Congregation for the Doctrine of the Faith, Some principles for collaboration of non-Catholic entities in the provision of Catholic healthcare services, 17 February 2014.
In response to a dubium submitted by Cardinal Timothy Dolan, then-President of the United States Conference of Catholic Bishops (USCCB), regarding collaboration between Catholic and non-Catholic healthcare entities, the Prefect of the Congregation for the Doctrine of the Faith responded to Archbishop Joseph Kurtz, President of the USCCB, with a letter accompanied by a set of Principles which were made available to the U.S. bishops. The Prefect’s letter and Principles follow.
CONGREGATION FOR THE DOCTRINE OF THE FAITHMost Reverend Joseph Kurtz
President, United States Conference of Catholic Bishops
3211 Fourth Street, NE
Washington, DC 20017
17 February 2014
Prot. N. _______
In a letter dated April 15, 2013, Cardinal Timothy Dolan, your predecessor as President of the United States Conference of Catholic Bishops, presented to this Congregation a dubium regarding the transformation of a Catholic health system into a non-Catholic health system. Of particular concern is the situation of Catholic health care systems which include non-Catholic members, organizations which resist the prohibition on morally unacceptable practices such as sterilization and contraception.
After an attentive study of this matter, this Dicastery recognizes that the dubium presents moral questions regarding cooperation with evil and the principles which govern the collaboration with non-Catholic entities in healthcare, some aspects of which go beyond what has already been articulated by the Conference in the Ethical and Religious Directives. However, the dubium is also framed around a particular set of circumstances to such a degree that it concerns more the application of moral principles to concrete situations and less an articulation or clarification of the operative moral principles.
In this light, the Congregation has concluded that it is not possible to respond to the dubium in the usual manner. Rather, in order to assist the Bishops of the United States in considering their teaching and governing responsibilities in the development and reorganization of Catholic health organizations or systems, we enclose Some Principles for the Collaboration with Non-Catholic Entities in the Provision of Healthcare Services (cf. enclosure). I would ask you to make this letter and the enclosed Principles available to the Bishops.
I would further note that these Principles do not address the canonical issue of the alienation, either virtual or actual, of Church institutions, a matter which the United Sates Conference of Bishops might wish to discuss with the appropriate curial Dicasteries.
It is also important to note that, in addition to the moral issues, there is an ecclesial principle involved in considering these questions in that health systems often extend into several dioceses and therefore necessarily imply a relationship with multiple Bishops, though usually only one Bishop exercises canonical oversight of the system. As the Principles articulate, the close collaboration of the Bishops in the development and reorganization of Catholic health systems is essential.
With gratitude for the work of the Committee on Doctrine and the Subcommittee on Health Care, I am
Sincerely yours in Christ,
+ Gerhard Müller
SOME PRINCIPLES FOR COLLABORATION WITH NON-CATHOLIC ENTITIES IN THE PROVISION OF HEALTHCARE SERVICESPROLOGUE
From the Church’s earliest days, certain Christians, as part of their prophetic witness to the Faith, have dedicated themselves to the care of the sick. Early and eloquent examples of this would be Saints Cosmas and Damian, both physicians, martyred together in the third century for the Faith as expressed in their care of the sick. As history progressed, this same evangelical spirit led to the founding of institutions for the provision of healthcare: clinics, hospitals, homes for the elderly, hospices, and so on.
Over these same centuries, the activities of such individuals, religious communities, and institutions have received much attention from Christian moral thinkers since, where life and death, health and sickness are concerned, moral issues inevitably arise. But in recent years, there have arisen moral issues not explicitly addressed in previous Church teaching or by the Catholic tradition. In today’s world, due in no small part to advances in medical technology and related costs, effective engagement in healthcare often calls for collaboration with non-Catholic healthcare institutions, even establishing joint working arrangements in which the Catholic and non-Catholic entities are full partners. In itself, collaboration in good works is, of course, a good thing, but it can also involve – in various ways and to different degrees – institutional connections with activities that conflict with the natural law and Church teaching. The unfortunate result of such involvement is a diminution of the prophetic witness to the Faith on the part of Catholic institutions.
