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PubMed1995

Safeguarding patients' dignity. The revised directives discuss spiritual and professional considerations.

The Catholic health ministry recognizes that caring for the spiritual nature of a person is a high priority. The rights of patients and residents in their relationship with care givers are also important. These topics are treated in Parts 2 and 3, respectively, of the Ethical and Religious Directives for Catholic Health Services. This article focuses on those directives. Directive 10 says pastoral care should be available to all persons in a Catholic healthcare facility, no matter their religious affiliation. Directives 12 to 20 are concerned with the reception of the sacraments of baptism, penance, anointing, and communion by Catholics. Directive 21 discusses the appointment of priests and deacons to the pastoral care staff. Directive 23 reminds care givers that respect for human dignity must inform all Catholic healthcare. Directives 24 and 25 discuss norms for responding to advance directives and the responsibilities of surrogates. Directives 26 to 28 are concerned with free and informed consent on the part of patients and surrogates. Directives 29 to 30 say care givers have a moral obligation to preserve a patient's anatomical and functional integrity. Directive 31 discusses the ethical limits on medical research, and Directive 33 discusses therapeutic procedures likely to harm the patient. Directive 34 says care givers must protect patients' privacy. Directive 36 discusses the care of women who have been raped, including treatment that would prevent ovulation as a result of the rape. Directive 37 says ethical consultation should be available to all Catholic facilities, usually through an ethics committee.

Bioethical Issues↗
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Guidance for a failing system. Catholic social teachings provide the needed principles.

Catholic healthcare has traditionally relied on four major ethical principles--nonmaleficence, beneficence, autonomy, and justice--to address conflicts between various goods. However, all healthcare now finds itself facing great changes. "Principleism" is too limited to guide the Church's health ministry through the current crisis. But the Church possesses a body of social justice teachings that may provide healthcare with the necessary guidance. Eight inseparable but distinct themes are found in the social teachings: human dignity, human solidarity, the option for the poor, the common good, human rights, social justice, stewardship, and liberation. The eight themes are here applied to five critical healthcare issues: the patient-physician relationship, the right to choose, healthcare as a communal good, rationing and limits, and work and its implications. The Church's social teachings may provide us with a basis for a structural reexamination of healthcare--including Catholic healthcare. In that analysis, we may find that Catholic healthcare has developed practices and standards that are at odds with its own teachings. Such an analysis will be painful, but it must be done.

Catholicism↗
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Care for the beginning of life. The revised Ethical and Religious Directives discuss abortion, contraception, and assisted reproduction.

Part 4 of the Ethical and Religious Directives for Catholic Health Care Services--which discusses such controversial issues as abortion, contraception, and assisted reproduction--is informed by a profound respect for human life and the institution of marriage. The controversies are familiar. But many in Catholic healthcare may be less familiar with the principles underlying Church teaching on these issues. Appropriate interpretation and application of these directives require that all concerned be educated in both the theological-ethical and the clinical dimensions of care giving. Directives 38 through 43 deal with reproductive technologies such as in vitro fertilization and surrogacy. Directives 52 and 53 express the Church's consistent teaching on contraceptive interventions. Directives 45 to 48, 50 to 51, and 54 reiterate the Church's firm stance on the inviolability of human life, including nascent human life. However, the directives also say that not all medical interventions resulting in fetal death are prohibited abortions. However, appropriate regard for human life, marriage, and the family require more than mere adherence to the directives' prescriptions and proscriptions. Ethics committees in Catholic healthcare should study clinical data as well as theological materials.

Abortion, Induced↗
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Pain management. Theological and ethical principles governing the use of pain relief for dying patients. Task Force on Pain Management, Catholic Health Association.

Pain management is a societal problem because of concerns about the use of drugs, the belief that patients are not good judges of the severity of their pain, and an alarming level of ignorance about pain and its treatment among physicians, nurses, and other healthcare providers. The result is that patients suffer pain unnecessarily, even up to the point of their death. Pain management is also a clinical-practice problem. Courses in pain and symptom management are not readily available to medical and nursing students. And in clinical practice, good pain assessment is not easy to accomplish because pain is so subjective. Fortunately, with education, doctors and nurses can vastly improve their ability to assess and manage patients' pain. Additional problems in pain management relate to the manner in which healthcare is provided today: an acute disease-oriented model of hospital care, frequent transfers, fragmented care, inadequate reimbursement, market forces that drive up costs, and maldistribution of clinical services. In improving their ability to manage pain, professionals must understand the difference between pain and suffering, acute and chronic pain, and the sensory and emotional aspects of pain. Guiding principles include Church teaching and ethical principles, such as patient self-determination, holistic care, the principle of beneficence, distributive justice, and the common good. Pain management strategies that will be instrumental in formulating effective responses to these problems include expanding professional and community education, affording pain funding priority, establishing institutional policies and protocols, forming clinical teams, encouraging hospice and home care, and requiring accreditation in pain and symptom management.

Attitude of Health Personnel↗
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Issues at the end of life. The revised Ethical and Religious Directives discuss suicide, euthanasia, and end-of-life procedures.

Part 5 of the Ethical and Religious Directives for Catholic Health Care Services reminds us that death is necessary for the transition to eternal life. Thus, although Christians have a duty to preserve worldly life, a gift from God, that duty is not absolute. Suicide and euthanasia are never morally acceptable. On the other hand, life-prolonging therapy need not be used if it provides insufficient benefit or imposes an excessive burden. Directive 55 describes the comfort and care that should be given to dying patients. Directives 56 through 59 discuss the ethical norms for either using or forgoing procedures designed to prolong life. Directive 60 repeats the Church's teaching in regard to euthanasia and physician-assisted suicide (PAS)--that is, whatever the intentions of those who employ them, euthanasia and PAS remain forms of murder. Directive 62 considers the methods used to determine that death has occurred. Directive 66 encourages patients to donate their organs and bodily tissue after death. However, the directive says, Catholic healthcare facilities should not make use of tissue obtained by direct abortions.

