Catholic Health Care Institutions:

Dinosaurs Awaiting Extinction or Safe Refuge in a Culture of Death

Margaret Monahan Hogan

McNerney-Hanson Professor of Ethics

University of Portland

Christian Bioethics

2001, Vol. 7, No. 1, 163-172 # Swets & Zeitlinger

Health care institutions in the United States are beset by many challenges, some of which are economic, some of which are political, and some of which are ethical. Among the economic pressures are insufficient levels of reimbursement from government or other third party providers, the reluctance of patients who now perceive themselves as "fully covered" to pay out of pocket for health care, the ever-increasing cost of the delivery of high-tech medicine and demand for ever-higher, occasionally obscene, levels of compensation by physicians, especially physician employees. Among the political, political as broadly construed, are the competing claims of the efficiency, efficacy, and appropriateness of the federal government as sole provider of health care as opposed to the similar claims of the free market to provide health care through for-profit managed care systems. Among the ethical are such problems as the appropriate use and just distribution of medical technological advances, what counts as disease to be ameliorated by medicine, the withdrawing and withholding of treatment that is no longer beneficial, the continuation of treatment that is beneficial, the rationing -- precipitated by infinite need in the presence of finite resources -- of potentially beneficial services.

Catholic health care institutions are beset by those same concerns and may, over time, be overwhelmed by those economic, political, and moral forces. However, if Catholic health care institutions should survive, they face an additional set of challenges that derive from their special mission and identity. Now, in the not too distant past, mission and identity were something that Catholic hospitals, as they were called way back then, just had. Catholic hospitals existed as a sign and reality of the presence of a living and rich tradition. While the hospitals operated within the American landscape, they were, and were perceived, as rather different, perhaps even alien, from the surrounding culture and its values. That rich and living tradition viewed human life as a journey through this "vale of tears" that reached its final terminus through the door of death to arrive at joyful union with God in the beatific vision. Suffering and death were considered the lot of every human born of woman, yet life and sickness were patiently endured in faith and in hope. The source of that faith and hope was centered in a robust grasp that our incarnate God took upon Himself our human nature, lived, suffered, and died in expiation for our sins, rose from the dead and returned to a loving Father Who now awaits us. This tradition shaped our expectations and our institutions, especially our hospitals. We acknowledged, not just as an abstract concept, but as lived reality, that we are finite creatures destined in our corporeal nature to die and invited in our spiritual nature to salvation to be had in the embrace of the cross. Catholic hospitals accepted the vocation of ministry to a people thus constituted and committed. There were certain things peculiar to Catholic hospitals -- women in white religious garb, black-suited, Roman-collared priests flowing in and out all morning, physicians and nurses Catholic in practice and profession, crucifixes, holy images, and continuous prayer. And there were certain things forbidden in Catholic hospitals -- abortion, contraception, sterilization, mercy killing, and meat on Fridays.

Some of these signs and realities are now close to extinction and with the loss of some of the visible markers, the visibility of the mission -- and perhaps even the viability itself -- of Catholic health care has diminished. The redirection of a significant number of Catholic women in the post-Vatican II Church away from nursing in the hospitals and teaching in the schools founded and sustained by the remarkable service of religious orders of women to "more meaningful" ministries has had a significant impact on the spirit and the structure of those institutions. (The departure of lay Catholic women from the roles of wife and mother for "more meaningful" jobs in the market is similarly not insignificant.) Furthermore, the assimilation of Catholics into mainstream American culture, both by adoption by Catholics of the values of the culture -- faith as quarantined in privacy, freedom and choice as absolute and as right making, individual autonomy, and personal sovereignty -- and by the shedding by Catholics of the truths of the tradition -- that the object of belief is truth, that the only true freedom is effective freedom, that choice must be right choice, that our lives are lived in real dependence on one another and in radical dependence on God -- may have diminished the perceived necessity for the continuation of a distinctive set of health care institutions. Perhaps Catholics have been co-opted by the comfort and lure of the culture. Perhaps the economic, social, and political successes experienced by so many American Catholics have eclipsed the dedication to religious understanding and commitment.

