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McCann Online Publication Date: 01 December 2000 To cite this Article: McCann, Dennis P. , (2000) 'Catholic Social Teaching and the Economics of Health Care Management', Christian Bioethics, 6:3, 231 - 250 To link to this article: DOI: 10.1076/chbi.184.108.40.20686 URL: http://dx.doi.org/10.1076/chbi.220.127.116.1186 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. © Taylor and Francis 2007 Christian Bioethics 1380-3603/00/0603-0231$15.00 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 2000, Vol. 6, No. 3, pp. 231–250 © Swets & Zeitlinger Catholic Social Teaching and the Economics of Health Care Management1 Dennis P. McCann Agnes Scott College ABSTRACT The author considers the issue of what it is for a health care institution to be intentionally Christian. He begins with a review of Catholic social teaching, and considers how this perspective is shaping Catholic thought and action regarding health care management and public policy reform. He then proposes some standards for intentionally Christian institu- tions. Prior to the current crisis in health care, hospitals managed by Catholic religious orders were a significant aspect of the Church’s ministry in the United States. During the current crisis Catholic hospitals have been under significant economic pressure, and many of them have either closed their doors, been sold outright to private for-profit health care systems, or are managed now as joint ventures in partnership with private health care businesses. These economic pressures have been intensified for Catholic hospitals because of the long-term impact of the decline in religious vocations after Vatican II, and the consequent “greying” of the religious communities that sponsor and administer Catholic hospitals. The religious orders often are facing a simultaneous crisis in providing for a decent retirement for the aged members of their communities, who often are close to becoming a majority of the members in good standing. The cost structure of Catholic health care institutions, as a result, has changed significantly, even as competition with for-profit health care sys- tems and pervasive pressure to implement “cost-containment” strategies have intensified. The questions posed for this issue of Christian Bioethics thus are very timely and decisive for the future of Catholic health care institutions. Even Correspondence: Dennis P. McCann, Ph.D., Department of Religious Studies, Agnes Scott College, 141 East College Avenue, Decatur, Georgia 30030, U.S.A. 232 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 before the current crisis, Catholic institutions were struggling with the issue of mission and/or Catholic identity. I became aware of their concern when, as founding director of DePaul University’s Center for the Study of Values, my work focused increasingly on the identity of the University as an “Urban, Catholic, Vincentian” institution of higher learning. As a Vin- centian institution, DePaul is part of the Vincentian “family” which in- cludes the health care and related institutions founded by the Daughters of Charity. Ten years ago I began inquiries into the health care institutions of the Daughters of Charity, locally, St. Joseph’s Hospital in the Lincoln Park neighborhood of Chicago, to find resources on how to address ques- tions of mission and Catholic identity. At that point my impression was that Catholic hospitals were ahead of Catholic universities in addressing this question. One of the things that became apparent to me was that active concern for the needs of the poor was a crucial element in the mission of Catholic hospitals, particularly those administered by the Daughters of Charity. The slogan of the Vincentian family, taken from the writings of St. Vin- cent dePaul, is to “Follow Christ by Evangelizing the Poor.” Hospitals faithful to this mission were to make the needs of the poor a special concern, over and above whatever pro bono policies toward indigent patients that all hospitals, in theory, are supposed to honor. Increasingly, Catholic social teaching, which has much to say about economic justice, but very little explicitly directed toward health care management, is re- garded by Catholic hospital administrators as a resource for sharpening their own thinking about mission. Like all segments of the American Catholic Church, these administrators found their thinking increasingly focused on questions of economic justice and the needs of the poor, because of significant public response to the NCCB’s pastoral letter (1986), Economic Justice for All: Catholic Social Teaching and the U.S. Economy. This document, too, has little to say about health care, but it does have much to say about the human costs of an economy that increas- ingly is focused on “the bottom line” to the exclusion of other human concerns. Because of my experience working with the Daughters of Charity ad- ministering St. Joseph’s Hospital, the responses that I give to the ques- tions to be considered in this issue will thus be informed by a review of Catholic social teaching, and how this perspective is shaping Catholic thought and action regarding health care management and public policy reform. After I have reviewed these developments, I will then try to formulate an answer to the specific questions posed by the editor of Christian Bioethics. THE ECONOMICS OF HEALTH CARE MANAGEMENT 233 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 I. CATHOLIC SOCIAL TEACHING: PRINCIPLES FOR HEALTH CARE REFORM Let us begin by asking, “What is Catholic Social Teaching?” Considered historically, it is the worldview of the Roman Catholic church articulated under conditions of modernization. Modernization is a social process whose origins are external to the Catholic church, in a way that they are not external to Protestantism, especially liberal Protestantism. Under con- ditions of modernization the church becomes aware of its distinctiveness or separateness from the mainstream of modern society. How and why the church should seek to engage with modern society, as Vatican II’s Gaudi- um et Spes makes abundantly clear, becomes an essential problem for the church’s continued mission in the world. Catholic social teaching is thus a worldview seeking to institutionalize itself as an ethos; it is a template for managing the often corrosive forces of modernization. Formally speaking, Catholic social teaching is a social vision, morally based, theologically grounded, publicly argued, and institutionally em- bodied. It is a social vision: it seeks to define the common good for a community of persons, based on its distinctive understanding of Scripture and Chris- tian tradition, the community’s own historical experience, as it has been tested by reason, that is, not by rationalist ideology, but by open-ended critical inquiry within the community. It is morally based: this vision highlights certain themes considered essential for interpreting the moral experience of the human race, such as respect