This is the sixth of a series of case studies, prepared for Health
Progress by the staff of CHA's Theology and Ethics Department.
St. Francis Medical Center is a 400-bed community hospital in an affluent
suburb of a major city. The hospital also serves a rather large and quite poor
Hispanic population on the outskirts of its service area. Most members of this
community are uninsured or underinsured. Hence, it has been very difficult to
get them to make use of the services of the hospital and of the associated physician
group in a timely way. Because of poor preventive care and delays in receiving
needed care, patients from this community tend to be more seriously ill when
they finally see a physician or come to the emergency department.
Two family practice physicians from the hospital have had informal conversations
with community leaders and the mayor about starting up an outreach clinic in
the community. The idea was received enthusiastically, and the mayor offered
city funds for the start-up and operation of the clinic, provided that the hospital
also committed resources. The two physicians have drawn up a proposal and submitted
it to the hospital CEO. Among other things, they request that they each be allowed
to work part-time at the clinic and that the hospital contribute $200,000 to
the clinic's start-up and $300,000 annually to its support.
The CEO is moderately interested. Such a project, after all, would be in line
with the organization's much publicized mission statement: "We answer God's
call to foster healing, act with compassion, and promote wellness for all persons
and communities, with special attention to our neighbors who are poor, undeserved,
and most vulnerable."
However, he also has another proposal on his desk—from the oncology group
and genetics department at the hospital. It wishes to start up, in collaboration
with the hospital, a specialty oncology hospital that would not only provide
the latest technology but also conduct cutting-edge genetics research and offer
a very active program of susceptibility testing for various forms of cancer,
in particular, breast, ovarian, and colon cancer. The oncologists believe that
an aggressive testing program would attract many individuals in the region (especially
private-pay individuals and those whose insurance covers susceptibility testing)
for the testing itself and also for follow-up care and possible treatment down
the road for those who develop cancer. They see this as potentially very lucrative
for themselves and an excellent investment for the hospital. The hospital would
be part owner and share in the profits.
The other pressing reason for the specialty hospital is that another oncology
group in the region apparently is considering doing the same thing. The St.
Francis group has several advantages: Most of its oncologists trained at a very
prestigious university, they are very active researchers and tops in their specialties,
they are doing a large number of experimental protocols, and they tend to admit
a high proportion of their patients to the hospital; and St. Francis itself
has a very capable genetics department. The group is looking for considerable
capital from the hospital to build the specialty clinic. Its leaders have insinuated
that if the hospital chooses not to participate in this venture they will look
elsewhere.
Questions for the Board
What factors would go into making a decision about this situation?
How would the organization's mission and values enter in?
How much weight would be given to the organization's mission and values?
Which consideration(s) would be decisive in resolving the situation?
What course of action would you—as a board member concerned with fidelity
to the organization's mission and values as well as with strategic planning
and good business development and the organization's bottom line—recommend?
Why?
Questions for Executive Management
What factors would go into making a decision about this situation? How would
the organization's mission and values enter in?
How much weight would be given to the organization's mission and values?
Which consideration(s) would be decisive in resolving the situation? Why would
you consider them to be decisive?
What course of action would you recommend? Why? How does this course of action
fit with the organization's mission and values?
How would you explain your decision to the relevant parties? To management
and staff?
Questions for the Ethics Committee
How would you describe the ethical issues in this situation?
What moral values/principles have relevance in addressing this case? How would
the organization's mission and values be relevant?
If the CEO were to request the ethics committee's guidance regarding how to
deal with this situation, what would you recommend? Why? What would be potential
of the option(s) not chosen? Are they acceptable from an ethical perspective?
From a mission perspective? From a business perspective?
Does your organization have criteria or a process for addressing these kinds
of situations?
Guiding Ethical Principles
The following principles are intended to provide some moral guidance to
discussions of the questions above. They are not exhaustive of the principles
that might be relevant to the case and to the various questions raised. They
should, however, be of some help.
A statement of the mission and values of the organization should play a central
role in these discussions as well.
- Care for Poor and Vulnerable Persons ýecause Jesus had a special
affection for poor and vulnerable persons, Catholic health care should "distinguish
itself by service to and advocacy for those people whose social condition
puts them at the margins of our society and makes them particularly vulnerable
to discrimination" (Directive 3, Ethical and Religious Directives for Catholic
Health Care Services1). Catholic health
care is characterized by its efforts to alleviate the conditions that perpetuate
the structures of poverty and vulnerability in society.
- Act on Behalf of Justice Because justice is an essential component
of the Gospel, Catholic health care strives to create and sustain right relationships
both within the ministry and with those served by the ministry. Toward this
end, Catholic health care attends to basic human needs for all (including
accessible and affordable health care) and seeks structures that enable the
full participation of all in society, the equitable distribution of societal
resources, and the contribution of all to the common good.
