Text: Health Care Ethics USA

Book Review: "Pope Francis and the Transformation of Health Care Ethics"

Winter/Spring 2022

Reviewed by Tobias Winright, Ph.D.

Todd A. Salzman and Michael G. Lawler, Pope Francis and the Transformation of Health Care Ethics (Washington, DC: Georgetown University Press, 2021), 240 pp., paperback, $34.95.

Coauthored by a pair of senior, prolific Catholic theological ethicists, who have previously collaborated on numerous books and articles, I eagerly anticipated reading and discussing Pope Francis and the Transformation of Health Care Ethics with my graduate students in our seminar on Catholic bioethics this past fall semester. Todd Salzman is the Amelia and Emil Graff Professor of Catholic Theology at Creighton University, and Michael Lawler is Professor Emeritus of Catholic Theology, also at Creighton. Although their latest work's title is undeniably eye-catching, it is slightly misleading in that the book focuses more on recasting the way that the US Catholic bishops ought to regard health care ethics.

Indeed, within its introductory pages and the subsequent seven chapters, the authors critically assess the sixth edition of the Ethical and Religious Directives for Catholic Health Care Services (ERDs), released in 2018 by the United States Conference of Catholic Bishops (USCCB). Highlighting anthropological, ecclesiological, ethical and methodological tensions that they discern within the ERDs, especially in light of the shifts in these theological areas encouraged by Pope Francis in Amoris Laetitia and Laudato Si', Salzman and Lawler ultimately offer their recommendations for revisions for the next edition of the ERDs. An ambitious endeavor, surely, but one that should not be unexpected, including on the part of the bishops. After all, near the end of the Preamble, it is noted that the ERDs "will be reviewed periodically … in the light of authoritative church teaching, in order to address new insights from theological and medical research or new requirements of public policy" (ERDs, pp. 4-5). This opening is something Salzman and Lawler highlight more than once, and they rightly regard it as an opportunity. Not only are there new insights and requirements from theology, medicine, and public policy, which Salzman and Lawler consider, but there is new light, too, from the authoritative church teaching reflected in Francis's papacy. However, evidence of such illumination, in their view, remains lacking in the sixth edition of the ERDs.

In the Introduction, Salzman and Lawler provide an overview of the ERDs, beginning with the first set of guidelines formulated by Michael Burke for the Archdiocese of Detroit in 1921, and the first edition of the ERDs, authored principally by Gerald Kelly SJ in 1948. Also considered are articles and commentaries about the ERDs by Kelly, Richard McCormick SJ, Orville Griese, Kevin Wildes SJ, Jean deBlois, Kevin O'Rourke, Thomas Kopfensteiner, and Ronald Hamel. In my view, Salzman and Lawler's book echoes and expands the corrective vision of McCormick's Health and Medicine in the Catholic Tradition: Tradition and Transition (NY: Crossroad, 1984), with its proposal for revision in light of anthropological, ethical methodological, and ecclesiological developments of Vatican II and its wake. This introductory overview of the history and contents of the ERDs traces some expansion from rule-based applications to clinical concerns to more complex ethical issues such as advance directives, reproductive technologies, artificial nutrition and hydration, and institutional delivery systems mergers. In the Introduction, Salzman and Lawler also offer a metaethical primer about ontology (physicalist or personalist?) and epistemology (ecclesial positivism or perspectivism?). Salzman and Lawler regard their Catholic theological ethics as encompassing both the biological and the relational aspects of the human person, and as aligned with Bernard Lonergan's account of perspectivism, which is not relativism, but a humble recognition of human finitude and partiality when it comes to knowledge of truth.

Chapter One shares the authors' understanding of the four traditional sources of moral guidance (i.e., the Wesleyan Quadrilateral) — scripture, tradition, science, and human experience — and shows "how their selection, interpretation, prioritization, and integration (SIPI) lead to different perspectives on the teachings and directives" of the latest version of the ERDs (p. 25).1 Salzman and Lawler argue that the ERDs narrow the scope of tradition to the magisterium and that the other three sources — scripture, experience, and science — are subordinated to that hierarchical perspective. In contrast, Pope Francis has sought "greater integration of science and Church teaching," for instance, and Salzman and Lawler propose more integration "on health care and sexual ethical issues" (p. 38). They also hold that conscience should not be reduced to obedience to the magisterium. They consider the 2009 case of Bishop Thomas J. Olmsted of Phoenix and Saint Joseph's Hospital and Medical Center to illustrate their points about how the four sources of ethical knowledge are misunderstood and misused by the episcopacy and the ERDs.

In Chapter Two, the authors highlight anthropological tensions within the ERDs. Anthropologically, the ERDs, like John Paul II's teaching on sexual ethics, continue to prioritize a biological over a relational ontology. Human dignity, while rightly considered foundational in Catholic bioethics, should be understood more holistically, Salzman and Lawler argue, as it is in Catholic social teaching.

Chapter Three continues to be devoted to tensions within the ERDs regarding ethical method. The ERDs exhibit three ethical methods — social, sexual, and health care — which are at times at odds or inconsistently employed. Salzman and Lawler call for a "holistic ethical method" that strives to integrate the best of the methods applied to a range of ethical issues: social, sexual, environmental, and health care. Pursuing this integrated approach includes a consistent ethic of life, dialogue or synodality, attention to virtues, an inductive rather than solely deductive methodology, and a preference for the poor. Health care issues addressed within this substantive chapter include administration of artificial nutrition and hydration, direct and indirect abortion, the greening of Catholic health care institutions, and artificial contraception.

