When All Roads Lead to Rome: The Catholic Hospital Dilemma Impacts Entire US Healthcare System

doi:10.4236/ojl.2013.24017

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Open Journal of Leadership

2013. Vol.2, No.4, 106-109

Published Online December 2013 in SciRes (http://www.scirp.org/journal/ojl) http://dx.doi.org/10.4236/ojl.2013.24017

Open Access

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When All Roads Lead to Rome: The Catholic Hospital Dilemma

Impacts Entire US Healthcare System

Mary Ann Keogh Hoss1, Kevin S. Decker2

1Department of Urban Planning Health and Public Administration, Ea stern Washington University,

Spokane, USA

2College of Arts, Letters & Education, Eastern Washington Univer sity, Spokane, USA

Email: [email protected], [email protected]

Received September 7th, 2013; revised October 7th, 2013; accepted Oct ob er 15th, 2013

Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

With the stripping of 2 Catholic Hospitals of their status as Catholic in 2010, much information has come

forward on the 72 Ethical and Religious Directives (ERDs) of the Catholic Hospital Association of the

United States (CHA). With this, the authority of the bishops of the Catholic Church in relationship to de-

livery of health care has been called into question. The decision of the bishop in Phoenix has raised clini-

cal, ethical and operational concerns which are explored. CHA claims that 1 in every 6 patients in the US

is in a Catholic Hospital. The questions related to the public on the impact of the ERDs for their health-

care are staggering. Is one’s healthcare in the hands of a bishop? Should some ethical dilemma occur?

These questions are explored.

Keywords: US Healthcare System; Catholic; Ethical and Religious Directives; Bishops

When All Roads Lead to Rome

The Catholic Hospital Association of the United States

(CHA, 2011) claims one in six patients in the United States is

cared for in a Catholic Hospital. The December 2010 decision

of Bishop Thomas J Olmsted of Phoenix, Arizona to strip St.

Joesph’s Hospital of its Catholic status creates additional chal-

lenges for Catholic Hospital administrators in healthcare today.

This is the second Catholic hospital to lose Catholic status in

2010. St. Charles Medical Center in Baker, Oregon lost its sta-

tus in February (Mann, 2011).

Phoenix Action

The Phoenix action arose over the following incident. In

2009, a woman 11 weeks pregnant presented at the hospital

with deteriorating pulmonary hypertension hat had begun to

seriously threaten her life. Doctors informed her that risk of

death was close to 100% (Tenety, 2011). An abortion was per-

formed to save the live that could be saved. Bishop Olmsted

stated,”…the baby was healthy and there were no problems

with the pregnancy; rather, the mother had a disease that

needed to be treated. But instead of treating the disease, St.

Joseph’s medical staff and ethics committee decided that the

healthy, 11 week old baby should be killed. This is contrary to

the teaching of the church” (Tenety, 2011: p. B02). It should be

noted that Bishop Olmsted’s bio does not include any clinical

training. It does include numerous years of service in Rome

(Roman Catholic Diocese of Phoenix, 2011).

Catholic Hospitals

According to the Catholic Hospital Association, there are

more than 600 Catholic hospitals in the United States with as

many as 45 of those being the sole providers of hospital care in

their communities. The total number of community hospitals in

the US according to the American Hospital Association is 5008

(AHA, 2010). Of those 2918 are nongovernmental not for profit

hospitals. The Catholic affiliated hospitals make up roughly one

fifth of that number. The parent company for St. Joseph’s Hos-

pital is Catholic Health Care West, the eighth largest healthcare

company in the US (Mann, 2011) The CHA (2011) fact sheet

based on AHA 2009 data shows 16.7% of care for Medicare

patients is received in Catholic Hospitals as well as 13.5% of

care for Medicaid patients. Catholic Hospital administrators

struggle with complex issues; among those challenges are

community trust, governance, damages in human capital, fi-

nance capital and quality of care. But the overriding issue of

community trust presents as the most serious of these chal-

lenges especially as this decision has been communicated

throughout the US. In a world of “perception is reality”, the

message take away from this incident is not positive to say the

least. This leaves a lingering after taste for women and indeed

any community member seeking care and treatment in Catholic

hospitals who may fear for their lives as this denunciation sug-

gests, follow doctrine not clinical indicators in matters of live

and death.

The rest of the nation must closely watch what is happening

with the Catholic Healthcare systems. A much larger picture

emerges with this type of news that travels the nation. While

bishops have long been silent most likely because of the nu-

merous scandals plaguing the Church, they now have an avenue

for visibly and vocally asserting their authority. This quote

from Bishop Olmsted says it all “It is my duty as the chief

M. A. K. HOSS, K. S. DECKE R

shepherd in the diocese to interpret where the actions at St.