In entering into collaborative relationships in healthcare and in assessing the moral character of such relationships as already exist, those involved in the oversight and governance of Catholic healthcare institutions must do everything they can to ensure that the witness of the Church is not adversely affected. Most importantly, they must do everything they can to ensure that the Church’s involvement in healthcare does not give scandal, whether to fellow Catholics and Christians, or to other persons of good will who look to the Church, however obliquely, for moral guidance.
The following Principles are meant to address this new situation. They are intended to ensure that Catholic healthcare institutions neither cooperate immorally with the unacceptable procedures conducted in other healthcare entities with which they may be connected nor cause scandal as a result of their collaboration with such other entities. The complexity and variety of institutional governing arrangements require careful adherence on the part of those responsible for the Catholic component to the teaching of the Church, the proper and correct application of moral principles, particularly the principle of cooperation, and the correct application of the Ethical and Religious Directives. The Principles offered here need to be applied and understood in terms of the actual governance and structure of each specific case, since each concrete manifestation of a working relationship involving Catholic and non-Catholic healthcare institutions cannot be anticipated.
1. Although it is quite proper to speak of institutions as acting or cooperating, morality – including the morality of cooperation – is ultimately about the actions of individual human beings. Yet, it is precisely the decisions of individuals that determine the identity and moral character of an institution. For this reason, the administrators of Catholic healthcare institutions are expected to adhere to the teaching of the Church and to consider ethical principles regarding healthcare articulated by the Church as normative for the healthcare institution and its members and staff.
The decisions or orders of a hospital administrator carry great moral weight because of their close connection with the actions performed in accordance with those decisions and orders. If the corresponding actions are in themselves immoral, such as are, for instance, abortion, sterilization, or contraception, such decisions and orders enter into the very voluntary character – the “formality” – of the actions they effect. This is true even when the decisions of the governing body of an organization that includes both Catholic and non-Catholic components may apply only to the non-Catholic facilities within the organization.
2. Formal cooperation in the immoral actions of others is always immoral; material cooperation in the immoral actions of others are sometimes immoral, depending on the nature of the acts involved and the nature of the connection with the primary immoral actions in question.
3. Formal cooperation need not involve sharing the intention motivating the immoral acts cooperated in. For instance, if the directors of a Catholic healthcare system grant approval for the distribution of abortifacient pills by a non-Catholic hospital within the system, their cooperation is formal even if their intention in giving the approval is to remain financially viable, while that of the non-Catholic hospital (or its directors) is quite different.
4. If a board member or an administrator of a healthcare institution comprised of both Catholic and non-Catholic healthcare facilities officially consents to an immoral procedure within the system or facility under his or her authority, this is likely an instance of formal cooperation. On the other hand, it may be morally licit for a non-administrative employee within a non-Catholic member institution of the system to cooperate materially with an immoral procedure conducted under the auspices of a non-Catholic member institution, provided that the employee’s actions satisfy the traditional criteria for legitimate material cooperation. In any case, a board member or administrator of such a system involving Catholic and non-Catholic facilities is obliged to do what is possible to ensure that whatever material cooperation does occur under the authority of the system itself is not immoral material cooperation.
5. In dealing with a Catholic healthcare institution that faces particular concrete circumstances involving its ability to continue its ministry at all, in order for material cooperation in such an institution to be moral, besides meeting the other relevant criteria, the institution must be under grave pressure to cooperate. Considerations of financial advantage or even of financial stability do not constitute sufficiently grave pressure; considerations having to do with the financial viability – that is, the ability of the healthcare institution to survive and to carry out its mission in the face of the complex circumstances that are present locally – do.
6. In a fully collaborative arrangement, the member institutions cannot do together that which each would not do ethically as individual institutions. This entails that, while the larger organization in which a Catholic institution finds itself need not be Catholic, the joint venture itself, if its fully enfranchised administrators are to include administrators of the Catholic institution, must function consistently with the ethical principles regarding healthcare articulated by the Church.
