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BY: Gordon Self, MDiv, DMin

I was surprised by how easy, and yet how hard, it has been to provide a theological reflection for this special issue of Health Progress on the influence of Pope Francis. Easy, in that during the short time since the Holy Father was elected Bishop of Rome, there have been innumerable images and quotes capturing the pastoral vision of Francis and what it means to be a poor church in service of the poor. Not a week goes by without my seeing or someone sending me an article with a statement from Pope Francis that invites deeper reflection.

Yet, in spite of these readily accessible examples of the "Francis Effect," I find it hard to distill the pope's message into implications for Catholic health care. Presuming to know the heart of another person and how his message ought to be interpreted smacks of naiveté, or worse, arrogance, and is best avoided. What I can offer, instead, in my leadership role as a senior executive, are some of my personal reflections on the impact of Pope Francis and what I believe are possibilities, as you and I endeavor to live out our call to ministry. To achieve this, I will draw primarily on the theology in section 24 of Francis' first encyclical, Evangelii Gaudium (The Joy of the Gospel), as well as on some of the Holy Father's other public statements.

THE EASIER WITNESS
We likely all have favorite Pope Francis stories or images. One of mine is Francis washing inmates' feet at the Casal del Marmo youth detention center on Holy Thursday, shortly after he was elected pope. It is not just the humility of Francis, photographed on his knees and bending down to kiss a prisoner's foot, that is remarkable. Nor is it the fact Francis broke from tradition by washing the feet of women and of individuals from other faith traditions. Rather, it is the fact that the image of the pope washing feet reveals something important about the mutuality of love.

Catholic health care is a ministry of service, but the act of such service is always personal. In fact, sometimes it is extremely intimate, as when cleaning up an embarrassed patient whose linens have been soiled. Service is about relationship, which means both give and take. Even if we hold back in some way about revealing our vulnerability in a care relationship, we nonetheless communicate something about ourselves. Thus, we cannot serve without at the same time becoming involved in a personal way. And that can be messy.

At the heart of Catholic health care is a series of encounters, beginning first with Jesus Christ — the Christ present in the continuing care bed, on the emergency department gurney, in the clinic waiting room chair. But also included are encounters with the Christ we work with, the Christ who dwells within you and me.

We encounter Jesus in the caregiver who is open to mutual expressions of love without hiding behind the guarded safety of his or her professional role. A person equally mortal and touched by life's fragility recognizes the same fragility in another, thus is able to offer authentic relationship that heals. Francis has been so influential because ordinary people can relate to him. Those in Catholic health care can especially relate to Francis because we, too, know something about the healing relationship that he models.

However, this kind of relationship of mutuality and reciprocal vulnerability can be threatening. We may be wary of putting out our foot to be held, caressed and kissed by another, risking exposure of any extension of ourselves. We may pull back from relationship for fear of being hurt and rejected.

While it is important that Catholic health care use standardized practices to ensure the highest level of quality and safety, within those practices there also must be room to ensure that the humanity of Catholic health care is not lost. Genuine service that risks becoming vulnerable in the process cannot be choreographed. We do not "do vulnerability" as if it were reducible to a strategy or leading practice. Vulnerability gets messy, especially when relationships expose our own soft underbelly.

Yet Francis challenges us to not hide behind desks, or titles, or roles. "I want to tell you something," he exhorted participants in 2013, at the conclusion of World Youth Day in Rio de Janeiro. "What is it that I expect as a consequence of World Youth Day? I want a mess. We knew that in Rio there would be great disorder, but I want trouble in the dioceses!

"I want to see the church get closer to the people. I want to get rid of clericalism, the mundane, this closing ourselves off within ourselves, in our parishes, schools or structures. Because these need to get out!"¹

The Holy Father's consistent critique of clericalism and closing off within ourselves is not confined to priests and bishops. I suggest the structures he refers to include the very health care ministries that we represent. Thus the challenge to get out and become involved in the messiness of people's lives applies to all of us in Catholic health care.

Such a proposition is both liberating and threatening. When Francis states in Evangelii Gaudium that we must "stand at the crossroads and welcome the outcast," even taking on the "smell of the sheep" while helping bear another's burdens, the ethical implications are clear.² We must be willing to get involved in people's lives, no matter their need, background or life circumstance. Life is messy, thus if we are called to be present to people in the most vulnerable moments of their lives, we must be prepared to get involved in the messy stuff, too.

