Catholic Identity in Healthcare: The Consistent Life Advocacy Helen Miller, MA Regis University, 2004 This paper is written

to illustrate the relationship between Catholic healthcare and the tenets of Catholic Social Teaching (CST). It examines the history, unique identifiers, and other social issues within Catholic healthcare as found in Scripture, papal encyclicals, bishops writings, theological studies, and other research efforts. It provides insight into elements of Catholic identity, which lie at the heart of the Catholic healthcare industry. Embedded deeply among the obvious elements of Catholic healthcare, such as medical care, professional ethics, and state-of-the-art facilities, are the social and economic justice issues of the people in community, i.e., poverty, racism, substance abuse, homelessness, unemployment, etc. These social justice concerns are addressed within the CST ethics, which provide the basis for the spirit of institutional identity in Catholic healthcare. This paper additionally suggests there is a need for increased multicultural awareness in order to continue to preserve the spiritual identity of Catholic healthcare and meet the needs of the diverse peoples served by Catholic institutions. Framework This work looks at many issues facing Catholic healthcare in the United States through the contextual examination of underlying religious doctrine, specifically the principles of Catholic Social Teaching (CST). The bishops, women religious, and Catholic healthcare officials see these institutions as directly connected with the Church and its ministry. According to the Ethical and Religious Directives for Catholic Health Care Services (1995), Catholic healthcare fulfills the healing ministry of Christ and the Church. Interestingly, this paper is as much about understanding the spirit and uniqueness of Catholic healthcare institutions as it is about strengthening the faith and spirituality of all people affected by Catholic healthcare (i.e., patients, faculty, students, staff, workers, vendors, community members, other healthcare systems, etc.). With new knowledge comes the understanding that Catholic Social Teaching is an essential and fundamental element of Catholicism. Its tenets are based on and inseparable from both personal and collective understanding of human life, human dignity, and human rights; the principles of which are closely interwoven into the fabric of Catholic healthcare practice. This authors description of the unique nature of Catholic healthcare is based upon a direct comparison of religious and secular healthcare institutions evidenced by personal experience, as well as upon archival research. The Catholic healthcare tradition provides service guided by the Gospel of Jesus Christ and the Church tradition to heal the physical and mental health of the sick and oppressed. It distinguishes itself through respect for human life and dignity, service and advocacy for marginalized people, and compassion and respect for communities overall. Life and human dignity Of all the CST principles, the most crucial is the concept of the consistent life ethic. It involves the inalienable human right to life, and the concept of human dignity is heavily dependent upon the respect for and right to human life. Focusing on relatively low support among Catholics for life positions on separate issues overlooks the possibility that the association of attitudes on these issues might be unique for Catholics. The consistent life ethic dogma integrates the pro-life position on abortion with positions on other sociopolitical issues that are also life affirming, rooted in the biblical values of Hebrew and Christian Scripture and reflected in centuries of Catholic tradition. From the times and narratives of Christ to the more recent papal encyclicals, the call for a commitment to human life and dignity, to human rights and solidarity, has always been a universal calling promoted by Catholic Social Teaching (CST). The protection of human rights and defense of dignity has become an outgrowth of faith and spirituality in contemporary Catholicism and a central principle

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of social teachings by which believers are challenged to role model and apply standards of human dignity in daily living. In addition to being widely recognized for its historical preferential option and care for indigent patients, the most notable element of Catholic healthcare involves the omission of certain services in an attempt to promote greater regard for human life and dignity (i.e., abortion, sterilization, in-vitro fertilization, euthanasia, stem cell cloning, advanced directives, etc.). Catholic healthcare adopts a strong position on what are considered unethical medical procedures with respect to human right to life principles. In the promotion of justice, peace, and social development, Catholic hospitals do not allow procedures on hospital grounds or make referrals to secular healthcare systems that strip the dignity or life from people. Preferential option With its roots based in Scripture and early Church teachings, the concept of the preferential option for the poor grew from the issues of human poverty and injustice that were at the heart of the ministry of Moses and behind Jesus teachings. The wide body of research that supports the invocation of the preferential option via Catholic responsibility, intentional action, and civic participation comes from an extensive and ongoing research effort into the human condition. The American application of preferential option grounds the human rights and responsibility for others into a call for stewardship and solidarity whether at home, in the community, and in the workplace. This concept expresses a special concern in distributive justice for poor and vulnerable persons. The "poor" includes but is not limited to those who are economically deprived. The principle is rooted in the biblical call to become advocates for the voiceless and the powerless and where right relationships are restored. Individuals who have been deprived of the basics of life or are particularly vulnerable have a special moral claim on the community, especially on Catholic health care institutions (Ethical and Religious Directives, n. 3). The closing of many community hospitals, particularly in rural areas, placed a greater burden of charitable outreach work and compassionate service in serving the poor on the remaining Catholic hospitals. The Catholic healthcare industry, historically known for its preferential option and indigent care practices, was forced to adopt competitive strategies to survive (Langlois, 2004). This healthcare industry involved primarily acute care, inpatient facilities in the past; however, with the current state of the national economy and increased competition from secular institutions, creative survival strategies have helped Catholic healthcare to continue to commit to the preferential option. Through the provision of ancillary services through smaller medical clinics, trauma facilities, community centers, nursing homes, hospices, pastoral counseling, etc., it continues to serve marginalized people. Dignity of work, Rights of workers The concepts of dignity of work and the rights of workers are inseparable from a personal understanding and modeling of human right to life and human dignity principles in Catholic healthcare (Laborem Exercens, 1981). The social mission of the Catholic Church has always been closely intertwined with its healthcare ministry in efforts to shape the development of standards for human rights and human dignity (Dorr, 1983). Although this paper focuses on the spiritual and philosophical elements of CST in Catholic healthcare, it would not be complete without mentioning the adversarial role CST plays in organized labor relations. The recognition that people have a social nature works in favor of the principle of subsidiarity, which is just as important in understanding the relationship between management and employees as it is in understanding the patient-provider or institution-community dynamics. Interestingly, as much as CST principles advocate for employee rights and organizations, Catholic healthcare institutions have received heavy news coverage of their active resistance of union involvement by employees (Schaeffer, 1998; Duncan, 2000).

