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by Jim Holman.
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Spiritually Toxic Healthcare

BISHOPS OFFER UNCLEAR GUIDANCE TO CATHOLIC HOSPITALS

By Hippocrates Wächter

It matters whom you climb into bed with. That this is true not only for individuals can be shown by the merger, last December, of eight Southern California non-Catholic hospitals with Catholic Healthcare West. As the Mission reported last January (see "Why Do the Feminists Rage?") this merger raised certain moral questions surrounding cooperation of Catholic healthcare providers with institutions that do not follow Catholic teaching regarding medical ethics, particularly in the issuing of artificial contraception, abortifacients, and sterilization.

Last January, Carol Bayley, director of ethics and justice education for Catholic Healthcare West in San Francisco told me that, though under their agreement with Catholic Healthcare the non-Catholic hospitals (formerly belonging to the Unihealth system) will not be allowed to do abortions, they will still be able to offer "morning-after pills" to rape victims, and sterilizations. Morning after pills, she explained, though they may be abortifacient, act primarily as contraceptives. Though the Church condemns artificial contraception, rape victims, said Bayley, have a right to such contraception: "I don't remember if the Ethical and Religious Directives actually underscore this, or if it is the opinion of a lot of theologians and bishops ... that a woman who has been raped has not consented to a sexual act, and is therefore not responsible for the result of it."

"The directives do address that, and she's wrong," said Monsignor William Smith, a moral theologian at Dunwoodie Seminary in New York. The difficulty of whether to give morning-after pills to rape victims, he said, is but an example of the difficulties Catholic health systems face when they begin cooperating with non-Catholic health providers. What does the Catholic system do if those with whom they contract provide, sterilization, euthanasia, or other illicit medical services?

The United States bishops' document, Ethical and Religious Directives for Health Care Services (1994), #69, states that "when a Catholic health care institution is participating in a partnership that may be involved in activities judged morally wrong by the Church, the Catholic institution should limit its involvement in accord with the moral principles governing cooperation." According to the "Statement on Cooperation, An Examination of the Fundamental Principles" issued by the the ethicists of the National Catholic Bioethics Center in Boston, Massachusetts, this directive states that "Catholic insititutions should use the principles of cooperation in order to limit involvement in evil with non-Catholic providers, not expand it."

Some Catholic health providers, said Monsignor Smith "seem to think that as long as they say 'no' to abortion, then [they] can get into bed with anybody. That's not true: the more difficult things are the non-therapeutic sterilization; a Catholic hospital should not do that. And if you govern, if you manage, if you financially direct this in other hospitals that you own, it just seems to me that that's an impermissible form of cooperation. If it's a Catholic hospital chain, it should be in accord with the Ethical and Religous Directives, both for individuals (if someone is going to work there, you ask them to sign that), and institutions, as well."

A Catholic health provider may be said to cooperate with the immoral activities of other institutions at different levels. One level is "formal cooperation," which, said Monsignor Smith, occurs when one agrees with the immoral activity and helps it along. "A formal cooperator," said Smith, "is just as bad as the original agent." On another level is "material cooperation" where the one cooperating does not agree with the immoral activity performed, but still cooperates in a fashion with it. While the bishops' directives speak to both kinds of cooperation, their definitions lack clarity: "to tell you the truth," said Monsignor Smith, "one of the problems is that the principle of cooperation in the Ethical Directives was very badly stated, very poorly stated."

The ethicists at the National Catholic Bioethics Center agree. Quoting the directives' definition of formal cooperation -- "if the cooperator intends the object of the wrongdoer's activity, then the cooperation is formal and, therefore, morally wrong" -- the ethicists write: "while we do not disagree with that definition, it may be too narrowly worded to account for the full dimension of formal cooperation."

The ethicists state that the directives did not take into account the "traditional 'fonts' of morality" in defining formal cooperation. In determing the moral liceity of an act, one must not only consider the act being done (the "moral object"), but also the intention behind the act, and the circumstances in which the act is performed. The directives, say the ethicists, consider only the component of intention, while they insist that formal cooperation is the "intending or concurring in any one or more of the immoral components of the principal agent's act, either as an end in itself or as a means."