Catholicism↗
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Healthcare reform's moral, spiritual issues. The problems are not just political.

Although President Clinton's proposals were defeated in 1994, healthcare reform is an issue that will not go away. But it is an especially complex issue because it is moral and spiritual as well as political. Catholic social teaching could help free us Americans from our confusion on the topic. For example, the Catholic ideas of justice, subsidiarity, and the common good could help us address the crux of the healthcare reform debate, which questions the fairness of forcing more fortunate people to provide healthcare for those who are sick and poor. Catholic social teaching tells us that our healthcare decisions must be made not only on the basis of what is good for me but what is good for us as a community. By the same token, we might find that several specifically spiritual ideas are helpful. Christianity says, for example, that sickness can be a gift because it is a window on immortality for us; that we should not prize life above all other values; and that friendship--including the civic friendship involved in healthcare--is a way we can enter full friendship with God. These moral and spiritual ideas lead us to certain political conclusions: Healthcare reform should be politically realistic, relatively simple. and inclusive. Because healthcare is a good like no other, it can be a powerful occasion for realizing God's own compassion, healing, and justice.

Attitude to Health↗
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Pursuing justice in an era of managed care. Seattle-based system makes room for the underserved and uninsured.

The Sisters of Providence Health System (SPHS), based in Seattle, is dedicated to the search for justice. In 1983 the system's leaders decided to create SPHS-owned and -operated managed care plans for residents of the Pacific Northwest because they saw such plans as both the best way to rationalize the region's healthcare delivery and an opportunity to serve its poor and underserved. In Oregon, where the legislature passed the Oregon Health Plan in 1989, 21,000 persons are covered by Providence Health Plans; another 15,000 receive care through SPHS providers and networks. In Washington, whose Basic Health Plan enables customers to purchase coverage through payments adjusted to family sizes and incomes, 13,600 persons are enrolled in the version offered by SPHS; another SPHS plan covers 20,000 beneficiaries of the state's Aid to Families with Dependent Children program; in addition 18,600 elderly Washingtonians are enrolled in an SPHS-sponsored Medicare supplement program. SPHS has found that ownership of its plans enables it to integrate mission and business. But ownership also carries certain challenges. SPHS must, for instance, compete with for-profit organizations without compromising its core values. It must carefully coordinate the insurer and provider parts of its organization. And it must train all its employees in Catholic values and insist that its leaders create and enhance an ethical corporate culture.

Catholicism↗
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Working for the common good. Catholic healthcare's opportunity to shape values-based managed care.

Managed care has come under fire lately, and states and the federal government have stepped in to regulate some plans' deficiencies. Some say regulation is not enough; managed care is morally flawed. But the evils of managed care are the result of letting it be shaped solely by market-driven forces rather than mission-driven values. In the Catholic tradition, healthcare is part of the common good. Viewed in this light, managed care becomes more than just a way to control costs. For managed care to serve the common good, we will have to collaborate with other providers that demonstrate a commitment to human life and dignity that is similar to our own. Such collaborations may force us to negotiate (without compromising) our values, but this gives us the opportunity to recognize a hierarchy of goods to be pursued and evils to be avoided. Through our involvement in managed care, we can help shape the greater culture, as well as the culture of healthcare. But we must prioritize our commitments according to values and principles grounded in the Catholic moral tradition. Without these values to guide us, Catholic healthcare will lose its identity and fade away.

Catholicism↗
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A dynamic force for change. The common good provides the rationale for a healthcare system for all.

In advocating for a reformed healthcare system, the Catholic healthcare community has claimed that responsibility for the common good is of the highest ethical importance. Yet to many the concept of the common good remains elusive. As the common good evolved in Catholic social teaching, it grew to include its anthropological origins, the principle of subsidiarity, and the virtue of solidarity. Above all, it is characterized by justice and refers to a social order that reflects peace, unity, and harmony. As an organizing principle for civil governments, the common good calls on them to foster societies that provide spiritual, cultural, political, and economic conditions in which all persons can realize their human dignity. By viewing healthcare and the right to security in case of sickness as among the particular goods that make up the societal common good, Catholic social teaching provides the rationale for a just healthcare system on a national level. In addition to advocating for a national healthcare system designed to serve the common good, Catholic healthcare entities must evaluate their own programs and services in light of the common good and examine proposed initiatives with other providers, especially for-profit organizations, in that context, as well.

Catholicism↗
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Catholic healthcare as "leaven". To penetrate and renew society, Catholic healthcare must meet five requirements.

Pope Paul VI described the church as the "leaven" of civil society. Catholic healthcare should strive to be the leaven of U.S. healthcare. To achieve this, it must do five things: Immerse itself in civil society. Catholic healthcare professionals and organizations should participate in efforts to improve public health, even when they are not in full agreement with those efforts. Provide high-quality care. Such care is not always easy to define, but Catholic healthcare can and should set high objective standards for the well-being of its patients. Minister to the suffering and dying. The Catholic view of suffering and death as necessary for human fulfillment is a countercultural idea in our society. Catholic healthcare should, while eliminating physical pain when possible, help people to die in a holy atmosphere. Be a responsible, just employer. Catholic healthcare should treat employees as individuals worthy of respect, not as economic units. Be advocates for the poor. Catholic healthcare should not only provide charity care for the poor; it should also work for universal coverage, care based on need rather than on ability to pay for it.

Catholicism↗