Ecclesiological tensions within the ERDs are the focus of Chapter Four. Salzman and Lawler critique the hierarchical model of Church that characterizes the ERDs, especially the authority of the bishops, and propose integrating a mutually reciprocating teaching and learning communion model with an appreciation for the sensus fidelium. As Pope Francis advises, "Keep an open mind. Don't get bogged down in your own limited ideas and opinions, but be prepared to change or expand them. The combination of two different ways of thinking can lead to a synthesis that enriches both" (Amoris Laetitia, §139, quoted on p. 108). Relatedly, Salzman and Lawler extend their critique of the hierarchical authority of the episcopacy to include the diocesan bishop's reliance upon "approved authors" for guidance on moral questions in health care. Indeed, numerous times in the book, the Salzman and Lawler lambaste the line within the ERDs (p. 7) about "the guidance of approved authors can offer appropriate guidance for ethical decision making" (pp. 12, 35, 86, 110, italics added by Salzman and Lawler). Salzman and Lawler rightly argue that the theologian's task includes but goes beyond catechesis, and they call for broader theological consultation, as "equal partners" (p. 117), including lay women and men across expanding demographics amongst the entire body of the baptized faithful. The authors also believe that doing so will prove helpful when bishops sometimes disagree amongst themselves, including when Catholic health systems bridge across dioceses.

The ERDs emaciated perception of and prescriptions for pastoral and spiritual care are dealt with in Chapter Five. In Salzman and Lawler's judgment, the ERDs focus too narrowly on the sacraments and are insufficient regarding spirituality and the human experience of sickness. My students and I had an engaging discussion of the authors' recommendation "that unconscious sick persons should not be involved in the celebration of any sacrament" (135), and their suggestion to expand our awareness of small-"s" sacramental presence beyond the seven Sacraments stimulated reflection and creative brainstorming about discernment, empathy, mercy, and being present to those in our care.

In Chapter Six, the authors tackle part 6 of the ERDs on "Collaborative Arrangements with Other Health Care Organizations and Providers," which is where the sixth edition noticeably has been revised compared to the previous one. Salzman and Lawler critically consider three revisions within this section. First, the ERDs reinforce the authority of the local bishop. Here Salzman and Lawler note that although directive 69 of the ERDs recognize that Catholic health care systems may span numerous dioceses, there are no guidelines for achieving consensus between bishops who may be in disagreement (p. 159). A remedy, in their view, would be the "communional-synodal approach to decision-making in the Church" (p. 164). Second, the ERDs attempt to clarify the principles governing cooperation, but Salzman and Lawler note its failure to consider proximate and remote material cooperation, as well as its lack of clarity concerning individual and institutional (e.g., a Catholic health care institution as "juridic person") aspects, including conscience, the common good, and the "moral act" (i.e., object[s], end, and circumstances). Third, the ERDs continue to be concerned about scandal, but Salzman and Lawler wonder "how claims of scandal are to be justified" (177).2 As for witness, the authors recommend reorienting it so that it includes Pope Francis's teachings on synodality and accompaniment.

The final chapter is the most constructive and, I suspect for most readers of Health Care Ethics USA, the one that will be of most interest. In Chapter Seven, Salzman and Lawler offer their suggestions for revisions of the ERDs. I don't want to spoil it for anyone, but I appreciate their extension of attention in Catholic health care to include the environment and climate change, race, immigration, technological developments, sex and gender, poverty, and law, policy, and religious freedom.

Because I share most of the concerns raised by Salzman and Lawler, whom for the sake of transparency I should say I count as friends, identifying weaknesses and offering criticisms of their work is difficult. A worry I have is that, while they rightly highlight the sex-abuse crisis and its impact on episcopal authority, repeatedly doing so may backfire by making bishops instead even more defensive against, and resistant to, Salzman and Lawler's criticisms and recommendations.3 Relatedly, Salzman and Lawler rightly call for "the way of dialogue of charity recommended by Popes John Paul II and Francis" (p. 4), and although the bishops might at times fall short on this, I worry that they might feel the same about Salzman and Lawler on occasion in the book. To mitigate the likelihood of such defensiveness, instead of spending most of the book's pages criticizing the bishops and critiquing the ERDs, perhaps it would have been better to expand the last chapter's excellent suggestions for revising them. Still, I do hope that future revisions of the ERDs will include attention to Salzman and Lawler's book.

Tobias Winright, Ph.D.
Albert Gnaegi Center for Health Care Ethics
Saint Louis University
St. Louis



  1. The four sources of the so-called Wesleyan Quadrilateral are often invoked, although the third and fourth fonts are explicated variously amongst authors. For example, where Salzman and Lawler refer to science, many others highlight reason. See Tobias Winright, "Introduction: Christian Ethics and the Four Sources," in T&T Clark Handbook of Christian Ethics, ed. Tobias Winright (London: Bloomsbury/T&T Clark, 2021), 1-4, and the subsequent four chapters devoted to each source by Kathryn D. Blanchard (on scripture), D. Stephen Long (on tradition), Laurie Johnston (on experience), and Kathryn Lilla Cox (on reason). Interested readers may also wish to see in this same volume the chapter by Todd A. Salzman and Michael G. Lawler, "Nondiscrimination Legislation and Sexual Orientation and Gender: A Critical Analysis of the Catholic Position," 473-481.
  2. Although Salzman and Lawler do not offer one, a helpful account of scandal and constructive framework for its justification, see Nathaniel Blanton Hibner, "Scandal: Delving Into Popular Versus Theological Definitions," Health Progress 99, no. 6 (November-December 2018): 71-72; and his "Discerning Scandal: Theological Scandal in Catholic Health Care Decision Making" (PhD diss., Saint Louis University, 2019).
  3. As I see it, such defensiveness would be similar to the way that some police in the United States react to criticisms such as "defund" or "abolish" the police. See Tobias Winright, "American policing on trial," The Tablet (May 6, 2021): https://www.thetablet.co.uk/features/2/19975/american-policing-on-trial.