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BY: FR. CHARLES E. BOUCHARD, OP, S.T.D.

North America, and especially the United States, has always been a cultural and ethnic melting pot. Unlike the German, Italian and Polish immigrants who preceded them, today's immigrants come from Africa, Asia and Eastern Europe. Some are still Catholic, Protestant and Jewish, but many others are Muslim, Hindu, Buddhist.

These newcomers are no longer melting in as immigrants might have in the past. They are retaining more of their cultural and religious identity, forcing those of us with deeper roots to consider anew what "inclusive" means. Governments and organizations that were initially hesitant to break patterns of racial, economic and gender division have developed a host of policies and laws designed to assure equity, respect and equal access in the work place. As a result, both management policies and the face of our workforce have evolved dramatically.

Catholic health care is at the heart of this evolution because we are faith-based but serve a diverse population. Our ministries have responded in a number of ways. We have incorporated diversity into mission statements and hiring policies.¹ In the workplace, our health care ministries have moved beyond mere compliance with non-discrimination laws. Some have launched strategic initiatives that would intentionally create and nurture diverse and "culturally competent" workforces.²

We also have developed policies designed to accommodate the cultural and spiritual sensitivities of patients. The Ethical and Religious Directives for Catholic Health Care Services, for example, call for "appropriate pastoral services … available to all in keeping with their religious beliefs and affiliation."³ Translation services to foster understanding and healing are widely available. Health care providers are taught how to recognize cultural and religious needs that may affect care. These steps are seen not just as a matter of justice, but of quality health care.

Although some Americans long for the idyllic (but largely imaginary) good old days of ethnic and religious homogeneity, it is clear that diversity is not just a cultural fad. In his book The Future Church, journalist John Allen describes 10 megatrends that will have an impact on the Catholic Church.⁴ Three of these — "world church," "globalization" and "multipolarism" — are clearly related to a new reality of diversity.

Diversity also has deep theological roots. It is present in the earliest pages of the Bible in which the diversity of creation — and creatures — is clearly understood as a sign of God's power and providence. It is present within the Trinity itself, where we have one God and three distinct — diverse — persons.⁵ This diversity was imaginatively depicted in the novel The Shack, in which a grieving father, trying to understand the violent death of his daughter, is led to an encounter with an unconventional (but in many ways orthodox) Trinitarian God.⁶ In this Trinity, God the Father is an African-American woman who likes to be called Papa. The Holy Spirit is an Asian woman named Sarayu. And Jesus is, well, a carpenter. Each person has his (or her) own personality, yet they form a dynamic, complementary and highly cohesive unity. This diversity-in-unity is reflected elsewhere in Scripture as well. St. Paul said there are many gifts but one body, and Jesus' prayer in the Gospel of John is that "all may be one."

Diversity is appealing because it is easier to arrive at than truth. "You just have to know how to count," said Fr. James Schall, SJ. Yet diversity is not an unalloyed blessing. It may be easy to establish, but it has its hazards. Schall noted the downside of the uncritical adoption of diversity as a value. It tends toward leveling, and especially with moral issues it is clear that not every view or practice is of equal value. "Diversity theory is never neutral," he said.⁷ He warned that if we don't keep it in perspective, at some point it will lead us to nominalism, the philosophical view that there are only individual things, with no unity or similarity. This would effectively lock each of us into our own unique world with no empathy, no shared experience and no common destiny. If I could not identify with your pain or your hunger, for example, why would I respond with care?

This is particularly important when we invoke solidarity, the virtue that leads us to see that the relations among persons are real, even if we exist in very different places and economic circumstances. Failure to acknowledge this vitiates the belief that we are created not just in, but into the image of God. In a great cosmic dynamic, we come from God and we move together, along with the rest of creation, back into God, the source of our being. Failure to recognize our common origin and destiny frustrates the great centripetal force that draws us back to God. It allows the centrifugal force of difference and sin to fling us into isolation, far from one another. This is reflected in our teleological, or goal-oriented, approach to ethics, where the determination of moral goodness is based on more than just obeying the law. In our tradition, we consider choices that draw us toward one another and toward God to be "moral," and those that push us away from one another and from God to be "immoral."

So diversity is a fact, but it is not an end in itself, something to be cultivated for its own sake. Diversity is a means that enables us to be co-creators with God. We have varied gifts and qualities, but together we are called to "make something of it." We can marvel at the diversity of people and of creation generally, but we must acknowledge too that there is a drive toward oneness and unity. Ultimately the similarities among us are even more important than our differences.

This highlights our dilemma: Given the deep roots and enduring importance of diversity in a global society, is it possible to accommodate and even celebrate diversity and also to deepen the intentional Catholic identity of our ministries? Is it possible to respect diversity in management and patient care and still stand for any one thing? Can we assume a clear identity as a Catholic ministry and yet still be open and inclusive?