7. In considering possible collaborative arrangements with other healthcare institutions, Catholic healthcare administrators should give preference to Catholic institutions and other institutions that operate in accordance with the ethical principles taught by the Church.
8. A Catholic healthcare system cannot ethically accept into itself an institution that has not agreed to abide by the ethical principles regarding healthcare articulated by the Church, for this would result in formal cooperation, at the very least on the part of the system’s directors, in the immoral practices conducted within the incoming institution.
9. A Catholic hospital contemplating joining a healthcare system that permits immoral procedures must, before entering into any such agreement, ensure that neither its administrators nor its employees will be involved directly in immoral procedures undertaken by other institutions within the system. It must also ensure that its facilities and other resources will not be utilized in such procedures and that no administrator or employee will be obliged to make referrals for immoral procedures. Great care must be exercised to avoid giving scandal.
10. “Scandal is an attitude or behavior which leads another to do evil” [Catechism of the Catholic Church, §2284]; “Anyone who uses the power at his disposal in such a way that it leads others to do wrong becomes guilty of scandal and responsible for the evil that he has directly or indirectly encouraged” [Catechism, §2287]. When a board member or administrator of a Catholic healthcare entity “uses the power at his disposal” to approve or administer immoral procedures, this diminishes the entity’s – and the Church’s – prophetic witness to the Faith.
11. If a Catholic healthcare institution is involved in the direction of a healthcare system that does not adhere to the ethical principles regarding healthcare articulated by the Church – if, for instance, the Catholic institution has a seat or seats on a such a system’s board of directors – the system’s and/or the Catholic institution’s statutes must isolate the representatives of the Catholic institution from any policy decisions proximately connected with immoral procedures.
12. Board members of a healthcare system or institution do not avoid cooperating formally by setting up – or helping to set up – an administrative body, such as a board of directors, independent or supposedly independent of the system or institution, that will oversee the provision of immoral services. The act of setting up such a body is itself formal cooperation in the prospective immoral procedures. To the extent that the new body remains under their authority and/or influence, the board members would formally cooperate in whatever immoral procedures occur under the authority of the subordinate body.
13. Board members of a healthcare system or institution do not avoid cooperating formally by setting up – or helping to set up – an entity, such as a clinic, independent or supposedly independent of the system or institution, that will be engaged in immoral procedures. The act of setting up such an entity is itself formal cooperation in the prospective immoral procedures. To the extent that the new entity remains under their authority and/or influence, the board members would formally cooperate in whatever immoral procedures occur within the subordinate entity.
14. If, because of its memberships in a healthcare system, a Catholic institution, through its representatives on the system’s board of directors, is cooperating formally in immoral procedures, the institution must extricate itself from this situation at the earliest opportunity that presents itself.
15. An institution’s extricating itself from a situation in which it is engaged in immoral cooperation could conceivably be consistent with remaining within the healthcare system, as long as none of its administrators is responsible for setting policies for the system itself with respect to the immoral procedures. In such an arrangement, great care must be exercised to avoid giving scandal.
16. When a Catholic institution (through its representatives on the system’s board of directors) is obliged to extricate itself from the direction of a healthcare system, it must do what it can to ensure that the system is left adhering as closely as possible to the principles of the natural moral law as related to healthcare. For instance, if separating itself from the direction of a healthcare system entails reconstituting the system as a non-Catholic entity, the departing Catholic institution must do what it can to ensure that the new statutes correspond as closely as possible to the principles of the natural law as related to healthcare.
17. Diocesan bishops must be informed of prospective agreements and cessations of agreements involving Catholic healthcare institutions within their jurisdiction. Such transactions require the authorization of the appropriate diocesan bishop. Given that very often a Catholic healthcare system comprises institutions – both Catholic and non-Catholic – in different dioceses, the bishop of the diocese in which the system’s headquarters are located must collaborate with the bishops of the other dioceses in which the member institutions are located.
Congregation for the Doctrine of the Faith, Some principles for collaboration of non-Catholic entities in the provision of Catholic healthcare services, 17 February 2014, CLSA, Roman Replies and CLSA Advisory Opinions, 2014, 23-30.