BY: M. THERESE LYSAUGHT, PhD
What Is Health Care Ethics's Connection to an Understanding of the Catholic Church?
Dr. Lysaught is associate professor, religious studies, University of Dayton, Dayton, OH.
I have been asked to provide in this essay an overview of the ecclesiology of Fr. Kevin D. O'Rourke, OP, JCD, STM, especially as it relates to health care ethics.
Ecclesiology is not usually one of the first things that come to mind when one thinks "health care ethics." Catholic health care ethics seems to take its bearings from an understanding of the human person (anthropology) rather than an understanding of the church. It seems to spend its time on principles, or "directives," rather than reflection on who and what the church is and the difference that might make for ethics and medicine. It seems to be concerned primarily with sex, death, and the poor, rather than with sacraments, disciples, and prelates.
However, the organizers of this special section of Health Progress on the work of Fr. O'Rourke have shown keen insight in highlighting the question of his ecclesiology. For one could argue that ecclesiology is precisely what lies behind the growing divide in the church — a divide the late Cardinal Joseph Bernardin attempted to address with his "Common Ground Initiative" — and in Catholic health care ethics.
That particular argument is beyond the scope of this essay. But I would like to suggest that one of the hallmarks of Fr. O'Rourke's work in health care ethics has been his unswerving attempt to work out of a theology of the church that pushes past this divide. In this, he is the consummate Dominican, embodying the Aristotelian/Thomistic insight that "virtue stands in the middle." Such a position, of course, means that his detractors hail equally from the left and the right.
Fr. O'Rourke's vision of the church drinks deeply from the wells of St. Thomas and the Second Vatican Council. If there is one passage that captures the basic outlines of his vision, it is this: "The Church, at once a visible organization and a spiritual community, travels the same journey as all human persons and shares the same earthly lot with the world: it is to be a leaven and as it were, the soul of human society [as it is to be renewed in Christ] in its transformation into the family of God" (Gaudium et spes, para. 40).
When Fr. O'Rourke turns to the question of the church, this is the passage that he cites, again and again.1 It is significant that when he turns to the documents of Vatican II, he turns to Gaudium et spes (Pastoral Constitution on the Church in the Modern World). For his vision of the church is largely a pastoral one, a vision of the church as it lives and works in the world, a vision reinforced by more than three decades of work in and with Catholic health care. And it is this vision that underlies his approach to health care ethics. Health care ethics a la Fr. O'Rourke is a discipline in which the teachings of the visible organization (the magisterium) meet the sacramentally formed community of the faithful (in this case, those who work in Catholic health care) to provide guidance as they journey with and minister to human persons in the world toward the goal of transforming society.
"As Leaven in the World": Fr. O'Rourke's Ecclesiology
Keeping in mind the passage above, let me outline Fr. O'Rourke's ecclesiology in six points. Since Christians hold that the church is "the Body of Christ," any vision of the church must be rooted in an understanding of the person of Jesus Christ. In Fr. O'Rourke's work, this Christologically grounded vision of the church plays out as a human community, aimed toward God, that inculcates virtue in its members and serves as a leaven in the world under the unifying guidance of the magisterium.
The Body of Christ Fr. O'Rourke does not explicitly root his vision of the church christologically. Rather, his view of the relationship between Jesus and the church can be pieced together from various comments. While not quite the hypostatic union, the church as Christ's body partakes to a lesser degree in Christ's divine/human synthesis. Jesus, of course, was fully divine and fully human. Fr. O'Rourke does not claim this same fullness for the church, but it is clearly, in his view, a body that comprises both. Following the Second Vatican Council, he holds the church to be "at once a visible organization and a spiritual community." Elsewhere he will maintain that while "the Catholic Church is of divine origin and depends on divine guidance . . . it is also a very human community."2
Moreover, as the church works in the world, through either official teaching or the work of the faithful, its mission is to embody Christ, to make the Jesus of the Gospels present in the world. The baptized follow Jesus, continue Jesus' work, make Jesus present to those they meet. A thickly "evangelical" Christology, therefore, informs Fr. O'Rourke's understanding of the church and Catholic health care.