In response to the exigencies of the contemporary moment, Catholic health care institutions and the Catholic Health Association have mounted several initiatives. The response to the economic pressures propelled the nisus toward mergers and operational effective alliances, appeals for better levels of reimbursement, and advocacy directed to governmental agencies on behalf of the poor. The response to mission and identity issues precipitated an introspective moment occasioning the press to examine their mission, to articulate identity through explicit mission statements, and to activate processes to internalize the meaning of those mission statements. Neither the economic initiatives nor the identity and mission initiatives are unproblematic. And neither will be successful without unified and sustained effort.

The Catholic Health Association in its strategic plan, begun in 1999 and projected through the year 2002, claimed a specific role for itself and identified four strategic directions for the organization and its member institutions. The new role to, "unite members to advance selected strategic ministry issues that are best addressed together rather than as individual organizations," affirms the reality of the need of a sufficiently large group to make an impact and the need of the reality to have intermediary organizations transposed between the individual qua individual possessed of very limited resources and the mega-powers of contemporary society. The four strategic directions are (1) Catholic identity, (2) health policies and initiatives, (3) church relations, and (4) ministry innovations. While all four are important, the first is essential, inasmuch as it forms the matrix which nourishes and directs the others. The first is rich and multifaceted. It cannot be contained in a simple mnemonic and it cannot be contained in a set of vague and general statements without ongoing proclamation, explication, and reflection. Hence the identity issue will be the central focus of the remarks that follow. The others will be addressed only within identity development.

Catholic health care institutions as Catholic accept as the core of their identity and directive of their practices the life of Christ and the creative providential action of a loving God. Acceptance of these core notions requires their proclamation and articulation as well as actualization in practice. Their proclamation provides a bold statement of love and commitment in a world groaning in a culture of killing and abandonment. Their proclamation recalls some central truths of our existence including the truth that we are God's creatures fashioned in a particular nature with minds and bodies to know, to love, and to serve God. Failure to make that proclamation is a kind of denial; it is to say, "I swear I do not know that man" (Matthew 26: 72). Failure to make the proclamation risks the possibility of forgetfulness that diminishes internal institutional purpose and the loss of the external role that acts, to use the words of Fr. Kevin O'Rourke, O.P., who has been a towering figure in Catholic health care ethics in the USA, as "leaven . . . by offering health care in accord with the example and teaching of Christ" (2001, p. 2) and acts to penetrate "secular society with the healing spirit of Christ" (p. 4).

The healing ministry of Christ is part of the identity of Catholic health care institutions and they rightly cite that activity of Jesus "to heal as Jesus healed." Examples abound in the scriptures, including the healing of the leper, the servant of the centurion, and the mother-in-law of Peter, the restoration of sight and speech and mobility. Yet, Jesus as healer of physical illness is just one dimension of His healing ministry. His radical healing ministry extended beyond the healing of bodily infirmity. He healed those who suffered from sin as well as those who suffer from physical infirmity. He drove out demons and forgave sinners and condemned hypocrisy. A health care institution worthy of the name Catholic would, through the continuous presence of clergy, as well as a full complement of medical practitioners, keep alive the multi-dimensional healing that our fallen human nature requires.

However, healing of physical illness is not always possible. Furthermore the exclusive focus on healing is too narrow and too exclusive a center. It is to buy into the Promethean myth of modern medicine that offers the promise of human salvation in more and better medicine. Jesus healed but he also suffered and died. Here Catholic health care institutions have special obligations because of the Jesus revealed in Scripture. Catholic health care institutions must be places of caring for the dying that is inevitable. And here they must offer visible witness to the truth of the finitude and promise of human existence. In His suffering and dying, Jesus, from the depths of His humanity, called out for consolation. In Gethsemane, He asked to be rescued, "My Father . . . take this cup of suffering from me." He revealed to His friends His grief and anguish. He said, "The sorrow in my heart is so great that it almost crushes me." He asked them to stay with Him and He is sorely disappointed by their failure to remain with Him. He experienced abandonment and, close to the end, He cried out to His heavenly Father, "Eli, Eli, lema sabachthani." And, at last, He placed Himself into His Father's care. Catholic health care institutions have to be places and have to provide services and spaces within which human beings who are experiencing crushing sorrow, anguish, and abandonment will find in attendance caring people to touch, and wash, and anoint their bodies, attentive people who do not turn away from them, loving people whose simple presence sustains them, and faithful people who do not abandon them in their dying.