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Unionization is one price that Catholic healthcare has paid for its survival response to market-driven health-system change (Glenn, 2000). The just wage, just workplace, and right to organize issues (CST core values) often conflict with strategies used by employees to counter nursing shortages, mandatory overtime, and cost-effective working conditions (labor union issues). At a 1998 meeting of leaders of Catholic Health Care, the AFL-CIO, and U.S. Catholic Bishops, guidelines were drafted (Fair and Just Workplace) to maneuver both Catholic healthcare officials and labor union leaders in the intense, sometimes lengthy collective bargaining sessions (Moore & Duncan, 1999). The Issue The issue involves the preservation of the concepts of consistent life ethic (also known as the seamless garment) and respect for human dignity within Catholic healthcare institutions as well as the widespread adoption of these concepts by non-Catholic individuals and institutions. As mentioned earlier, Catholic medical systems are widely distinguished by the inclusion of CST principles in healthcare management and practice. The lack of emphasis on human rights to life and dignity not only distinctly shapes the patient care within secular medical institutions (i.e., provision of abortion services, withholding of treatment, end-of-life care, etc.), but the pseudo-Democratic foundation for labor relationships as well. To this end, a brief summary of the history of medicine and Catholic heath care system is presented below. History of Medicine The history of medicine, in general, can be traced back at least to the ancient Greeks (e.g., the Hippocratic oath). There have been several models of medical care that contribute to the characteristics of early healthcare, each of which depended upon the socially accepted theories of biological science of a particular era. At the turn of the century American healthcare revolved around the family doctor who made house calls to care for the sick. Then a few decades ago, the local hospitals became the center of patient care. The medical profession exuded empathy and compassion for the sick and dying. Patient care occupied a prominent place in medical objectives, while reimbursement came second. Physician financial gains were not open to public scrutiny. Even with the personalized and compassionate service, many people lacked medical coverage (i.e., the poor, the elderly, the incarcerated, etc.). In the 1960s, attempts to reduce the escalating costs of medical services prompted the birth of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), which acted to ration patient services while reducing costs. Coincidentally, the organization of entire systems of healthcare institutions resulted in billions of dollars of profit for institutions providing managed care, which is now one of the major challenges for healthcare ethicists. With the advent of professional accreditation and managed care organizations, physicians began to specialize. While family practice was but one subfield of medicine, each specialty referral added to the care cost and increased the burden on the overall patient community. Medicare programs developed which provided health coverage for low-income populations. These programs became a guaranteed source of income for medical institutions willing to work with marginalized and disadvantaged people, although did not particularly equate with charitable attitudes or practices, per se. Medicaid programs were also developed which provided coverage to the elderly and became the advent of the nursing home and assisted-care-living industries. Both Medicare and Medicaid programs suffered serious financial abuse and misuse as many program managers were penalized for defrauding the government through misdiagnosis and overcharging for services rendered. Corporate integrity programs arose in response to this abuse in an effort to monitor healthcare institutions for compliance to ethical standards. Consequently, employees of

