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BY: BR. DANIEL P. SULMASY, OFM, MD, PhD

Dr. Sulmasy is Sisters of Charity chair in ethics, St. Vincent's Hospital Manhattan, and professor of medicine and director, Bioethics Institute, New York Medical College, Valhalla, NY. His article is adapted from a talk he gave at the Commonweal Winter 2002 Colloquium, February 2002, Malibu, CA.

For Two Reasons, Catholic Universities Should Continue Sponsoring Such Schools

Catholic hospitals and Catholic medical schools have much in common, but they are also very different. The mission and purpose of Catholic hospitals was clear and purposeful from the outset in a way that has not been historically true of Catholic medical schools. By and large, American Catholic hospitals were founded by orders of religious women who were spiritually inspired to respond to God's call in their lives by caring for the sick. Sociologically, these were generally poor women who found in nursing opportunities for educational advancement and professionalism. They came to the United States largely to escape poverty such as that in Ireland or oppression like that of the Kulturkampf in Germany. They responded to the emerging needs of a growing American nation for nurses and hospitals during the Civil War and then afterwards in recurring epidemics of cholera, typhoid, and tuberculosis, in the Western expansion, and in Eastern urban poverty. These Catholic women essentially shaped the American nursing profession and hospital care, and they grew and adapted as medical science grew. While there were struggles along the way, there was also, until recent years, a synergy between what nursing sisters offered and what America needed and wanted. Their care for the sick was their prayer and their preaching, and for 150 years it was resoundingly American, Catholic, and professional.¹

American Catholic medical schools, by contrast, grew up rather accidentally. American Catholics originally founded colleges to train seminarians, eventually expanding their purposes to teach advanced catechesis and apologetics and to provide social opportunities for Catholic immigrants. In time, they added professional schools, providing a quick way for the college to become a university while serving the needs of Catholic students (who otherwise faced discrimination) with possibilities for professional advancement.²

Nine U.S. Catholic colleges have had medical schools, four of which have been closed or sold.³ One of these (Niagara) lasted only two years (1888-1900). Another (Fordham) closed in 1921. Seton Hall's medical school opened in 1956 and was purchased by the state of New Jersey in 1965. Marquette's medical school became the Medical College of Wisconsin in 1967. Four Jesuit institutions (Saint Louis, Georgetown, Creighton, and Loyola Chicago) still operate medical schools. The newest, New York Medical College, became affiliated with the Archdiocese of New York in 1978, making it the lone non-Jesuit U.S. Catholic medical school still in existence.

The students and faculty of the first eight of these medical schools were, by and large, culturally Catholic. The students came from Catholic undergraduate institutions where the work of catechesis was assumed to have been completed. The mission of these schools was never really so much to train doctors to be Catholic as it was to train Catholics to be doctors. There never really were any clergy on the faculty of Catholic medical schools. Canon law at the time prohibited priests from performing surgery.⁴ A token Jesuit taught the requisite brief course on medical morals. But there has never been any such thing as a distinctively Catholic approach to histology. So these schools just taught histology and concentrated on producing competent physicians.

Over the last few decades, however, the students and faculty at all of the five extant U.S. Catholic medical schools have become increasingly diverse and the cultures of these schools have become increasingly secularized. All of these schools are struggling financially—three have been forced to sell their university hospitals; one, which never owned its teaching hospital, simply employs strong teaching affiliation agreements. None of these is ranked among the top 25 U.S. medical schools. And, when companied with Catholic hospitals and nursing schools, these medical schools have been a sideshow in the history of U.S. Catholic health care.

So the question why the church should sponsor medical schools is genuine. With increased opportunities for Catholics at secular medical schools, one of the major historical reasons for their existence has become obsolete. And the historical basis of the Catholicity of these schools has also become a thing of the past: Large minorities or even majorities of the student bodies and faculties at Catholic medical schools are no longer even nominally Catholic. Keeping any medical school open these days is hard work. Keeping a medical school open and Catholic is even harder.

Perhaps the best thing to do for the sake of the church would be to empower lay Catholic men and women to go to secular schools and to live the Gospel. At least it seems that the burden of proof has shifted to those who would keep Catholic medical schools going.