In healing the sick and caring for the dying, Catholic health care institutions must provide living witness, simultaneously, to respect for the sanctity of human life and acknowledgement of the transcendent end of human life. The direct destruction of innocent nascent human life hidden under such euphemisms as "pregnancy termination," "selective fetal reduction," or "beneficent killing" must remain proscribed. With this forbidding comes the obligation to offer succor to women in a manner which respects the dignity, the intelligence, and the moral strength of women, even as they may be experiencing a temporal and particular vulnerability. Rather than leave her in privacy, she needs to know and to be welcomed into a community of care. When a woman is pregnant, she knows she is with child. If, within the contemporary horizon this truth is being hidden from her, Catholic health care institutions ought to speak this truth publicly and often in order to contribute to the recognition of women as moral agents to whom the truth is owed. The brute fact of more than a million abortions a year in the USA suggests the societal fabrication of a kind of amnesia in regard to the reality and life of the conceived but unborn human being.

There may be no direct killing and no prolongation of dying in Catholic health care institutions. The exact and powerful conceptual tools, such as the distinction of extraordinary care from ordinary care, developed in the Catholic philosophical and theological tradition, must be applied with resolute firmness. We need to affirm the goodness of the gift of life and the goodness of its end. It is, perhaps, in our dying that we experience, finally, our nature as created beings. Fr. Richard McCormick, S.J. sketched out a careful path for us here. In his words and in his living to the very end, he reminded us frequently that dependency, whether from age or illness, is a call to cling to the power of God. He, when speaking of physician assisted suicide as an act of isolation and abandonment, said, "rejection of our dependence means ultimately rejection of our interdependence and eventually of our very mortality" (1991, p. 1133). And when he addressed the issue of the cessation of no longer beneficial nutrition and hydration, he reminded us that we as a people who say we believe in life after death ought to act as if we actually believe that (1992, p. 214). He warned us, too, that failure to attend to these distinctions and failure to use the intellectual tools and concepts of the tradition might force people who desire to hold to the tradition to flee it. He recalled in the pages of this journal the words of Dr. André Hellegers, who in 1979, just before his own death, warned us about the inevitable consequences of the displacement of the traditional caring task by the curing goal. Hellegers said, "as the caring branches of medicine were gradually pushed aside by the curing ones, there seemed to be less use for the Christian virtues. I think that shortly the need of those old Christian virtues will return and once again be at a premium. Our patients will need a helping hand and not a helping knife . . . We must either recapture the Christian virtues of care or we shall be screaming to be induced into death to reach the discomfort free society" (quoted in McCormick, 1995, p. 101). The time is at hand.

On these two issues of abortion and mercy killing, Catholic health care institutions ought to continue their powerful witness and absolute prohibition. They will find many allies, if they are willing to disturb the false peace fashioned by the euphemism of "compassionate killing." They and their allies may be the agents in the reversal of the culture of death by faithful, prayerful, patient building brick by brick, truth by truth, witness by witness of communities who strive to love each other as God loves us.