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most large hospitals are required to participate in yearly education modules for risk management and social accountability purposes. Technology became increasingly important in the field of medicine as a diagnostic tool, intervention technique, and research apparatus in the battle against disease. Americans began to enjoy increased longevity, while wellness issues became the focus of many marketing and advertising campaigns for health education. As Medicare, Medicaid, managed care, and technology influenced both secular and Catholic healthcare institutions, Faith-based healthcare institutions were particularly affected by secular affiliations (Glenn & Stack, 2000). With the acceptance of government funding and mergers with non-Catholic affiliate hospitals, came a greater emphasis on preservation of the Catholic identity in healthcare. The government-subsidized medical education, new hospital construction via government bonds, and contracts with Catholic Charities through Medicare and Medicaid grants have created challenges for many people who wish to preserve the values inherent within Catholic medical care systems (Kauffman, 1995). The economic basis for these developments prompted an overall re-evaluation of Catholic bioethics in order to co-exist with non-Catholic entities, patients, employees, and communities, yet retain CST values and Catholic identity in healthcare. History of Catholic Healthcare Catholic healthcare holds a distinct place in history in its contribution to the lessening of human suffering. Adopting Christs goals as healer and physician (Luke 4:23), the Catholic healthcare industry models Christs efforts to heal spiritual as well as physical pain. Healthcare was a ministry of Christs church, which was subsequently transferred on to his disciples and then to deacons in the early Church who assumed individual responsibility for caring for the sick. According to Dr. Guinan, president of the Catholic Physicians Guild of Chicago (1998), Catholic healthcare increased dramatically after Christianity was formally recognized as a religion in the Roman Empire. The first in-patient hospitals were founded by 11th and 12th century religious orders in Europe who emphasized the preferential option for the poor in caring for the sick. Interestingly, when the Protestant reformation reached its height in England, the Catholic hospitals were closed and multitudes of poor populations were left without health care. Hundreds of years later, however, the Catholic commitment to healthcare still involves caring for large numbers of indigent patients while maintaining the consistency of life ethic and respect for human dignity upon which it was founded. The first American hospital was organized in 1503 in Santo Domingo when Spanish missionaries worked to treat the medical needs of Native Americans and convert them to Christianity (Guinan, 1998). Eventually hospitals evolved around the country focused on the needs of Catholic immigrants who could not afford medical care. Catholic healthcare has since been characterized by non-profit inpatient care provided by religious orders. The early hospitals were run predominantly by women religious who lived in Christian communities, worked long hard hours, and received no monetary compensation. Coincidentally, with the second Vatican Council request for the greater role of laity in Church affairs (Paul IV, 1965) came a turbulent period of change for Catholic healthcare institutions. Much of the indigent Catholic immigrant populations served by the early Catholic hospitals had been assimilated into mainstream American society and replaced by non-Catholic patient populations. The decrease in numbers of women religious and priests in the last half of the 20th century disproportionately paralleled the increase in numbers of new hospitals. A largely non-Catholic leadership and staffing had begun to fill the executive boards and committees of Catholic healthcare institutions once previously occupied by religious orders.

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Contemporary Catholic Healthcare Healthcare, in general, has become a major industry affecting the American economy (Labor Statistics, 1999). As this mega-service industry became more competitive, a marketdriven focus on profit margins forced many small Catholic institutions to choose between permanent closure and merger with non-Catholic hospitals (Cochran, 2000). Coverage and cost issues dominated national health care reform and became a prominent national preoccupation (McLaughlin, 2000). The Catholic healthcare industry, widely known for its preferential option and indigent care practices, was forced to adopt competitive strategies to survive that mimicked the practices of secular institutions (Langlois, 2004). Like secular healthcare, Catholic hospitals have moved toward diversity in the decentralization of acute care medical facilities toward an integrated network of comprehensive health services, such as medical clinics, drug and alcohol rehab, dialysis centers, nursing homes, hospices, research facilities, medical schools, etc. The largest medical care systems1 in the U.S. are for-profit (e.g., Columbia/HCA, Tenet, Universal Health services). However, there are 662 hospitals among 61 Catholic medical care systems (i.e., Ascension Health, Catholic Healthcare West, Daughters of Charity, etc.) that together form the largest nongovernmental, nonprofit health care sector in the United States (CFFC, 2004). This diverse group involves over 220 orders of women and men religious, whose decreasing membership strives to retain the ethical flavor of social justice and Catholic Social Teachings in institutional operations. Catholic Identity in Healthcare Catholic healthcare systems meet daily challenges that other medical care systems do not, such as sustaining relationships with local bishops, observing Catholic teaching, practicing charity care and outreach. The Catholic bishops, as a national organization, act as silent observers in the management and operations of Catholic healthcare. The bishops preside over the moral issues that may pose scandal or conflict, such as abortion, fetal research, in vitro fertilization, etc. In this respect, Catholic identity can be considered granted by local bishops, but is overall characterized by fidelity to the gospel and church teachings From both Christian and Catholic perspectives the origins of human dignity began with the concept of Imago Dei, or the fact that humanity was created in Gods likeness with a spiritual connection to Him. This presupposes the fact that human dignity rises above any social manmade order as the basis for human rights. Human dignity is not granted by people, and cannot be rejected by people. This perception of human dignity greatly impacts Catholic tradition as it addresses a wide range of issues pertaining to the human condition, such as economic justice, the common good, the right to life, the right to healthcare, etc. According to the Catholic Health Association guidelines, healthcare is a human right and a social good, not a commodity exchanged for profit. Every person is the subject of human dignity with intrinsic worth at every stage of human growth and development, regardless of ethnicity or age (embryo or geriatric). People are inherently social, and a consistency of life ethic and respect for human dignity are fully realized only in association with others. The just interests of the greater good in society outweigh the selfish interests of the few. Preferential option for the poor is not about charitable giving, but commitment to the equitable distribution of healthcare and other services to indigent and marginalized populations. The call to stewardship emphasizes environmentalism as a human responsibility, which needs to be managed wisely. The above five concepts constitute the foundation of Catholic identity that underlies the uniqueness nature of Catholic healthcare institutions.