for human dignity and social solidarity. It is theologically grounded: these themes reflect the church’s self- understanding of its relationship to God in Christ, a relationship in which all that the church would hope to accomplish comes as a response to God’s own initiative working in the world and through the church. Catholic social teaching thus increasingly makes its points in a Biblically oriented discourse, structured by the notions – as the NCCB pastoral letter on the US economy (1986) showed – of “Creation/Covenant/Community,” “Love and Justice,” and “Vocation and Stewardship.” It is publicly argued: Catholic social teaching, true to its origins in Medieval social philosophy, notably that of St. Thomas Aquinas, contin- ues to make its moral claim upon the world in terms of the Natural Law tradition. This is believed to represent a common ground available to all persons capable of using their reason and experience to discover truth. Roughly from the time of Vatican II (1962-1965), Catholic social teach- ing has developed this Natural Law tradition as a contribution to the 234 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 world’s ongoing discussion concerning the theory and practice of human rights. It is institutionally embodied: Catholic social teaching is not only the expression of moral and religious aspirations for a better life. It is also a philosophy of social and political action, in which various institutional sectors of modern society are critically assessed for the role they may play in implementing the priorities of Catholic social teaching. The strategy for social change implicit in the whole of Catholic social teaching is explicit in its second-order principle of subsidiarity. Having defined Catholic social teaching, we may now consider what, if anything, this tradition has had to say about health care, particularly the economics of health care and the ethical dilemmas involved in providing universal access to adequate health care. The most recent official and comprehensive statements of Catholic social teaching with reference to questions of economic and social justice are Pope John Paul II’s encyclical letter, Centesimus Annus, “On the Hundredth Anniversary of Rerum No- varum” (1991), and the pastoral letter of the National Conference of Cath- olic Bishops, Economic Justice for All (1986). Though neither of these statements is concerned even peripherally with the current debate over health care reform, they do illustrate how the general principles of Catho- lic social teaching may be related to public policy issues. Centesimus Annus is noteworthy not only because it continues the recent Papal tradition of issuing such encyclicals on the decade anniversary of Pope Leo XIII’s Rerum Novarum, “On the Condition of Labor” (1891) – the encyclical celebrated by the Magisterium as the point of departure for the development of modern Catholic social teaching – but also because it is the first major statement issued after the collapse of communism in eastern Eu- rope. The posture of Catholic social teaching prior to 1989 had been one of evenhanded criticism of both atheistic communism and laissez-faire capi- talism, or, if you will, Manchester-style economic liberalism. “A plague on both your houses!” might be a useful way to think of its perspective in those days. Centesimus Annus breaks new ground in that, after honoring Leo XIII’s anti-communism, it seeks to situate the tradition as an ethically en- gaged critical perspective within the emerging global market system. Its tenor is clearly reformist, and it models a kind of constructive engagement with capitalism that was not characteristic of earlier Papal pronouncements. Thus it is not surprising that, while Centesimus Annus reaffirms Leo’s general principles, it merely mentions “health insurance” as one of the reforms that over the past century have been introduced “within the frame- work of greater respect for the rights of workers” (O’Brien and Shannon, 1992, p. 451). Its only other mention of health-related concerns comes in a THE ECONOMICS OF HEALTH CARE MANAGEMENT 235 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 paragraph focused on the “specific problems and threats emerging within the more advanced economies and which are related to their particular characteristics.” Here, under the heading of “consumerism,” which is char- acterized as an ideology or tendency to promote “artificial consumption contrary to the health and dignity of the human person,” John Paul II notes specifically that “widespread drug use is a sign of a serious malfunction in the social system; it also implies a materialistic and, in a certain sense, destructive ‘reading’ of human needs” (O’Brien and Shannon, 1992, p. 467). The point is that Centesimus Annus does not seek to revise the basic principles of Catholic social teaching so much as refine the church’s un- derstanding of the social world in which these are to be implemented. The capitalist market system, as such, is no longer the villain; but it does still tend to exacerbate social problems that may be deeper and more intracta- ble than problems of distributive justice. The NCCB pastoral letter, Economic Justice for All, is far more exten- sive and explicit in its references to the economics of health care. This, too, is not surprising; for it was written during the mid-1980s when public concern about rising US health care costs was growing once again. Early in the letter, in a section titled, “Urgent Problems of Today,” the bishops set the tone for their remarks on this issue by linking the economics of health care to the arms race. Resources that could be used, among other things, to ensure adequate health care for the poor are unavailable because of the excessive levels of expenditure for national defense (O’Brien and Shannon, 1992, p. 582). Far more significant is their reaffirmation – echo- ing the robust human rights doctrine spelled out in Pope John XXIII’s memorable encyclical, Pacem in Terris, “Peace on Earth” (1963) – of a “right to medical care” as among the “welfare rights” strongly supported by the Catholic social teaching: These fundamental personal rights – civil and political as well as social and economic – state the minimum conditions for social insti- tutions that respect human dignity, social solidarity, and justice. They are all essential to human dignity and to the integral development of both individuals and society, and are thus moral issues. Any denial of these rights harms persons and wounds the human community. Their serious and sustained denial violates individuals and destroys soli- darity among persons (O’Brien and Shannon, 1992, p. 598). As far as the NCCB is concerned, there’s no question whether valid human rights doctrine thus includes a “right to medical care.” The important and vexing question, instead, is how to implement such rights: 236 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 Social and economic rights call for a mode of implementation differ- ent from that required to