CAN WE MOVE BEYOND MERE ACCOMMODATION?
Ethical discussions about accommodating diversity focus largely on negative rights. We respect the belief of another and we agree not to coerce, proselytize or attempt to convert anyone. But true diversity is not a one-way street. It imposes complementary responsibilities on all parties. Therefore, it is fair to ask how much commitment to our mission and values we can expect from those who work with us. If we accommodate and even celebrate racial, cultural and religious diversity among patients and co-workers, do we have the right to expect some kind of consideration or respect for our faith commitment in return? How do we honor and even benefit from the wide variety of experience and personal convictions they bring to their work while still maintaining the distinctiveness of our own tradition?

H. Tristram Engelhardt, Jr., Ph.D., MD, argued bluntly that "if the staff and employees are not inculturated into a Christian ethos, the institution will be a Christian health care institution in name only, or perhaps at best in terms of a few prohibitions which will appear as external constraints" over the actual life of the institution. He fears that even now "the language of Christian spiritual concerns has been displaced by the language of social justice," and that the "pursuit of salvation is obscured by the pursuit of excellence in health care."⁸

Engelhardt made a challenging case for a very explicit religious identity in our sponsored ministries. However, many in Catholic health care would call for a more nuanced approach, one that acknowledges various levels of commitment within the institution.

First, at the broadest level we must expect that all of our associates embrace our core values. Although these values differ from one health care system to another, many of them include respect, stewardship, compassion, caring, justice, integrity, solidarity and so forth. Because they are also fundamentally human values and not a matter of religious faith or revelation, we should expect all of our associates to embrace them.

The second question concerns religious values. Although some ministries have been reluctant to use "Jesus language" in their official documents for fear it would violate the inclusivity we profess, many of our mission statements and other foundational documents speak of the "healing ministry of Jesus." Sr. Carol Taylor, CSFN, Ph.D., RN, surveyed the use of this language and concluded that at least from an ethical perspective, there is no way to develop and own a conception of the good institutional life "apart from the Gospel accounts of Jesus' healing ministry."⁹

This is a specifically Christian belief and we see it through the lens of Roman Catholic Christianity. We believe it is important for our ministries to be clear that even though we are committed to serving a diverse population, we do so because of our belief in Jesus and his healing ministry. Our associates do not have to be Christian or Catholic, nor do they have to believe in the divinity of Jesus. Our respect for their own faith and conscience requires us to refrain from demanding assent to these doctrines. However, we believe that at a minimum, all associates must at least respect and be open to a fuller understanding of the mission of Jesus and of several fundamental doctrinal principles that animate our ministry. These include:

• The Incarnation: God became flesh in Jesus Christ. This means that God entered human history and culture at a particular point; it also means that our institutions are a tangible sign of God's presence in the world.
• Eternal Life: Even though we all die, Christians believe that in his own death and resurrection, Christ triumphed over death and that we are destined to eternal life. Especially when we help our patients face incurable disease or impending death, we must treat them as though we believe in eternal life, or that we allow for its possibility.
• Sacramentality: Sacramentality means that we do not take the goodness of human actions at face value. Good things, like acts of healing or compassion, also have the possibility of grace; that is, they are ways in which God invites us to cooperate with the ongoing act of creation. All of our associates must at least allow for the possibility that their actions may have an effect beyond what they intend. They must act as though their work of healing has an element of mystery that may reveal "something more" to them or to their patients at any time. Sacramentality is perhaps the most distinctive feature of Roman Catholic Christianity. It has particular significance for health care and we should not hesitate to deepen our awareness of it.
• Healing and Justice as Signs of the Reign of God: Healing and justice are two of the primary "sacramental opportunities" we have in health care. When we heal, we restore a physical person to wholeness, but we also restore a spiritual person and we create an opportunity for grace. Similarly, when we strive for justice and equitable distribution of the good things of creation through our advocacy work, community benefit, charity care and even effective revenue-cycle management, we are striving for the Reign of God. Any justice we achieve here on this earth is a foreshadowing and an experience of God's own justice and the reign.

A third question relates to the special responsibility that leaders (including executives, board members and sponsors¹⁰) have to understand and promote these values, both human and religious. Again, we do not require an assent of faith to Christian doctrine from our senior leaders and board members. But we do expect them to have a basic understanding of these fundamental doctrines and to be able to explain how they are the theological foundations of the ministry. They are not required to say, "I believe that Jesus Christ is the Word of God made flesh," but they should be able to say, "Our healing mission and care for persons is rooted in the Christian conviction that God became human in Jesus Christ." It goes without saying that if we expect our leaders to understand and present the theological roots of our mission, we have to provide them with formation opportunities that will give them the tools to do so.

