Catholic Health Care Advocates Papers

A Call to Preserve Catholic Health Care Through its Employees

Faith D. Daggs, M.D.

In fulfilling the "Ethical and Religious Directives for Catholic Health Care Services" promulgated by the National Conference of Catholic Bishops, Catholic health care institutions incur a responsibility to inform and educate their employees in an authentic understanding and adherence to the "Directives". This task is essential to preserving the identity of Catholic health care into the third millenium.

 Collectively, Catholic health care services are the largest source of not-for-profit health care in the United States.¹ The milieu of health care delivery today is a dynamic one of technology, economics and social service. In this context, Catholic health care ministry seeks to survive and grow while maintaining its Catholic identity and fulfilling its gospel mission. Cognizant of the dynamic atmosphere in which health care finds itself and of the challenges it places on Catholic health care institutions, the Church gives guidance and direction as shepherd to its flock. In 1994 the National Conference of Catholic Bishops presented a revised "Ethical and Religious Directives for Catholic Health Care Services" (ERDs). The ERDs underscore the defining principles governing the provision of health care in Catholic institutions: the dignity of the human person and the social responsibility to ensure this dignity through medical and pastoral care, particularly to the marginalized. To this end, the bishops draw upon the "moral teachings ... (which) flow principally from the natural law, understood in the light of revelation Christ has entrusted to His Church."² The Bishops have provided a general framework for the continued mission of Catholic health care services as well as "authoritative guidance on certain moral issues that face Catholic health care today."³

 Catholic health care occupies a unique role within the Church, as Pope John Paul II describes: "one of the most vital apostolates of the ecclesial community and one of the most significant services which the Catholic Church offers society in the name of Jesus Christ."⁴ Truly Catholic health care is an integral part of the Church's mission in the world. As such, the ERDs deserve a primary place at every Catholic health care institution, underpinning the very way Catholic health care is carried out - from the bedside to the boardroom table. Indeed, the Bishops regard the ERDs as fundamental to the daily functioning of Catholic health care institutions, mandating in Directive #5:

"Catholic health care services must adopt the Directives as policy, require adherence to them within the Institution as a condition for medical privileges and employment, and provides appropriate instruction regarding the Directives for administration, medical and nursing staff, and other personnel."⁵

 Further, recognizing that the employees are the Catholic health care institution much more than the physical plant, Directive #9 instructs:

"Employees of a Catholic health care institution must respect and uphold the religious mission of the institution and adhere to these Directives. They should maintain professional standards and promote the institution's commitment to human dignity and the common good."⁶

 These two directives in particular and their implementation lay the foundation in an institution for truly making the ERDs as a whole the " policy" in Catholic health care in that those most directly involved in providing health care to individuals or communities, whether they are clinicians or CEOs, need the the sound moral ground the ERDs provide. Fr. Germain Kopaczynski succinctly puts it, "The ERDs are replete with the basic tenet of our Catholic identity: a truth of faith and a truth of reason, a truth of science, can never contradict." Even pithier, he translates that to: "if it's good medicine, it's good morals."⁷

 At a minimum, institutions benefit from employee education in the ERDs by reiterating their institutional mission and giving them specific guidelines for use when difficult medico-ethical situations arise. At a maximum, employees can understand their greater role and responsibility in preserving human dignity and serving the common good in the healing ministry of Jesus Christ. As of 1997, Catholic Hospitals employed more than 706,000 full and part time employees - almost 15% of all U.S. hospitals⁸ - a potential army of advocates to preserve and maintain the identity and integrity of Catholic health care in the United States. Institutional commitment to authentic and consistent employee education and implementation of the ERDs is a key to ensuring the survival of Catholic health care into the next millenium. But, on a practical level, how many of those 706,000, particularly those in clinical decision making, have any knowledge of the ERDs? Are Catholic health care institutions active in education and implementation of the ERDs? Are the bishops involved in the health care institutions within their dioceses, promoting compliance with the ERDs?

