal systems, structures, and processes. Managing diversity also requires the transformation of the organization's culture. Initiatives that are useful for setting a positive future course include conducting a cultural audit, establishing a cultural diversity task force, and putting in place a diversity "champion" who is accountable directly to the chief executive officer.     

Philosophizing social justice in rural palliative care: Hayek's moral stone?

Increasingly, palliative care is being referred to as an essential programme and in some cases as a human right. Once it is recognized as such, it becomes part of the lexicon of social justice in that it can be argued that all members of society should have access to such care. However, this begs the question of how that care should be enacted, particularly in rural and remote areas. This question illustrates some of Friedrich Hayek's critiques of social justice. Hayek has likened social justice to a 'moral stone' arguing that social justice is meaningless to the extent that society is impersonal and as such cannot be just, only those individuals who make up that society can be just. When responsibility for justice is assigned to an impersonal society, ideas of social justice can become a clarion call for whom no one is directly accountable. This opens the door for questionable macro-level political agendas that have no capacity to enact the ideal, and worse, may suppress individual moral acts towards the desired end. Further, acts of interference at the macro level with the ideal of equal opportunity run the risk of disadvantaging other members of society. Instead, he has argued that a better approach lies in finding ways to induce and support individual moral acts that promote the human good. Hayek's arguments are particularly compelling for rural palliative care. In this paper we draw upon data from an ethnographic study in rural palliative care to illustrate the potential misfit between the ethical ideal of palliative care as expressed by rural participants and the narratives of social justice.     

Strong Catholic identity key to effective health care apostolate

Catholic health care facilities must define what it means to be human and what it means to be Catholic before confronting current moral and ethical issues.     

Health reform: what to expect from the coming debate. Interview by Jeannie Mankelker, Dan Wise, and Steven Findlay

Health care reform is in limbo as 1994 draws to a close. Last month's Republican sweep puts the issue in a starkly new political environment. The new Congressional leadership said last month it will put forth a reform plan in 1995. Also, the Clinton administration is working on a scaled-back proposal. To get an idea of what might happen next year, we invited 20 informed persons to give us their opinions and to tell us what action they'd prefer. Because of B&H's production schedule, the interviews took place before the election. We don't think that diminishes their insights and analyses.