secure civil and political rights. Freedom of worship and of speech imply immunity from interference on the part of both other persons and the government. The rights to education, employment, and social security, for example, are empowerments that call for positive action by individuals and society at large (O’Brien and Shannon, 1992, p. 598). As we shall see, how the right to medical care is implemented is an illus- tration of Catholic social teaching’s principle of subsidiarity. The pastoral letter’s other references to health care occur within this framework of human rights doctrine. Since a major concern of the letter overall is to secure, as the title indicates, Economic Justice for All, most of these references occur in the context of special concern for the poor and the marginalized. In moving from abstract generality to concrete policy proposals, the letter makes explicit the “moral priorities” that the church would urge upon society as a whole. The highest of these priorities is “the fulfillment of the basic needs of the poor,” especially those who “lack the minimum necessities of nutrition, housing, education and health care” (O’Brien and Shannon, 1992, p. 600). It is in this context that the bishops highlight the health care needs of female-headed, single-parent house- holds (p. 619), of farm workers (p. 630), and of the poor of the developing nations (643). In emphasizing their needs, the bishops urge policies that support rather than undermine the stability of families (p. 625), and poli- cies that are consistent with Catholic teaching on family planning (p. 644). Currently existing government health care programs, such as Medicare and Medicaid, are specifically praised as “successful” in enhancing “the life expectancy and health status of the elderly and disabled people” and in reducing “infant mortality” and greatly improving “access to health care for the poor” (p. 622). Because the letter’s discussion of public policy is directed toward the problem of poverty, it does not consider the larger question of a compre- hensive overhaul of the entire health care system, such as emerged in debates over the health care reforms proposed by the Clinton administra- tion. There is no agenda for radical change in health care policy here, but a religiously motivated impulse toward incremental reform in the direction of inclusiveness or an expansion of coveage under existing programs. Nor is this simply an omission. The principle of subsidiarity, first articulated in Pope Pius XI’s encyclical, Quadragesimo Anno, “After Forty Years” (1931), requires that government intervention in society be of a limited nature: THE ECONOMICS OF HEALTH CARE MANAGEMENT 237 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 Just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community, so also it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher associ- ation what lesser and subordinate organizations can do. For every social activity ought of its very nature to furnish help to the members of the body social, and never destroy and absorb them (p. 60). First articulated as a basis for resisting the totalitarian tendencies of Italian Fascism that were then threatening the autonomy of church-related institu- tions, the principle of subsidiarity makes the needs of the human person and the capacity of his or her primary communities – such as the family – to fulfill them, the ultimate criterion of government intervention. The assistance (“subsidium” and, hence, “subsidiarity”) provided must em- power citizens to fulfill their own social responsibilities, and never usurp or preempt what persons living in communities are capable of doing for themselves. The principle of subsidiarity thus implies a theory of limited govern- ment, not necessarily democracy, but still a role for the State that is constrained by the natural capacities of persons and communities to act responsibly in their own behalf. As such it provides first of all a prima facie rule for interpreting and implementing Catholic human rights doc- trine. Rights, as we’ve just seen the NCCB’s pastoral letter describe them, are “empowerments,” not government entitlements. Rights are to be fulfilled in and through the ordinary operations of myriad social institutions, private and public; government is expected to intervene to safeguard rights only as a last resort, that is, only when the government’s action provides the “subsidium” that social institutions need in order to carry out their own responsibilities more effectively. Given this view of the social order, it is not surprising that though Catholic social teaching strongly supports access to adequate health care as a human right, it is noticeably cautious about endorsing any policy that would tend to preempt the existence of private health care institutions, both for-profit and not- for-profit. The principle of subsidiarity thus helps account for what otherwise may seem like a vague and perversely unfocused understanding of the practical processes involved in fulfilling a strong commitment to “welfare rights.” The State has a role to play, according to Catholic social teaching, but so do all other social instititutions and the persons whose lives unfold within them. Affirming a right to health care does not necessarily entail disman- tling the current “mixed” system of health care delivery. Catholic social 238 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 teaching cannot be interpreted in such a way that its commitment to social justice becomes a pretext for undermining the private hospitals and other health care institutions that have emerged as an integral component of the Church’s own mission and ministry. Despite the paucity of past references to the economics of health care, the principles of Catholic social teaching have become increasingly im- portant as a resource for thinking about economic and social justice in Catholic health care institutions. Richard A. McCormick’s contribution to the Park Ridge Center’s Project X survey of world religions, Health and Medicine in the Catholic Tradition: Tradition in Transition (1987), is an important example of this trend. Though it, too, was penned before the current controversy over health care reform, it defines the problems of “access to health care” and “allocation of resources” as the two “most pressing issues… [to be] considered under the rubric of justice” (1987, p. 75). McCormick’s review of Catholic tradition takes the form of a com- mentary on a document, “Ethical Guidelines for Catholic Health Care Institutions,” that had been offered to provoke discussion on precisely how Catholic institutions can work to implement not only Catholic social teaching, but all other aspects as well of Catholic moral theology relevant to health care. The Guidelines are comprehensive, covering everything from Catholic theological interpretations of health, sickness, and well- being, to specific policies for implementing Catholic teaching on abortion, birth control, euthanasia, and other controversial questions. Below are numbers 4 through 10 of the Guidelines, that address ques- tions of social and economic justice in health care: 4. A health care institution relates to United States society and culture in significant ways: a) it can be seen as a microcosm of the larger society and its value priorities; b) it has strong bonds of interdependence with major dimensions of this society: legal, economic, technological, political, profession- al. In all of these societal relationships, institutions are presented with challenges regarding justice. Responses to these challenges should be shaped by the social teachings of the Church. 