 Beginning in 1991 as a medical student at a Catholic medical school in a University system, I looked forward to pursuing my vocation in an institution that would reinforce and support my faith. However, I was often disappointed by inconsistencies between the application of medical science and the moral foundations of the Catholic faith. Continuing my graduate medical education at the same University medical center, I never knew the ERDs existed until my second year of training, while on rotation at an educational affiliate. In reading the Directives I found the embodiment of the "Catholic health care" which I had sought to identify myself with from the beginning of my medical education, what Fr. Kopaczynski calls "basic components of a Catholic approach to quality health care."⁹ The General Introduction to the ERDs surmises:

"The dialogue between medical science and Christian faith has for its primary purpose the common good of all human persons. It presupposes that science and faith do not contradict each other. Both are grounded in respect for truth and freedom."¹⁰

 The ERDs are intended for all Catholic health care services in the United States; as such they are directives not just recommendations of the National Conference of Catholic Bishops. Reading the ERDs prompted a wake up call in myself and prompted several questions: Do my colleagues know about the ERDs? (How) Are the ERDs implemented at my institution and at other Catholic health care institutions? In looking for the answers I found that there is a spectrum of compliance amongst institutions and that others in Catholic health care were looking for answers too.

 There are no set standards or programs for implementation of the ERDs nationally. What is found are wide variations among individual health care institutions and health care systems. At some institutions there are efforts on the parts of individuals or groups to educate staff regarding the Directives; however, these efforts often are not supported by the institution itself at a fundamental level, i.e. the ERDs are not regarded as policy. On the other hand, certain Catholic health care systems give a central role to the ERDs: implementing ERD orientation programs for their Board of Directors, nurse managers, housestaff, etc.; incorporating ethics rounds to highlight specific directives as part of required resident education; training physician recruitment staff with respect to the ERDs; and sponsoring CMEs on ethics for physicians. Other institutions incorporate the ERDs and compliance with them into employee contracts and lease agreements. Some Catholic health care systems have produced videos to facilitate education of the ERDs and incorporate them with their mission. The National Catholic Bioethics Center, an independent institution for bioethics research and education has offered a Workshop: "Understanding, Communicating and Implementing the Ethical and Religious Directives for Catholic Health Care Services" since 1995. The National Catholic Bioethics Center aims its workshop and related seminars on the ERDs to those in key administrative and educational roles at Catholic health care facilities in a "teach the teacher" framework in order to enhance dissemination and implementation at these institutions.¹¹

 Further underscoring the need for education regarding the ERDs at Catholic health care facilities is the disparity of any formal training in ethics among health care professionals whether they are involved in the clinical or business side of health care delivery. Courses in ethics as part of the curriculum at medical and nursing schools has been a recent phenomenon. For example, of the 127 medical schools in the AAMC( American Association of Medical Colleges) only 63 have ethics as a required course.¹² Thus, even physicians, often looked to as leading the "health care team" may have little more than "visceral sensations" to go on when facing tough decisions with patients; therefore, the Catholic health care institution can serve a vital role in educating its staff and filling the void by way of the Directives. At the same time, daily critical decisions are made regarding the "business" side of Catholic health care with respect to new mergers and affiliations between Catholic and secular health care institutions and providers, placing challenges before financial officers and Boards of Directors.

 In part six of the ERDs "Forming New Partnerships with Health Care Organizations and Providers", the Bishops recognize and speak directly to the impact of the economy of health care on Catholic Institutions and its effect on Catholic authenticity and identity of the care provided. In particular, the Bishops recognize the potential grave implications these partnerships pose with respect to moral cooperation and scandal especially when: "partnerships are driven by financial considerations alone."¹³ Oftentimes, these "healthcare alliances" are what is most widely seen by the community served by a particular Catholic Health Care facility and speaks to the organization's Catholicity or compromise of such at an ostensible level. Even where mergers are thought to be a remote mediate material cooperative type, the opportunity for scandal exists and the erosion of an institution's Catholic authenticity occurs. This has been evidenced by an article which ran in a February 1999 edition of The Wall Street Journal regarding the merger of a Catholic hospital and a secular hospital in Buffalo which had the approval of the local bishop. Therein the author indicated that certain of the arrangements were subterfuges to get around "The Directives."¹⁴

 As noted earlier Catholic Health Care, as is the whole of organized health care, is at a crossroads, and the Bishops in their apostolic wisdom have provided a roadmap in the form of the ERDs. However, there are threats to conscientiously following this path for medically and socially ethical Catholic health care. Such detours and diversions, however small or remote with respect to the institution as a whole, will ultimately deprecate and deteriorate the whole of Catholic health care the faithful and general public has grown to expect.