A health care system is a corporation of one or more hospitals plus affiliated services such as outpatient clinics, laboratories, mental health facilities, assisted care living centers, etc.

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Unique Identifiers There are many unique characteristics in the Catholic Tradition that distinguish Catholic healthcare from other healthcare institutions, the first of which is the right to life of every human individual. The human right to life is presumed from the moment of conception and is the foundation and condition for the exercise of all other rights and responsibilities of every human being. The following are just some of the major topics within healthcare for which the Catholic Church has established strong opinions and which are based on the consistent life ethic and respect for human dignity. Abortion Abortion involves any type of procedure that terminates a pregnancy regardless of the gestational age or means preventing the survival of a fetus. The human fetus is considered only a potential person and is not accorded any civil rights under the United States Constitution (Roe v. Wade, 1973). According to Catholic teaching, the morality of abortion revolves around when human life begins, since all human life is considered sacred and deserving of respect and protection (Celebrate Life, 1979). The examination of abortion issues through consistency of life and human dignity filters has reached interesting levels of intellectual tradition in the realm of Catholic bioethics. Following the intellectual tradition, the contemporary implication is that the zygote, the blastocyst, the embryo, and the fetus are all as deserving of the right to life and of protection as much as the terminally-ill cancer patient near the end of life (Donum Vitae, 1987). In this regard, the sanctity of life and the right to life apply to all human beings at any and every stage of human growth and development, visible and invisible, seen and unseen. Very early Church documents addressed the ethos of when human life began and determined that the spiritual soul was present from conception (Gorman, 1982). In the true spirit of pro-life ideology, intentional abortions have been considered an offensive, intrinsic evil against humanity for hundreds of years (Declaration on Procured Abortion, 1974). With a strategy adopted from the consistent life ethic (Bernardin, 1998), U.S. Catholic Bishops and other Church leaders rejected the "child exclusion" measure as a form of healthcare reform in their stance against issues related to abortion. This particular legislative proposal was intended as a means to end benefit increases upon the birth of an additional child to a woman receiving welfare funds. Unintended effects of the passing of this proposal, however, would have included a consequent increase in abortions by marginalized women attempting to maintain welfare funds for their families. The same secular logic that considered welfare benefits contingent on women's reproductive choices also included temporary sterilization as disciplinary measure, such as mandatory Norplant for welfare recipients (Davis, 1995). Advance Directives An advanced directive is written instruction (e.g., Living Will, Durable Power of Attorney for Healthcare) that provides information for the provision of medical treatment in anticipation of a time when the author is temporarily or permanently incapacitated. Recent federal law (Federal Patient Self-Determination Act, 1990) requires that upon admission to a hospital patients be educated on the benefits of having a living will. According to research by Upadya, et al. (2002), many people (patients, family, staff, physicians, etc.) do not understand living wills, particularly with regard to the use of endotracheal intubation and cardiopulmonary resuscitation. These differences in understanding can unknowingly affect the treatment plan (via withholding of pain medication, oxygen, hydration, etc.). End-of-life or emergent-care decisions in which an advance directive would be presented often require numerous meetings of healthcare teams and the patients family members to consider not only the patients wishes, but also the ethical aspects of the treatment options. While most healthcare providers attempt to be ethical, secular healthcare institutions