A Human Community As befits work done by a Dominican, Fr. O'Rourke's reflects an appreciative fidelity to St. Thomas. This influence emerges in his vision of the church. On the one hand, Fr. O'Rourke sees the church in its communal aspect as, in many ways, natural. "People [he writes] form communities or societies in order to accomplish together things they cannot accomplish alone. . . . [They] strive for goals they cannot accomplish through solitary efforts. . . . [F]orming communities is entirely natural."3
Thus, to be church is consonant with our nature as human persons. Church is constituted by persons, with all their strengths and weaknesses. As such, it cannot but reflect our nature as finite, evolving, at times subject to human sinfulness.4
Aimed Toward God Yet the church is distinguished from other human communities by its origin as well as by the goal toward which it strives. The church is a gift from God to the world, instituted and sustained by the Spirit. So, in good Thomistic fashion, Fr. O'Rourke's ecclesiology is also teleological. Fr. O'Rourke views human life, in all its facets — actions, persons, communities — as always oriented toward some particular end or goal.
Therefore, as a community, the church has a goal, an endpoint toward which it aims. And it is no timid goal. As Fr. O'Rourke notes: "[An] expression of this primary goal says: The church exists to enable people to become friends of God."5
Inculcating Virtue How is it possible for people to become friends with God? For the baptized, the church fosters this friendship through the sacraments. The sacraments, Fr. O'Rourke holds, serve to accomplish "the first and foremost purpose of the church," which is "to instill and develop the virtues of faith, hope, and charity in the minds of its members."6 Through the sacraments, Christians enter into, participate in, and experience the presence of God.7 Bringing us into God's presence, they orient us again and again toward God, toward our proper end, thus fostering the friendship toward which our lives properly tend. Over time, we become different people — people of Christian character, people of Christ-like character.
As Leaven in the World So formed, Christians are then called to be sacraments to the world, to be Christ's presence in the world.8 It is in this way that the church pursues its purpose or goal of enabling all people to become friends of God. It is in this way that the church exists for the world. For what else is "salvation" — Christ's work in the world mediated through the church — but friendship with God? In this way, we could say that the church is the sacrament of Christ in the world.
In an essay entitled "Catholic Healthcare as 'Leaven,'" Fr. O'Rourke emphasizes Jesus' commission — "I send you into the world" — in order to remind us that the church must "immerse itself fully in civil society."9 This identity as "leaven" cuts two ways. On one hand, it requires the church to practice humility and openness: "As the Church witnesses in society, it does not place itself above society. As the Second Vatican Council declared, the relationship between the Church and the world is a dialogue while the world has much to learn from the Church, the Church as much to learn from the world."10 At the same time, however, the leaven must do its work, which in the church's case is the work of bringing the truth of the Gospel to the world, living it in action, witnessing to its power. While the church is never called to impose God's grace or coerce others with it, neither can it ever cease to joyfully embody the Love that it has met through the Gospels, the sacraments, and the gathered community.
Under Magisterial Guidance Being leaven, however, is no breezy task. As a human community, the church "is not always perfect," and its "witness may be obscured by sin and ignorance," serving more as a leaven of a given culture than of the Gospel.11 Market logic in health care, for example, is hard to resist and always threatens to become a false god. At the same time, Christians should listen honestly to other belief systems, science, history, and personal experience, and integrate legitimate insights from them with those of the Christian tradition. For Fr. O'Rourke, the magisterium is critical for negotiating both of these tasks.
The magisterium provides guidance and unity. For those immersed in and witnessing to the world, the magisterium provides guidance for the formation of conscience. As Christian women and men "apply the faith to actual life," trying to discern what it means to live the Gospel in particular situations, they inevitably find that knowing how to proceed is not always obvious. Faithful witness requires a well-formed conscience, and one role of the magisterium is to provide clear direction for such formation.12
This immersion of the faithful in the world returns to the church a bounty of new perspectives through which the church grows in truth. Managing this bounty in a way that integrates new perspectives with the tradition and helps move the community toward its goal requires leadership, historically embodied in the role of the bishop. As Fr. O'Rourke puts it, "A special leadership responsibility falls [on bishops] to unify all these different witnessing voices, to express their consensus in clear terms suited to the times, to correct this in light of the Bible and Sacred Tradition when necessary and link it to the tradition of the Christian community throughout the world in its historical development."13
The bishops most often exercise this leadership through their "teaching" office.
