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BY: REV. FRANCIS G. MORRISEY, OMI, JCD

Fr. Morrisey is on the faculty of canon law, Saint Paul University, Ottawa, Canada. This article is based on a presentation he gave to the CHA Canon Law Forum in San Diego in April 1999.

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Summary

How can we assess the Catholicity of Catholic healthcare organizations that establish connections with other, often other-than-Catholic institutions?

Although canon law was not designed for such situations, it does suggest three ways of approaching the question of Catholic identity: through criteria derived from the law, from doctrinal commitment, or from traditional Catholic values. All three sets of criteria require communion with the diocesan bishop.

Another approach to the assessment of Catholicity involves four critical, inseparable themes: mission, sponsorship, holistic care, and ethics. An organization lacking even one would be incompletely Catholic.

A truly Catholic healthcare organization must also observe the bishops' directives and take care in its relationships with civil legislation, alienation of Church property, recruitment of board members, cooperation with other providers, and other similar matters.

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Today many Catholic healthcare organizations are finding it necessary to collaborate in various ways with other organizations. In many cases, these new arrangements involve other-than-Catholic institutions. The question then often arises: To what extent are such arrangements Catholic?

This question has no easy answers. In this article I will look at different approaches to assessing the Catholicity of an organization or arrangement.¹

Canon Law and Its Limits
Canon law was not originally designed to apply to the restructuring situations Catholic healthcare organizations face today. And insofar as canon law did deal with organizational restructuring, it focused on the alienation of stable property. Today the focus tends to be much more on safeguarding the Catholic identity of the work and its mission.

We must also remember that we are dealing with a process, not with a cut-and-dried situation. As life evolves, so too do medical techniques, business practices — and canon law. Canonists do not pretend to have all the answers on organizational restructuring. If we did, there would be no need to study the questions further. We know that some answers suggested today will later be found to be wrong or incomplete or even to have negative effects. The U.S. government's initial approval of thalidomide, years ago, is an excellent example of a negative result. Although the immediate effects of the drug were seen as beneficial, the long-term ones were disastrous.

It is consoling to note that the Church itself is forced to update its teachings continually. The teaching on the death penalty is one example. Approved by the Church as recently as the 1992 edition of the Catechism of the Catholic Church (art. 2207), the death penalty was condemned only three years later by Pope John Paul II in the encyclical Evangelium vitae (no. 25).

Catholic Identity and Mission
The Code of Canon Law does not specify criteria for Catholic identity. We must therefore proceed by analogy (c. 19). In addition, we must recognize that there are different ways of approaching the issue of Catholic identity. We might, for example, take a purely legal (or "institutional") approach, using verifiable criteria and principles to determine what might be termed "Catholicity." Or we might employ a more doctrinal approach, building on the examples and criteria derived from the Apostolic Constitution Ex Corde Ecclesiae and the accompanying "norms," to identify Catholic educational institutions.² Or we might choose a third way, which involves identifying certain values we wish to promote.

The key point to keep in mind is that there are many ways of being "Catholic," and no single approach can claim superiority over the others. "In my Father's house there are many dwelling places" (Jn 14:2).

Criteria Derived from Canon Law Canonists and other lawyers will obviously prefer the legal approach, because it is clear and precise. Some also like the hierarchical dimension found in it because it establishes clear lines of responsibility. We must, however, keep in mind that there is more to the life of the Church than law and institutions. Law presupposes faith and commitment. Otherwise, it is of little avail.

Four canons tell us that no institution, school, undertaking, or association may call itself "Catholic" without the authorization of the competent ecclesiastical authorities (cc. 216; 300; 803, para. 3; and 808). Although the code says little specifically about healthcare organizations, these canons, which deal with Catholic schools, provide us with many applicable elements.

According to these norms, to call itself Catholic a healthcare organization must:

• Demonstrate Catholic values (e.g., Christian inspiration, contribution by research to the understanding of the truth, fidelity to the Christian message as it comes through the Church, an institutional commitment to service)³
• Be guided by Church authorities (particularly the diocesan bishop)
• Be canonically established (e.g., be set up by Church authorities, have its statutes recognized by such authorities, or originate as an apostolate of an established religious congregation)
• Be bound by canon law concerning the organization of pastoral care and the administration of property
• Be subject to visitation by the diocesan bishop⁴

Criteria Derived from a Doctrinal Commitment This approach is based on Church principles that are directed more to the organization's purpose than to its structure. The criteria are less precise than those used in the legal approach, but they are sometimes more demanding. According to this approach, to be Catholic an organization must meet the following kinds of criteria:

