The Ethical and Religious Directives for Catholic Health Care Services (ERDs) outline the moral and theological principles guiding Catholic hospitals and health systems in fulfilling their mission of healing. They articulate the Church's deep convictions about human dignity, the common good and faithful stewardship within the modern practice of medicine. As science and social questions evolve, so too must the guidance that supports the Catholic health ministry.
The United States Conference of Catholic Bishops (USCCB) has completed the latest revision of the ERDs, marking the seventh edition of the document. Understanding what the ERDs are, how they have been revised, and what themes are emerging in the current version is essential for all those serving in Catholic health care today.
WHAT ARE THE ERDs?
The ERDs express how the Catholic Church understands health care as a ministry of the Church rooted in the life and mission of Jesus Christ. They connect Catholic moral theology with clinical and organizational realities, helping health systems uphold both ethical integrity and clinical excellence.
The document's structure has remained consistent for decades. It opens with a general introduction that explains its purpose and theological grounding, followed by six main parts, each addressing a particular area of health care practice:
- The Social Responsibility of Catholic Health Care Services: Articulates the Church's call to promote the common good, serve the poor and ensure just stewardship of resources.
- The Pastoral and Spiritual Responsibility of Catholic Health Care: Emphasizes holistic care that attends to spiritual needs.
- The Professional–Patient Relationship: Explores ethical decision-making, informed consent, and the moral responsibilities shared by clinicians and patients.
- Issues in Care for the Beginning of Life: Offers moral guidance for fertility, conception, pregnancy and reproductive technologies.
- Issues in Care for the Seriously Ill and Dying: Focuses on end-of-life care, pain management and respect for human dignity in dying.
- Collaborative Arrangements with Other Health Care Organizations and Providers: Outlines principles for partnerships and mergers to ensure Catholic identity is preserved.
The ERDs are not a rule book; rather, they serve as a moral and spiritual compass. They must be read in dialogue with the Church's broader body of ethical reflection developed over centuries. Their intent is not to provide every answer, but to orient Catholic health care toward moral coherence, compassion and the healing mission of Christ.
A BRIEF HISTORY OF THE ERDs
The directives have evolved alongside modern medicine and the institutional growth of Catholic hospitals in the United States.1
- 1921: First written as a short set of ethical norms for Catholic hospitals.
- 1947–1949: Early drafts started and the first Ethical and Religious Directives for Catholic Hospitals appeared in The Linacre Quarterly, then in a CHA brochure.
- 1956: The first official revision appeared.
- 1960s–1971: Authorship shifted from CHA to the U.S. bishops, who published the Second Edition in 1971.
- 1994–1995: The Third Edition established the modern format still used today.
- 2001: The Fourth Edition incorporated Vatican guidance on sterilization.
- 2009: The Fifth Edition revised directives on medically administered nutrition and hydration.
- 2018: The Sixth Edition addressed issues surrounding institutional partnerships and Catholic identity.
Each edition has reflected both moral teachings of the Church and medical advancements to address new questions in ethics, medicine and health care delivery.
WHY WERE THE ERDs REVISED AGAIN?
Revisions occur when new developments in medicine or Church teaching require clarification or guidance. The latest revision, begun by the U.S. bishops in June 2023,2 was prompted largely by new moral questions about gender identity, transitioning procedures and technological manipulation of the human body.
In March 2023, the USCCB's Committee on Doctrine released a theological note titled "Doctrinal Note on the Moral Limits to Technological Manipulation of the Human Body." That note, together with related Vatican statements, underscored the need to revisit the ERDs to address emerging issues related to gender. Although these questions served as the catalyst, the bishops' review has extended more broadly to other parts of the text.
HOW THE REVISION PROCESS WORKS
The USCCB Committee on Doctrine leads the process. A team of bishops and staff draft proposed changes and seek consultation from experts in theology, medicine, law, ethics and health care operations.
Organizations such as CHA are included as commentators, offering input on language, practical implications and clarity for those who will implement the ERDs at the system and clinical levels.
Once a final draft is complete, the entire body of U.S. bishops votes to approve it, which they did in November 2025.
The process is deliberative and careful, often taking several years. Most revisions take between two and four years from authorization to publication. This time it took two and a half years.
CHA'S ROLE AND PRIORITIES
CHA participated in the revision process as both a collaborator and a commentator, seeking to ensure that the final document balances fidelity to Church teaching with clarity for practitioners.
CHA's main priorities include:
- Focusing on principles and virtues, not procedures. The ERDs should orient Catholic health care around enduring moral truths, not attempt to regulate every specific clinical scenario.
- Emphasizing obligations and mission over prohibitions. Rather than only listing what cannot be done, the ERDs should emphasize what Catholic health care is called to do.
- Using clear, pastoral language. The document should speak in accessible terms to clinicians, administrators and ethicists who use it in real time.
- Avoiding unnecessary conflict with civil law. The directives should articulate Catholic moral teaching without positioning Catholic institutions in legal jeopardy.
CHA ethicists, members and scholars provided detailed written commentary throughout the drafting process to ensure the final directives met these goals as much as possible, and we saw a positive impact on the drafts due to our thoughtful input.
Several dozen member experts provided their insight into the draft texts. Many did so virtually, and several graciously came together in Denver and St. Louis to have a rigorous dialogue about CHA's official response. I am particularly grateful for the help of these members, as they met the time constraints of the process with diligence and excellence.
THE REVISION'S BROADER SIGNIFICANCE
This revision process offers more than updated language; it's a moment for the Church to reflect on what it means to practice Catholic health care in a rapidly changing moral and scientific landscape. Catholic health ministries today navigate questions that could not have been imagined when the first set of medical ethical norms were written in 1921. The ERDs serve as a unifying moral framework.
The changes to the text address areas critical to the mission of the health care ministry, including defending human dignity; attention to people experiencing gender dysphoria; commitment to hospice and palliative care for the seriously ill and dying; physicians' responsibility to transfer care when requested; protection of women and children; and patients' informed consent, among others. As we live into these revisions, we must remind ourselves that as a ministry of the Church, we are called to act like Jesus to all who seek our care. These revisions must continue to meet that ultimate end as we put them into our daily practice.
LOOKING AHEAD
As the revision has been approved and published, Catholic health leaders are encouraged to remain engaged. We look forward to ongoing dialogue between Catholic health care and the USCCB on how we can best live out these revisions together. Understanding the process helps ministry leaders prepare for how new directives may affect policy development, staff formation and clinical decision-making. CHA will be hosting a variety of educational events to help orient members to the changes in the text. These will include webinars, podcasts, published articles and learning modules. We will keep everyone informed about these resources and events as they are released.
As the conversation continues, Catholic health care leaders, clinicians and ethicists are invited to participate in the spirit of hope. We must ensure that, whatever new technologies or social issues emerge, the heart of the ministry remains the same: to continue the healing mission of Jesus Christ.
NATHANIEL BLANTON HIBNER, PhD, is senior director, ethics, for the Catholic Health Association, St. Louis.
NOTES
- Rev. Kevin O'Rourke, Rev. Thomas Kopfensteiner, STD, and Ron Hamel, PhD, "A Brief History: A Summary of the Development of the Ethical and Religious Directives for Catholic Health Care Services," Health Progress 82, no. 6 (November/December 2001): 18-21.
- Michael J. O'Loughlin, "Transgender Treatment at Catholic Hospitals: U.S. Bishops Vote to Begin Process That Could Formally Ban It," America: The Jesuit Review, June 16, 2023, https://www.americamagazine.org/politics-society/2023/06/16/usccb-transgender-healthcare-catholic-hospitals-245508/.