Birgitta N. Sujdak Mackiewicz, Ph.D.
Director of Ethics
OSF Saint Francis Medical Center & Children's Hospital of Illinois
Peoria, Ill.
[email protected]
Pope Francis' encyclical, Laudato Si': On Care for Our Common Home, speaks of our responsibilities towards our Sister, the Earth. Reflecting on the conservation of natural resources and the often negative impact that technicalization and progress have had on our environment, the pope implores us to see creation as that with which we are in relation. But Laudato Si' is not limited to concern for the environment in the traditional sense. This concern must also be "joined to a sincere love for our fellow human beings and an unwavering commitment to resolving the problems of society" (91). Like Rerum Novarum and Laborem Exercens the encyclical has a particular focus on the dignity of the human person, in connection with the environment. Francis' understanding of environment is holistic, encompassing the physical, social and human aspects of being. "[E]very ecological approach needs to incorporate a social perspective which takes into account the fundamental rights of the poor and underprivileged" (93).
Laudato Si' is fundamentally about relationship, the integral relationship that exists between God, the earth and human persons (224). The word "relationship" or some form of it appears 71 times in the encyclical. "System" appears 58 times and "integrated" or "integral" appears 42 times. Care for the earth necessitates care for the human person. Francis posits that a "true ecological approach always becomes a social approach" allowing us to "hear both the cry of the earth and the cry of the poor" (49). These two areas of concern are inseparable: "Social love moves us to devise larger strategies to halt environmental degradation and to encourage a 'culture of care' which permeates all of society" (231). In health care we often speak of the patient-physician relationship or the patient-professional relationship, but rarely of the relationship of Catholic health care to creation, to the environment, or to the larger world.
Early in the encyclical, Francis introduces the notion of systems thinking in relation to "authentic human development" which must, according to John Paul II, "take into account ... [our] mutual connection in an ordered system" (5). Our "relationships with nature [are] inseparable from fraternity, justice and faithfulness to others" (70). There is not a singular way of relationship or means of participation, but "countless forms" (79). "Our relationship with the environment can never be isolated from our relationship with others and with God" (119). We must always remember that we are in relationship "with" persons as subjects and not see ourselves in relationship "to" objects. We must see the poor and the vulnerable as subject, not object (81). Relationship is mutual and requires participation of all.
Practically speaking, what impact does this encyclical have on Catholic health care? More specifically, what might Laudato Si' imply for the work of ethics committees and ethics professionals in Catholic health care? The work of ethics committees is centered around the promotion of the dignity of the human person. The advent of next generation ethics committees calls for ethics committees in Catholic health care to be integrated into the entire organization and to utilize systems thinking. Committees should be equipped to examine organizational and clinical ethics issues, and engage in proactive preventative ethics. It does not take much imagination to see that organizational ethics in Catholic health care should support environmental stewardship via minimization of medical waste, recycling, and forming business relationships with companies who seek to do the same (21). Yet it is rare that ethics committees or ethics professionals are engaged in such decision making.
As ethics committees strive to become more integrated within their organizations in areas such as quality and safety which are heavily data driven, they have a particular duty to keep human persons at the forefront of health care. Francis cautions against the negative impact that data and media overload can have and the resulting depersonalization (47). A focus on objective data points may also constitute an institutional blind spot: "fragmentation of knowledge and the isolation of bits of information can actually become a form of ignorance, unless they are integrated into a broader vision of reality" (138) and "it often leads to a loss of appreciation for the whole ... which then becomes irrelevant. This very fact makes it hard to find adequate ways of solving the more complex problems of today's world, particularly those regarding the environment and the poor; these problems cannot be dealt with from a single perspective or from a single set of interests" (110).
Ethics committees also have an opportunity to engage in population health efforts keeping the human person at the forefront where in fact the individual may become lost in a sea of quantitative measures. Catholic health care organizations are engaging the challenge of population health and wellness via Accountable Care Organizations (ACO), Patient-Centered Medical Homes (PCMH) and Clinically Integrated Networks (CIN) or similar approaches. The promotion of the health of the population rather than an exclusive focus on the individual is consonant with the commitment to the common good. It is no longer enough to care only for the individual poor and vulnerable patient in the acute care setting. "Social problems must be addressed by community networks and not simply by the sum of individual good deeds" (219).
Laudato Si' presents a challenge to look beyond the organization and even beyond the care continuum. Though Catholic health care has always provided various levels of care in various locations, the intentional focus on the systems in which Catholic health care exists and serves is imperative. A focus on population health and participation in ACOs and similar modes of health care delivery force us to examine the relationship between our care of the individual patient and the health of the population. We can see what impact Catholic health care is actually having on the community at large. Ethics committees have opportunities to engage with organizations in developing measures in conjunction with the local community that can discern whether the care being provided is contributing to the common good.
Ethics committees must discern what integration and systems thinking looks like when examining the relationship of the Catholic organization with other health care or social organizations in the community. The ethics committee must ask what it means to be in relationship with an ethics committee of a non-Catholic organization. For example, should ethics committees work together with one another and with the community to form policies regarding withholding of non-therapeutic CPR as the Harvard community ethics committee did? (http://bioethics.hms.harvard.edu/sites/g/files/mcu336/f/CEC-Report-on-Withholding-Non-therapeutic-CPR-022009.pdf) Similarly, ethics committees in Catholic health care should be in relationship with community health initiatives, particularly those focused on public health. These initiatives may currently have representation from Catholic health care organizations but how many of them have ethics committee representation? The participation of Catholic ethics committees in these sorts of groups provide additional opportunities for promoting respect for the dignity of the human person, particularly the poor and the vulnerable, that otherwise may be overlooked.
In the spirit of Laudato Si', ethics committees and ethics professionals in Catholic health care should engage in reflection about how their work contributes to the care of our common home and thus of the common good, recognizing the need for integration within and outside of the organizations in which they serve, for participation with "politics and economics" in "a frank dialogue in the service of life, especially human life" (189).
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