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.     

"Like shining from shook foil". A "virtuous organization" is prepared to treat both the body and the soul

The Catholic health care ministry is about mission, and the role of organizational ethical reflection is to encourage people in the ministry to think about the institutional performance and practice of medicine within a ministry of the Catholic Church. By engaging a creative process that identifies the needs of people served by Catholic health care, institutions are able to mediate the healing and redeeming power of Jesus, thereby creating virtuous organizations. To depict the mission of Catholic health care as an extension of the healing ministry of Jesus is to evoke explicitly Catholic theological language, and such language is appropriate because Catholic health care is a ministry of the Catholic Church. The church itself is the embodiment of the healing and redeeming ministry of Jesus, and the institutional ministries it has created over time need to bear witness to this fundamental reason for their existence.     

Catholic identity: realized in conversation

Catholic literature leaders must constantly engage the Catholic tradition, because it provides the framework for everything we do. The way they can do this is through conversation--discussion about the profound values and philosophical and theological assumptions that are at the heart of our ministry. Yet many healthcare boards and senior managers do not engage in such conversations. This is a serious omission, with potentially serious consequences. Too often mission and pastoral care values are regarded as separate from the business aspects of a healthcare organization. If we are to understand and integrate our mission into our healthcare work, this must change. The entire organization must make a commitment to foster an understanding of Catholic identity through conversation. As important as the dialogue is, some Catholic healthcare leaders let obstacles prevent them from delving into Catholic identity. They may not understand it, or they may be deterred by our cultural tendency to regard religion as personal, not part of the business realm. Some may be embarrassed, uncomfortable with abstraction, or reluctant to spend the time required. To encourage the conversation among Catholic healthcare leaders, we may take a lesson from our counterparts in Catholic education, who struggle with the same questions. A model Catholic university, where Catholic values are incorporated at all levels, may be a model for Catholic healthcare.     

For-profit and Catholic: how would the ministry fare?

Let's begin with Catholic identity. When is something entitled to be called Catholic in any official sense? I would suggest that there are three requirements. First of all, the entity must assert and claim its identity as Catholic by some sort of public declaration. By way of counter-example, in early 2012, a major West Coast health system renamed itself Dignity Health and asserted that it is no longer Catholic. According to Dignity Health's Jan. 23 press release, it is a "not-for-profit organization, rooted in the Catholic tradition, but is not an official ministry of the Catholic Church". Secondly, this Catholic identity has to be validated by Catholic Church authority, usually the bishop of the place, but sometimes by a dicastery in Rome. There is not really a formal procedure for this. Typically, a religious congregation founds an organizational ministry with the implicit, if not explicit, consent of the bishop and has it listed in the Catholic directory of     

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.     

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.     

A synergy of values. Catholic healthcare leaders must implement their organization's mission and model its values

Catholic organizations need to select, develop, and retain healthcare leaders who dedicate themselves to carrying on the Church's healing ministry and the work begun by those who have preceded them. Persons entrusted to carry on Jesus' healing mission perform their duties out of a sense of commitment to the ministry and a love for the persons with whom they work and whom they serve. They recognize a synergy between their own values and the values of the healthcare organizations they lead. Dedication to leadership in Catholic healthcare can be viewed from three perspectives: the Bible and selected documents of the Catholic Church; the transfer of responsibility for Catholic healthcare from religious congregations to evolving forms of sponsorship; and the implications for the selection, development, and retention of healthcare leaders, both lay and religious. Servant-leadership is an integral part of the religious tradition that underlies Catholic healthcare. As cooperation increases between healthcare providers, third-party payers, employers, and other healthcare agents. Catholic healthcare organizations are challenged to reassert a mission and values that will enable healthcare in the United States to be delivered both compassionately and competently.     

