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BY: BISHOP ANTHONY M. PILLA

Bishop Pilla is bishop of Cleveland. This article is adapted with permission from his October 18, 2000, address to the Catholic Ministry of Health Professionals, which appeared in the November 16, 2000, issue of Origins.

The Catholic Health Ministry Involves the Practice of Faith in the Practice of Medicine

Disturbing as they sometimes are, current trends in health care are not happening in isolation. Managed care, for example, is part of a larger shift in American culture toward greater efficiency and productivity, a shift that has been evident in business and industry for many years. Layoffs, closings, and consolidations were felt in the workplace long before they became part of the health care lexicon. And, indeed, the problem is not managed care itself. The problem is the way powerful forces affect people's lives, shape their choices, distribute their resources, and decide what is good for them.

Life for many has become increasingly alienating and frustrating. Many people have a sense that they are up against forces beyond their control. This is evident in every sphere of life. Whether dealing with the IRS, trying to function in a dehumanizing workplace, doing business with indifferent salespeople, driving an unsafe vehicle, or talking to telemarketers who disrupt meals, one sometimes feels as if the whole world has turned hostile. Many men and women live with the growing belief that no one cares about them as people, that their needs do not matter. This feeling is unpleasant enough when one is healthy. It is even worse when one is ill.

What does the average person expect from the health care system? A few expect it to be yet another experience of impersonal power, limited choices, indifferent bureaucracies, and unlimited frustration. Sometimes they are right. But most people come to health care hoping they will find caring providers and a sympathetic ear, competent treatment and an experience of healing. Because people come to us with such hope, we must resist the forces that would reduce health care to no more than another business instead of a healing ministry.

How can we make sure that health care remains a healing presence in people's lives? In this article, I want to focus on the role of faith. What follows here will be personal reflections, personal because they are shaped by the perspective of the author, the person doing the reflecting. But they will be personal also in the sense that they ask readers — especially those who are professionals working in Catholic health care — a fairly intimate question: How does faith support your work?

I believe that discussions of the future of health care are necessarily moral discussions. When we say, for example, that we would like to create a cost-controlled, cost-efficient health care system, we are articulating a choice. Such a choice expresses values — instrumentality, efficiency, and conformity, among others — that happen to be those of the marketplace. However, I do not believe that the marketplace should determine the values governing health care. Those values can only be determined through moral dialogue. The interaction of people and health care has always had a moral as well as a medical dimension. The issues of health, illness, life, and death put us all in touch with the things that matter most: with our mortality and the moral trajectory of our life.

The Link between the Church and Health Care
The link between the church and health care is long-standing. Catholic health care developed in this nation as an expression of the church's belief in the value of human life and in the moral necessity to provide care to those in need. It is not possible to tell the story of health care in the United States without telling the story of the church's contribution to it. I can think of at least four vital links.

Historical and Institutional Links I can perhaps best illustrate this link by referring to the history of my own diocese. A group of women religious, the Little Sisters of the Poor, were providing care to Cleveland's ill and elderly 130 years ago. The members of another congregation, Sisters of Charity of Saint Augustine, were among the city's first public health nurses. The city's first school of nursing opened, 100 years ago, in a Catholic hospital. The first acute care facility anywhere to admit people for the treatment of alcoholism was a Catholic hospital in nearby Akron. Alcoholics Anonymous has in its long history helped many people; but if a Catholic woman religious had not helped open that hospital's doors to problem drinkers, AA might never have developed at all.

We have a long, proud tradition of health care in the Cleveland diocese because we have an unbroken commitment to the values that made that tradition possible. Health care has become increasingly complex, but the ministry's values remain the same. When things seem difficult, Catholic health care workers should remember those pioneers, especially the communities of religious women that established so many of this nation's hospitals, nursing homes, orphanages, and homes for the poor and infirm. They made health care ministry a central part of the work of the church.

