1. The Ethical and Religious Directives for Catholic Health Care Services: A Brief Tour N.A.C.C. Meeting November 4, 2008 Tom Nairn, O.F.M. Senior Director, Ethics

2. Why Look at the Directives?  What Catholic health care is about—purpose and fundamental value commitments  How Catholic health care should be delivered; sets some basic parameters  Document to which all in Catholic health care are accountable

3. Why Look at the Directives?  As leaders within the health care ministry, Catholic chaplains –Have a responsibility for educating about the Directives –May be asked to interpret and apply the Directives –Should be able to direct others to appropriate sections

4. What Are the Directives?  A limited attempt to answer two questions: – Who are we? Who should we be? (Identity) – What should we do in light of this? (Integrity)  And … to provide guidance on ethical issues in health care delivery

5. Purpose of the Directives (Preamble)  To affirm ethical standards and norms  To provide authoritative guidance  To provide professionals, patients and families with principles and guides for making decisions

6. For Whom Are the ERDs Intended? (Preamble)  Those entrusted with identity and integrity of the ministry and the organization (sponsors and trustees; CEOs)  Those embodying the mission in day-to-day operations (administrators, health care professionals, spiritual caregivers, etc.)  Recipients of health care (patients, residents, families, and surrogates)

7. General Format  Six parts covering six major areas of concern in Catholic health care  Each part divided into two sections: –Introduction: narrative, providing a biblical and theological context –Individually numbered directives addressing specific issues

8. The Parts  General Introduction  Part One: Social Responsibility  Part Two: Pastoral Responsibility  Part Three: Patient/Professional Relationship  Part Four: Beginning of Life  Part Five: Care for the Dying  Part Six: Forming New Partnerships

9. Approaching the ERDs  Not an answer book—usually requires interpretation and application to concrete situations  Not exhaustive either of –The church’s moral teaching –Issues in health care ethics  May need assistance  Different conclusions are possible

10. Approaching the ERDs

11. General Introduction: Who Should We Be? The reason for Catholic health care:  Continuing God’s life-giving and healing work (p.7)  By imitating Jesus’ service to the sick, suffering, and dying (pp. 4, 5)  Response to Jesus’ challenge to “Go and do likewise” (p. 38)  Carrying on Jesus’ radical healing (p.4)

12. General Introduction: Who Should We Be?  Ought to be Christ’s “healing compassion in the world” (p.38)  Ought to restore and preserve health and serve as a sign of final healing (p. 38)  As a ministry of the church (p. 6)

13. PART ONE: Social Responsibility VALUETHEOLOGICAL REFLECTION Human Dignity Catholic health care is rooted in a commitment to defend human dignity Care of the Poor Catholic health care is mandated to care for the poor, the uninsured and the underinsured Common Good Catholic health care contributes to the common good, ensuring protection for fundamental rights of individuals and groups Responsible Stewardship Catholic health care is concerned both with the quality of care for the individual and with the health of the community Respect for Conscience To the extent it is able, Catholic health care respects the individual’s conscience but also asks the individual to respect its institutional conscience

14. Part One: Social Responsibility Introduction (pp. 4-5)  Common values that should distinguish Catholic health care: –human dignity –care for the poor –contribution to the common good –responsible stewardship of resources –consonance with church teaching

15. Part One: Social Responsibility Key Directives  #1: We are a community of care animated by the Gospel and respectful of the church’s moral tradition  # 2: We act in a manner characterized by mutual respect among caregivers and serving with compassion of Christ  #6: Use health care resources responsibly

16. Part One: Social Responsibility  #7: Treat employees respectfully and justly – non-discrimination in hiring – employee participation in decision-making – workplace that ensures safety and well-being – just compensation and benefits – recognition of right to organize

17. Part One: Social Responsibility  #3: Organization should distinguish itself by service to and advocacy for marginalized and vulnerable

18. PART TWO: Pastoral and Spiritual Care VALUETHEOLOGICAL REFLECTION Human Dignity Catholic health care has the responsibility to treat those in need in a way that respects the human dignity and eternal destiny of all. Holistic Care Catholic health care institutions are communities of healing that embrace treatment of the physical, psychological, social and spiritual dimensions of the person. Healing Presence Catholic health care combines medical expertise with other forms of care to promote health and relieve human suffering Diverse Roles and Collaboration Within the health care institution, clergy, religious and laity exercise diverse but complementary roles in pastoral care. Also, more frequently, the local parish assumes greater involvement in pastoral care both before and after hospitalization.