From ministry to market. Catholic healthcare can survive in an age of commercialization

Large, for-profit healthcare corporations now dominate hospital and physician services in many parts of the nation. Such organizations are under unrelenting pressure to produce profits; news stories show that these pressures can lead for-profits to engage in questionable, even illegal activities. Also, for-profits are unlikely to provide much care for the poor and uninsured. Unfortunately, Catholic providers have several disadvantages when competing with for-profits, and one is the fact that they do provide care for the poor. Catholic providers are handicapped also by: Problems with their geographic locations. Difficulties in creating partnerships with physicians. Lack of access to capital. Loss of political influence. On the other hand, Catholic healthcare providers have several advantages over for-profits. Among them are: A reservoir of public goodwill. Experience in forming networks The potential for prudent growth. A common vision. Access to Church pulpits. The influence of women and men religious Given theses advantages, Catholic health ministry leaders could boldly restructure their own organizations, and, in doing so, mitigate the commercialization of healthcare in the United States.     

Church law's role in collaborations. Principles to guide Catholic healthcare providers contemplating new arrangements

To ensure the success of collaborative arrangements between Catholic and non-Catholic organizations, Catholic providers are advised to look at Church law in canonical and civil documents and at the role of Church law in arrangements between parties. First, Catholic healthcare providers should identify persons subject to Church law as they become engaged in apostolic activities such as providing healthcare on behalf of the Church. They need to distinguish among physical persons, moral and juridic persons, and associations of the faithful and other persons. To verify whether a party is a juridic person, Catholic healthcare providers must turn to historical documents. When cooperative arrangements are made between parties, they must consider a number of elements of Church law if the work is to remain Catholic. These include acquired rights and obligations, administration of temporal goods, observance of moral teachings, and respect of applicable legislation. The law places no limits on the types of arrangements that religious institutes can enter into. However, when cooperative arrangements are being considered between Catholic and non-Catholic religious institutes, the moral issues involved must be taken into consideration. In such arrangements all parties should clearly determine beforehand common purposes, structures, and rights and obligations involved, so that there will not be any misunderstandings along the way.     

How to approach Catholic identity in changing times. Catholic Health Association of the United States

The Catholic healthcare ministry is at a challenging moment in its history. Not only is the ministry called to continue to be authentic to its own self, but the ministry also has the opportunity to communicate the richness and universality of its values to others. In response to our members' genuine concerns, the Catholic Health Association of the United States (CHA) has prepared this document to support our members in the expression of their Catholic identity in new forms of healthcare service.     

After the shaking stops. Catholic healthcare workers should prepare for seismic changes

In an attempt to cap spiraling costs and remain competitive, both providers and insurers are going through a frenzy of consolidation. Experts are predicting these changes: The integrated delivery system (IDS) will be the prevailing type of healthcare organization. There will be fewer acute care beds and fewer hospitals. Hospitals will be subsidiary to IDSs. Catholic and non-Catholic providers will join together to form IDSs. Regional IDSs will join statewide networks. The Catholic healthcare ministry can survive in such an era of consolidation if its leaders (1) collaborate with others on a basis of shared values, (2) have a well-defined mission, (3) provide holistic care, and (4) ensure that the organization remains true to its mission and demonstrates core values in its decisions and behaviors. Sponsors will need to find ways to share management of IDSs with non-Catholic organizations; to collaborate in the formation of regional and statewide IDSs; to urge other Church leaders to support social justice, human dignity, and community service; to be mindful of the stresses these changes will place on physicians and employees; to encourage dialogue about other changes in religious life; and to prepare laypersons to be their successors in the leadership of Catholic healthcare.     

Partnerships for the future. A new vision for the Catholic healthcare ministry

Collaboration among healthcare providers will help them more effectively meet the needs of their communities in the 1990s. San Francisco-based Catholic Healthcare West (CHW), formed in 1986, strives to provide high-quality healthcare by collaborating with Catholic and non-Catholic providers. CHW leaders believe that Catholic providers make ideal partners; however, they have found that Catholic healthcare providers often must look outside the Catholic healthcare ministry to find these partnership opportunities in order to remain viable and effectively carry out their mission. Besides system-to-system or hospital-to-hospital linkages, collaboration is also achievable with other types of healthcare providers, such as physicians. In collaborations between Catholic and non-Catholic healthcare providers, Catholic providers must strive to maintain their Catholic identity. When evaluating potential partners, they must consider issues such as corporate culture, organizational compatibility, and sponsor influence. CHW leaders believe that for any merger or affiliation to be successful, it must clearly produce market and financial advantages for the new partnership and offer the community a significant improvement in quality of care and services.     