This is another way in which we in Catholic health care relate to Francis and are affirmed and encouraged by his words. We do get involved in people's lives, every day, and we know something about being present to people, no matter what their circumstance, sometimes at great personal cost. We know, for example, about being present to the ailing staff member who struggles to keep up at work when he or she is mentally exhausted and on the verge of collapse. Or treating the refugee whose uncompensated care challenges our ability to balance our values of stewardship and compassion. Or providing quality care to the wounded drunk driver in our emergency department who killed the family whose bodies now lie in the adjacent morgue.

This is the messiness that we know.

We also know the pregnant woman whose life-threatening conditions force heart-wrenching decisions over saving the lives of both mother and baby, if we can. We encounter the person who laments the loss of meaning in life and asks you, in a moment of desperation, if it's possible to help hasten death. And we see before us the person who is unable or unwilling to abstain from substance abuse, who requires creative strategies to help mitigate the harm done to his or her body while still addressing the deep-seated pain fueling the addictive behavior.

These are human beings with names, hopes and regrets — not ethics cases. It is a lot messier when we encounter these individuals in our clinics in real time, taking hold of their lives in our hands to find some way forward, compared to debating these clinical realities afterwards, when time and emotional distance are on our side. We know intimately the tensions of faithfully upholding the Ethical and Religious Directives for Catholic Health Care Services (and the Health Ethics Guide in Canada) and remaining in communion with the church's teachings, while at the same time staying engaged in the messiness. We relate to Francis, who models the tension to neither abandon personal and institutional integrity, nor abandon the Christ who is in our care.

And so it is liberating to see so many examples of Pope Francis' expressions of mercy, in acknowledging his own sinfulness, including his famous admission, "Who am I to judge?"³ As I reflect on the impact of Pope Francis' pastoral ministry in our organization, Covenant Health, I see a great affirmation of the blessing of our work. The decisions that leaders face every day are daunting, yet the witness of Francis to celebrate the joy of the Gospel has served to energize my colleagues for ministry.

We know Catholic health care is both complex and complicated. And yet we shoulder this responsibility and take on the smell of the sheep with the confidence of the call we have been given. We hear in the pope's message the assurance that we are trusted witnesses of the Gospel who are the very clinicians, board members, sponsors, volunteers, staff and administrators comprising the "field hospital after battle"⁴ to which Francis likens the church. Indeed, we know how to tend the wounds. And now we have a fitting metaphor to celebrate the healing ministry to which we dedicate our lives in service of others.

THE HARDER WITNESS
While this is reassuring, it is looking within ourselves to see an equally wounded person that is perhaps not so easy. We can close ourselves off from looking at our drivenness, our compulsions, our workaholism and other addictive behavior that is rampant in the healing profession. We struggle with market forces and opportunities for growth, even survival, through strategic partnerships, ensuring our cooperation is morally licit. And here lies our own capacity for sin, if we do not discern carefully partnerships that potentially compromise our Catholic identity in the name of growth and innovation. The social justice tradition in which we are rooted requires us to consider whether our ministry is consistently oriented to the preferential option for the poor.

If Francis can be honest about his own sinfulness, so can we all.

Francis warns that a "church that does not go out of itself, sooner or later, sickens from the stale air of closed rooms."⁵ Going out of oneself does not mean we deny our humanity, our sinfulness, our vulnerability. Rather, it is acknowledging we are all a pilgrim people in need of healing — including Catholic health care as a ministry of the church. It means taking risks to go out of ourselves and meet others at the crossroads and on the edges of existence, as Francis challenges. We may make mistakes along the way, but Francis prefers "a thousand times over, a church of accidents than a sick church."⁶ It is this authentic sense of mission in facing the truth, including both the promise and challenges of Catholic health care, that Francis states is key to ministry.

We can all look back at our lives wishing we had made different decisions, or could take back words said in anger. But we are who we are today because of such humbling experiences. Looking honestly at the messiness of our own lives can deepen our capacity to be compassionate to others in their own pain and suffering.

For all that has been celebrated about Francis, there remain questions regarding whether he could have done more as provincial superior of the Jesuits in Argentina when, in 1976, two of his priests were abducted and tortured by the military junta. I can imagine that this test of his leadership has made him who he is today.

FROM PERFECTION TO MESS
When I consider the invitation to name and touch the messes of life, I do not view it as a negative experience. Rather, it is honest inquiry to see our lives for who we are, and our institutions for what they are, and our need for God's grace to go on. Such sober reflections will invariably reveal where we could have done more — thus it is tempting to avoid looking altogether. That is a mistake. Our capacity for reflecting on the realities of our lives is the very capacity required to know and see another person in their brokenness.

