BY: MSGR. CHARLES J. FAHEY

Dioceses Should Do More in Providing Care for Dependent and Dying Persons

Summary
In 1988, with the publication of Catholic Health Ministry: A New Vision for a New Century, the Commission on Catholic Health Care Ministry called on the Church to redefine its healing mission in society. Unfortunately, despite various efforts, the Church has not yet fully articulated a shared vision of Catholic healthcare, healing, and support.

Healing human brokenness has always been the Church's work in the world, whether the brokenness be physical, emotional, intellectual, moral, or spiritual. The Church, having a broader definition of brokenness than that of the larger healthcare system, must sometimes act as a countercultural critic of that system.

Two of the great challenges facing healthcare today are providing care for dependent persons (people with chronic illnesses and older people) and for dying persons. In both cases, much more coordination of the various actors is needed. The Church could ensure that this coordination is carried out.

In each diocese, the bishop should organize a pastoral health and social service planning group to assess community needs and apply Church resources to them. Local Catholic healthcare providers and social service agencies should develop a corporate culture of healing and support. Parishes should accept the idea that healing and supporting frail people are integral parts of parish life.

In 1988, with the publication of Catholic Health Ministry: A New Vision for a New Century, the Commission on Catholic Health Care Ministry called on the Church to redefine its healing mission in society.

Healing human brokenness has always been the Catholic Church's work in the world, whether the brokenness is physical, emotional, intellectual, moral, or spiritual. In fact, the Church has traditionally viewed apparently different kinds of brokenness holistically — as aspects of a single whole — and has applied its healing arts holistically as well.

The commission noted, however, that several recent trends threatened the healing ministry's holistic vision. One trend was the increasingly tenuous relationship between Catholic healthcare organizations and local churches. Another was the declining membership of the religious congregations that had traditionally sponsored healthcare organizations. Still another trend, closely related to the second, was the steadily increasing number of laypeople leading Catholic hospitals and systems. The commission feared that, "without a massive effort, it will be impossible to sustain, develop, and organize this lay commitment to the degree necessary to ensure the continuity of Catholic health care" (Catholic Health Ministry: A New Vision for a New Century, Marriottsville, MD, 1988, p. 10).

Partly in response to A New Vision for a New Century, the National Conference of Catholic Bishops published two documents, The Role of the Diocesan Bishop in Catholic Health Care and the Ethical and Religious Directives for Catholic Health Care Services. In addition, the Catholic Health Association, the National Coalition on Catholic Health Care Ministry, and Consolidated Catholic Health Care have cosponsored New Covenant, a process meant to strengthen the Church's presence in healthcare through regional and national collaborative strategies.

However, despite these efforts, the ministry continues to fall short of the hopes espoused in A New Vision for a New Century. We have not yet sufficiently articulated a shared vision of Catholic health, healing, and support. Nor have we created a technique that could integrate this vision into the life of the Church at either diocesan or parochial levels, or at the intersection where the Church and Catholic healthcare organizations meet.

The Church and Community Leadership
The Church has two roles in the local community. First, the Church is in its most "catholic" sense concerned with all people and their well-being; with all social structures, both those that enhance and those that inhibit people's lives; and with all healthcare providers, public, not-for-profit, and proprietary. And, second, the Church sponsors some healthcare organizations, either directly or through religious congregations.

If the Church fails to balance these roles carefully, they can be a source of confusion and conflict. All too easily, the Church can foster a harmful competition that threatens, rather than strengthens, the community.

The local bishop is in a particularly delicate position because his responsibility extends beyond the Church's own programs to include all others that influence the common good. The bishop's moral leadership must be used prudently and fairly. He is bishop to all the people and institutions of his diocese, not just those that are Catholic.

Laypeople are increasingly becoming Church leaders in the local community. To the degree that the laity is encouraged to exercise a leading role in the health ministry, the hurts of people will be better addressed, the ministers themselves will grow in faith and commitment, and the Church will give powerful witness to the Gospel message.

Catholic Identity and Healthcare Providers
Although external signs such as names and symbols are one element of Catholic identity, they are not fundamental. The fundamental elements are four:

• A recognized connection with an official Church entity, that is, a diocese or religious congregation
• A world vision rooted in the Catholic tradition
• A set of values rooted in this vision
• Corporate behavior consistent with the vision and values

Although formal connection with the Church is a constitutive element in a healthcare organization's Catholic identity, the organization's behavior is the truly critical measure. This issue becomes more problematic as Catholic providers become ever more deeply embedded in a predominantly secular culture. The market, third-party payers, government regulation, strategic alliances, participation in systems, professional accreditation, collective bargaining — all these make demands on the identity of Catholic providers. The identity problem is exacerbated by the dwindling number of women religious on healthcare staffs; the diminishing (though still important) role of private philanthropy in healthcare finances; and the growth of local, regional, and national healthcare systems and the concomitant dispersal of authority and responsibility. Taken together, these forces have a powerful homogenizing, secularizing effect.

