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.     

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 To verify whether a party is a juridic person, Catholic healthcare providers must turn to historical documents.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.     

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.     

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.     

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.     

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.     

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.     

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.     

Care of the dying: a Catholic perspective. Part II: Social and political context--Catholic providers must exemplify a caring community. Catholic Health Association

Fears of abandonment and isolation in an institution have increased the public demand for euthanasia and assisted suicide. To quell this movement, Catholic healthcare providers must provide a caring community where patients and care givers enable each other to confront the fear of death and find support in living with human limitation. To begin to address the social and political dimensions of issues about the end of life, Catholic healthcare providers must use clear and consistent definitions of the terms used to describe these issues, such as death with dignity, right to die, euthanasia, allowing to die, and assisted suicide. By acknowledging the influence of the media in forming attitudes and opinions, healthcare institutions can seize opportunities for public education on fundamental human and religious values. The first effort has to be directed toward educating members of the media. The Catholic Church supports the concept of advance directives, which provide an opportunity for people to express their values and the ways they would expect those values to be honored in decisions about medical treatment. Courts' role in resolving decisions about treatment should be limited. Patient self-determination is best exercised when a patient (or surrogate), in consultation with a physician, decides what is best. Catholic healthcare institutions should advocate for legislation that fosters an appropriate balance between protecting a patient's right to self-determination and the state's interests to protect life. At the same time, institutions' advocacy efforts should demand sufficient resources for holistic care for the dying.     

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.     

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.     

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.     

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.     

Theology links Christian ministry with God's call

Catholic health care ministry originates in and is shaped by the theme of call in the Old and New Testaments. To be specifically Catholic, health professionals and facilities must define their ministries according to the values expressed in this theological tradition. Sponsorship. The opportunity to provide health care enables religious communities to contribute to God's ongoing creation process and to reiterate Christ's call to minister to others. Although health care facility sponsorship thrusts religious communities into the arena of big business, the abandonment of the health care mission could be considered a betrayal of evangelical values. Quality of life. The implicit concern for human dignity that distinguishes Catholic health care facilities should be evident in personalized patient care, just working conditions, and a commitment to healing in the civic community. Stewardship in ethics. The development of business policies and procedures and institutional responses to social change should be carefully considered in light of the Catholic understanding of loving covenant and the Christian way of life. Shared ministry. Health care facilities have played a leading role in implementing the Second Vatican Council's vision of ministry. Sponsoring communities' continued willingness to share responsibilities with laity will be imperative in meeting the health care demands of the future.     

Healthy communities: good mission, good sense. Holistic approach is the key

Catholic healthcare's mission is keeping people healthy, and providers must listen closely to determine their needs in these fast-paced, stressful times. In a society preoccupied with technology and acute care, which has the least overall impact on people's health, providers must implement more preventive strategies. The shift to promoting community health will require diverse, creative approaches. Catholic facilities must offer holistic healing, becoming community resources for children and the elderly. Religious institutes also must prepare for the laity's increasing role in the ministry. Providers must develop initiatives that define Catholic healthcare, such as the Welfare-to-Work Program in St. Louis, which offers women employment opportunities and benefits as a starting point to gain control of their lives. With increased school collaboration, nurses can help children develop good health habits. The guiding vision must be the health of the whole person and the community. Catholic providers must restore public trust and confidence by emphasizing person-centered healthcare. Only by becoming an integral part of the community can Catholic healthcare make a difference in people's lives.     

Alternative agendas. System priorities for the 1990s will differ from those of the last decade

The Sisters of Charity Health Care Systems (SCHCS) was established in 1979 in response to changes in the U.S. healthcare system and to new needs of sponsors and Catholic healthcare facilities. However, the agenda that SCHCS leaders (and leaders of other systems) set at that time must now give way to an agenda that will address the new challenges and responsibilities facing the Catholic healthcare ministry in the 1990s. In its first decade of existence, SCHCS established and fulfilled a number of goals: It strengthened governance relationships, helped systems and sponsors better identify with local communities, enabled facilities to steward resources more effectively, and facilitated members' understanding of mission and sponsorship values. In the 1990s, however, systems will have to create more opportunities for regional, collaborative, and networking relationships among member facilities and between members and non-members. To achieve this, they will have to reevaluate their structures, find ways to faciliatate collaboration, make resources available to institutions outside the system, and develop an overall philosophy that enhances both the fiscal and spiritual well-being of member facilities.     

Toward a just healthcare system

The U.S. healthcare delivery system is a patchwork nonsystem full of inequities, whose symptoms include the prolongation of the dying process, a lack of preventive care, and patient dumping. What can be done to make this nation's healthcare delivery system more just? The U.S. healthcare system should be modeled on the same underlying assumptions and justice-related values as the U.S. education system, a system based on need. Americans would find such a model psychologically acceptable because they are familiar with it, even though it is not perfect. Because they have the facilities and resources at their disposal, care givers must experience solidarity with all those who need care. The unity and solidarity of all creation is an explicitly Christian theme and is an appropriate value to emphasize with regard to compassionate healthcare. To establish a fairer healthcare delivery system, providers must consider their own Christian responsibilities and those of the Church, as well as the civic responsibilities of the government. If Catholic healthcare professionals do their part to change the status quo, Americans will be able to enjoy a fair system of healthcare delivery based on need, not on ability to pay.     

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.     

Network integration. A new vision for Catholic healthcare systems in the 1990s

The 1990s will be the decade of network integration for many of the nation's healthcare organizations. Catholic healthcare systems will have to refocus on local and regional healthcare delivery. To succeed in local and regional markets, the systems will have to offer various levels of care through numerous types of providers, share services among facilities, cooperate with secular organizations, and build stronger affiliations with local parishes. Managing this change (from offering fragmented healthcare services to offering integrated services) will be a major challenge facing organizations in the decade ahead. They must develop a clearly articulated vision to provide stability during this time of rapid change. To meet the challenges of the 1990s, Catholic healthcare systems will have to determine the types of functional sharing that will be beneficial at the local level, divest and transfer sponsorship of facilities that burden the system's mission, and expand the activities of the laity.