• Have a general apostolic purpose — "to help others" — based on the personal commitment of those involved in it.
• Have results appropriate and proportionate to the activity spent on it (i.e., be cost-effective in terms of persons, time, and financial resources).
• Be perceived by the faithful as "Catholic" (e.g., operating under the auspices of a Catholic group and being trustworthy as a result).
• Be permeated by Catholicity, in the sense that it has, for example, a religious name (e.g., St. Francis's Hospital), a general relation to the Vatican, Catholic traditions, or religious symbols displayed.
• Correspond to a need that is perceived as being in harmony with the purposes of the Church.

Criteria Based on Values This approach identifies values that are to be promoted by those responsible for the organization. These criteria,⁵ which are not incompatible with those used in the other approaches, require a Catholic organization to be:

• Recognized as an apostolic activity by the diocesan bishop.
• Identified publicly with the Catholic Church and guided by its teachings. Responsible stewardship of temporal goods, one of the pillars of the Church's social teachings, requires that we use natural and social resources prudently and in service to all.
• Committed in its corporate decisions to the preferential option for the poor, in particular to providing high-quality care to those who would otherwise be deprived of it.
• Characterized, in all its activities, by a holistic approach to the human person. Every person is assumed to have intrinsic spiritual worth, at every stage of his or her development.
• Respectful of each person's needs and right of self-determination. People are inherently social; their dignity is fully realized only in association with others. Our social nature calls for the common good to be served; the self-interest of a few must not compromise the well-being of all.
• Respectful of human life, and of suffering and death in the context of a full life.
• A service, not simply a commodity to be exchanged for profit.

A Common Thread In all these approaches, there is one common thread: a link with the diocesan bishop. In fact, we could state that if a work is not in communion with the diocesan bishop, there is no way it can be considered Catholic (see c. 394, para. 1). A work is Catholic if the bishop says it is and is willing to recognize it as such.

Four Catholic "Ingredients"
If we took the above-mentioned criteria and applied them to our healthcare organizations, some would easily pass the Catholicity test and others would not. However, there is still another approach, and this consists in grouping our data around four critical themes: mission, sponsorship, holistic care, and ethics.⁶ These themes, like ingredients in a cake, cannot be separated once they have been put together. Catholicity, like the cake, is more than the sum of its components, although it presupposes them and is based on them.

Mission The mission of the Church is to demonstrate God's love and saving power present in the world. This power, incarnated in the person of Jesus, is clearly seen in the Gospel, which shows him touching, healing, and restoring persons to physical life. The meaning of life is expanded to include one's relationship with God and others and hope for life to come.

The mission of a healthcare organization leads it to actualize its core values and philosophy. Mission is also a benchmark enabling one to evaluate the organization's authenticity and effectiveness. Mission should be the driving force by which decisions are made and structure and systems are developed. The criteria mentioned above related to apostolic purpose and communion with the diocesan bishop would apply here.

A Catholic healthcare organization should be able to determine the values shaping its corporate culture, choosing ones that are consistent with the Gospel. These must also become evident both in policies and in practice.

Sponsorship Given the changing circumstances affecting healthcare delivery, it is likely that sponsorship, as we presently know it — operating, that is, in the name of and under the authority of a given juridic person — will in the future influence rather than control healthcare organizations. Indeed, the day may come when a sponsor can no longer even influence organizations. Reduced to a role as advocates, sponsors would then be voices crying in the wilderness.

Criteria relating to accountability are applicable under this heading. Sponsors must be able to articulate the "non-negotiables" for the Catholic ministry, yet be flexible enough to choose between exercising total control, on one hand, and merely retaining some influence, on the other. Doing so demands a commitment to collaboration with others that permits a transition to new forms of healthcare delivery.

Holistic Care Humans are wonderfully whole beings. No aspect of a person should be considered apart from the totality of personhood. Simply put, holistic care is sensitivity to the whole person — to his or her physical, emotional, intellectual, spiritual, and occupational aspects — and not just to a problem requiring medical intervention.

Criteria relating to quality control would apply here. A genuinely Catholic organization would ask itself how it understands holistic care and how this understanding is expressed in its policies, procedures, and practices. It would thus have to ask itself how spiritual care is integrated into its overall care program. Does this care, for example, meet the needs of people from all religions and denominations?