The Church should be concerned about serving people in the spirit of the Gospel. To do that, the local Church and the local Catholic healthcare provider must discover a way to collaborate. Indeed, searching for and implementing a collaborative strategy is itself a sign of the provider's Catholicity. For its part, the local Church must reexamine its mission of healing in contemporary society.

Today the vast majority of Catholic healthcare providers are part of a community resource, supported by the broader community and serving it. Catholic providers are now quasipublic institutions that happen to be involved in a highly competitive market. The leaders of these organizations must make deliberate efforts to infuse them with Catholicity.

Healthcare, Healing, and Support
Three concepts are useful in discussing the Church's role in Catholic healthcare:

• "Healthcare" is used in the broadest sense, to include healthcare services for chronic illnesses.
• "Healing" means dealing with all the hurts a person might suffer.
• "Support" is the central need of chronically ill and dying people (and also the central need of those who provide care for the chronically ill and the dying).

The Church and Healthcare
The primary role of the Church is to proclaim the good news and see to the administration of the sacraments. In performing these duties, the Church must constantly reflect on the changing human condition in the light of Catholicism's traditions. The Church has a prophetic — and often countercultural — role that can place it in tension with prevailing social values and structures.

This tension can be especially marked in healthcare, where Catholic providers not only provide care for the injured and the ill, but — like other Church-sponsored organizations — also encourage people to do good works and give direct witness to the continuing presence of Christ. In carrying out its mission, Catholic healthcare must sometimes criticize aspects of the larger healthcare system.

The Church and Healing
The Church must sometimes act as a critic because its view of brokenness is much broader than that of the larger healthcare system, involving as it does all elements of the human person: the moral, intellectual, and spiritual as well as the physical and emotional. Since an individual's hurt will affect his or her family and neighborhood, brokenness inevitably has its social aspects. Healing thus requires providing care for both the individual and the milieu.

It is in providing care for the milieu that Catholic healthcare is most sharply in tension with the larger healthcare system. On one hand, the larger system increasingly realizes that it must, through prevention and public health, treat "the whole person." On the other hand, funding cuts restrict both the services the larger system offers and the number of people it can offer them to. And note that we are now discussing only basic healthcare services, not healing in its broader sense.

But Catholic healthcare, ever more aware of the body-soul connection, knows that health is indivisible. Both hurts and healing have psychological and emotional elements. Anomie, alienation, and a sense of powerlessness are at once the cause and effect of trauma and illness. Ignorance is a kind of disease. Immoral behavior hurts the sinner as well as the sinned against. A person with but a tenuous, uncertain relationship to God is afflicted with brokenness and in need of healing.

The Church is not only a provider of healthcare services but also a conceptualizer of needs, an advocate for the poor and the uninsured, and a promoter of healing. The Church is one of the few institutions in society that can bridge domains both theoretically and practically. Through its parishes, the Church is geographically present to all people.

From a Christian perspective, healing involves many processes. Indeed, it is likely to be most effective when all these processes — physical, intellectual, emotional, moral, and spiritual — are brought to bear. The Church and Catholic healthcare have a unique opportunity to foster holistic healing both within healthcare organizations and in the neighborhood.

The Church and Support
Two of the great challenges facing society today are providing care for dependent persons (people with chronic illnesses and older people) and for dying persons.

• Care of Dependent Persons  Society is experiencing great growth in the number of its citizens who, because of physical, intellectual, or emotional limitations, cannot care for themselves, let alone participate in the work force. Many of these are older people.

  Unfortunately, government programs for the dependent are limited in various ways. Medicare, for example, is restricted to older people suffering episodes of acute illness. Medicaid is restricted to poor people. Supplemental Security Income is restricted to people who have physical or mental impairments that keep them from working. These and other government programs fail to reach a majority of the people requiring support. What is worse, funding for even this minimal support faces likely cuts in the future.

  The growth of a dependent population, coupled with the failure of government safety-net programs, means that many people are bound to suffer not just inconvenience but grave threats to basic decency.

  The Church and Catholic healthcare have an opportunity to collaborate in providing care for the dependent. Although they cannot solve the problem alone, they are uniquely placed to offer an array of services. For example, the Church has long taken the Eucharist to people in their homes, and this practice has been expanded and enriched as laypeople carry out the ministry.

• Care of Dying Persons  The debate over assisted suicide has at least increased society's awareness of a larger problem: inadequacies in the care given to dying people.

The Church should be a leader in care for the dying. Although Catholic healthcare encourages people to sign advance directives, for example, it all too often treats the execution of such directives as a formal, legalistic exercise that will have little real impact on the signers' lives. The Church should insist that its healthcare organizations see the signing of these instruments as sacramental — ceremonies in which caregivers express their commitment to patients, and patients express their trust in the caregivers. What greater confidence in caregivers can a patient show than to say, "I want you to act as my other self and — if it should come to that — to be there to hold my hand as I enter eternal life"?

In care of both dying and dependent persons, much more coordination of the various actors is needed. The Church — through its healthcare organizations, its social service agencies, and its parishes — could ensure that this coordination is carried out.