Too often we resort to plasticine images to portray our institutional values. Staff who struggle to keep up with the demands of their work — perhaps feeling they are always falling short of meeting people's needs; or who struggle with morally difficult decisions around allocating resources and implementing program changes; or who simply struggle with chronic change fatigue — need more than two-dimensional messages that do not mirror their experience.

I have found it is a lot more powerful to engage the moral imagination of our staff and clinicians when I reflect on our values while showing images of an empty resuscitation room following a cardiac arrest. Imagine, for a moment, the resuscitation room floor: Scattered about is smeared blood, used plastic gloves, soiled gauze, plastic tubing and wrapping torn open in a hurry to insert a line or to intubate the patient.

Now imagine you are family, invited to be present with your loved one as you stand in one corner, awaiting the outcome. What do you see and hear? Are you able to spend some time alone with your loved one if the resuscitation is unsuccessful and the patient dies? What compassionate support is offered you? And how do the interdisciplinary staff collaborate, all working together and respectfully, for one common goal? Who explains to the other patients that their wait may be even longer, given our ethical obligation and values of integrity and social justice to serve the sickest first? Who ensures the room is cleaned and restocked with all the necessary medical supplies, as good stewards of our resources, to be ready for the next patient?

During the past few years, I consulted colleagues regarding some of the ministry opportunities present in the Downtown Eastside district in Vancouver, Canada, as we pursued our own programs around newborn safe havens, addiction services and homeless strategies in Alberta. The Eastside is a far cry from the sanitized images of Catholic health care that is a product of stale air. Ironically, it is these encounters with the poorest of the poor, the biblical anawim, whose clothes do not always smell so pretty, who have taught me how to breathe fresh air. As has Francis.

In Evangelii Gaudium, Pope Francis calls us to take on the smell of the sheep, which any farmer knows is not very pleasant. My daughter has a small hobby farm, and I can tell you that I will not be putting one of her sheep over my shoulders. Still, I do know I am called to help bear the weight of others in my life who are hurting. Often they are the people closest to us, whom we take for granted. We are called to get involved in the messy issues of life, to name issues for what they are without sanitizing the experience. We are called to be merciful to ourselves and others, standing at the crossroads with the decisions people make, sometimes under extremely difficult circumstances.

Francis challenges us to be a community with "endless desire to show mercy."⁷ A board colleague who is a Sister of Mercy informed me the other day that mercy is the charism most often quoted by Francis. I have no reason to doubt either my colleague or Pope Francis; for it is mercy that begins at home, so to speak, allowing us to "try a little harder to take the first step and to become involved."⁸ We become involved in the realities of people's lives with mercy, and in our courageous witness of the joy of the Gospel, in Catholic health care. We are indeed an evangelizing community, as Francis describes it, that gets involved, gets its hands dirty, and by being close to those who are hurting and suffering, we may even risk getting the smell of the sheep on us.

Acts of compassion may leave an indelible impression. They bear fruit by leaving us a little more connected to humanity, a little more compassionate, a little more human in all our shared vulnerability. This is the blessing Jesus promises his disciples who serve, who give of themselves and commit their lives in service of others in Catholic health care.

GORDON SELF is vice president, mission, ethics and spirituality for Covenant Health, Edmonton, Alberta, Canada.

NOTES

1. As quoted by the Huffington Post, "Pope Francis 'Slum Pope' Visits Varginha Favela to Huge Welcome," July 25, 2013. See: www.huffingtonpost.com/2013/07/25/pope-francis-slum-_n_3652793.html (accessed June 16, 2014).
2. Francis, Evangelii Gaudium, section 24. w2.vatican.va/content/francesco/en/apost_exhortations/documents/papa-francesco_esortazione-ap_20131124_evangelii-gaudium.html#Star_of_the_new_evangelization.
3. Antonio Spadaro, "A Big Heart Open to God," America, Sept. 30, 2013. www.americamagazine.org/pope-interview (accessed June 15, 2014).
4. Spadaro.
5. A letter from Pope Francis to the Argentinian bishops as reported by Vatican Radio, April 18, 2013. www.news.va/en/news/pope-mission-the-best-cure-for-the-church (Accessed June 15, 2014).
6. Vatican Radio.
7. Evangelii Gaudium, section 24.
8. Evangelii Gaudium, section 24.