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Director of the Edmund D. Pellegrino Center for Clinical Bioethics at Georgetown University

Over my many years in Catholic health care, both as a physician and as someone working in Catholic health care ethics, it has been my responsibility to explain the Ethical and Religious Directives for Catholic Health Care Services (ERDs) to coworkers, students and others. One of the clearest lessons I have learned is that to jump into a discussion of an individual directive — especially with people who have little or no awareness of the ERDs — can often result in confusion and a sense that it is some arbitrary Catholic rule book that appears to say "no" most of the time.

To help clear any possible misunderstandings when having discussions around the ERDs, I suggest some strategies I use in my work in Catholic health care. I know that many of you reading will have your own wisdom, probably much deeper than mine, and I do not want to suggest my ideas are the best. But the key insight I follow, and one from which my other strategies flow, is that good teaching and discussions about the ERDs can help a hospital and health care system communicate what it means to be Catholic in a way that is authentic, faithful, respectful of other voices and can deepen the commitment of those who work in the ministry.

For those of you who might not know much about the ERDs, or who are looking to do your own study, here are a few basic facts:

• The ERDs are developed by the United States Conference of Catholic Bishops in consultation with health care professionals, theologians and other competent individuals in the areas covered by the document.
• The ERDs are currently in their sixth edition. After each edition is developed, it is reviewed in Rome by the Congregation for the Doctrine of the Faith for suggestions, revisions and, ultimately, approval. It serves as a basis for understanding what it means for Catholic health care services to be considered Catholic and provides a point of contact for the diocesan bishop in his role to ensure that health care is provided in a way that reflects the Church's understanding and teachings.
• The document is divided into six sections and, additionally, includes a preamble, general introduction and conclusion. Each section begins with an introduction and is then followed by a list of prescriptive directives that provide detail and explanation to the introductory material.
• Understanding the individual directives requires spending time with the material in the introduction. Otherwise, it is easy to inappropriately assume the meaning of a particular directive or miss its point.

My suggestion is that individual Catholic institutions use the ERDs as a roadmap to consider locally what makes their hospital or system authentically Catholic. There is a profound vision contained in the ERDs that is countercultural to aspects of contemporary American society. What do you do with that, and how do you work with people in your institution to make this document not just a rule book, but the starting point for how your hospital lives out its mission? Most Catholic hospitals have their own mission and vision
statements that can provide an excellent way to begin and further this discussion. The lived witness of generations of Catholic religious, mostly women, animates our present day, and the ERDs can be a way to deepen the local charism of a particular hospital.

A TESTAMENT TO THE COMMON GOOD
The ERDs are based on our Catholic understanding that our faith rests on our reason as expressed in the natural law, the revelation we have from Scripture — especially the example of Jesus in the Gospels — and the Church's traditions expressed in official magisterial documents and papal teachings. A challenge in our society is that phrases like natural law, revelation, tradition and magisterial teaching are not understood by many of those with whom we work. That challenge is also an opportunity to express the reality that Catholic health care views human reason and science as critical and nothing to be feared.

Another opportunity is to present the compelling ministry of Jesus in caring for those who are sick, forgotten, on the margins of society or viewed by others as sinners or wayward people. The ERDs emphasize human dignity, but that expression may not be readily understood. In keeping with Jesus' ministry, the simplest way to explain human dignity is that every life counts and is valuable because of God's love and our shared humanity. Our expression of respect for human dignity means that we care for life from the moment of conception to the moment of natural death. This includes not just the unborn, but the woman who is carrying a pregnancy she may not want to continue, or the person with a life-threatening illness who, even with good pain and symptom control, seeks the means to end his or her life. ERD #3 states these thoughts:

In accord with its mission, 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: the poor; the uninsured and the underinsured; children and the unborn; single parents; the elderly; those with incurable diseases and chemical dependencies; racial minorities; immigrants and refugees. In particular, the person with mental or physical disabilities, regardless of the cause or severity, must be treated as a unique person of incomparable worth, with the same right to life and to adequate health care as all other persons.¹

Living the spirit of our faith that is contained in the ERDs requires that we seek excellence in helping every person who feels that the life they carry or the life they live is untenable to continue. We work to help those in difficulty to recognize the value of life even in tough times.