Church's Participation in Healthcare
In each diocese, the local Church should participate in Catholic healthcare in the following ways.

Dioceses
The bishop should organize a pastoral health and social service planning group that:

• Assesses community needs
• Assesses the local Church's resources
• Convenes representatives of the relevant local Catholic organizations and asks them to develop a comprehensive Church response to human hurts
• Develops pastoral plans for local Church action
• Facilitates collaboration among those Catholic organizations skilled in healing and supporting activities
• Develops and implements supporting activities that are beyond the capability of any single organization

Healthcare Providers and Social Service Agencies
Catholic healthcare providers and social service agencies vary in their sizes, missions, and capacities. However, most providers and agencies can:

• Develop a corporate culture of healing and support
• Commit themselves to the healing and support of people in their own purview and in the community at large
• Participate with other community organizations in planning, developing, and implementing healing and supporting activities
• Participate in a diocesan pastoral planning process

Parishes
Parishes should accept the idea that healing and supporting frail people is an integral part of parish life. Each parish should include in its leadership a group that:

• Understands the many kinds of brokenness found in any community
• Assesses the resources the parish might contribute to healing brokenness
• Participates in planning healing and supporting activities facilitated or convened by the diocese or local providers
• Creates linkages with resources from the broader community, especially Catholic agencies and providers

All parts of the Church have something to contribute to healthcare, healing, and support. Although the parts are limited in what they can do by themselves, they can, when they join together, make a larger contribution than any other social constellation.

Msgr. Fahey is Marie Ward Doty Professor of Aging Studies and senior associate, Third Age Center, Fordham University, Bronx, NY. He also serves as a program officer for the Milbank Memorial Fund.

KEY POINTS FOR CHURCH LEADERSHIP

In discussing Church leadership of Catholic healthcare, we should keep in mind the following key points:

• Although the Church has a unique ability to meet the needs of broken people in society, it needs leadership at the diocesan level to do so. Currently, however, few dioceses have pastoral leadership units that can outline, let alone organize, a broad response to brokenness.
• Catholic healthcare providers' identities tend to be shaped by forces exogenous to the Church. In addition, provider-patient relationships remain highly autonomous, even in relatively small Catholic organizations. As such organizations grow larger and more complex, they will find it even more difficult to monitor provider-patient relationships, let alone control them. To the extent that sponsors attempt to control these relationships, they often find themselves entangled in legal, economic, and moral difficulties. Is this worthwhile, especially since such sponsors are trying to control what is probably uncontrollable?
• Local bishops should exercise care in using the Church's moral and financial resources to support Catholic healthcare providers. A bishop is the pastor of the whole community, including its institutions and the people who work in and are served by them. Is it justifiable, in a competitive economic system, for the Church to favor one competitor — even one with which it has a special relationship — over others?
• All healthcare providers are flawed in that they define "hurt" too narrowly and respond inadequately to the needs of the poor. The services provided by Catholic institutions, like those of their secular counterparts, will always be less than ideal, despite their best efforts.
• To whom do the assets of a healthcare provider belong? Who has the right to decide how they should be used? Legal and moral questions arise when assets are removed from a particular geographic location or from healthcare altogether.
• Healthcare in our society continues to focus on acute illness. This is ironic, given medical science's success in dealing with such illness. Many people now live long enough to develop chronic illnesses to which society pays much less attention.M
• Today all healthcare providers face changing funding patterns. In a competitive market, providers must do more with less to satisfy purchasers prepared to demand what they want. At the same time, both providers and consumers are losing power to managed care organizations. In addition, many people now find themselves without access to healthcare as either healing or support.
• Catholic healthcare providers find it difficult to maintain their faith-based identity in the face of powerful forces for homogeneity. And even their best efforts may be constrained by funding sources that define healthcare narrowly (as acute care, for example). On the other hand, Catholic providers may well find that their role as part of the broader Church is a unique asset.
• Catholic providers' relationship with the Church cannot adequately be addressed in the context of control. It can only be done in a context of shared vision, values, and activities.

FOUR LEADERSHIP AREAS

The Church is uniquely placed to lead Catholic healthcare in four areas.

Conceptualization of the Issues
The Church is in a position to define the issues — healthcare, healing, and support — in the light of its understanding of the human condition in today's world.

Communication and Linkages
The Church is, among other things, a unique configuration of community institutions. It can communicate with those institutions through a common language and set of values. In many instances, the Church also has a juridical relationship with the institutions. The Church lives through its parishes. It has its life in neighborhoods where people live and die.

The Church also has external linkages. It is — directly through the state, local, national, and international level, and indirectly through its members — in constant dialogue with society and all of its structures.

Moral Standing
The Church calls on individuals to respond to the Gospel imperative of working for peace and justice and practicing the virtues. It is interested in the well-being of people and society, not self-aggrandizement.

Spiritual Resources
The Church has prayer and the sacraments — that is, both the message that touches people at the core of their being and the means of delivering that message.