The women who launched Catholic health care in this country faced obstacles we can barely imagine. For one thing, they were few in number. They came to this country as strangers. They served what was mainly a population of poor immigrants. They faced discrimination because of their gender and prejudice because of their faith. Starting with almost nothing, they nevertheless managed to fund, build, staff, and administer an amazing number of institutions. Nothing we face today is more daunting than what they encountered. Yes, we face serious challenges in the current health care climate, but we do it in the context of a long history of facing — and overcoming — challenges. Before we get too concerned about where we are going, we should first remember where we have been.

Along with its hospitals, nursing homes, and other health care facilities, the church also created institutions for the education of the professionals who provide health care. Catholic medical schools and universities have trained countless numbers of physicians, nurses, administrators, technicians, social workers, and others.

Ethical Links However, the link between the church and health care also has a more direct moral dimension. The church has always taken an active role in addressing the ethical and moral issues related to life and death, access to health care, and procedures and policies that affect the dignity of the individual and the sanctity of life. No institution or community has more at stake or, perhaps, more to contribute, than the church does. I say this because, in some circles, the church is today treated as if it were an interloper. In some circles, these ethical and moral issues are treated as merely personal choices. They are not. The consequences of such choices tend to fall most heavily on the weak and powerless. The principles we live by tell us what kind of society we will have and what kind of people we will be.

What the church brings to the choice-making process is a set of fundamental beliefs that provide its adherents with guidance and direction. These beliefs are based on the teachings of Jesus Christ, a long history of ethical reflection, a vast store of day-to-day experience, and a tradition of principled, public advocacy. The foundation for all of this is the deep conviction that all life is sacred. From this conviction several fundamental values emerge:

A Consistent Commitment to the Safeguarding of Human Life and Dignity We believe that health care, because it provides the essential safeguard of life and dignity, can never be reduced to a commodity.

A Concern for the Poor and Vulnerable We believe that the measure of a society is the way it treats its weak and powerless. In an age when some institutions act without regard for the needs of families and individuals, the church and its health care organizations must be advocates for the poor and vulnerable — those who often have no one else to speak for them.

A Tradition of Stewardship The church recognizes that any resource has limits, including health care. For that reason, the church and its health care organizations see the allocation of resources as a moral issue, not just a financial one. They seek to provide the greatest benefit for all people.

From principles such as these the church has fashioned a moral framework for health care, an important summary of which can be found in the Ethical and Religious Directives for Catholic Health Care Services. This body of medical and moral principles, emerging over many centuries and from vast experience, reminds us of "the priority of ethics over technology, the primacy of people over things, and the superiority of the spirit over matter."¹

The Human Link for Patients Those who seek help from Catholic health care bring more than a list of symptoms. They often come with faith as an important part of their lives, a faith that forms a significant part of their understanding of illness, healing, and the meaning of life and death.

Epidemiological studies suggest that religious beliefs can help the healing process. One recent study, for example, described five ways that faith and healing are linked:

• Faith encourages human connections between patients and family, among friends, and in the wider community. Belief in God reminds us that we are not alone.
• Faith can help patients make sense of their situation and lead them to acceptance.
• Faith helps people maintain hope.
• The connection people have with a faith community can bolster their sense of self-worth.
• Faith helps people maintain a positive attitude and see themselves as active participants in their own healing.²

Several years ago, I had an extended experience as a patient. As I underwent surgery and then a long recovery, I was reminded of still another dimension of the importance of faith. God becomes present to us in our weakness. Illness can cause us to reconsider our priorities, reassess the things that matter most, and let go of the myth of invulnerability. Being a patient can be a vulnerable experience. It is always a humbling one. It makes an enormous difference to have people around you who understand this process, who are sensitive to the workings of God, and who are willing to act not only as health care professionals but also as fellow human beings.

The Human Link for Health Care Professionals But perhaps the most important way that the church is linked to health care is through people of faith who are also health care professionals. Each of them represents the church, often in a more immediate and effective way than anyone else. Such people are engaged in an enterprise that is moral as well scientific or medical. Morality is, in fact, at the core of what they do and who they are.