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are not familiar with the doctrine of extraordinary/ordinary means, which permits the refusal of treatment if it interferes with the higher needs of spirituality. For several centuries, Catholic theologians have made a distinction between ordinary and extraordinary measures, holding that a person is obligated to use ordinary measures to prolong life but has the choice whether to accept extraordinary measures (Cronin, 1958). It is interesting to note that the failure to use ordinary measures to preserve life has otherwise been morally likened to suicide within Catholic doctrine. The religious beliefs of Judaism, Islam and Christianity have always maintained the human duty to protect life and have always rejected suicide. The early Church writings of Augustine and Aquinas also condemned rational suicide. What is less clear is whether this position commits the Church to an absolute duty to prolong life in all circumstances, regardless of the condition of the patient. In compliance with federal law, Catholic healthcare institutions have begun to inform patients upon admission of their legal rights to possess an advance directive as an adjunct tool for medical treatment. The field of patient care has moved from a physician-centered directive position to a patient-centered one in which the risks and benefits of a procedure must be explained and informed consent must be obtained beforehand. Catholic hospitals will not honor an advance directive that is contrary to Catholic teaching. For example, when the living will conflicts with the principles of Catholic thought, patients and their families must understand why that particular advance directive cannot be honored (Ethical and Religious Directives, n. 24). Brain Death The legal definition of brain death is constantly undergoing revision (Harvard, 1968) in attempts to set parameters that satisfy both scientific and religious communities with regards to protocol for harvesting donor organs and tissues. The currently most widely accepted definition of brain death in the U.S. healthcare industry is the irreversible cessation of all functions of the brain including the cortex and the brain stem (AMA, 2003; ABA, 2003). Additionally, the Uniform Determination of Death Act (UDDA) includes whole brain death as a legal determination of death as well. By legal criteria, if brain death occurs, the patient is legally dead and the deceaseds remains may be kept on life support until donated organs can be harvested. Death therefore is determined by the absence of neurological activity and not by cardiopulmonary cessation. Because of the intrinsic value placed on all human life in the Catholic tradition, it is imperative that the religious community be satisfied that the spirit has left the body, that true death has occurred before organs are harvested for transplantation. The shifting definitions of death in the scientific community and the convenience with which they have satisfied political and legal requirements for organ transplantation procedures has been under scrutiny by the religious community for hundreds of years. Religious documents produced by Pope Pius XII, Pope John Paul II, the Council of Vienne, the Council of the Fifth Lateran, and the Catechism of the Catholic Church have come to the conclusion that the unity of the body is present until the organs are removed. A unifying summary on this topic: if for any reason there is any doubt about the separation of body and spirit, organs cannot be harvested. If any party feels that the spirit has not verifiably departed from a particular donors body, death has not occurred and pro-life treatment should be continued. Cooperation in Evil The cooperation in evil is a very complex moral issue, and there may always be confusion of facts and misunderstanding of principles in that personal choices are made based on familiarity with the Catholic moral tradition. For example, the principle of the human right to life does not allow the use of fetal tissue that is obtained from abortions and will never support the destruction of human embryos to establish embryonic stem cell lines for research. Some of

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the most prominent, widely-used vaccines for the immunization of children (e.g., measles, mumps, rubella and chicken pox) only became available in the United States due to the immoral research use of stem cell lines that originated from tissue taken from two different aborted babies approximately forty years ago (cell lines MRC 5 and WI 38). Multiple sets of researchers, each not knowing where the cell lines for the vaccine actually originated, were implicated in the evil deed that provided valuable health benefits to millions of children. Some Catholic parents actually refrain from inoculating their children based on these facts. Similarly, the principle of the human right to life does not allow Catholic hospitals to provide services that take life, such as abortions, male and female sterilizations, hysterectomies, morning-after pill as emergency contraception for rape, etc. However, issues involving the omission of womens reproductive services (or referral for those services) can greatly affect the economic survival of a Catholic hospital or healthcare system entering into a merger with a non-Catholic institution who might lose a substantial portion of the market and income without those services. Although very detailed documentation is drawn up with which the secular or non-Catholic merging party agrees to abide by the CST ethics and values underlying Catholic healthcare, an escape clause usually provides for the non-Catholic party to provide the womens services at a separate location, staffed by separate providers, and funded by separate budgets from the merger. Embryo Research The moral objections to embryo research are similar to those of abortion and stem cell research (Biological Experimentation, 1982). All human life is sacred and of intrinsic worth, regardless of the stage or state of development (Evangelium Vitae, 1995). The basis of the human rights to life is that there is a minimum respect, which is due to all human beings simply by virtue of their innate humanity. The humanity of embryonic life is what entitles the zygote, the blastocyst, the embryo, and the fetus to the human rights of life with as much unfailing loyalty as the elderly patient who deserves to be treated with respect and dignity at the end of life. According to the guidelines of the Ethical and Religious Directives, human tissue cannot be used from abortions, regardless of research or therapeutic purposes (2001). Catholic healthcare institutions are directed to respect the remains of human embryos and fetuses as the remains of a fully matured human being (Donum vitae, 1987). The cell lines from which vaccines are developed carry hefty moral implications, if they are obtained from directly aborted fetuses. There is a moral difference between creating cell lines from the fetal tissue of a miscarried child, the fetal tissue of an intentionally aborted child, and the tissue from the placenta/cord of a live birth. Researchers have a moral obligation to become intimately familiar with the literature surrounding their project focus and to acquire detailed information on the history and chain of evidence of every piece of a research project, particularly ones that diminish the human right to life or implicate a cooperative of evil to produce positive results. Human Organs & Transplantations The Catholic principles guiding the transplantation of human organs are heavily dependent upon the concept of brain death, the current definition of which serves as the rationalization for the surgical removal of vital organs. The Ethical and Religious Directives (1998, n. 30) listed two very blatant norms that govern the practice of organ procurement for transplantation purposes. The first rule was that vital organs should only be taken from dead patients, which while although very simply stated, involved complicated moral uncertainties of the religious community (see brain death section above) as to what actually constitutes the separation of spirit from body. The second rule states that living patients should not be killed for or harmed by organ procurement. Out of respect for human life, a persons life cannot be intentionally ended to preserve the integrity of internal organs for transplantation, regardless of the terminal nature of