A MISSION FOR SPIRITUAL CARE
A distinctive feature of Catholic health care is the recognition that health is not limited to the biological. We prioritize the spiritual care of those who come to our institutions as part of our witness to Jesus' ministry as well as our belief that wholeness requires a holistic response. As the introduction to Part Two of the ERDs states, quoting from the 1981 U.S. Bishops' pastoral letter titled Health and Health Care:

Since a Catholic health care institution is a community of healing and compassion, the care offered is not limited to the treatment of a disease or bodily ailment but embraces the physical, psychological, social, and spiritual dimensions of the human person. The medical expertise offered through Catholic health care is combined with other forms of care to promote health and relieve human suffering. For this reason, Catholic health care extends to the spiritual nature of the person. "Without health of the spirit, high technology focused strictly on the body offers limited hope for healing the whole person."²

In a time of financial constraints, it is worth emphasizing the importance of having robust pastoral care services to attend to the needs of our patients that cannot be met by strictly medical and nursing care, as a lack of spiritual care may well be a significant part of the suffering or illness they are experiencing. The availability of the sacraments is an essential part of Catholic health care. Although the skills of the doctors, nurses and other health care professionals are obviously essential as well, the presence of Christ in the Eucharist, the power of forgiveness in the sacrament of Reconciliation and the healing available in the sacrament of the Anointing of the Sick all give real presence to the role of Christ as divine physician working alongside our other caregivers. For those patients who are not Catholic, the presence of spiritual care that respects their traditions is also critical. All the technology and advanced science in the world cannot bring healing alone; our emphasis on spiritual care serves as a witness to this reality.

RESPECT FOR THE PROFESSIONAL-PATIENT RELATIONSHIP
Along with pastoral care, Catholic health care obviously relies on the skilled work and compassion of the doctors, nurses and other health care professionals who directly care for our patients. Part Three of the ERDs deals specifically with the health care professional-patient relationship. It covers a number of topics related to the patient's right to information about their condition, the importance of confidentiality, the patient's ability to defer or refuse treatment considered overly burdensome, and, among other topics, the care for patients who agree to participate in clinical research. A specific directive in Part Three, ERD #36, considers care of women who suffer sexual assault and permits, with appropriate safeguards, contraceptive efforts for women in this situation:

Compassionate and understanding care should be given to a person who is the victim of sexual assault. Health care providers should cooperate with law enforcement officials and offer the person psychological and spiritual support as well as accurate medical information. A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization.³

The work of health care professionals in Catholic health care services is often a source of misinformation and confusion. Sharing the content of this section of the ERDs can help with inaccurate opinions about how patients are meant to be treated. Unfortunately, the pro-life teachings of the Church can be misconstrued, and people wrongly believe that the Church always requires aggressive care or is not willing to assist sexual assault victims. That is simply not true.

CARE FOR THE SERIOUSLY ILL AND DYING
Another area where people are often poorly informed about the ERDs and Catholic health care concerns people with life-threatening illness and at the end of life. Part Five of the ERDs, "Issues in Care for the Seriously Ill and Dying," highlights the importance of pain control, well-informed choices about life-sustaining therapy and caution regarding the overzealous use of technology. Some will be surprised that individuals can refuse life-sustaining technology and request withdrawal when the burdens of treatment overwhelm the likely benefit:

The task of medicine is to care even when it cannot cure. Physicians and their patients must evaluate the use of the technology at their disposal. Reflection on the innate dignity of human life in all its dimensions and on the purpose of medical care is indispensable for formulating a true moral judgment about the use of technology to maintain life. The use of life-sustaining technology is judged in light of the Christian meaning of life, suffering, and death. In this way two extremes are avoided: on the one hand, an insistence on useless or burdensome technology even when a patient may legitimately wish to forgo it and, on the other hand, the withdrawal of technology with the intention of causing death.⁴

The Church is opposed to euthanasia and assisted suicide. The emphasis in Part Five of the ERDs on care for the dying, effective pain treatment and creating a community where the gift of life and human dignity is respected ensures that this refusal to kill is embedded in a culture of deep care and compassionate treatment.

PROCREATION AND RESPECT FOR LIFE
Some may find Part Four of the ERDs, "Issues in Care for the Beginning of Life," especially challenging in contemporary American society. Indeed, it presents a countercultural vision of sexuality, marriage and human reproduction. It is one that respects marriage as the commitment made before the creation of new life and defends the dignity of the unborn, women and children. The teaching is one of respect for life at every stage:

The Church's commitment to human dignity inspires an abiding concern for the sanctity of human life from its very beginning, and with the dignity of marriage and of the marriage act by which human life is transmitted. The Church cannot approve medical practices that undermine the biological, psychological, and moral bonds on which the strength of marriage and the family depends.