- Solidarity Because we are made in the image of a triune God, we
are social by nature. The fundamental relationality with others implies responsibilities
to others. At minimum, we should not harm them. Optimally, we ought to seek
their good.
- Distributive Justice Societal goods and resources should be distributed
equitably.
- Common Good Because of our social nature, we ought to contribute
to the creation of "conditions of social life which enable individuals, families,
and organizations to achieve complete and efficacious fulfillment."2
In this light, health care organizations ought to contribute to the public
good in part by seeking to improve the health status of the community.
- Respect Human Dignity Because we believe that each person is made
in the image and likeness of God, we ought to treat others with profound respect
and utmost regard.
- Beneficence Our decisions and actions ought to contribute to the
well-being of others.
- Nonmaleficence Our decisions and actions should not harm others.
- Economics in the Service of People While seeking profit is certainly
a legitimate goal of economic decisions, policies, and institutions, they
must ultimately be in the service of all people, especially the poor.
- Stewardship Health care resources should be delivered and used prudently,
efficiently, effectively, equitably, and in a manner that reflects professional
standards of quality.
NOTES
- Ethical and Religious Directives for Catholic Health
Care Services, U.S. Conference of Catholic Bishops, Washington, DC, 2001,
pp. 9-10.
- "Gaudium et Spes," in Austin Flanery, ed., Vatican Council
II: The Conciliar and Post-Conciliar Documents, vol. 1, Costello Publishing,
Northport, NY, 1975, section 74.
RESOURCES
Cahill, Lisa, "The Genome Project: More Than a Medical Milestone,"
America, August 12-19, 2000, pp. 7-13.
Cahill, Lisa, "The New Biotech World Order," Hastings
Center Report, March-April 1999, pp. 45-48.
Emmanuel, Ezekiel, "Justice and Managed Care: Four Principles
for the Just Allocation of Health Care Resources," Hastings Center Report,
May-June 2000, pp. 8-16.
Hamel, Ron, "Genetic Research: Putting Justice to the Test,"
Chicago Studies, November 1994, pp. 240-251.
Hofmann, Paul, and Nelson, William, eds., Managing Ethically:
An Executive's Guide, Health Administration Press, Chicago, 2001.
Lebacqz, Karen, "Fair Shares: Is the Genome Project Just?"
in Ted Peters, ed., Genetics: Issues of Social Justice, Pilgrim Press,
Cleveland, 1998, pp. 82-107.
Mehlman, Maxwell, and Botkin, Jeffrey, Access to the
Genome: The Challenge to Equality, Georgetown University Press, Washington,
DC, 1998.
National Conference of Catholic Bishops, Economic Justice
for All, U.S. Catholic Conference, Washington, DC, 1986.
>
Both of these engagements make the church's witness visible in the community,
witnessing the core principles and commitments of mission and identity.
Ask the Hard Questions
Catholic health care is sacramental. Catholic health care can be more sacramental.
Sponsors, boards, and management must ask hard questions of their institutions.
Are there standard medical or institutional rituals that distance and dehumanize
patients and families (and staff)? What can we do to make our facilities more
personal, more human?
In the area of the visual, there are many opportunities for making Catholic
facilities more sacramental. Sponsors, boards, and management should tour their
facilities, walking in the shoes of first-time patients and families. What do
they see, hear, and smell? Do these sights and sounds draw them into a community
of healing, or scare them away?
Finally, in the arena of visible witness, Catholic health care already does
a great deal to identify unmet needs and promote social justice, but this identity
is never complete. New needs, new marginal groups, and new challenges regularly
emerge. Taking stock of the institution's visible witness to mission and identity
is a ceaseless task.
NOTES
- Richard P. McBrien, Catholicism,Orev. ed., HarperCollins,
New York City, 1994, p. 1,196. Emphasis in original.
- See Catholic Health Association, "The Dynamics of Catholic
Identity in Healthcare: A Working Document," St. Louis, 1987.
- Dennis M. Doyle, Communion Ecclesiology, Orbis Books,
Maryknoll, NY, 2000, p. 22.
- Clarke E. Cochran and Kenneth R. White, "Does Catholic
Sponsorship Matter?" Health Progress, January-February 2002, pp. 14-16,
50.
- Wayne Ruga, "A Healing Environment, by Design," Modern
Healthcare, October 23, 2000, p. 24.
- Loring W. Batten III, letter to the editor, Commonweal,
April 21, 2000, p. 36.
- Michael D. Place, "Faith and Public Policy" (the inaugural
Cardinal Bernardin Lecture), Elmhurst College, Elmhurst, IL, October 26, 1998.
See also Michael D. Place, "Elements of Theological Foundations of Sponsorship,"
Health Progress, November-December 2000, pp. 6-10.