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their disease, proximity to end of life, or receipt of their informed consent. Additionally, to avoid the cooperation of evil, such as taking one life to save another, a person cannot willing sacrifice or prematurely end his or her life in order to provide organs to a loved one in need. On one hand the Church advocates (Evangelium Vitae, n. 86) that when performed ethically and morally organ donation can nurture a genuine Culture of Life and can become a true gift of life. On the other hand, Catholic doctrine places conflictual restrictions on the excision criteria. For vital organs to be reasonably suitable for transplantation, they need to be living organs removed from living human beings. As noted above on brain death, persons declared legally "brain dead" may not be considered morally dead. The logic guiding this claims states case there is in theory a defining moment when spirit is separated from body, just as when life begins at conception. Religious thought states no method exists with which to differentiate that point in time with 100% accuracy, until the patients body has remained off life support to the point of initial decomposition (at which time the organs would no longer be viable for transplantation). Thus adherence to changing scientific definitions of death nets an increase in human organs and tissues. The doctrine governing living organ donors, such as a donor may only donate one of a paired-set of organs (one kidney, one lobe of the lungs or liver) or one part of a multi-set of organs (blood, bone marrow) that will not impair the donors health or life. Under Catholic law payment can never be accepted for organ donations; it is considered a gift of life, never to be considered as a commodity. The life and health of the donor is considered priority over the recipient and includes an explanation of the risks and benefits and receipt of informed consent beforehand. Respect for the Elderly Catholic tradition in medicine is based on the conviction that the human person has a unique worth and dignity and that the persons worth and dignity are neither lost nor diminished at a time of sickness, old age, debility or senility (Vasa, 2001). In Catholic healthcare the problems of the elderly are not only biological, but mental, social and spiritual and involve many overlapping areas of care (i.e., curative, palliative, end-of-life care, etc.). Particularly in the case of chronic pain and terminal illness, palliative care for the elderly can be based on the alleviation of symptoms without hope for resolution of the underlying pathology. According to the Ethical and Religious Directives patients should be kept as free of pain as possible so that they may die comfortably and with dignity (2001, n. 61). Managed care providers in the past have set a six-month waiting period for the diagnosis and reimbursement of care providers in the presence of terminal illness. During this time palliative care has included treating the deteriorating medical condition (e.g., pharmaceuticals, hydration) or utilizing curative therapies (e.g., chemotherapy, radiation therapy). The concern with narcotic treatment from a Catholic healthcare orientation has been mentioned many times in Church writings (John Paul II, Evangelium Vitae, n. 65). A contemporary, increasingly supportive stance toward aggressive pain management and palliative care has grown in recent years (1994, Directive, n. 61). Interestingly, a distinctively more traditional Catholic emphasis on the Christian understanding of redemptive suffering for terminally ill patients is also referred to within the Directives in an effort to interpret the spiritual suffering that medical treatment does not address. This holistic approach to healing is traditionally characteristic of the Catholic beliefs. Stem Cell Research & Cloning Stem cells are undifferentiated cells that have the ability to morph into any type of body tissue or specialized cell. Scientists believe that cures for many diseases could be found from research using stem cells (Holland, Lebacqz, & Zoloth, 2001). There are four basic kinds of human stem cells: embryonic stem cells that are about one week old; fetal stem cells from 4-6