Catholic health care ministry witnesses to the sanctity of life "from the moment of conception until death." The Church's defense of life encompasses the unborn and the care of women and their children during and after pregnancy. The Church's commitment to life is seen in its willingness to collaborate with others to alleviate the causes of the high infant mortality rate and to provide adequate health care to mothers and their children before and after birth.⁵

I believe the best way to present challenging items from this part of the ERDs is to be clear about what your health system does to care for women and children, including the unborn, that demonstrates the commitment to providing witness to the dignity of human life. This includes programs that help women and children, especially women who have difficult pregnancies or whose human flourishing is threatened by social privation and lack of opportunity.

ENACTING POSITIVE CHANGE THROUGH THE ERDs
The key to effective teaching of the ERDs is being very clear in describing and showcasing the positive ways in which following the example of Jesus and the tradition of the Church results in concrete actions and programs devoted to healing, less suffering, improvement of peoples' lives and the demonstration of special concern for those whom society neglects or devalues. Making the ERDs a way to promote a distinctly Catholic identity for your hospital or system means that what can sometimes be perceived as a dry list of regulations actually serves as a blueprint that follows the spirit of the document and not just dry attention to the letter.

As you think about how to present the ERDs and use them as a resource for positive change, there are some questions that can be helpful to consider:

1. How does your hospital or health system distinguish itself in the care of people who are poor or marginalized?
2. Is the health care professional and patient relationship respected, and do demands for productivity and increased patient volumes not threaten the development and maintenance of meaningful, caring relationships?
3. Are pastoral care services front and center? Or, do chaplains operate a bit in the shadows, with doctors and nurses perceived as doing "the real work," while pastoral care is considered supplemental and not essential? In a time of fiscal tightening, is the commitment to spiritual care expressed in the ERDs respected, or are the cuts too deep?
4. What does your institution do that promotes family health, women's ability to access resources to continue a pregnancy despite pressures, and support for women and children? Do you have enough services to help counteract the negative sentiment that Catholic health care is not friendly to women?
5. Remembering that care of the seriously ill and dying is grounded in our faith that life continues after death and the meaning of our life is our destiny with God, does your hospital have palliative care and hospice services readily available? Are there resources, like ethics consult services, that can work with patients, families, doctors and nurses in difficult cases to ensure that appropriate care — neither too little or too much — is provided?

Finally, the point of this article is for you to make the ERDs a living document that reflects the particular charism of your hospital or system's founders, shows how the faith of those founders continues in the actions and programs in place today, and creates a health care environment that is respectful and welcoming to a diverse patient population and workforce while honoring our own tradition.⁶ These words from the conclusion of the ERDs emphasize that vision:

Sickness speaks to us of our limitations and human frailty. … Yet the follower of Jesus faces illness and the consequences of the human condition aware that our Lord always shows compassion toward the infirm. … Catholic health care is a response to the challenge of Jesus to go and do likewise. Catholic health care services rejoice in the challenge to be Christ's healing compassion in the world and see their ministry not only as an effort to restore and preserve health but also as a spiritual service and a sign of that final healing that will one day bring about the new creation that is the ultimate fruit of Jesus' ministry and God's love for us.⁷

DR. MYLES N. SHEEHAN, SJ, is director of the Edmund D. Pellegrino Center for Clinical Bioethics, a professor of medicine and the David Lauler chair of Catholic Health Care Ethics at Georgetown University Medical Center, Washington, D.C.

NOTES

1. Ethical and Religious Directives for Catholic Health Care Services: Sixth Edition (Washington, DC: United States Conference of Catholic Bishops, 2018), 9.
2. Ethical and Religious Directives, 10.
3. Ethical and Religious Directives, 15.
4. Ethical and Religious Directives, 20.
5. Ethical and Religious Directives, 16.
6. I have not mentioned Part Six of the ERDs, "Collaborative Arrangements with Other Health Care Organizations and Providers." This is an important part of the ERDs, but I usually present this only in the setting of a particular question and concern, and, ideally, after those involved have a basic grasp of the rest of the document.
7. Ethical and Religious Directives, 27.