A final question relates to associates and leaders who are Catholic. We believe that as members of the church that sponsors Catholic health care, Catholics are called not only to believe and understand these basic doctrines, but to appropriate them in their own lives. They are called to this by virtue of baptism, which enables them to share in the priesthood of all believers. Even though Catholics have been accustomed to seeing themselves as consumers of grace dispensed by the clergy, in reality they, too, share in the priestly ministry of Jesus and are themselves transforming signs in the world. Their participation in the ministry of health care, whether as entry-level associates or board chairs, should be an occasion of grace for them and for those they serve.¹¹ In short, participation in the health care ministry should be a formative experience for Catholics. It should deepen their own spirituality and enable them to participate more fully in the life of the church.

We are suggesting that respect for diversity and cultivation of an unambiguous religious identity are not mutually exclusive. We can deepen the spiritual and theological roots of the health care ministry and invite those who do not fully share our faith convictions to collaborate with us in keeping this human service vital long into the future. This does not involve imposing our faith perspective on anyone, but, rather, living it fully and humbly offering it to others as one perspective on the mystery of human life.

FR. CHARLES BOUCHARD, OP, is vice president, theological education, Ascension Health, St. Louis.

PHILIP J. BOYLE, Ph.D., contributed to this article. Dr. Boyle is vice president, mission and ethics, Catholic Health East, Newtown Square, Pa.

NOTES

1. The Catholic Health Association, for example, says it "welcomes and respects people of all beliefs and traditions." This movement has been especially prevalent in higher education. A quick review of mission statements of Catholic colleges and universities indicates that many of them put diversity front and center. One, for example, says "We advocate respect for diversity. As a Catholic college we are called upon to be particularly attentive to the rich variety among people of the world." Another says, "We value dialogue, respect for diversity and the nurturing of personal conscience." Yet another says, "The university is committed to expanding academic excellence and creating a diverse and inclusive community."
2. In 2007, Joseph Swedish, CEO of Trinity Health, outlined a three-year, seven-point diversity strategy that he said would be the cornerstone of a "culturally competent workforce." "As we become a more ethnically and racially diverse nation, health care must respond to patients' cultural heritage, varied perspectives, values, beliefs and behaviors about health and well-being," he said. "In order for our health care organizations to serve an increasingly multicultural environment, leaders must recognize the urgency of our situation and be proactive in our efforts to reflect the fabric of our communities."
3. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 11.
4. John L. Allen, Jr., The Future Church: How Ten Trends Are Revolutionizing the Catholic Church (New York: Doubleday, 2009).
5. St. Thomas Aquinas notes that it would not be fitting if God were only one person, or even two, because "the perfect goodness of divine happiness and glory postulate friendship within God. It appears that God's charity would not love to the utmost were he only one person. Nor even if he were only two, for with perfect friendship the lover wills that what he loves should also be equally loved by another. . . . (Quaestiones Disp. De Potentia, IX, 9, my own translation. Alternate English translation available online at www.dhspriory.org/thomas/QDdePotentia.htm#9:9).
6. Thomas Mulholland, The Shack (Lincoln, Neb.: iuniverse, 2005).
7. "Diversity" in blog titled The Catholic Thing (www.thecatholicthing.org), posted Feb. 10, 2010.
8. H. Tristram Engelhardt, Jr., "The DeChristianization of Christian Health Care Institutions, or How the Pursuit of Social Justice and Excellence Can Obscure the Pursuit of Holiness," Christian Bioethics 7:1 (2001) 151-161, at 152. Englehardt goes so far as to argue that acquisition of an "appropriate moral ethos" for faith-based health care requires a Christian institutional identity that is, at its roots, liturgical, 157-58.
9. Carol Taylor, "Roman Catholic Health Care Identity and Mission: Does Jesus Language Matter?" Christian Bioethics 7:1 (2001) 29-47 at 33. She provides an overview of Catholic health care mission statements, about half of which use Jesus language, as well as an explanation of key Christian values that animate health care ethics.
10. Because their unique responsibility to maintain communion with the church is part of their baptismal call, sponsors should be Catholic and embrace these doctrines as a matter of faith.
11. Paul Philibert, The Priesthood of the Faithful: Key to a Living Church (Collegeville, Minn.: Liturgical Press, 2005), esp. 64. I am indebted to Fr. Philibert's marvelous retrieval of the tradition of the priesthood of all believers. He notes that the Documents of the Second Vatican Council, especially Lumen Gentium 34, give attention not "to rite or the sacramental elements of bread and wine, but to the assembly of the faithful gathered in faith to offer their lives."