Joseph’s meet the criteria of fulfilling the parameters of the

moral law as seen in the Ethical and Religious Directives

(ERD)” (Hendershott, 2010). How safe does the American

public feel in having a bishop of the Catholic Church with no

known clinical background deciding their fate while in a Catho-

lic hospital? The Catholic Hospital United States Conference of

Catholic Bishops Association (CHA) with the United States

Conference of Catholic Bishops (USCCB) announced that they

have agreed on the following after much discussion:

… Archbishop Dolan of New York goes on to say “any

medical case, and especially one with unique complications,

certainly requires appropriate consultation with the medical

professionals and ethical experts with specialization in the

teaching of the church. Still, as you have reasserted, it is the

diocesan bishop’s authentic interpretation of the ERD’s that

must govern their implementation. Where conflict arises, it is

again the bishop who provides the authoritative resolution

based on his teaching office. Once such a resolution of doubt

has been given, it is no longer a question of competing moral

theories or the offering of various ethical interpretations or

opinions of the medical data that can still be legitimately es-

poused and followed. The matter has now reached the level of

an authoritative resolution” (Zenit News Agency, 2011: p. 1).

The implications for this are staggering.

The Ethical and Religious Directives for the

Catholic Health Care Services

In November 2009, the USCCB issued the 5th edition of the

ERD. These are 72 directives which direct Catholic Health Care

Services. The updated ERD has 2 purposes. These are “to reaf-

firm the ethical standards of behavior in health care that flow

from the church’s teaching about the dignity of the human per-

son and to provide authoritative guidance on certain moral is-

sues that face Catholic health care today” (USCCB, 2009: p. 4).

These directives are guided by 5 principles for the Church’s

healing ministries. As stated by Archbishop Dolan, the author-

ity of the bishop supersedes the rights of patients and individual

doctors. What does the stripping of Catholic status really mean?

A hospital may no longer refer to itself as Catholic, mass can’t

be said and the diocese where it resides will not support it (Ge-

rardi, 2010). It is unclear what types of support that includes

and whether or not communion may be received by patients.

US Healthcare Crisis

With a US healthcare system in crisis, having one fifth of the

system engaged in this type of controversy is onerous. The

American Hospital Association report on the economic reces-

sion shows that 74% of hospitals reported reduced operating

margins. Half of hospitals are reporting decreased non-operating

income. 89% of hospitals report back that they have not added

back staff or increased staff hours and 98% have not restored

services or programs previously cut (AHA, 2010). Medicare

and Medicaid fact sheet show that” payments continue to fall

below costs and the shortfall is growing” (AHA, 2010: p. 2).

Is there trust in the bishop’s of the United States to fairly and

justly deal with the very serious issues pertaining to healthcare

in each and every community where a Catholic hospital resides?

Based on the most recent scandals is there faith in their judg-

ment based on the nation’s view of how the sex abuse issues

were handled? In the large hospital systems residing in multiple

states where the consistency of thought may not go across bi-

shops, who decides and how is that transmitted throughout the

system?

Where do these issues become the issues for the nation fac-

ing a crisis in healthcare? Catholic healthcare administrators

and leaders should now be required to respond to the following.

What is the average consumer to do? If there is only one pro-

vider of hospital care in a geographic area what does a con-

sumer do? Do the ERDs impact all healthcare arenas where

Catholic services are provided-subacute care, skilled nursing,

home health, adult day care/assisted living/residential care and

hospice? Are all potential clients notified in writing of what

constitutes the ERDs and the possible impact on them? Are

physicians with admitting privileges aware of the 72 directives

and their impact on care. Are providers educated on the 72

ERDs? Do patients and providers understand what rights re-

garding privacy and confidentiality may be violated when a

bishop becomes involved in individual healthcare decision

making? Do all providers and their patients understand the

implications of this and are they advised in writin g?

As a nation, healthcare is taking more and more of a toll on

the US public. Health care systems are trying desperately to

meet the demands of a nation unclear on how to proceed with

the delivery of services. The Phoenix decision is evidence that

patient rights and clinical judgment appear to be secondary to

the authority of a bishop. Would the government refuse to pay

for care based on a decision made? Who is liable? Who pays?

All of these issues could be pushed based on the fact that seri-

ous dilemmas will arise as technology and constant change in

healthcare continue to occur. Is the patient at risk and does he

or she know it based on Catholic doctrine?

Biomedica Ethics Involved

Some of the reportage of the case of Bishop Olmsted and St.