Mark Sargent, the dean of Villanova Law School, has stated that the purpose of a Catholic law school is to be a vehicle by which the church "confronts in creative dialogue the world's different truth claims."⁵ Whether such a mission is strong enough to carry the Catholic identity of a law school can certainly be debated. However, there is no debating the fact that such a statement would seem senseless to the faculty of a Catholic medical school. What purposes can there be for having Catholic medical schools?

Professionalism and Catholic Identity
By and large, the demands for technical and professional excellence have caused Catholic medical schools to lose sight of their Catholic missions and religious sensibilities more completely than either Catholic undergraduate institutions or Catholic hospitals. This leads one to wonder whether the demands of professionalism are in essential tension with the demands of Catholic education, or whether the present situation has simply been an accident of history.

There are many definitions of professionalism. However, the criteria set forth by Abraham Flexner, the great reformer of American medical education, seem especially relevant since the five extant U.S. Catholic medical schools survived his careful scrutiny and initially flourished because of his famous report.⁶ Flexner set forth six criteria that distinguish professions from other human enterprises. He suggested that professions:

• Are intellectual operations with large individual responsibility
• Depend upon science and learning
• Put their learning to a practical and definite end
• Possess an educationally communicable technique
• Engage in self-organization and self-regulation
• Tend to become increasingly altruistic in motivation⁷

The first four of these criteria do not, it seems, raise any immediate issues for Catholic professional education that are not true of Catholic higher education in general. Science and the church have certainly had their struggles, especially over physics. But the church does not claim the competence to declare the function of the pituitary gland. Gaudium et Spes (nos. 36 and 59) explicitly reserves such pronouncements for the proper sciences. Ex Corde Ecclesiae (no. 29) states that, "The Church, accepting 'the legitimate autonomy of human culture and especially of the sciences,' recognizes the academic freedom of scholars in each discipline in accordance with its own principles and proper methods, and within the confines of the truth and the common good." So, at least in medicine, the issue does not seem to be one of competing claims about empirical truth.

However, Flexner's last two criteria are very interesting. I think that the fifth, the mandate of professions to engage in self-organization and self-regulation, does pose significant tensions for Catholic professional schools, while the sixth, altruism, points to what Catholicism can best give to our desperately needy professions. Out of the tensions involving the church and these two defining characteristics of genuine professions, I will suggest, arise the best reasons one can hope to give for having Catholic professional schools in the 21st century.

First, one should pay attention to the similarities between a profession such as medicine and an organization such as the Catholic Church. Both are self-organizing, self-regulating, monolithic, powerful, and inherently conservative social institutions. They function as societies within society and at the same time are inherently international. They have rituals, rules, and expected patterns of behavior. Both demand sacrifice from members, and the members of both take oaths. Both are practical and service oriented. Both have tremendous influence over society at large and exercise socially sanctioned authority over quite intimate aspects of the lives of individuals. Both have structures for coming to internal consensus about how best to serve society, based on the application of their own most fundamental principles and established methods of reason and analysis. Although other academic disciplines might have hints of this sort of structure, these features are far truer of the professions, such as law and medicine, than they are of other disciplines, such as English literature or mathematics.

And so, when there is a conflict between the church and a profession, it becomes a conflict between titans. Since the beginning in the late 20th century, the nature of these conflicts has become not one of competing scientific truth claims, but one of clashing claims about the moral use of scientific truth. When medicine decides, for example, as a profession, that abortion is a medical procedure for which there are legitimate medical "indications," one monolith sets itself against another that says that the practice is always morally wrong. Two self-organizing and self-correcting international institutions are set against each other. There is no established social mechanism for adjudicating such conflicts in modern society. And this sort of tension inevitably strains the relationship between the professions and a church that sponsors professional schools.

Second, despite Flexner's perhaps exhortatory description of a professional tendency toward altruism, most observers think that the professions in the 21st century are approaching the nadir of their altruistic calling. At the same time, dissatisfaction among medical professionals is very high,⁸ and physicians may be said to be suffering from a sort of spiritual malaise.⁹ Unmoored from any religious source of spirituality or moral guidance, professionals are adrift on a sea of market forces and nihilism where dark undercurrents seem to threaten the meaning of their professions.