5. The employer/employee relationship demands particular attention. A just structure in this relationship calls for fairness and mutual ac- countability. Only in this way will the health care institution become a model of the justice it recommends to the broader society. THE ECONOMICS OF HEALTH CARE MANAGEMENT 239 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 6. Independent practitioners are an important part of the health care institution’s community. They are, then, accountable for the same standards of justice as are the salaried employees. 7. Concern for justice means that the health care institution will also turn outward to meet the needs of the underserved and the poor and do everything possible to influence public policy in this direction. 8. The health care institution should take seriously its responsibility to work for an equitable distribution of health care resources, both within the institution and in society as a whole. This includes in- volvement in areas of law and public policy. 9. Minority races have suffered deeply at the hands of our society. The same is often true in Catholic health care institutions, both with regard to employees and patients. Catholic institutions should play a leading and aggressive role in redressing this imbalance, especially with regard to opportunities for advancement and respect for the dignity of patients. 10. A similar justice concern about the welfare of women – both patients and employees – should characterize a Catholic health care institution. Women and men should be afforded the same respect and consideration with regard to diagnoses and treatment. Women em- ployees should have equal opportunity for employment and career development, and their work should be fairly compensated, i.e., in accord with the principle of equal pay for work of equal value (Mc- Cormick, 1987, p. 10–11). McCormick’s comments on this segment of the Guidelines attempt an honest appraisal of the cultural climate in which Catholic health care insti- tutions operate in the United States. “Becoming institutions of Christian priority is a monumental undertaking. We are not tuning an instrument in the orchestra; we are attempting to redefine the orchestra itself....” The Catholic health care facility, whether we like it or not, is often “a micro- cosm of the larger society,” and thus it will tend to carry both the strengths and weaknesses of the larger society. Following Daniel Maguire’s think- ing, McCormick outlines a systematic contrast between “American” jus- tice and “Biblical” justice, in which the former clearly comes off second best to the latter. Though Maguire’s sharp contrast is problematic, it does help fill out what McCormick has in mind for Catholic hospitals seeking to 240 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 become “institutions of Christian priority.” Clearly, such institutions must be countercultural, to the extent that Christian values themselves have become countercultural in the USA today. At the same time, McCormick recognizes that such a transformation must meet the formidable challenges involved in the structures of interde- pendence, legal, economic, technological, political, and professional, that bind Catholic institutions to their peers, both public and private. On the one hand, then, each of the guidelines involves a certain amount of con- sciousness-raising regarding how far Catholic hospitals have fallen short of their professed Christian aspirations. On the other hand, each seems to go no further than urging more concerted efforts to do better. Such a posture may reflect the moral anguish experienced daily by Catholic health care administrators, such as the Daughters of Charity managing the daily affairs of St. Joseph’s Hospital. But, except in a few sensitive areas, such as prohibiting abortions, the guidelines do not clearly draw the line on what, minimally, it takes for any hospital honestly to claim a Catholic identity for itself. A telling example of this syndrome is the results McCormick cites from a survey – conducted by the California Association of Catholic Hospitals (CACH) – of Catholic hospital administrators and their spon- soring religious communities on the question, “Health Care of the Poor.” The vast majority of those responding agreed with the statement, “One of the primary reasons for Catholic hospitals is to provide health care to the poor.” But a similar proportion also agreed that Catholic hospitals, in the current environment are not “doing the best they can to respond to the needs of the poor” (McCormick, 1987, p. 80). The CACH’s set of recom- mendations for doing more for the poor, however, are diffuse, suggesting incremental reforms and promoting fresh initiatives on a variety of levels. Consistent with the principle of subsidiarity, the recommendations entail a lot of networking, but they do not envision a complete overhaul of the health care system as such. McCormick rightly notes the modesty of what is being proposed and what has been accomplished. The recommenda- tions are only a beginning, one more indication of a “tradition in transi- tion”: We are challenging the imaginations and the pocketbooks of our society. And we who struggle to do it are not from Mars or mainland China – we too bear the stamp ‘Made in America’. But we have also been nurtured by a religious tradition that holds out a vision. Our struggle is both within ourselves and in our communities (1987, p. 76). THE ECONOMICS OF HEALTH CARE MANAGEMENT 241 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 The national debate over President Clinton’s proposals for health care reform, of course, did generate significant Catholic response later on. Informed lay Catholic opinion tended to favor Clinton’s proposals with some modifications, but a significant minority also lined up behind a more radical approach to health care finance, for example, “single-payer” poli- cies mirroring the Canadian health care system. Given the legacy of Cath- olic social teaching and its emphasis on the priority of the common good, it comes as no surprise that very few informed Catholics were comfortable simply with allowing the markets to decide questions of who gets access to health care and how scarce health care resources are to be allocated. At the same time, informed Catholic opinion tended to be wary of any wholesale government takeover of the health care