Their work is moral because of the nature of the relationship they have with their patients. Patients come to health care professionals when they are vulnerable and place their lives, quite literally, in the professional's hands. This action creates a moral relationship based on trust. Morality is at the center of what the professionals does because it demands that the good of the patient be put over the interests, financial or otherwise, of the professional, the insurance company, or the system of care. This trust is increasingly difficult to secure in an environment in which some professionals (physicians in this case) are given incentives to substitute others' judgments (insurance companies') for their own. Morality is at the center of what health care professionals do because they, more than anyone else, are responsible for upholding the sanctity of life from conception to natural death.³

Some people might prefer to keep their religion and their personal lives separate, but that is not how life works. We live what we believe. The link between faith and practice is not optional; it is essential. The things we truly believe will become evident in the decisions we make, the values we affirm, and the way we deal with others. For each of us, this forms our moral center.

Current Challenges
This moral center may be the most important thing professionals of the Catholic health ministry bring to the current challenges in health care. This is not easy. In a 1995 address to the American Medical Association, Cardinal Joseph Bernardin noted that many people in health care no longer agree on the existence of universal moral principles or on the appropriate way to put those principles into practice. Even the most conscientious practitioners are often perplexed about how to act, caught up as they are in a web of economic forces, politics, business practices, and social responsibilities. As a result, health care itself sometimes seems to lack a sure and accurate sense of how to find its way through difficult times.⁴

The values of faith are therefore important in the practice of medicine. A moral center does not provide simple answers to complex problems. It does not tell one precisely what to think about specific issues. Rather, an effective morality puts us in touch with something that transcends our immediate concerns and particular perplexities. A morality of life — because it makes us aware of our addictions and illusions, casts a pitiless light on our myopic self-interest, and detaches us from our capacity for selfishness and our propensity to do what is most expedient — frees us to sort out and make decision on the important issues in life. Moral principle frees us from the delusion that we can play God and allows God to speak for us.

I can, for example, think of three particular sets of issues in which moral principles are absolutely necessary.

Access to Care Safeguarding human dignity is one of the church's fundamental principles. And safeguarding the dignity of human life includes affirming the right of every person to comprehensive, high-quality health care. This is not a naïve assertion. I understand that administrators need to make wise business decisions about how services are distributed, who will benefit from them, and what will keep their institutions solvent. The problem is that, as a nation, we have been more concerned with harnessing health care costs than with ensuring access to care. The result is "a morally untenable situation in which we have created health care ceilings without floors."⁵

End-of-Life Issues Nowhere is the link between morality and medicine clearer than at the end of life, because the question is not simply what kind of care is appropriate but also the meaning of that care.

Professionals face two kinds of pressure in such situations. On one hand, they are urged to commit heroic resources to preserve a life, beyond the point where that life has lost all meaning and human dignity. On the other hand, they are urged, in the name of compassion, to hurry the aging and dying from our midst. The consequences of the former can be seen in the enormously costly resources often committed to the last months of life. The consequences of the latter can be seen in the growing interest in euthanasia and assisted suicide.⁶

Professionals in Catholic health care have a vital role to play in helping people accept compassionate care at the end of life — care that is willing to manage pain, to be present to the dying, to learn from them and help them recognize that human life is a gift from God. One of the most important tasks in medicine is to respect the dying. Sometimes that means putting aside aggressive medical treatment and helping patients accept death.

It says something about Catholic values that the ministry's hospitals, nursing homes, and hospices, as well its Catholic physicians, nurses, and chaplains, are in the forefront of providing compassionate care to the dying. (For example, Ursuline College, in the Cleveland area, has established the first palliative care training program of its kind in the country.)

Research and Treatment We are riding the crest of the most sustained period of medical innovation in history. This creates new possibilities for diagnosis and treatment, but it also raises new ethical and moral concerns. Research in human stem cells, for example, already poses serious ethical questions only partially addressed by recent government guidelines. The sponsors of the Human Genome Project, recognizing that huge ethical issues would emerge from it, set aside about 5 percent of the project's funds to examine the ethical, legal and social issues involved. The project's sponsors understood that the ethical implications were too important to be left to scientists alone. Christian values, which we hope will guide us through the complex choices we face, constitute one of the singular contributions of faith to medicine.