Contemporary scientific, social, economic, and legal forces have driven the medical profession into a genuine identity crisis. A new movement has arisen to try to re-articulate what professionalism means for physicians today. This has led to the rediscovery of altruism as an essential element of professional identity.¹⁰ But this has, in turn, left many physicians wondering what reasons can be given for this requirement, how one can strive for altruism in medical finance systems built upon the presumption of physician self-interest, and whether professionalism itself has any higher purpose. Further, over the last five to 10 years, patients have begun to express increasing interest in spirituality and health care, and physicians are now searching for a spirituality of their own. If the church has anything to say to medicine, this should be where the conversation begins.

Yet it must also be acknowledged that such a conversation begins in a setting of fierce internal opposition within the profession. Medicine is the last bastion of positivism, and many medical scientists and physician educators have reacted with vitriolic attacks upon anything that smells like religion in medicine.¹¹

To add to the complexity of the situation, all of this tension between the church and medicine, when played out in a medical school, is also plunged into the controversies surrounding academic freedom at a university. The academy is generally suspicious of any and all claims to legitimate authority. On campus, there is a tendency to avoid hostile conflict by pushing religion to the periphery as the simplest solution to the challenges raised by pluralism and freedom.

Finally, in an increasingly secular society, medicine now directly competes with the church for the role of transnational moral authority, supervening beyond all governments. The increasing medicalization of personal and social life provides a kind of alternative to the church. Those who mourn now see psychiatrists, not priests. Firearms in the home have become a medical issue. "Doctors without Borders" constitutes the new form of the medical missionary. And only a high-cholesterol piece of chocolate cake is truly sinful. Medicine is thus becoming something of an all-encompassing secular religion, competing for adherents.

Why Catholic Medical Schools?
In the face of so much tension, why should Catholic universities continue to sponsor medical schools? I see two reasons, arising from these conflicting claims to authority and unacknowledged needs. First, Catholic professional schools are in the best position possible to exert the leadership necessary to give the professions the spirituality they so desperately need, both for the sake of the professions themselves and for the society they serve. Second, Catholic professional schools will best serve the church and society at large by giving the church a direct, insider's voice in the moral and social issues through which the professions so deeply affect the lives of the people of God.

Although the church must be humble, it does, after all, serve that higher authority that the professions must ultimately somehow embrace if they are to be fully human enterprises. It is precisely when the professions threaten to substitute for the church that the church must stand in and point out that the God for whom the church exists is also the ultimate right reason for the professions to exist.

But given all that I have said, it would be profoundly naïve to think that there will be a simple solution to the problematic question of Catholic medical education. On the one hand, unilateral assertions of authority by the church fail to recognize the legitimate authority that the professions must have. On the other hand, pious pronouncements of "values" that amount to nothing more than the intersection of Catholic social teaching with the standard canons of political rectitude amount to a mere charade.

How?
How might Catholic medical schools accomplish such a mission? First, there are some obvious and relatively uncontroversial ways. Catholic medical schools should cease trying to hide their identity and its symbolic representation. They should emphasize ethics in practice, teaching, and research. They should develop programs that cultivate spirituality within the professions. And they should emphasize service to the poor.

More controversially, I think they should consciously and explicitly recruit Catholic faculty. Very little of this is currently done. Recruitment is always of "the best" according to the standards of the professions, with little effort to reach out to entice "the best" professionals who happen to be Catholic. And this should happen in all subspecialties— anatomy and nephrology as well as medical ethics. The ethos of a school is embodied in its faculty. If a Catholic ethos is established, Catholic students will come. And other-than-Catholic students, treated in a manner respectful of their beliefs, will also benefit.

Another very important but little discussed suggestion is that Catholic philanthropy must be engaged in this mission. Catholic philanthropy has traditionally given admirably to direct service to the poor and to people involved in very narrowly conservative social issues. But there must be a way to engage increasingly wealthy Catholics in giving to professorial chairs and centers of ethics and spirituality in Catholic professional schools. There must be a way to persuade someone to establish a type of "Catholic Public Health Service," offering scholarships in exchange for working with Catholic Charities or overseas missions. Carefully placed money can do a great deal of good.