19. Part Two: Pastoral and Spiritual Care Introduction (pp. 6-7)  Catholic health care must treat all in a manner that respects human dignity and their eternal destiny; help others experience own dignity and value  Care offered must embrace whole person: physical, psychological, social, spiritual

20. Part Two: Pastoral and Spiritual Care  Pastoral care is an integral part of Catholic health care  Pastoral care encompasses full range of spiritual services – listening presence – help in dealing with powerlessness, pain, etc. – assistance in responding to God’s will  Establish good relationships between pastoral care and parish clergy and ministers of care

21. Part Two: Pastoral and Spiritual Care Key Directives  #15: Addresses holistic needs of persons  # 10: Maintain appropriate professional preparation and credentials for staff  # 10-14, # 20-22: Respect proper authorities in each religion or Christian denomination regarding appointments

22. Part Two: Pastoral and Spiritual Care  #10: Addresses the particular religious needs of patients  #11, #22: Maintain an ecumenical staff or make appropriate referrals  #10, 12-20: Address the sacramental needs of Catholics

23. PART THREE: Patient/Professional Relationship VALUETHEOLOGICAL REFLECTION Respect for Persons Relationship requires mutual respect, honesty and appropriate confidentiality; avoids manipulation, intimidation or condescension Interdependence Neither professional or patient acts independently; both participate in healing process Commitment Fact that there is a team of providers does not alter the personal character of the interaction Professional Ethical Responsibility Professionals take into account the patient’s convictions and spiritual needs and the moral responsibilities of all concerned, including the institution

24. Part Three: Patient/Professional Relationship Introduction (p.8)  Grounded in respect for human dignity  Requires mutual respect, trust, honesty, and appropriate confidentiality  Participatory and collaborative  Both parties have responsibilities

25. Part Three: Patient/Professional Relationship Key Directives  #23: Inherent dignity of human person must be respected and protected – honor patients’ right to make treatment decisions (#s 26 and 27) – honor informed consent (#s 26 and 27) – encourage and respect advance directives (#24)

26. Part Three: Patient/Professional Relationship – respect choices of surrogate decision makers (#25) – respect privacy and confidentiality (#34) – consider whole person when deciding about therapeutic interventions (#33) – respect decisions to forego treatment (#32); ordinary or proportionate means (morally obligatory); extraordinary or disproportionate means (morally optional)

27. Part Three: Patient/Professional Relationship  # 36: Provide compassionate and appropriate care to victims of sexual assault – cooperate with law enforcement officials – offer psychological and spiritual support – offer “accurate medical information” – provide treatment to prevent conception pregnancy approach ovulation approach

28. PART FOUR: Care for the Beginning of Life VALUETHEOLOGICAL REFLECTION Sanctity of life The Church’s commitment to human dignity inspires a concern for the sanctity of human life from conception until natural death Respect for Marriage and Family The Church cannot approve practices that undermine the biological, psychological and moral bonds of marriage and family. Respect for the Procreative Act The Church cannot approve interventions that have the direct purpose of rendering procreation impossible, or separating procreation from intercourse. Appropriate Use of Technology What is technologically possible is not always moral. Reproductive technologies that substitute for the marriage act are not consistent with human dignity.

29. Part Four: Care for the Beginning of Life Introduction (pp. 10-11)  Catholic health care ministry witnesses to the sanctity of human life “from the moment of conception until death”  Commitment to life includes care of women and children before and after pregnancy and addressing causes of inadequate care

30. Part Four: Care for the Beginning of Life  Profound regard for the covenant of marriage and for the family  Cannot do anything that separates the unitive and procreative aspects of conjugal act  Reproductive technologies that substitute for marriage act inconsistent with human dignity

31. Part Four: Care for the Beginning of Life Key Directives What the Directives forbid:  #45: Direct abortions  #53: Direct sterilization  #52: Contraceptive practices  #40: Heterologous fertilization (AID)  #41: Homologous fertilization (AIH)

32. Part Four: Care for the Beginning of Life What the Directives permit:  #47: Indirect abortions (those procedures whose sole immediate purpose is to save the mother’s life, where the death of embryo or fetus is foreseen but unavoidable)  #53: Indirect sterilizations  #50: Prenatal diagnosis  #54: Genetic counseling  #43: Infertility treatments

33. PART FIVE: Care for the Dying VALUETHEOLOGICAL REFLECTION Stewardship over Human Life We are not the owners of our lives and hence do not have absolute power over them. We have a duty to preserve life. Priority of Care The task of medicine is to care even when it cannot cure. Such caring involves relief from pain and the suffering caused by it. Community of Care A Catholic health care institution will be a community of respect, love and support to patients and their families as they face the reality of death Respect for the Dying The use of life-sustaining technology is judged in the light of the Christian meaning of life, suffering and death. One should avoid two extremes: (1) insistence on useless and burdensome technology even when a patient legitimately wishes to forego it and (2) withdrawal of technology with the intention of causing death.