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week old aborted fetuses; placental blood stem cells, which are obtained from the umbilical cord or placenta immediately after birth; and adult stem cells, which are obtained through a biopsy of mature tissues or from bone marrow of a post-natal human being. Embryonic stem cells are virtually indispensable, meaning they can become any type of human cell, regardless of their stage of maturity or development. The temptation to cooperate with evil is great when potential good lies in the balance. Additionally, current thought in the scientific community is that embryonic stem cells have increased benefit over adult stem cells in the discovery of cures for diseases such as Parkinson's, Alzheimer's and spinal cord injuries. From a research viewpoint, however, the disadvantage of manipulating embryonic stem cells is the level of difficulty in controlling the direction of their growth. Research on fetal stem cells is obviously an ethical issue, particularly if tissue is obtained through intentional abortions rather than miscarriages. The consistent life ethic and the human right to dignity reiterate the destruction of any human life at any stage of growth is intrinsically immoral. Most genetic research creates a moral dilemma for scientists whose success in part depends upon the acceptance of research results by the scientific community as well as the general public. Because human life at all stages of development is deserving of great respect, questionable research should either be postponed or its conclusions not utilized out of respect for human rights to life (Doerflinger, 1999) Gender Considerations Given the current state of debate over the involvement of women in the Catholic Church and the abundance of gender-related research, it is interesting to note a few gender variables obtained in the research for this paper. Over forth percent of the physicians in the early American colonies were women, including the large numbers of midwives who at that time were considered doctors. While male physicians received the formal education, the female physicians received the practical training and hands-on experience. At that time healing was considered an art and was handed down from woman to woman. Direct patient care positions in Catholic healthcare are currently still filled primarily by women, although the numbers of female physicians has been slowing increasing over the years. Physicians from ethnic populations only make up a very small number of all physicians with respect to percentages representative of various races and cultures. Women Religious Secular healthcare systems based on market-driven competition, profit margins, and bottom-lines are almost all exclusively managed and operated by the elite patriarchy of educated, middle-class, married Caucasian men. Catholic healthcare, on the other hand, is the largest women-owned, women-run industry in the world. The religious orders founded the first hospitals in the country, which were managed and operated by women religious and priests. This set the precedence for new healthcare systems which have continued to grow over time and sustain the instability of mergers and consolidations of a fluctuating national economy. While the numbers of nuns and women religious entering religious orders have declined in recent years, women continue to head the boards of directors and executive administrative positions at most of the Catholic healthcare institutions. Interestingly, it has been estimated that the women religious who run the Catholic hospitals in the U.S. have more disposable income at their fingertips than all the Bishops and Vatican leaders combined. Womens Healthcare Services According to research performed by Catholics For a Free Choice, about half of all mergers between Catholic and non-Catholic hospitals caused either the reduction or elimination of reproductive health services. Because abortion services have traditionally been a forbidden procedure at hospitals affiliated with Catholic healthcare, the absence of this service was not as noticeably lamented as others. Female sterilization procedures including tubal ligations and hysterectomies, male procedures such as vasectomies, family planning programs, in-vitro

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reproduction services, the-morning-after pill (emergency contraception) for women who have been raped, and even comprehensive HIV/AIDS counseling (available in most public schools) including condom and safe sex education is prohibited in Catholic healthcare institutions. Apparently, the most seriously affected by the absence of these services are low-income women in rural or isolated areas who have limited access to networking within a Faith community where CST values support of the consistent life ethic are nurtured. Unfortunately, these same individuals also have limited access to Catholic healthcare providers who promote the same generalized concepts of human rights to life and human dignity expressed in the pulpit. Ironically, for all the publicity given to the omission of what has been coined womens reproductive service, no articles researched for this reported include pregnancy, birthing, parenting services within their definition of womens services or reproductive services. Coincidentally, non-Catholic hospitals continue to offer these services even after a Catholic merger by carefully following the written terms of the mergers, yet establishing independent clinics in or near non-Catholic partner facilities and elsewhere. Social and Environmental Context There is no one size fits all approach to either physical or mental health care. One of the central premises for this paper is that widespread recognition of the values underlying the character of Catholic healthcare institutions encompasses a respect for human life and dignity. It is with an appreciation of the diversity of human life, that the consistent life ethic is advocated. For this hypothesis to become valid, for the foundation to be set from which the seamless garment can begin to take shape, macrostructural change needs to occur within society. Statistics on economic inequities in the U.S., however, indicate a wide disparity in education levels of ethnic cultures in K-12 institutions (NCES, 2001), which coincidentally affects the numbers of college graduates (e.g., physicians, nurses, techs) who represent multicultural populations in healthcare professions. In this respect educational institutions and associated governing bodies need to become change agents for cultural sensitivity in the community and place an emphasis on cultural diversity in medicine curricula, while at the same time working to resolve the issue of the inequitable distribution of resources in American society. At this time the diversity of the general U.S. population exists in direct disproportion to the numbers of both college graduates (U.S. Census Bureau, 2001) and healthcare professionals. Research suggests that patient education and self-care regimens are more effective when based on an understanding of the cultural context of a particular populations values, strengths, and weakness. For example, the availability of alcohol has been measured in terms of the location of alcohol sales outlets and linked to patterns of E.R. patients in alcohol-related traffic accidents (Gruenewald, Millar, Ponicki, & Brinkley, 2000) indicates another need for macrostructural reorganization. Similar studies indicate the greatest concentrations of liquor stores are found in low-income ethnic communities (Treno, Alaniz, & Gruenewald, 2000), which influences attitudes of patient and staff from these communities. Ethnic Programs/Ethnic Match It is well documented that racial and ethnic minorities in the United States are less likely than whites to seek health treatment, which largely accounts for their under-representation in most health services (Kessler, et al., 1996). Research indicates that some ethnic groups are more likely than whites to delay seeking treatment until symptoms are severe. African- and Hispanic-American clients are particularly less inclined than Caucasians to seek treatment from mental health specialists (Gallo & Matthews, 2003). Instead, studies indicate that many people from ethnic cultures turn to informal sources of care such as clergy, traditional healers, and family and friends (Neighbors & Jackson, 1984; Peifer et al., 2000). Hispanic subgroups, such as Puerto Ricans and Cubans, are noted for their reliance on traditional healers, while many Native Americans prefer to consult with shamans on the reservation.