Life issues, and having excellent health care is a life issue, need to be carefully distinguished from reproductive issues. The asserted necessary connection between contraception and abortion, as the direct destruction of the conceived but unborn human being, seems a tenuous claim. While a contraceptive mentality, a mentality that sets the mind and heart against the good of procreation, may be factually linked to the procurement of abortion, there is no such necessary link between contraception itself and abortion. The inability to make this distinction, on occasion, has impeded the completion of mergers of health care institutions whose co-operative might have provided more effective and more efficient health care to communities and has, on many occasions, impeded the work of the work of the pro-life movement to advance their case as a civil rights movement. The untangling of this Gordian knot needs careful attention by Catholic scholars, academicians and medical practitioners, lay and ordained, and men and women. Its resolution will be found only in the careful articulation of the nature of marriage and careful specification and delineation of the goods to be accomplished within marriage. It will require openness to the question of the appropriate moral referent in marriage so that the goods of marriage may be properly ordered. Failure to continue to unwrap the realities contained in the mystery of marriage is to reject, out of fear, two gifts -- the gift of marriage and the gift of intellect. The Catholic identity of health care institutions is tied to the authority of the Church -- its teachers and its doctrines. The hierarchy has an authority, bequeathed to it by Christ, to guide the faithful. And Catholic health care institutions have strong responsibilities to operate within the ambit of that authority. Nonetheless, as health care institutions, Catholic health care institutions are subject to other authorities, the most significant of which is the authority found in the art and practice of medicine. Authority exercised rightly recognizes the power of the dialectical tension between theory and practice in the pursuit of the truth. Authority is not exercised for its own sake or for the sake of power but for the sake of truth (McCormick, 1996). Both domains of authority, medicine and Church, are capable of incredible hubris and authoritarianism. Nonetheless, there are remarkable examples of the cooperation of the authority of the Church and the authority of medicine in the service of the good of God's people in health care. One of the most recent products of that cooperation is the 1995 Ethical and Religious Directives for Catholic Health Care Services. One particular example within the directives is evident in Directive 58 which asserts a presumption in favor of providing food and water to patients so long as the food and water provide a benefit for that patient. Directive 58 was accomplished by the careful testimony of physicians, theologians, and philosophers. The physicians offered their medical judgment that there are some conditions of illness and decline in which food and water no longer benefit the person. Philosophers and theologians offered their expertise in the careful application of the distinction between ordinary and extraordinary means of preserving human life of the person, in their affirmation of life as a fundamental, not an absolute, value, and in the distinguishing of physical continuation from human existence.

There are, within the contemporary horizon, two points of contention simmering just below the surface in Catholic hospitals. These two issues require careful attention on the part of the authorities of medicine and church. One is found in the distinction between withdrawing and withholding of treatment; the other is the question of the care appropriate to certain children such as those who are anencephalic and those with Potter's syndrome. In regard to the distinction between withdrawing and withholding of treatment, theologians and philosophers are now, for the most part, quite content to say that the ethical assessment of withdrawing and withholding treatment is entirely dependent on benefit to the patient. If there is no benefit, withdrawing and withholding treatment are morally equivalent. Many physicians, on the other hand, persist in maintaining that withdrawing feels different from withholding. In their professional experience these actions are not the same. Philosophers and theologians need to listen attentively to this testimony by physicians. There needs to be a reopening of the conversation.

The appropriate care of children who are anencephalic and children with Potter's syndrome has become a more sensitive and pressing issues with the advance of technologies surrounding pregnancy and prenatal care. Once the diagnosis of anencephaly or Potter's syndrome has been confirmed, how do we care for the human beings, mother and child, in this sad and temporarily devastating situation? Catholic health care institutions have responded in various ways to this tragedy. The two most common are to forbid intervention or to proceed with early induction. The former response directs attention solely to the child and the sanctity of the child's life. If the woman and her family persist, she and they must seek help elsewhere. In regard to the latter option, some Catholic health care institutions, paying very close attention to Directives 45 and 49 in the Ethical and Religious Directives for Catholic Health Care Services, allow the early induction, after twenty weeks, of delivery of the child and the provision of comfort care for the child until death occurs.