Ethics Ethics is the discipline that seeks to answer the question: What is good behavior for persons as individuals and as members of the human community? Ethics helps us understand how a person is fulfilled as a human being by relating properly to self, to others, and to God.

For Christians, ethical behavior means living one's life in accord with Gospel values, so that ethics is never separate from anything one does. One requires continuous self-reflection to be certain that the person one claims to be is consistent with the person one is in practice. In the same way, an organization's Catholic identity requires ongoing ethical analysis to ensure that the values at the heart of Catholic tradition are expressed in each of the organization's daily operations. Criteria related to doctrinal issues would fit this category.

Several types of ethics affect the Catholicity of an institution or system:

• Social ethics govern the provision of healthcare services to individual members of the community, thus taking into account the common good.
• Corporate ethics are expressed in an organization's personnel policies and practices concerning social justice.
• Clinical ethics, which demonstrate respect for the sacredness of life at all stages of development, are concerned with issues related to (among others) human genetics and reproduction, treatment decisions at the beginning and end of life, and research involving human subjects.

Inseparable Dimensions These four areas — mission, sponsorship, holistic care, ethics — cannot be separated. An organization that lacked even one of them would be incompletely Catholic. Of course, it is often difficult to determine whether the criteria are being met to a required degree in any given organization. But that does not mean they can be overlooked.

The Ministry's New Challenges
Because of today's complex environment and the interrelatedness of healthcare providers in a given locality, new challenges arise that may threaten the future of Catholic healthcare. In addition to an ongoing analysis of Catholicity discussed above, healthcare leaders must attend to the following issues.

Monitoring Observance of Ethical Directives In the United States, the National Conference of Catholic Bishops' Ethical and Religious Directives for Catholic Health Care Services govern Church-sponsored healthcare organizations. But, although all such institutions subscribe to the directives in theory, not all follow them in practice.

Indeed, we can ask ourselves how many persons today are fully prepared to describe what the Catholic position is on a given medical issue. Even priests and religious are sometimes at a loss when faced with new and untested medical procedures. In the future, the Church will need to have available more persons who know the official positions relating to medical ethics and can apply these positions prudently and intelligently.

The question has frequently arisen recently in the restructuring of Catholic healthcare organizations: Who will be responsible for monitoring the application of the directives? It is not enough to say that they will be followed; a person or process must make sure they are applied.

Relationships with Civil Legislation A number of canons call for the observance of civil legislation, particularly in matters relating to contracts (c. 1290) and the protection of ownership of ecclesiastical goods (c. 1284, para. 2, section 2). Difficulties arise when civil legislation imposes requirements that are contrary to the Catholic position. In some parts of the United States, for instance, Catholic providers are expected to offer a full range of procedures, including some proscribed by the Church (e.g., contraceptives, sterilization), in order to receive financial support from the government. In other areas, "conscience clauses" understood to protect Catholic individuals who refuse to participate in proscribed activities are not always recognized as extending to Catholic institutions.

Alienation of Church Property The norms relating to the alienation of Church property have been carefully observed in many jurisdictions. Today, however, the definition of "property" is changing. Given the fact that brick-and-mortar buildings are sometimes becoming liabilities instead of assets, the Church should perhaps emphasize the work being done rather than the buildings themselves.

This becomes even more acute where capitation is in effect. Whereas, in previous times, a hospital was considered very profitable if it had a high occupancy rate, under capitation high occupancy is often a liability. What, then, remains to be alienated? Canonists have not yet found a satisfactory answer to this question.

Dealing with For-Profit Partners The Church has traditionally considered its basic services as being offered for the good of the community, even when fees are charged for them. Today, however, some providers are seeking to take over and operate Catholic institutions on a for-profit basis while, at the same time, maintaining that the institutions remain Catholic.

For some people, such arrangements are a contradiction in terms. Others can sometimes tolerate them. The jury may still be out on this point. However, we might ask ourselves: Can sound personal and corporate ethics continue to prevail in Catholic healthcare if the profit factor becomes predominant?

Cooperation with Other Providers The problems in collaborative arrangements vary, depending on whether the prospective partner is Catholic or not.

Although it is easy in theory for one Catholic healthcare institution to consider a joint venture with another, this is sometimes more difficult in practice, particularly when the two organizations are the only ones in the area. Their history as competitors and their differing traditions may prevent them from cooperating fully.

Attempts to form joint ventures or other affiliations with other-than-Catholic organizations raise other issues. To what extent, for example, can a Catholic institution cooperate with one that offers procedures not morally acceptable to the Church, even if these do not include abortion? The ground in this area is shifting; what may have appeared acceptable yesterday could be called into question tomorrow.