The Professional in an Era of Change
This is a time of enormous change in health care: innovations in clinical practice, technological advances, mergers and consolidations, a growing number of uninsured, and a highly competitive environment. But for health care professionals, all this is complicated by the need to determine whether a given change is helpful or harmful.

Periods of change can be especially creative for any system, including health care. Change forces people to rethink who they are and what they do. Health care professionals who are prepared to deal with change can help shape their system's future, but only if they refuse to give in to fear or anxiety and stay focused on the things that matter most.

In the same way, the church is in a position to help shape the future direction of health care in this country, but only if we are able to move beyond our anxiety, only if we stay focused on our core values and beliefs. We Catholics have the advantage of history: We have been through change before. We have the advantage of insight: a core of values and beliefs that are worth affirming, not simply because they are the church's beliefs but because they affirm what is most basic to human life. And, so long as ministry professionals are willing to support each other in affirming those values, we have the advantage of commitment. No other segment of American society has a similar system of services, network of institutions, and body of professionals and administrators sharing common values and beliefs. But this will be an advantage only to the extent that people in the ministry are willing to work together.

Catholic health care clearly needs to live what has been called the "virtue of solidarity." Solidarity can be summed up in a single sentence: We stand together with those in need so that they need not stand alone. Solidarity means that, in making our decisions and shaping our institutions, we look beyond narrow self-interest. It affirms the value of the common good and the dignity of all people. It views each of us as an advocate for the poor and the marginalized. Solidarity believes in mutuality: It recognizes that the poor, the elderly, the uninsured, and the underserved have a role to play in building society — a society in which, as Pope John Paul II has put it, none are so poor that they have nothing to give and none are so rich that they have nothing to receive.

Although many things are changing in health care, three things, along with an underlying faith in a caring God, remain constant for the person of faith:

• The church's commitment to health care as an essential ministry, a reflection of Christ's own compassion and care
• The core of values that provide a moral center for health care
• The people who embody that commitment and those values

In the end, merely listing principles and affirming values is not enough. They must be lived.

Finding Meaning
Before any of us learns how to take care of another person, we must first learn how to take care of ourselves. Where do health care professionals find strength and meaning in their lives? I suggest four sources.

Personal Integrity A person's character is made up of his or her commitments. What we believe is expressed not only in ritual and prayer but also in the countless decisions and interactions that make up our lives. There is no such thing as a "private" morality. "One of the gravest errors of our time," said the Second Vatican Council, "is the dichotomy between the faith which many profess and the practice of their daily lives."⁷

Just as individuals need integrity, so do institutions. The way we treat one another in the workplace matters. The way Catholic institutions treat their employees also matters. If we cannot be models of justice and fairness in dealing with those who work with us, how can we expect justice and equity from others? A recent survey of nurses showed that their sense of satisfaction was tied not only to their wages but also to the respect they received as well.⁸

Work as a Bearer of Hope One role that a health care professional fills each day is as a bearer of hope to patients and their families. Calming anxiety, listening to concerns, sharing one's expertise — each of these actions brings hope to suffering people. This is the benefit of the personal approach in medicine. It makes a difference in people's lives.

But there is a larger picture, too. The church and health care community share a commitment to the people we serve. We are their advocates. The church and the health care community play a mediating role with patients. We are the ones who — as opposed to government and business, which tend to view human needs in purely political or economic terms — stand with patients and families, the poor and vulnerable, the uninsured and underinsured. Ours is the moral voice. To those who need our help, we say (as God says to us), "Whatever you face, you will not face it alone."

Of course, I cannot know what leads people into health care work the first place. Some may have been driving toward such a career since childhood; others may have more or less wandered into it just a few years ago. It does not matter how professionals got here. What does matter is that they have arrived in health care at a critical moment in history. They must be advocates for the uninsured and the underinsured. No one else can do it.

An Awareness of Limits No one knows about limits better than those who deal every day with illness and recovery, life and death. This sometimes means helping people deal with the limits they must face, but it also sometimes means facing one's own limits.