system. Whatever the economic benefits of a single, government administered system, Catholic opinion tends to fear that such a system will impose certain values and standards, particularly with regard to procedures like abortion, fertility therapy, fam- ily planning, etc., that diverge significantly from Catholic belief and prac- tice. Catholic caution regarding any radical departure from the current “mixed system” of health care delivery and finance thus is best explained, not as a failure of nerve in the face of measures that, it is alleged, would guarantee “economic justice for all,” but rather as a commitment to a certain view of the human person as embodying values that transcend considerations – as important as they are – of cost-effectiveness and eco- nomic justice. The best recent Catholic thinking on health care reform has occurred under the auspices of the ongoing Seminar on Business Ethics at George- town University’s Woodstock Theological Center. In October, 1993, the Center sponsored a forum on ethical considerations in the business and financial aspects of health care, with three panelists, each representing an important constituency for health care reform: the medical profession, the insurance industry and the academic community. The panelists struggled to achieve ethical clarity about the basic thrust of reform given the con- straints imposed by the current embodiment of the “mixed system,” one in which “third party payers,” namely insurance companies, necessarily pledged to make a profit for their investors, increasingly hold the key to whatever cost-containment or fiscal responsibility is now operating within the system. Obviously, leaving the financial decision-making about health care primarily in the hands of the insurance industry creates a host of ethical dilemmas, particularly for the professional care-givers, the doctors, nurses, and other health care practitioners, who feel themselves caught between their patient’s needs and the policies of the insurance companies. 242 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 These dilemmas were to have been eased to some extent by the Clinton reform effort, but in the absence of major Congressional legislation the Woodstock seminar went ahead and developed a statement, Ethical Con- siderations in the Business Aspects of Health Care (1995), which offers guidlines for moral action even as the national debate remains unresolved on the economics of health care. The statement is systematic and compre- hensive. It formulates principles and faces squarely the dilemmas that health care professionals encounter in the fierce trade-offs between patient welfare and fiscal responsibility. As such it provides a useful illustration of how Catholic social teaching may be applied or extended to complex institutional environments. At first glance, the statement’s relationship to Catholic social teaching may seem, if not nonexistent, at least disappointingly unemphatic. The statement contains no explicit references to God or Jesus Christ, nor to sin and grace; no explicit reference to Catholic social teaching or to certain of its standard themes such as social justice, solidarity, or subsidiarity. The lack of a theological horizon here is less an omission than a result of a deliberate decision, rightly or wrongly, to propose an ethical consensus that transcends the limitations of distinctively confessional traditions. How, then, is it shaped by Catholic social teaching? In light of my summa- ry of Catholic social teaching, it is clear that the statement echoes many of the substantive insights found in the tradition. Here is an important charac- terization of the statement’s ethical framework: Respect for human dignity is fundamental, providing a basis for com- passion, honesty, integrity, and confidentiality, each of which will be discussed separately. While there are differences, often quite sharp, within our society about how to interpret and specify this fundamen- tal value, it is strongly affirmed within the major religious and philo- sophical traditions of our pluralistic society. Compassion, in turn, provides the basis for the central tenet of the social covenant between health care providers and society: that health care professionals must be committed, first and foremost, to the welfare of their patients (Woodstock Theological Center, 1995, p. 18). A normative concept of “human dignity” thus is given as the warrant for acknowledging universal access to health care as a right (pp. 23 and 37), and other rights that patients are regarded as having, such as a right to confidentiality (p. 28), and the right to know whether the physician is also playing the role of a “gatekeeper” on behalf of the health care provider (p. 39), a role that may undermine the physician’s ability to act as the pa- THE ECONOMICS OF HEALTH CARE MANAGEMENT 243 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 tient’s most effective “advocate” within the system. Indeed, though the statement does not elaborate on the normative basis for its own perspec- tive on human rights, in light of the tendency for all health care “needs” to become entitlements, it calls for deeper ethical reflection on the basic right to health care and its public policy consequences: But our political system makes it very difficult for anyone in author- ity to address head on any questions about what level of care consti- tutes an irreducible minimum human right, or even what level should constitute a civil right that citizens and legal residents in the United States would be entitled to receive. Yet, without some such discus- sion, there seems to be no way to set an upper limit on how much of society’s resources should be spent in this way, and expenditures on the health care entitlements that have already been promised to our citizens continue to rise (p. 14). The statement also uses the language of vocation, covenant, and steward- ship in order to situate certain points that it wishes to make about ethical responsibility in health care management. Nevertheless, these references are minimal, with the exception of the term, “social covenant,” though even here the term tends to echo one of the campaign themes elaborated early in Clinton’s 1992 bid for the U.S. Presidency, rather than anything overtly Biblical. The most frequently invoked term indicating the moral framework operative in this statement is “responsibility,” which is elabo- rated on a multiplicity of interrelated levels, systemic, institutional, pro- fessional and personal. What the statement says about responsibility, as in the other points it makes, is entirely consistent with Catholic social teach- ing, but it is not explicitly related to this tradition. The statement’s chief contribution, then, is to model a way of thinking responsibly and concrete- ly about the conflicting priorities that health care professionals are likely to face in seeking to fulfill the “social covenant” that binds their profes- sion to the needs of their patients while also fulfilling their contractual obligations to the health care providers who employ them. No hard and fast rules are laid down, but a detailed set of “checkpoints” are outlined that any conscientious health care professional will want to observe in making ethical decisions. 