A Balanced Theology
Cardinal Avery Dulles, SJ, STD, in his classic work Models of the Church, provides a useful framework for evaluating ecclesiologies. He outlines six predominant ways theologians have characterized the church (as institution, mystical communion, sacrament, herald, servant, and community of disciples). He notes that each of these models has strengths and weaknesses. And, most importantly, he argues against a one-sided ecclesiology. He argues that to overemphasize any one aspect of the church to the exclusion of the others will lead to distortions, and that "a balanced theology of the Church must find a way of incorporating the major affirmations" of each basic type.14
Following Cardinal Dulles, how might we assess Fr. O'Rourke's ecclesiology? What are its strengths and weaknesses? Is it a "balanced theology"?
One of the strengths of Fr. O'Rourke's understanding of the church, I would argue, is precisely its balance. Although he never set out to construct an ecclesiology, his working vision of the church does incorporate most of Cardinal Dulles's models.
Institution Clearly, Fr. O'Rourke has a strong sense of the institutional church and the function of the magisterium vis-à-vis the church's work in the world, including the work of Catholic health care. He consistently brings church teaching — the Ethical and Religious Directives, the insights of the Second Vatican Council, and papal encyclicals — to bear on the questions at hand.
Sacrament As outlined above, Fr. O'Rourke's sense of the church as "leaven" integrates aspects of sacrament, herald, and servant. Following Henri de Lubac's thickly sacramental vision of the church, Fr. O'Rourke's work conveys a sense that the divine and the human in the church can never be dissociated, and that the church truly makes Christ present in the world, truly continuing Christ's work.
Herald But the church is equally a body that proclaims Christ to the world, a herald announcing God's Word of truth to those who might have ears to hear. At times, that word might take the form of natural law reasoning; at others it might be shaped by the words of Scripture, St. Thomas, or the teachings of the church.
Servant Clearly, the vision of Gaudium et spes — the church as the servant in the world — deeply forms Fr. O'Rourke's theology. Not only does the church provide concrete aid to those in need, embodying the healing, ministering, suffering work of Jesus; in this encounter, Fr. O'Rourke's theology affirms, the church and world will mutually be transformed.
Community of Disciples Fr. O'Rourke's theology even resonates with Cardinal Dulles's idea of the community of disciples, a model that, added to the 1994 revision of the cardinal's book, built on Pope John Paul II's use of this phrase in his first encyclical. For Cardinal Dulles, it is a model that "incorporates what is valid in all the others."15
This balanced ecclesiology undergirds a balanced approach to health care ethics, an approach that confounds the conservative/liberal divide.
Keeping the balance, of course, is an ongoing challenge. For, certainly, emphases do appear in Fr. O'Rourke's work. Opponents may take issue with, alternatively, his emphasis on the institutional or servant dimensions of the church. For Fr. O'Rourke, the apostolic character of the church, and the concrete ways that Christians embody the mission of Jesus in the world, especially to the poor and suffering, is without a doubt the heart of his ecclesiology and his ethics. Yet the church's institutional dimension, embodied in the teachings of the magisterium, plays a stronger role than one might find in the work of other Catholic moral theologians. This is due in part, no doubt, to Fr. O'Rourke's professional training in canon law, an expertise he has carried along throughout his work in health care ethics.
Indeed, one might ask whether "the church" is not too often equated, in Fr. O'Rourke's corpus, with the magisterium. When referring to lay persons, he tends to use the phrase "the Catholic community."16 What is the function of this distinction in language? Fr. O'Rourke's recognition of the church as "a very human community" seems to emphasize the finitude of the faithful without making sufficient space for the finitude of the ordained or the growth in grace and discipleship of persons in the lay state. The laity are often described as those more in need of guidance than full-fledged participants in the community. In this, Fr. O'Rourke would find support both in the documents of Vatican II and theologies of the lay and clerical state articulated by Rome over the past 25 years. Yet, while orthodox, a fuller theology of the laity could be desired.