Life itself is limited. Dealing with limits thus means respecting life at every stage and in all its circumstances, upholding the sanctity of life from conception to natural death. Accepting life's limits affirms the dignity of life and the importance of compassion.

Dealing with limits means ensuring that the use of advanced medical technology does not come at the expense of real caring. A few years ago, a study published in JAMA documented a compulsion on the part of many in the medical community to spare no cost in an effort to save an obviously dying patient, regardless of the patient's dignity, comfort, or peace of mind.⁹ This is not genuine caring.

Dealing with limits also means attending to one's own spiritual needs as a healer. We can only give from what we have. We must take care to nurture our own moral center because that is where we get the strength to care. It helps us to navigate the failures and setbacks that all health care professionals inevitably face.

A Willingness to Seek God In the catechism I studied when I was young, one of the first questions asked was, "Where is God?" Every good Catholic learned the answer: "God is everywhere." But nowhere is that more true than in the work done by health care professionals. God is everywhere — in the suffering patient, in the family that prays for the patient's recovery; in the gifts and talents possessed by health care professionals, and in the institutions in which such professionals serve. God is in the challenge the professional faces and also in the response to the professional's prayers. God is in those moments when the professional has done everything he or she can do — and must place the rest in the hands of the divine healer.

We affirm the presence of God when we pick up the pieces of a failing health care system. We reinforce God's presence when, as a church, we open our arms in welcome to children without care and families without insurance. God is present when we bring a human face and a humane perspective to highly technical debates. The presence of God is in the accountant who struggles to balance numbers with human needs, in the steadying hand of a surgeon, and the comforting word of a night-duty nurse. It is in the administrator who fights to maintain a program and in the community that fights to keep a hospital that would otherwise close.

Why do we do it? Why do we provide help for the infirm and disabled? Why do we provide care for those with AIDS or continue to fight for the poor and homeless? We do it because we believe that every life is sacred, that everyone is precious in the eyes of God.

And why, on the other hand, do people come to a church-sponsored cancer facility when they know their illness is terminal? Why do families entrust their loved ones to our nursing homes when they can no longer care for them at home? How is it that, year after year, those with drinking problems continue to find their way to church-sponsored alcoholism treatment centers? Why do people in trouble come to our hospitals or to Catholic Charities agencies?

They come expecting competent care, of course. But they also come for something more than competence. They come because they hope they will find God there. They hope that, in the most vulnerable moments of their life, they will find God's compassion, God's comfort, God's gentleness, and God's healing. And they expect those things to come from the hands of health care professionals.

On his visit to America a few years ago, Pope John Paul II said that reflecting God's love is the basis for a fulfilling life. He said, "Love makes us seek what is good; love makes us better persons. . . . Love makes you reach out to others in need, whoever they are, wherever they are. Every genuine human love is a reflection of the love that is God Himself."¹⁰

NOTES

1. John Paul II, The Redeemer of Man, 1979, para. 16.
2. Laurie Skokan and Diana Bader, "Spirituality and Healing," Health Progress, January-February 2000, pp. 38-42. The Sisters of Providence Health System, Seattle, conducted the study described in the article in 1996-1997.
3. See Joseph Bernardin, "Medicine's Moral Crisis," Origins, December 21, 1995.
4. Bernardin.
5. Joseph Bernardin, "Managing Managed Care," Origins, May 30, 1996.
6. See National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care, U.S. Catholic Conference, Washington, DC, 1995, p. 21.
7. "Pastoral Constitution on the Church in the Modern World," in Austin Flannery, ed., Vatican Council II: The Conciliar and Post Conciliar Documents, St. Paul's Editions, Boston, 1987, p. 943.
8. Nursing Executive Center, National R.N. Survey, October 1999. According to the survey, 64 percent of the respondents who had considered leaving nursing in the previous two years listed insufficient compensation and lack of respect as key factors.
9. The SUPPORT Principal Investigators, "A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients," JAMA, November 22-29, 1995, pp. 1,591-1,598.
10. John Paul II, "Homily at Central Park, October 7, 1995," Origins, October 19, 1995.