244 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 II. THE PROSPECTS FOR A CHRISTIAN APPROACH TO HEALTH CARE ADMINISTRATION In light of this review of Catholic social teaching and its impact on Amer- ican Catholic attempts to grapple with the current crisis in health care, let me now take up the questions that this issue of Christian Bioethics is meant to address. Some of these focus on the question of whether the Christian communities can or ought to weigh in with distinctive public policy proposals for resolving the crisis. Such, I gather, is the point of asking whether “intentionally Christian organizations” might “attempt to provide equal access to high cost/low yield treatments or primarily low cost/high yield treatment with the option that one could purchase more if one posessed the funds.” This and similar questions regarding health care “rationing” and “appropriate standards of care” are primarily public policy questions. Not only have such questions been the focus, as we have seen, of discussions within the American Catholic community, they are also regarded as crucial for creating the kind of societal support system in which Catholic health care institutions could do a better job of fulfilling their mission as “intentionally Christian organizations.” The Woodstock statement concludes with a “A Request for Institutional Arrangements that Support Ethical Behavior”: Policies and customs can help to clarify responsibilities and support ethical decision making, or they can exacerbate conflicts of interest, create incentives for unethical choices, and undermine accountabili- ty. Because ethical decision making is so important to healthy human relationships, institutional arrangements that send contradictory mes- sages about what is appropriate, or that undermine or discourage ethical decision making, are socially destructive (1995, p. 36). The point made here seems to be a specific instance of the assertion made in the NCCB pastoral letter, regarding businesses’ “right to an institution- al framework that does not penalize enterprises that act responsibly” (1992, p. 606). The minimum to be hoped for from public policy is that health care reform legislation should not create any additional obstacles that would prevent health care professionals from acting responsibly, which, according to the Woodstock statement means acting first in the best inter- ests of their patients. The Woodstock statement, consistent with the overall thrust of Catholic social teaching, thus does not advocate any particular model for health care reform. But it does highlight the ethical criteria that any useful reform THE ECONOMICS OF HEALTH CARE MANAGEMENT 245 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 must meet. First, the program must provide “a decent minimum care for all” (1995, p. 36). Anything short of that will only intensify the ethical dilemmas generated by the current system, and thus further strain the integrity and credibility of health care professionals who are forced to use their ingenuity to make the system work in spite of itself. Second, for the reform program also to be fiscally sound, society must set certain limits to the resources it is willing and able to devote to health care. Health care rationing of some sort will be a part of any reasonable and just solution. Better that rationing be based on explicit social consensus than imposed as the consequence of decisions postponed or evaded. Finally, since – what- ever the final shape of reform legislation – any policy is still likely to generate fresh dilemmas, it is better to anticipate these dilemmas and recognize that no system can eliminate the role-conflict that health care professionals are likely to suffer as they seek to fulfill all the demands society makes upon them. Educating health care professionals in how to deal responsibly with these conflicts becomes essential to the success of any reform program. The Woodstock approach to the public policy dimension of health care reform thus is minimalist, but not disappointingly so. The statement may be overly concerned not to give the impression of seeking to impose a distinctively Catholic or “intentionally Christian” agenda. But the source of this concern is not spiritual tepidity or religious indifference, but a profound respect for the religious and cultural pluralism that is character- istic of American society and politics in the late 20th century. Consistent with the principles of Catholic social teaching, especially the principle of subsidiarity, the Woodstock statement does not look to the government policy-makers to favor or to foster an intentionally Christian health care system. The government’s role in health care reform is to devise a system that meets basic and – so the Catholic tradition believes – universal stand- ards of justice based on our commonly shared respect for human dignity. Were the government to succeed in this effort, its results would neither usurp the role of “intentionally Christian” health care institutions nor im- pede the development of such. That’s all, it seems, that informed Ameri- can Catholic opinion is prepared to ask of Washington, no more and no less. If asked to speculate on this basis about whether Catholic hospitals should attempt to provide “equal access to high cost/low yield treatments or primarily low cost/high yield treatment with the option that one could purchase more if one posessed the funds,” I can only point out that, since Catholic hospitals are private institutions, and thus essentially oriented to what their patients and benefactors are willing and able to pay for, neither 246 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 option as such is easily achievable for them. Clearly, they are not in a position to offer “equal access to high cost/low yield treatments,” if equal access means offering them significantly below their actual costs. Many informed Catholics would clearly prefer to reorient the church’s health care institutions to the “low cost/high yield” profile, but such may also be impossible, in the absence of significant health care reform legislation. A promising middle ground may be emerging between these two op- tions. Increasingly, the various Catholic religious orders – whose tradi- tions and, of course, loyalties are quite distinct – have begun exploring the possibility of collaborating on major strategic decisions such as the acqui- sition of new high-cost technology in a given locale, or developing a division of labor, especially in high-tech specializations, so that not every Catholic hospital would have to provide the whole range of high cost/high tech treatments, but that all such treatments could still be available within the local association of Catholic hospitals. Understandably, there is resist- ance