Ecclesiology and Health Care Ethics
What can we learn from Fr. O'Rourke's ecclesiology vis-à-vis "doing" health care ethics going forward? Let us return to the passage from Gaudium et spes cited at the outset. It would be legitimate to rephrase the passage as follows: "[Catholic health care], at once a visible organization and a spiritual community, travels the same journey as all human persons and shares the same earthly lot with the world: it is to be a leaven and as it were, the soul of human society [as it is to be renewed in Christ] in its transformation into the family of God."
For Fr. O'Rourke, Catholic health care, as a ministry of the church, incarnates its very nature. It is a human community, fulfilling a natural good (the care of sick persons) but transformed by being oriented by its supernatural end of enabling people to become friends with God. It can only do this as "leaven," immersed in civil society, embodying and carrying out the healing mission of Christ. So immersed, Catholic health care finds itself engaged in a thoroughly pluralistic and ecumenical context, working with others as yeast works with flour toward the common good while always witnessing to and communicating the Christian vision.
This ecclesial context of health care cannot help but make a difference for the practice of health care ethics. Let me highlight four implications of this reflection on ecclesiology for health care ethics:
Ecclesiology Matters Whether we explicitly articulate it or not, Catholic health care ethicists and Catholic health care institutions have an operative ecclesiology. Clarifying our ecclesiologies, identifying their sources, strengths, and weaknesses is a critical task. Not only will such an examination help us see where we might be "out of balance"; it is of vital importance in minimizing the growing polarization in the Catholic community, especially around issues in health care. We need to understand our own ecclesiology if we are going to begin the critical work of bridging these divides.
A Human Community Might this sort of ecclesiological self-understanding augment how Catholics "do" health care ethics? Understanding the church as "a human community" highlights the intrinsic connections between anthropology and ecclesiology. Most often, Catholic health care ethics takes its bearings from anthropology, from a vision of the human person. The church is presumed as a backdrop but rarely enters into the discussion in a substantive way. Here it parallels secular bioethics, which clearly proceeds from a particular anthropology — an anthropology that sees persons as rational and autonomous, as existing prior to any particular institution, and as related to institutions only by voluntary choice. Certain secular anthropologies may highlight the "social" nature of human persons, but the nature of that sociality is left open-ended.
How, we might ask, does our understanding of the church play out in how we understand persons to be moral agents? Baptized persons — those who serve as "leaven" in the world, who carry out the work of Catholic health care — are not properly understood simply as free-floating generic persons, independent of institutional identity. Baptism changes everything, rendering one a member of a community of persons claimed as members of and constituted into Christ's body, Christ's church. In other words, ecclesial identity is a critical component of anthropology, not something added on, like chocolate frosting on a generic cake. Ecclesial identity is a significant part of "who we are," and knowing "who we are" is essential for determining "who we hope to become" and how we might get there.
Ethics Is a Function of Mission In other words, as one might say in the health care context, ethics is a function of mission. If so, Catholic health care ethics — not just Catholic health care — becomes an embodiment of the apostolic mission of the Spirit in the world, a form of discipleship. Catholic health care ethics becomes that discipline which articulates for the community the norms and rules that will guide it toward its goal.
In what ways, we might ask, does Catholic health care ethics contribute to the goal of the church ("salvation")? For a long time, Catholic moral theology (and therefore Catholic health care ethics) was explicitly tied to salvation through its connection with the sacrament of penance. With the Second Vatican Council, this connection was severed. While this was not all bad, Catholic moral theology lost its moorings. Might it make sense to ask anew: How does the work of health care ethics bring its practitioners closer to friendship with God? Does health care ethics serve as a discipline that helps others — patients, families, health care practitioners — become friends of God? What would it look like to see health care ethics as a work of embodying Jesus' work in the world — health care ethics as a practice that fosters healing, that privileges forgiveness, that ministers to the poor and the outcast?