Neither interpretation is without problems. The first seems to dismiss the woman and her concerns and the concerns of her family. Some women report feeling abandoned by another institution in a church within which they already feel marginalized. The child that they so desperately loved will not be, and they wish to bring closure to the tragedy by an early induction. Some women, on the other hand, find comfort in carrying the child to term. They experience consolation in the fact that they cared for their child in the only way still possible for them, that is, the patient accompanying of the child in this brief life until the child dies. Here there needs to be a sustained conversation. And in that conversation the voices of women must be heard. Rather than being dismissed as having vested interests, they must be accorded respect as the voice of experience. The recording of the conversation itself is important. We shall have listened and we may learn.

The second, induction and delivery at twenty weeks, is problematic, even while it intends to stay within the letter of the law. There is a very real sense in which the child with anencephaly or the child with Potter's syndrome is never viable. These children have conditions incompatible with human life; they are not disabled as is the child with Down's syndrome. So an early induction with all equipment on hand for resuscitation may have the appearance of a sham.

The identity of Catholic health care institutions requires these institutions to pursue justice. Nevertheless, a too-narrow conception of justice, a too facile acceptance of justice as only a scheme involving the redistribution of resources, here tax revenues, controlled by governmental agencies, places in jeopardy both the existence and the witness of Catholic health care institutions. In regard to continued existence, it is important to recall the early efforts, although to this point unsuccessful efforts, to require Catholic hospitals to accept abortion as part of a package of total reproductive services or to lose their perinatal centers entirely. {While some tax generated payment, money which comes from individuals -- not the government -- to support basic goods, here health care, needed by other more vulnerable less capable individuals, Catholic health care institutions cannot limit their role in just service to the poor to advocacy only.} A role limited to advocacy casts Catholic health care as just another special interest lobby group. Each Catholic health care institution must find and set aside resources, even if only the Biblical tithe, to provide direct services to vulnerable people. This will call for sacrifice by the institutions, by physicians, by other health care providers, and by patients. The call to sacrifice should not appear strange to a people who call themselves Christian. If a largely immigrant population, led by and inspired by lively and committed religious leaders and committed physicians and other professionals, could build and sustain a vast network of Catholic health care institutions, what could possibly excuse an affluent and free Catholic population from its obligation in justice, not charity, to respond generously to the call and example of its model to serve the poor. Perhaps we have lost the biblical sense of justice found in the realization of our reality in shared creaturehood directed to live in right relationships that we may have that salvation offered in Jesus.

If Catholic health care is to flourish in the USA, if it is to serve as leaven, witnessing the life and love of an incarnate God, then it must be prepared to act as light and salt too. Its mission must be clear and it must be open to appropriate development as both medical science advances and Catholic teaching advances. Catholic health care must reflect on its identity and teach its mission. It must be visible reproof to a kind of contemporary medicine which prescribes killing to cure illness and disability. The continuation of the mission, as leaven and light and salt, of Catholic health care requires the continuous sacrificial commitment of converted individual Catholics, lay and religious, to accept that mission. The conversion of individuals (Were there not once only twelve?) can make possible the conversion of institutions, which in turn can sustain the energy of committed individuals and can draw other individuals into the shared mission. If Catholic health care institutions should choose not to affirm their identity and live their mission, then their fate should be that of the dinosaurs. The choice is now: either a robust Christo-centric identity and mission or extinction.

REFERENCES

National Conference of Catholic Bishops (1995). Ethical and Religious Directives for Catholic Health Care Services. Washington, DC: United States Catholic Conference.

McCormick, R.A., S.J. (1991). "Physician Assisted Suicide: Flight from Compassion." The Christian Century, December 4.

McCormick, R.A., S.J. (1992). "'Moral Considerations' Ill Considered." America, March 14.

McCormick, R.A, S.J. (1995). "Does Christianity Make a Difference?" Christian Bioethics, 1, 97-101.

McCormick, R.A., S.J. (1996). "Authority and Leadership: The Moral Challenge." America, July 20.

O'Rourke, K. (2001). "Catholic Hospitals and Catholic Identity," Christian Bioethics, 7, 15-28.