even to this modest reform, for some fear that it is tantamount to collusion or price-fixing for Catholic hospitals to seek not to compete with each other in providing the full range of medical treatments, and others are skeptical in the face of the fiercely competitive posture that Catholic reli- gious orders and their health care institutions have often exhibited toward one another in the past. Here, too, the factors weighing in against a radical- ly countercultural transformation in Catholic health care are formidable. The second set of concerns underscored by the editors of Christian Bioethics is, of course, the ongoing challenge of founding and administer- ing “intentionally Christian” health care organizations. What would such an organization look like in the perspective of Catholic social teaching? Would it mean, as the issue editor asked me, that the ideal Catholic hospi- tal be one in which patients were “cared for only by Catholic physicians and Catholic nurses under the standards of care outlined by the tradition, with a focus first on God’s good purposes, even in the midst of suffering?” I find that ideal not only hard to imagine, but actually contrary to the basic thrust of Catholic social teaching, especially after Vatican II. It makes as much sense as mandating that all faculty members at a Catholic university must be Catholics, and that all courses in one way or another must afford an opportunity for theological reflection. Let me explain why such a strat- egy is likely to be both ineffective and inappropriate. It is likely to be ineffective for reasons apparent in McCormick’s obser- vations about the “Made in America” label that Catholic health care insti- tutions wear sometimes proudly and sometimes for simple reasons of truth in advertising. The patients as well as the health care professionals who minister to them are religiously, culturally, and ethnically diverse; and THE ECONOMICS OF HEALTH CARE MANAGEMENT 247 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 given the markets in which private health care institutions must operate, any attempt to restrict this diversity risks making the institution less at- tractive both to patients and professionals, and thus less cost-effective as well. It would also be inappropriate because, in Catholic institutions shaped by the reforms of Vatican II, diversity is seen as a positive value to be honored for its own sake. Obviously, for an institution to claim a Catholic identity, its mission must be consistent with Catholic values and priorities. But the way of framing the mission, i.e., the terms in which it is described and implemented, will seek to identify a common ground that all partici- pants can share, a nonsectarian translation of values and priorities rooted in the Catholic identity but not exclusive to it. Cultivating a distinctively Catholic identity is part of what it means to be an “intentionally Christian organization”; but, after Vatican II, so is acknowledging and welcoming diversity. In order to balance both aspects of what it means, after Vatican II, for Catholic institutions to be “intentionally Christian,” there must be a strong Catholic presence in the institution, i.e., health care professionals who are “intentional” about their faith, or at least are open to opportunities to grow in faithfulness as they mature professionally. There should be opportuni- ties, invitations to participate “intentionally” in the religious mission of the institution, and its founding community. But religious affiliation as such cannot and should not be a condition of employment. Not everyone will want to answer such invitations. But those who come to see their careers tied increasingly to the history of a particular institution are likely to find comfort and challenge in taking advantage of whatever opportuni- ties there are to understand the history of the founding religious communi- ty, its distinctive experience in health care, and the distinctive spirituality that sustains it. It is my experience that health care professionals working in Catholic hospitals may feel a greater sense of community with, say, the Daughters of Charity, than with something as large and problematic as the Roman Catholic Church and its checkered history. Honoring the local traditions of the founding community may be an effective way of sustaining the Catho- lic identity of the institution, or at least of inviting lay Catholic and non- Catholic professionals to participate in it on their own terms. The implications of claiming a Catholic identity include a willingness to abide by institutional guidelines that honor Catholic moral teaching on controversial questions like abortion and sterilization. After Vatican II, Catholicism is open to diversity, but that doesn’t mean that “anything goes.” Catholic teaching on abortion and sterilization claims to be reason- able in that it does not require Divine revelation to understand the evils 248 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 involved, nor does the teaching rely exclusively on Scriptural warrants. As long as the Catholic community remains convinced, rightly or wrongly, that its teachings are reasonable and thus in principle binding upon all human beings, Catholic institutions will continue to implement these teach- ings in their own institutional policies, and understandably so. This, too, is implicit in the statements we have considered, and it is ex- plicit in McCormick’s discussion of comprehensive “ethical guidelines for Catholic hospitals.” Nevertheless, McCormick rightly cautions against an overly restrictive approach to institutionally sanctioned medical procedures. While he, too, insists that Catholic hospitals must uphold Catholic teaching on abortion, he does not agree that, because they prohibit abortion proce- dures, they should also prohibit, for example, amniocentesis (1987, pp. 140- 142). While it may be true that the fetal defects disclosed in an amniocente- sis test might be considered by some as sufficient moral justification for having an abortion, the amniocentesis procedure can and ought to be evalu- ated ethically independent of the morality of abortion. The disclosure of a serious defect may not necessarily result in abortion, and Catholic hospitals should provide opportunities for counseling in support of continuing the pregnancy. That the patient and her physician may decide to have an abor- tion elsewhere, in McCormick’s view, does not affect the moral legitimacy of having the testing procedure available to those who have need of it. This strikes me as a reasonable position. The Church’s teaching is observed by the institution, without unduly restricting the freedom and responsibilities of either patients or health care professionals. The patient or health care professional who feels that his or her own conscience is violated by the Catholic hospital’s policies restricting or prohibiting procedures like abortion and sterilization, of course, have an option. No one is forcing him or her to use the services