A Sacramental Ethic Such questions highlight the important connections between health care ethics and the sacraments. Doing health care ethics in an ecclesial context, however, allows us to ask how the sacramental life of the church forms us in the virtues that make it possible for Christians (ethicists, health care practitioners, families, and current-or-would-be-patients) to embody Christ in the world.
Does our practice of health care ethics perpetuate an understanding of the sacraments as compartmentalized in "pastoral care," as primarily "medicinal" interventions for patients? Or do we see sacraments as formative of the identity and character of the people who deliver Catholic health care, as important resources to draw upon to understand the norms which ought to govern and guide our work? Closer attention to sacramental formation could refocus the language of health care ethics, so that what formerly was a discussion of abstract philosophical principles (autonomy, nonmaleficence) would become a discussion of the virtues critical to Catholic health care — humility, patience, faithfulness, compassion, hope, caritas, and so on.
Moreover, sacraments as practices not only can form character; they train us in a vision of God's presence and way in the world, a vision central to the practice of health care. Fr. O'Rourke concludes his most recent edition of Health Care Ethics: A Catholic Theological Analysis (fifth edition) with this broader, more deeply sacramental view of health care and health care ethics. As he notes:
[M]edical ethics has to do not with certain rules about forbidden procedures, but with a healing process by which the dignity of every human person in all its dimensions is respected by the community and the sick person is restored to full life in community. Unethical behavior tends to exclude persons from the deepest sharing of communal life centered in the Trinity. Ethical behavior fosters this communion. This ethical vision with its perception of the true scale of values is summed up and expressed in the sacraments, especially in the Eucharist. A Catholic health facility that really understands the healing character of the sacraments will have a perfect model for an ethical treatment of patients. The sacraments represent for us how Jesus in love went about treating sick people. What makes a Catholic hospital different from all other hospitals? Its vision of the sick is a Eucharistic vision, carried out in all details of the treatment of the sick and the mission of the healing team.17
Doing health care ethics in an ecclesial context, then, makes a difference. Ultimately, I hope, highlighting questions of ecclesiology will move us to develop a richer and more theological method in Catholic health care ethics, helping us to articulate a more complete anthropology and a distinctive and theological goal; emphasize the importance of formative, sacramental practices; and focus on virtue. Fr. O'Rourke's work over the past 30 years provides, I believe, the "leaven" for these developments in health care ethics. May we, who carry on his legacy, rise to the occasion.
NOTES
- K. D. O'Rourke, "Catholic Healthcare as 'Leaven,'" Health Progress, vol. 78, no. 2, March-April 1997, p. 34. See also K. D. O'Rourke, "An Exposition of Evangelium Vitae," Josephinum Journal of Theology, vol. 4, no. 1, Winter/Spring 1997, p. 4.
- K. D. O'Rourke, "Concerning Canon Law: Three Questions," Health Progress, vol. 86, no. 3, May-June 2005, p. 45.
- K. D. O'Rourke, "Canon Law and Ethical and Religious Directives," Health Progress, vol. 87, no 3, May-June 2006, p. 42.
- B. Ashley, J. deBlois, and K. D. O'Rourke, Health Care Ethics: A Catholic Theological Analysis, 5th ed., Georgetown University Press, Washington, DC, 2006, p. 28.
- O'Rourke, "Canon Law."
- O'Rourke, "Canon Law."
- Ashley, deBlois, and O'Rourke, p. 249.
- Ashley, deBlois, and O'Rourke.
- O'Rourke, "Catholic Healthcare as 'Leaven,'" p. 35.
- O'Rourke, "An Exposition."
- O'Rourke, "An Exposition."
- O'Rourke, "An Exposition," pp. 22-23.
- O'Rourke, "An Exposition," p. 23.
- Dulles, Models of the Church, expanded edition, Image Books, New York City, 1987, p. 9.
- Dulles, p. 206.
- K. O'Rourke, "As Time Goes By: Twenty-Five Years of Bioethics," Cambridge Quarterly of Healthcare Ethics, vol. 11, no. 4, 2002, p. 385. See also Ashley, deBlois, and O'Rourke, p. 28.
- Ashley, deBlois, and O'Rourke, pp. 254-255.