In a particular way, Catholic medical schools ought to become centers of excellence in the sort of research that does not conflict with church teaching.¹² Why can't we, for example, rather than grumbling about not being able to use stem cells from frozen embryos, leapfrog the scientific community and work on creating continuous cultures of stem cells derived from sources that raise moral problems for no one? Instead of grousing about not being able to do in vitro fertilization (IVF), why not become the pioneers in the repair of the underlying causes of infertility that lead patients to seek IVF as a substitute?

Catholic medical schools should also strive to assert and preserve the notion of institutional conscience as the sole guarantor of true diversity in American professional education. And they should strive, wherever possible, to work with Catholic hospitals as their teaching hospitals, their natural allies in almost all these endeavors. Even so, I think there might be a role for Catholic medical schools even if there were no Catholic hospitals. I hope we will not need to face that day.¹³

Genuine Integration
Gaudium et Spes challenges believers to "integrate human, domestic, professional, scientific, and technical enterprises with religious values, under whose supreme direction all things are ordered to the glory of God" (no. 43). I think that Catholic professional schools, if they do things right, will do exactly this.

NOTES

1. See Christopher J. Kauffman, Ministry and Meaning: A Religious History of Catholic Health Care in the United States, Crossroad, New York City, 1995; and Sioban Nelson, Say Little, Do Much: Nurses, Nuns, and Hospitals in the Nineteenth Century, University of Pennsylvania Press, Philadelphia, 2001.
2. See Philip Gleason, "American Catholic Higher Education: A Historical Perspective," in Robert Hassenger, ed., The Shape of Catholic Higher Education, University of Chicago Press, Chicago, 1967, pp. 15-53; Andrew Greeley, From Backwater to Mainstream: A Profile of Catholic Higher Education, McGraw-Hill, New York City, 1969, pp. 13-14; Andrew Greeley, The Changing Catholic College, Aldine, Chicago, 1967, pp. 21-54; and Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, Oxford University Press, New York City, 1999, pp. 63-64.
3. Most of this history can be found in: Edward J. Power, A History of Catholic Higher Education in the United States, Bruce, Milwaukee, WI, 1958, pp. 243-248. I have updated this with searches of these websites: Seton Hall College of Medicine and Dentistry Records; Marquette Medical Alumni Association.
4. For an interesting history of how this happened, see Darrell Amundsen, "Medieval Canon Law on Medical and Surgical Practice by the Clergy," Bulletin of the History of Medicine, 1978, vol. 52, pp. 22-44.
5. Mark Sargent, "Catholic Social Thought and Professional Education," a paper read at the Commonweal Winter 2002 Colloquium, Malibu, CA, February 24, 2002.
6. Abraham Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, 1910, reprinted by the Heritage Press, Buffalo, NY, 1973.
7. Abraham Flexner, "Is Social Work a Profession?" School and Society, 1915, vol. 1, pp. 901-911.
8. Jack Hadley, Jean M. Mitchell, Daniel P. Sulmasy, and M. Gregg Bloche, "Perceived Financial Incentives, HMO Market Penetration, and Physicians' Practice Styles and Satisfaction," Health Services Research, 1999, vol. 34, pp. 307-321.
9. Daniel P. Sulmasy, The Healer's Calling: A Spirituality for Physicians and Other Health Care Professionals, Paulist Press, Mahwah, NJ, 1997.
10. See, for example, The ABIM Foundation, American Board of Internal Medicine, ACP-ASIM Foundation, American College of Physicians-American Society of Internal Medicine, and the European Federation of Internal Medicine, "Medical Professionalism in the New Millennium: A Physician Charter," Annals of Internal Medicine 2002, vol. 136, pp. 243-266.
11. Richard P. Sloan, Emilia Bagiella, T. Powell, "Religion, Spirituality, and Medicine," Lancet, 1999, vol. 353, pp. 664-667; see also Relman's commentary in Arnold S. Relman and Andrew Weil, "Is Integrative Medicine the Medicine of the Future?" Archives of Internal Medicine, 1999, vol. 159, pp. 2,122-2,126.
12. Daniel P. Sulmasy, "The Fullness of Life: Integrating Patient Care, Teaching, and Research," Health Progress, January 1993, vol. 74, pp. 76-78.
13. Daniel P. Sulmasy, "Catholic Health Care: Not Dead Yet," The National Catholic Bioethics Quarterly, 2001, vol. 1, pp. 41-50.