of a Catholic hospital or to work within one. Any reasonable person, even if he or she disagrees with the church’s teachings, will understand how and why it is that an institution claiming a Catholic identity would, in its own policies, observe the church’s teachings governing what the church regards as seri- ous moral issues. Of course, before any health care professional is hired by a Catholic hospital he or she should be fully informed about any such policies, afforded the opportunity to discuss them, and then asked for his or her cooperation. A willingness to work within these policies and not against them is and ought to be a condition for employment in a Catholic hospital. Similarly, patients should also be informed. Insisting on the right and the duty of Catholic hospitals to enforce Catholic teaching regarding grave violations of what are believed to be common moral principles, however, in no way undermines the institution’s commitment to diversity. THE ECONOMICS OF HEALTH CARE MANAGEMENT 249 Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 Indeed, it lends an appropriate gravity to such a commitment, for it makes clear that welcoming diversity does not mean indifference either to the legacy of one’s own tradition, or to commonly shared human values. Becoming an “intentionally Christian organization,” as the issue editor implies, involves much more than honoring, and where necessary, imple- menting policies consistent with Catholic morality. It also involves ad- dressing deep questions regarding spirituality, ministering to the spiritual needs of both patients and health care professionals, and making sure that both patients and professionals have the opportunity to discern and strug- gle with “God’s good purposes, even in the midst of suffering.” The insi- tution’s invitation to respond to these questions has usually been delivered by hospital chaplains or health care professionals involved in pastoral ministry. Given the Catholic hospital’s commitment to diversity, its pasto- ral care teams should include or be capable of networking with profession- als representing a variety of religious traditions, so that no patient is de- prived of spiritual comfort and challenge from his or her own community. The challenge of discerning meaning in human suffering, and its signif- icance for health care, is not met simply by providing opportunities for pastoral care. This also becomes a policy question. Distinctively Catholic attitudes and practices regarding suffering and death should, and increas- ingly are, leading Catholic health care professionals to consider the role of palliative care and hospices for the terminally ill as an important part of their institutional mission. The virtual neglect of palliative care in Ameri- can medicine is, in the eyes of many Catholic professionals, the single biggest factor influencing the shift in public opinion toward increasing acceptance of physician-assisted suicide. Catholic institutions and all oth- ers seeking to become “intentionally Christian” should consider making palliative care a priority, so that patients can find in such institutions an appropriate setting for struggling with distinctively Christian attitudes and practices in the face of suffering, especially toward the end of one’s life. The provision of hospices where the dying may be enabled, through inno- vative drug therapies and other forms of advanced medicine, to participate meaningfully in the mystery of death, without unnecessary pain and dis- comfort, in a setting where they may still respond to God’s call to share in the mystery of Christ’s own death and resurrection – this ought to become an increasingly visible sign of the institution’s commitment to becoming an “intentionally Christian organization.” The irony is that making palliative care a priority may also help Catholic hospitals to become more cost-effective, and thus contribute in some small way to easing the current crisis in health care. But the economic attractive- ness of palliative care is no reason to despise it! What I’m suggesting, in 250 DENNIS P. MCCANN Downloaded By: [EBSCOHost EJS Content Distribution] At: 17:40 15 July 2007 conclusion, is that there is and need be no contradiction between a responsi- ble concern for “the bottom line,” i.e., for a reasonable and appropriate con- cern for the business aspects of health care and “Christian values.” After all, a responsible concern for the bottom line is simply another name for “stew- ardship,” which ever since Genesis has been honored as a Christian value. There are right ways and wrong ways to be concerned about the bottom line, just as there are right ways and wrong ways to do business ethics. But an “intentionally Christian organization” has absolutely no stake in promoting the fallacy that business ethics is an oxymoron, or that a concern for the bottom line is inherently immoral. One could just as well argue that “inten- tionally Christian organization” is an oxymoron, and that any attempt to institutionalize Christianity is inherently immoral. The Catholic tradition in health care, like Catholic social teaching as a whole, continues to trust that the truth of the matter lies elsewhere. NOTE 1. This paper is dedicated to the Daughters of Charity with whom I have worked as a faculty member at DePaul University in Chicago and from whom I have learned the meaning of the Vincentian motto, “To Follow Christ through Evangelizing the Poor,” especially Sr. Jean Maher, D.C. I wish also to thank Dr. Gerhold Becker, Director, Centre for Applied Ethics, Hong Kong Baptist University. This paper was researched, conceived and written entirely during my residence at the Centre as University Fellow in the Spring semester of 1998. REFERENCES Centesiums Annus (1991). www.vatican.va/holy_father/john_paul_ii/encyclicals/docu- ments/hf_ip-ii_enc_01051991_centesiums-annus_en.html Gaudium et Spes (1965). www.vatican.va/archive/hist_councils/ii_vatican_council/docu- ments/vat-ii_cons_19651207_gaudiume-et-spes_en.html McCormick, R.A. (1987). Health and Medicine in the Catholic Tradition: Tradition in Transition, Crossroad Books, New York. National Conference of Catholic Bishops (1986). Economic Justice for All: Pastoral Letter on Catholic Social Teaching and the Economy, National Conference of Catholic Bishops, Washington, D.C. O’Brien, D.J. and T.A. Shannon (eds.) (1992). Catholic Social Thought: The Documentary Heritage, Maryknoll, Orbis Books, New York. Pacem in Terris (1963). www.vatican.va/holy_father/john_xxiii/encyclicals/documents/ hf_j-xxiii_enc_11041963_pacem_en.html Quadragesimo Anno (1931). www.vatican.va/holy_father/pius_xi/encyclicals/documents/ hf_p-xi_enc_19310515_quadragesimon-anno_en.html Rerum Nevarum(1891). www.vatican.va/holy-father/leo_xiii/encyclicals/documents/hf_l- xiii_enc_15051891_rerum-nevarum_en.html Woodstock Theological Center (1995). Ethical Considerations in the Business Aspects of Health Care, Georgetown University Press, Washington, D.C.
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