Dealing with Insurance Providers The moral norms on material cooperation come into play here. This is why many Catholic healthcare providers have sought to establish links with non-Catholic institutions that can perform the procedures insurance companies insist must be offered.

Establishing Networks For some reason, Catholic healthcare organizations have in the past often found it very difficult to cooperate with other Catholic organizations. They have frequently preferred to deal with institutions that have no religious affiliation.

Unfortunately, Catholic providers that enter networks containing secular or other faith-based (but non-Catholic) providers have often been swallowed up by their partners, for all practical purposes. Because of this, some bishops have issued protocols relating to the approval to be given to joint ventures with non-Catholic providers. Those bishops want Catholic institutions to cooperate with other Catholic institutions, and rightly so.

Today religious congregations are more open to cooperation with other congregations. Indeed, there are now many instances in which religious institutes are working together, forming cosponsorship arrangements, and even pooling their financial resources to ensure the viability of their ministries.

Identifying Factors Driving Apostolic Endeavors Is mission or finance the driving force in Catholic healthcare today? We all realize that appropriate financial arrangements are necessary if we are to offer high-quality care that is at least as outstanding as that offered by secular institutions (see c. 806). But when the primary concern becomes the financial "bottom line," we must ask ourselves whether, and to what extent, we are continuing to offer high-quality charity care to those in need.

Moving to Outpatient Services Many medical interventions that previously would have required several days of hospitalization can today be performed on an outpatient basis. In such circumstances, the institution has less opportunity to exert its holistic influence on patients.

Given that fact, our focus will in some instances have to shift from acute care to extended care and care for the elderly, care in which a holistic approach can be better put into effect.

Of course, with extended care come the issues of euthanasia and the responsible use of limited temporal resources. Just as, in recent decades, the Church has had to face the abortion issue, it also has to address the so-called death-with-dignity and assisted suicide issues.

Finding Appropriate Board Members The fact that a person is Catholic does not necessarily mean that he or she is aware of Church teachings. Board members are often chosen for their business acumen, their piety, or because they represent diverse parts of the community. But these qualities, important as they are, may be of little assistance when it comes to the difficult and delicate issues often faced by boards today.

For this reason, the mechanisms in place to ensure the continuity of the board and the selection of appropriate members are being examined. To strengthen board members' role in the Church, we will certainly have to initiate more formation programs for them.

Catholic Healthcare in a Secularized Society
It is obvious to all of us that today the Church has numerous challenges to face if it is to continue to offer to the world the health-giving image of Jesus Christ.

Catholic healthcare organizations are trying to find ways whereby they can continue their ministry without compromising their values. Some of our institutions no longer answer a real need of society; they probably should be closed. There are other institutions whose quality leaves something to be desired. They too should be looked at, and either improved or closed.

But the Church's healthcare heritage cannot be given up. We must find new ways of exercising it in a changed, secularized society. The answer does not lie in retreating from the battlefield, but rather in making certain that we are operating on principles in conformity with the Church's moral and ethical teachings. It is in this way that Catholic identity will be enhanced and preserved.

NOTES

1. This article is based on my earlier paper, "Catholic Identity of Healthcare Institutions in a Time of Change," in R. Torfs, ed., A Swing of the Pendulum: Canon Law in Modern Society, Peeters, Leuven, Belgium, 1996, pp. 47-64, and on the sources mentioned in that article.
2. See J. H. Provost, "The Canonical Aspects of Catholic Identity in the Light of Ex Corde Ecclesiae," in Studia Canonica, vol. 25, 1991, pp. 155-191.
3. See John Paul II, "Apostolic Constitution," Ex Corde Ecclesiae, August 15, 1990, no. 13.
4. See Provost, p. 167. See also F. G. Morrisey, "What Makes an Institution Catholic?" in Jurist, vol. 47, 1987, pp. 531-544.
5. See, for instance, the following Catholic Health Association publications: The Dynamics of Catholic Identity in Healthcare: A Working Document, St. Louis, 1987, pp. viii-52; "How to Approach Catholic Identity in Changing Times," Health Progress, April 1994, pp. 23-29; The Search for Identity: Canonical Sponsorship of Catholic Healthcare, St. Louis, 1993, pp. xi-88.
6. This section borrows heavily from CHA, "How to Approach Catholic Identity in Changing Times."