Joseph’s Hospital has mischaracterized the issues at stake by

ignoring the fact that the debate over the correctness of care at

St. Joseph’s (or, indeed, any hospital or care facility) should be

evaluated in terms of plural cultures within a democratic setting

that legally and morally values an individual’s autonomous

decisions. One should not be surprised, for example, that Ben-

jamin Mann, staff writer of the Catholic News Agency, toes the

Olmstedian party line when reporting on the controversy. More

worrisome, however, is his citing of John Brehany, executive

director of the Catholic Medical Association, who puts the onus

for the excommunication of St. Joseph’s on the hospital itself.

“We don’t want you in our life”, was the message that St. Jo-

seph’s sent to the Church by their actions, Brehany claimed.

Brehany further went on to compare “the situation between the

bishop and St. Joseph’s to a child who decides to break off

contact with his parents” (Mann, 2011). Taken at face value,

this seems to derogate the clinical and ethical claims of the St.

Joseph’s staff, supported by the arguments of theologians and

bioethicsts, to the whining of teenagers. Is this a morally ac-

ceptable way to characterize one’s opponents in an argument?

Framing the Issu e

In a more insidious example of framing in the issue, Anne

Hendershott (2010), uncharitably portrays the claims of Lloyd

Dean, president of Catholic Healthcare West, the hospital’s

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M. A. K. HOSS, K. S. DECKE R

parent company. Hendershott parses Dean’s opposition to Olm-

sted’s decision in this way: “… Mr. Dean appeared to suggest

that the teaching authority of the Phoenix Bishop was just one

more ‘opinion’ on a ‘complex matter’.” In fact, Dean said that

“this is a complex matter on which the best minds disagree,”

and cited the expert opinion of M. Therese Lysaught, Associate

Professor of Theology at Marquette University, whose training

includes an MA in Theology from Notre Dame and a PhD in

Religion and Theological Ethics from Duke University. But

Hendershott has clearly made her mind up in advance about the

results of a disagreement between, say, Olmsted and Lysaught

when she writes: “Many theologians … write that theologians

comprise ‘an alternative magisterium’ to the teaching authority

of the bishops. And in cases like the one at St. Joseph’s, the

alternative magisterium often trumps the true Magisterium of

the church.” She apparently ignores that fact that many “alter-

native” church fathers, including Saint Clement, Origen, Ter-

tullian, and Saint Jerome, never held any formal position within

the church hierarchy. And as guilty as Dean was in omitting the

considered views of ethicists who disagreed with him in his

communications with Olmsted, Hendershott herself is as guilty

in failing to consider the Bishop’s complete lack of clinical

competence.

To cast the issue, as Hender shott and many Catholic com-

mentators do, as a failure to heed prescriptive authorities is to

cede the controversy to Bishop Olmsted without debate and,

further, to ignore the opportunity for moral deliberation and

transformation that might ensue. From the perspective of med-

ical care within a pluralistic democracy such as the United

States, there are at least two key issues at stake in the St. Jo-

seph’s Hospital case: clinical competence and conscience. As

can be shown, these are not necessarily at odds with each other,

either in this case or in such cases in general.

Patient’s Right

There is at least a prima facie plausibility to the individual’s

claim that, in a clinical or pharmaceutical setting, their con-

science requires them to “opt out” of a professionally required

duty. However, it is a mistake to think that conscience should

automatically trump such duties, since in any scenario where

treatment or services might be denied, one also must weight in

the pre-commitment of the medical professional to the normal

performance of their duties, as well as the claim of the patient

to their well-being. Claims of conscience, at least in American

legislative history (the Church Amendment, 1973; the Hyde

Amendment, 1976; the Weldon Amendment, 2004) are based

on two principles: 1) the right of an individual to secure his or

her own moral integrity, and 2) the incorrigibility of the dictates

of conscience. While individuals do have the right to their

moral integrity, this is not an absolute right, especially in cases

where it can be shown that an autonomous individual accepted

professional responsibilities that they were aware might im-

pinge on their sense of moral integrity. Especially in such cases

of conscience, the strict burden of proof should be placed on the

individual to indicate the precise reasons for their opting out.

Further, because of a patient’s right to receive therapeutic

treatments or critical care that are not forbidden by law, con-

scientious dissenters and/or their institutions should be obli-

gated to inform a patient where and how they can receive the

treatment or services requested; in other words, the right to

conscientious opting out does not extend to a right to absolutely

deny a patient services and information.

It is also arguable that the dictates of conscience are incorri-

gible; while an individual may have a strong moral intuition in

a given situation, it is not always true that their conscience is

speaking. Particularly in cases where an individual’s moral

intuitions are inconsistent with each other, we have good reason

to believe that at least some of their intuitions are actually giv-

ing voice to habit, woolly thinking, parental or peer influence,

or religious training. It may also be the case that while I do not

doubt that my conscience has “spoken”, I may be wrong about

the fact that such a moral intuition applies in this particular case,

or how it applies in this case. This is another reason why the

presence of biomedical ethicists is still significant in clinical

care settings, and a reminder of the danger of having one indi-

vidual make decisions that directly and irreversibly impact, in a

negative fashion, the fundamental health and well-being of

hundreds or thousands of others.