 How is the disparity resolved from those institutions that are Catholic to the core and compliant with the ERDs to those whose practices are in blatant discord with the ERDs and the wide variation in between? Ultimately, each diocesan bishop is the head of the ship as the pastoral leader and apostolic voice of the Church responsible for the various ministries within his diocese, including health care. The late Cardinal Bernadin spoke to this directly: "...health care ministry is not the possession of any one religious community, health care institution or health care executive. Rather, it belongs to the entire Church." He further states, "it is inappropriate to suggest that the pastoral office of the Church, the ministry of diocesan bishop, has no rightful role. Such a perspective would marginalize health care as less than essential to the Church's institutional mission."¹⁵

 The Bishops have provided the ERDs, they need to take the institutions in their dioceses to task regarding their compliance with them and the means used to ensure their education and implementation from the boardroom to the bedside. Just as the pastoral office ensures its faithful are instructed in a manner consistent with the Magisterium in its parishes, so too should it actively ensure its faithful receive health care ethically and socially consistent with the teachings of the Church. Moreover, those health care institutions which promulgate themselves as "Catholic" are called to serve their communities  persons of every creed and race, truly as the "Good Samaritan" and the face of Christ - and as such are viewed as public representatives of the Roman Catholic Church in the community at large. This holds a very powerful potential to define what being and acting "Catholic" means by the actions and associations of the individuals and organizations which provide Catholic health care.

 If Catholic authenticity is then stressed from the top: from the Bishop to the CEOs and Chief Medical Officers, it can become a priority and policy not just lip service and outward concordance without substantive compliance with the ERDs. An institution desiring a "Catholic" designation, not merely a "quasi" association with the Catholic Church, should show it through their faithful enactment and execution of the ERDs as illustrated in its own mission, policies and actions. The fruit of such authenticity and consistently "Catholic" care will be evident in the individuals at every level, from nursing assistant to houseofficer, and from payroll clerk to chief financial officer, and in the compassionate, charity-filled care given to the community. Ultimately, as an extension of the Church and of Christ's healing mission, those providing health care at Catholic institutions must be evaluated by a single criterion to which the ERDs point: how do we lead others and ourselves to Christ?

1. Factsheet. The Catholic Health Association of the United States. February 28, 1999.
2. National Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services. November, 1994. p. 2.
3. Ibid p. 1.
4. Bernadin, Joseph. "What Makes a Hospital Catholic  A Response." America. 174 (15). P. 10.
5. National Conference of Catholic Bishops. ERDs. p. 5.
6. Ibid, p. 8.
7. Kopaczynski, Germain. "Catholic Identity in Health Care and the Relevance of the 1994 Ethical and Religious Directives for Catholic Health Care Services." Linacre Quarterly. 64 (2). May 1997. p. 30.
8. Factsheet. The Catholic Health Association of the United States. February 28, 1999.
9. Kopaczynski, Germain. Linacre Quarterly. 64 (2). May 1997. p. 30.
10. National Conference of Catholic Bishops. ERDs. November 1994. p. 5.
11. National Catholic Bioethics Center website. www.ncbcenter.org

12. personal communication, AAMC.
13. National Conference of Catholic Bishops. ERDs. November 1994. p. 26.
14. Lagnado, L. "Religious Practice: Their Role Growing; Catholic Hospital Juggle Doctrine and Medicine." The Wall Street Journal. February 4, 1999. p. 8A.
15. Bernadin, Joseph. America. 174 (15). p. 10.