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.     

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.     

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.     

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.     

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.     

The transition to regional networks. Changes in reimbursement and approaches to care favor cooperative arrangements among providers

As costs escalate and the delivery system becomes more fragmented, organizations throughout the United States have begun to call for basic reform of the healthcare system. Several national organizations, including the American Hospital Association and the Catholic Health Association, have presented working proposals advocating coordinated regional healthcare delivery systems. The proposed networks would provide a full continuum of services from prevention through aftercare and long-term care, and from primary through tertiary care. In the past few years, providers themselves have begun to see the value of cooperative efforts. Collaborative ventures such as group purchasing and sharing mobile equipment have increased as hospitals look for ways to reduce costs and control overhead. Mergers and affiliations are also becoming more common. As they develop, different networks will allow for various kinds of interrelationships among components. In general, these systems will provide high-volume, low-cost services at a number of sites and low-volume, high-cost services at a central location. Secondary and tertiary campuses will focus increasingly on specialty care, and as volume increases at primary campuses, secondary and tertiary organizations will establish more primary affiliations. To make the transition from a competitive to a cooperative healthcare delivery system, providers will have to reexamine their mission and values and, in many cases, refocus their vision of the future.     

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.     

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.     

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.     

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.     

The modern association. Preserving a Catholic presence in the U. S. healthcare system

A leader in U. S. Catholic healthcare since 1915, CHA has helped Catholic hospitals meet the challenges of the standardization movement, the Depression, and two world wars. The fifth Health Progress article on CHA's history (June 1990) described the association's postwar emergence as a service organization under the leadership of Rev. John J. Flanagan, SJ. This article, the last in the series, charts CHA's response to the revolutionary changes within Catholic healthcare brought about by the Second Vatican Council and the passage of Medicare. It recounts the struggles within the U.S. Catholic healthcare community to sustain its Catholic identity, as well as the community's increased presence as an advocate for a just healthcare system. In the spirit of the institutes of women religious who established the Catholic healthcare ministry in the United States, CHA enters the 1990s committed to advocating for universal access to healthcare and enhancing its members' ability to serve the poor and vulnerable.     

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.     

Congregation transfers its healthcare system. Franciscan Sisters of Little Falls list critical factors for a successful transfer of sponsorship

In 1993 the Franciscan Sisters of Little Falls, MN, transferred ownership and sponsorship of their 12 healthcare facilities to Catholic Health Corporation of Omaha. The sisters had had two goals from the start of the process: To transfer the facilities to another Catholic system, and in such a way that both members of the religious institute and the facilities' personnel would "own" the decision To complete the transfer with minimal upheaval in facility operations The sisters accomplished both of these goals. They attribute their success to prayer and several critical factors. First, having pondered their healthcare ministry in light of their Franciscan tradition, the sisters decided that a larger system could better meet their facilities' needs. Second, they developed a set of criteria for the new sponsor, including the requirement that it be both Catholic and dedicated to rural healthcare. Third, the sisters became willing to take the risks a transfer involved for both their congregation and the 12 facilities. Fourth, the sisters clearly communicated their decision to everyone affected by it. Fifth, they sought the help of experts in making the transfer. Sixth, they worked hard to create trust, so that all involved--including those who would lose their jobs--took ownership of the transfer decision. After completion of the transfer, each of the facilities held a ritual celebrating the friendships and respect built over the long years the Franciscan Sisters were their sponsors. The sisters held their own ritual of commemoration. They continue their ministries in health, education, social services, and pastoral care.     

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.     

A journal of community. Catholic healthcare providers' presence is necessary to sustain a values-based system

Catholic healthcare leaders must use all their will and creative imagination to find a way to maintain a significant Catholic presence in healthcare. Catholic healthcare leaders across the nation are acquiring, consolidating, and merging hospitals; forming alliances and networks of integrated services; and bringing together Catholic healthcare systems on a regional and local basis. The next few years are critical for Catholic sponsors of healthcare services. The unique challenge is to pursue the development of a Catholic network that would include a wide range of health, mental health, home care, long-term care, social, and housing services. The key ingredient to making networks happen will be leadership, and I think CHA and sponsors rightly emphasize the need for continuing leadership formation and development of trustees and executives in Catholic healthcare. A united effort by Catholic healthcare providers could have a penetrating influence on the overall development of healthcare in this nation. Now is the time to exercise imaginative leadership; to reach out to the existing Catholic and community-based providers of health and human services; and to create networks that can provide a continuum of accessible, high-quality, values-based, and cost-efficient services.     

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.     

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.     

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.     

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.