The mission imperative: our foundation and market advantage

Simply put, MISSION means being sent as Jesus was sent to be a presence of radical healing in the world on behalf of the kingdom of God. Our capacity to sustain Catholic healthcare as a ministry of the Church depends on our realization that all our activities must flow from the core of who we are, that is, from our spirituality. Thus MISSION requires certain attitudes and behaviors, including that we reach out to all persons in need, that we be immersed in the world, that we be prophetic, and that we express the kind of love that led Jesus to give his life. As ministry, we must provide witness as well as service because of the call to be MISSION in the world is also the call to build up the kingdom of God within. Several basic committees lie at the heart of who we are: supporting the dignity of all persons, caring for the poor and vulnerable, building up the common good, and practicing responsible stewardship. Changes within the environment and within the ministry itself present some potential perils but also great opportunities. For example, although managed care, when misused, is a flawed system, it is also has possibilities that are very consistent with ministry values and commitments, forcing us to look at the needs of communities, not just individuals. The requirements of MISSION should also be understood as ways to gain market advantage. Unless we have sufficient advantage in the markets where Catholic health ministry is present, our capacity to effectively transform the present reality on behalf of God's kingdom will be limited.     

Healthcare and social responsibility. The revised directives clarify the Catholic position

The Catholic Church participates in the U.S. healthcare system by reason of its contribution to the common good of society. To facilitate this, the Ethical and Religious Directives for Catholic Health Care Services set forth certain normative principles. Catholic healthcare is dedicated to promoting human dignity and the sacredness of life; it has an "option for the poor"; it seeks the common good, cooperating with other providers toward that end; it prohibits abortion, in vitro fertilization, contraceptive sterilization, and assisted suicide procedures in free-standing Catholic healthcare institutions. This article focuses on the directives in Parts 1 and 6 of the ERD. Directive 2 calls for mutual respect among care givers. Directive 3 discusses ways to care for people "at the margins of society." Directive 4 describes the medical research permitted in Catholic facilities, and Directives 5 and 9 suggest how such facilities can best perpetuate their Catholic identity. Directive 7 mandates that Catholic facilities treat employees justly. Directive 8 says that such facilities must observe canon law in transferring sponsorship or in founding, closing, or selling an institution. Directive 68 suggests that the bishop be involved in a proposed partnership that may infringe upon Catholic identity. Directive 70 urges Catholic facilities to avoid scandal, and Directive 69 warns that some forms of cooperation are unethical even when scandal is not present.     

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.     

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 better approach to care of the dying. Catholic healthcare and the Catholic community can present an alternative to physician-assisted suicide

To combat physician-assisted suicide, Catholic healthcare and the Catholic community cannot solely focus on mounting campaigns and formulating policies. They must also demonstrate an alternative way to approach death and care of the dying, taking a leadership role in improving end-of-life care. To accomplish this, Catholic healthcare must foster a culture that recognizes death as the inevitable outcome of human life and makes care for the dying as important as care for those who may get well. The ministry must acknowledge the limits of human life, human abilities, human ingenuity, and medical technology; and respect decisions to forgo life-sustaining therapies. In addition, physicians must address advance directives with patients before hospitalization and must be willing to offer hospice care as an option to dying patients and their families. More effective pain management must be devised. Catholic facilities must develop palliative care policies and commit to ongoing education to provide such care. It is essential that they pay attention to the environment in which patients die; identify the physical, psychosocial, and spiritual needs of family members; and use prayer and rituals in meaningful ways. With a clear focus on improving end-of-life care, Catholic healthcare--in partnership with other denominations--can eliminate some of the factors that can make physician-assisted suicide seem appealing to suffering people.     

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.     

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.     

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.