34. Part Five: Care for the Dying Introduction (pp. 13-14)  We face death with the confidence of faith (in eternal life); basis for our hope  Should be a community of respect, love, and support to patients and families  Relief of pain and suffering are critical  Medicine must care even if it cannot cure

35. Part Five: Care for the Dying  Stewardship of and duty to preserve life – this is a limited duty. Why? – human life is sacred and of value, but not absolute – because it is a limited good, duty to preserve it is limited to what is beneficial and reasonable in view of purposes of human life

36. Part Five: Care for the Dying  Decisions about use of technology made in light of … – human dignity – Christian meaning of life, suffering and death  Avoid two extremes – employing useless or burdensome means – withdrawing technology to cause death

37. Part Five: Care for the Dying Key Directives  # 55: Provide opportunities to prepare for death  # 56: Moral obligation to use proportionate means of preserving life  # 57: No moral obligation to employ disproportionate or too burdensome treatments

38. Part Five: Care for the Dying  #59: Respect free and informed decision of patient about forgoing treatment  # 61: Appropriateness of good pain management, even where death may be indirectly hastened through use of analgesics  #60: Euthanasia and physician-assisted suicide are not permitted  #62-66: Encourage appropriate use of tissue and organ donation

39.  # 58: Presumption in favor of nutrition and hydration as long as it is of sufficient benefit to outweigh burdens Part Five: Nutrition and Hydration (#58)

40. PART SIX: Forming New Partnerships VALUETHEOLOGICAL REFLECTION Value-based Collaboration New partnerships can be opportunities for Catholic health care institutions and services to witness to their religious and ethical commitments and so influence the Church’s social teaching. Ethical Challenges New partnerships can pose serious challenges to the viability of the identity of Catholic health care institutions and services. Importance of Moral Analysis The significant challenges that partnerships may pose do not necessarily preclude their possibility on moral grounds... but require that they undergo systematic and objective moral analysis. Formal and Material Cooperation Reliable theological experts should be consulted in interpreting and applying principles governing cooperation, with the proviso that, as a rule, Catholic partners should avoid entering into partnerships that involve them in cooperation with wrongdoing.

41. Introduction (pp.15-16)  Section added with the 1994 revision  Primarily concerned with “outside the family” arrangements  Concern: some potential partners engaged in wrongdoing  How does Catholic party maintain integrity? Part Six: Forming New Partnerships

42.  Appendix omitted: led to misunderstanding and misapplication of principle of cooperation  Consult reliable theological experts  Catholic health care organizations should avoid cooperating in wrongdoing as much as possible Part Six: Forming New Partnerships

43. Key Directives  #67: Consult with diocesan bishop or liaison if partnership could have serious impact on the Catholic identity or reputation of the organization, or cause scandal  #68: Proper authorization should be sought (maintain respect for church teaching and authority of diocesan bishop) Part Six: Forming New Partnerships

44.  #69: Must limit partnership to what is in accord with the principles governing cooperation (POC), i.e.: – POC helps determine whether and how one may be present to the wrongdoing of another – To determine whether cooperation is morally permissible, one must analyze the cooperator’s intention and action Part Six: Forming New Partnerships

45.  Intention: intending, desiring or approving the wrongdoing is always morally wrong (formal cooperation)  Action: directly participating in the wrongdoing or providing essential conditions for the evil to occur (i.e., the immoral act could not be performed without this cooperation) is morally wrong (immediate material cooperation) Part Six: The Principle of Cooperation

46.  Essential conditions with regard to partnership would include ownership, governance, management, financial benefit, material, and personnel support  Earlier edition of ERDs permitted immediate material cooperation under situations of duress Part Six: The Principle of Cooperation

47.  #70: Forbids Catholic health care institutions from engaging in immediate material cooperation in intrinsically evil actions (e.g. sterilization) Part Six: The Principle of Cooperation

48.  Being present to the wrongdoing of another in a non- essential way (i.e., the cooperator’s act assists in the performance of the wrongdoing but is not itself essential) can be morally licit when there is a proportionately grave reason (mediate material cooperation) –cooperator’s action should be as distant (in causal terms) as possible from wrongdoer’s –the more proximate (in causal terms) the cooperation, the more serious the reason Part Six: The Principle of Cooperation

49.  #71: “Scandal” must be considered when applying the principle – means “leading others into sin” and not causing shock or discomfort – may foreclose cooperation even if licit – may be avoided by good explanation – bishop has final responsibility for assessing and addressing scandal Part Six: Forming New Partnerships

50.  #72: Periodically, the Catholic partner should assess whether the agreement is being properly observed and implemented Part Six: Forming New Partnerships

51. Conclusion  The ERDs are a valuable document for better understanding who we ought to be (our identity)  They also help us to understand what we ought to do (our integrity) in light of our identity  Ultimately, they call upon us to “walk our talk”