The bishops distinguish between two sorts of formal cooperation -- explicit and implicit. While explicit formal cooperation implies both the agent's and the cooperator's agreement to the act, implict formal cooperation, say the bishops, "is attributed when, even though the cooperator denies intending the wrongdoer's object, no other explanation can distinguish the cooperator's object from the wrongdoer's object." The ethicists, basing their definition of implicit formal cooperation on their definition of formal cooperation, state: "implicit formal cooperation [is the] intending any one or more of the immoral components of the principal agent's act but as a means to something other than the principal agent's act." In such cooperation, the cooperator does not, say, agree with abortion, but provides for the apparatus by which abortions are performed.

While formal cooperation, whether implicit or explicit, is never permissible, material cooperation may be. A permissible kind of material cooperation occurs, say the ethicists, "when the cooperator contributes only to the morally licit circumstances associated with the principal agent's act, and those circumstances are not essential to the prinicipal agent's performance of the evil action." An example of such material cooperation, said Monsignor Smith, occurs where nurses in hospitals might be said to cooperate in an abortion when they "prepare people before and after operation, but don't set foot in the operating suite." In such a case, the nurse does not intend the abortion and her cooperation is not essential to the performance of the abortion.

"On the other hand," continued Monsignor Smith, "if you had a late-term abortion and someone is the anesthesiologist, and you can't do the abortion without the anesthesia -- that's an impermissible form of immediate, material cooperation. The guy could say he's the head of the parish council, a lector, and everything else, and say he is opposed to abortion; but, because this can't take place without his help, there's a much higher level of scrutiny and responsibility."

This sort of material cooperation, which the ethicists call "immediate" occurs when there is "any willful, intentional contribution to the circumstances essential to the principal agent's immoral action," though that action may not be intended by the cooperator. Such ccoperation, they say, is always wrong, though "its culpability is significantly reduced or eliminated if done thorugh a legitimate fear of losing a great good."

These definitions of material cooperation are a refinement of the U.S bishops' definitions, which say the ethicists, do not sufficiently distinguish material from implict formal cooperation. Another difficulty arises from the fact that the bishops' directives do not address institutional cooperation in immoral actions -- an issue directly bearing on the Catholic Healthcare West/Unihealth merger. "One of the problems with cooperation [in the bishops directives]," said Monsignor Smith, "is that it all evolves, basically, in the context of the individuals, to try to protect individuals from getting through some policy that they did not bring on their own heads. When you shift to institutions, in governance, management, or finance, you've got a problem. Any Catholic institution, through a written contract or whatever establishes that governance, that management, or that financing -- that, to me, is an impermissible form of moral cooperation. You cannot govern, you cannot manage, you cannot profit by [immoral acts]. Now, some of them will say, well, it's distance; if it's at another place, that solves it all. Others will speak of 'duress,' [which means] they're going to lose money -- the end justifies the means."

In relation to duress, the ethicists state that "one of the major areas of difficulty concerns the question of whether any potential harm that might face a corporate person [such as a hospital] could be equivalent to that possibly faced by an individual person." A person under threat of death materially cooperating in a robbery (say, by opening the safe) may be justified in so doing because the good of his life is a higher good than the good of property; in this case, say the ethicists, "the threat of the loss of life and the accompanying fear could so reduce the free exercise of the will that one might question whether the act can even properly be evaluated in terms of the principles of cooperation." Such duress they say, however, is not applicable to institutions.

No human life is in jeopardy, say the ethicists, when a Catholic health care institution closes down or is sold to a non-Catholic provider: "there could be diministed access to quality health care in a given community, but this is not a Catholic problem as such nor one for which the Catholic entity would be morally culpable." Though the closing of such an institution would be "regrettable" and "tragic," it is not, say the ethicists, "equivalent to the loss of the life of a human being." Too, "Catholic institutions are bound to a more rigorous application of the principles limiting cooperation in evil than are individuals, because Catholic institutions stand as very public witnesses to Catholic teaching and morality."

This last point is most important, according to the ethicists. "Jesus healed physically," write the ethicists, "in order to give witness to a greater healing which He and His Church offer, healing from moral evil. Catholic institutions can do nothing which would contribute to the advancement of evil in the world nor can they do anything which would lead to confusion in people's minds about what constitutes sin without betraying Jesus Christ Himself, in other words, without betraying the One who gives meaning to their very existence. Sacrifice of moral principle for the sake of financial gain, for the sake of an increase in market share, for the sake of gaining a competitive edge, even for the sake of serving the poor cannot be legitimate, for Catholic institutions must give constant preference to spiritual goods over those that are temporal."

-- from the Los Angeles Lay Catholic Mission, October 1999

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