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Differences in perception, approaches to illness, and orientation toward health practices vary widely among different cultures and ethnicities, and so bilingualism has become a very valuable skill for anyone who possesses it. Demographically, bi- or multilingualism has been defined as the presence and use of two or more languages in a modern nation or state (Asher & Simpson, 1994). About 47.3% of the world's population speaks more than one language (Reich, 1986), yet the percentages of bilingual care providers are extremely disproportionate to patient populations. Matching a patients ethnic background to a healthcare program in his/her neighborhood, where a care provider of similar ethnic background can deliver medical care has been proven to produce positive effects on the health-seek behaviors and recovery rates of multicultural patients. Ideally, ethnic healthcare services, in a language patients can identify with and by a healthcare provider they can culturally identify with, in a facility located in their community, and at affordable prices depending on their financial situation is the healthcare challenge of a lifetime. An awareness of the various issues that act to influence alcohol and drug behaviors among ethnic populations may help in the identification of strengths and weakness when dealing with patients or coworkers from ethnic neighborhoods. Simple techniques such as language switching in conversation or self-disclosing at intake have been known to have positive effects in many instances. It is interesting to note that the four major ethnic groups most commonly identified in the U.S. were defined so by the federal government purely for research purposes. These four major groups include Asian American, Native American (including Native Indian and Native Eskimo), African American, and non-white Hispanic American and hundreds of distinct ethnic or racial populations, each of which differ markedly in cultural characteristics and health behaviors. Interestingly, most medical research (which is not multicultural to begin with) does not support broad generalizations about specific subpopulations, many of which have not been studied individually, but whom hospitals in different parts of the country serve regardless. The field of education, on the other hand, delves significantly into matters of diversity and multiculturalism, particularly as they affect issues of social justice. Research Issues The most significant gap between research and practice with respect to diversity are lack of familiarity with research results, the lag time between publishing and the adoption of results into the clinical setting, and the cost of introducing new diversity plans into service systems. Most treatment programs operate without benefit of managed care support and within a highly competitive marketplace, risking much on the unproven effects of multicultural training. The gap between research and practice in medicine for racial and ethnic minorities is large concern for counseling professionals, where cross-cultural research on pharmaceuticals and organic pathology is scarce. Studies indicate that many controlled clinical trials used to generate professional treatment guidelines did not consider ethnicity as a variable, a serious issue given that controlled clinical trials offer the highest level of scientific rigor for proving that a particular medication works (Litten & Allen, 1995). Conclusion An obvious point about the principles of consistent life ethic and right to human dignity is that people cannot practice that which they have not learned. Research shows that many Catholics remain ignorant of declarations made by Church leaders. For example, one Gallup poll (D'Antonio; Davidson, Hoge & Wallace, 1989) concluded that fewer than 30% of lay Catholics had heard about the Bishops' pastoral letter on the U.S. economy (Economic Justice For All, 1986) even though it received general news coverage in both prime time and in print (Tamney, et al., 1988). Another poll (Fox, 1987) claimed laity wanted more control in Church matters, yet were not familiar with the official views. The Catholic identity in health care, however, is firmly embedded in the doctrine of Catholic Social Teaching (CST) and can be traced back at least two centuries to Rerum Novarum, the works of St. Thomas Aquinas, and

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the Bible itself. With advocacy so distinctive to the global promotion of peace and justice, Catholic identity will continue to expand Church doctrine in health care and other industries.

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Appendix 1 Promise of the Catholic Doctor. Approved by the Executive Committee of FIAMC and by the Pontifical Council of the Pastoral for Health Care Workers. I, ___________________ , medical doctor, solemnly promise:

1. To continually improve my professional abilities, in order to give my patients the best care I can. 2. To respect my patients as human persons, putting their interests ahead of political and economic consideration, and to treat them without prejudice arising from religious, racial, ethnic, socio-economic, or sexual differences. 3. To defend and protect human life from conception to its natural end, believing that human life, transmitted by parents, is created by God and has an eternal destiny that belongs to Him. 4. To refuse to become an instrument of violent or oppressive applications of medicine. 5. To serve the public health, promoting health policies respectful of life and of the dignity and nature of the human person. 6. To cooperate with the applications of just law, except on grounds of conscientious objection when the civil law does not respect human rights, especially the right to life. 7. To work with openness towards every person, independently of their religious beliefs. 8. To donate part of my time for free and charitable care of the poor.

In order to achieve these goals, as a catholic Doctor, I also promise:

1. To recognize the Word of God as the inspiration of all my actions, to be faithful to the teachings of the Church, and to form my professional conscience in accord with them. 2. To cultivate a filial relationship with God, nourished by prayer, and to be a faithful witness of Christ. 3. To practice Catholic moral principles, in particular those related to biomedical ethics. 4. To express the benevolence of Christ in my life, and in my relationships with patients, colleagues, and society. 5. To participate in evangelization of the suffering world, in co-operation with the pastoral ministry of the Church.

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