Claims of Conscience

Claims of conscience in the Catholic healthcare setting are

most likely to be encountered by providers demurring from

providing services that violate principles the ERD That is,

Catholic health professionals may make negative conscience

claims that they should not be compelled to provide services

that impinge on their conscientious moral intuitions. However,

as Mark Wicclair points out, there are also positive conscience

claims that can be made to justify “provid[ing] professionally

permitted medical goods or services (e.g., medications and

procedures) when do so is prohibited by law, institutional rules,

employer policies, and so forth” (Wicclair, 2009: p. 15).

The termination of the pregnancy of the 11-week pregnant

woman at St. Joseph’s that incited Olmsted is best justified as

demanded as a positive claim of conscience. Sister McBride’s

decision in the case was made more difficult, of course, by the

Church’s teaching that the fetus is a person. But at a non-viable

age of 11 weeks old, the fetus could not have been classified as

a disti nct patient, deserving o f patient rights and treatment con-

siderations, at least in non-Catholic hospitals. In these settings,

the standard ethical practice is that “beneficence-based obliga-

tions to the fetal patient should be negotiated in the context of

the beneficence and autonomy of the mother” (Springer, 2011).

In following the ERD, McBride and the staff at St. Joseph’s

attempted to save the only life that was possible to save. The

decision hinged on the mother’s diagnosis of pulmonary hyper-

tension as a near-certain risk of death; The patient realized this

in her decision to abort the pregnancy. What Bishop Olmsted

failed to comprehend, but what St. Joseph’s apparently did, is

that a mother need not suffer from a “grave illness” in order

that both the lives of her and her baby are at risk. The doctrine

of double effect (DDE) clearly allows McBride, in this case, to

make a decision in which the intention is to save the life of the

mother even though she also knows that the fetus’s life will be

ended; the alternative would be that both would die. Whether or

not the reasoning of the DDE is sound, McBride’s case should

be one of a positive claim to conscience. What we then have is

the unusual case of assessing the justifiability of this claim not

from within the structure of a religious institution, but against

it. Which issue should one weight more heavily in this case,

Bishop Olmsted’s lack of clinical competence or the claims of

St. Joseph’s clinical professionals to permissibly dissent, on the

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M. A. K. HOSS, K. S. DECKE R

Open Access 109

basis of conscience, from Olmsted’s interpretation of Catholic

doctrine? Despite Bishop Olmsted’s diverse background in

Catholic affairs, including his current service as member of the

Catholic Association of Latino Leaders and the USCCB Mis-

sions Committee, as well as various positions dealing in Per-

sonal and Priestly Formation and a stint on the Board of Direc-

tors for the Catholic Legal Immigration Network, appears to

have no formal clinical or documented biomedical ethical

training. With regard to the last of these, it is not enough to say

that Olmsted encountered Catholic bioethics in seminary work

in philosophy and his doctoral studies at Rome’s Gregorian

University.

The pluralistic nature of the field of American bioethics re-

quires that an expert in this field have documented evidence of

having engaged with moral theories, including not only secular

views such as deontology and utilitarianism, but also non-

Catholic religious theories; it further requires lay academic or

advisory committee engagement with argumentative opponents

from a diverse range of ethical perspectives.

Summary

Bishop Olmsted’s lack of experience in these regards con-

trasts distinctly with that of Sister Margaret McBride and Lloyd

Dean of Catholic Healthcare West. Olmsted’s repeated claims

that his retributive acts against St. Joseph’s are sanctioned by

his role as “shepherd” and “teacher” seem oxymoronic. His

decision to declare that St. Joseph’s is no longer “Catholic” is

one that will undoubtedly (and unjustifiably) hurt the hospital’s

reputation with many of its more doctrinaire clientele. Faith and

moral claims of conscience have been, and likely will always

be, central to the religious life. If Catholic identity is partly

based on the ability of being faithful to invoke their conscience

against a wider, secular society’s standards, isn’t there hypoc-

risy to denying individuals the right of reasoned, conscientious

dissent within the church (O’Rourke, 2001)? Particularly when,

as in this case, the central Catholic value of life was maximize d

in a case in which the only other alternative was two deaths.

Adherents of freedom of conscience supported (and perhaps

challenged) by a robust debate on ethical and clinical issues

underpinning hard cases should stand with Sister Margaret

McBride and the rest of the hospital administrators and staff.

They—and not Bishop Olmsted—represent the synthesis of

clinical competence and ethical sensitivity required to further

the mission of genuinely Christian hospitals in a pluralistic

democracy.

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