BY: REV. KEVIN D. O'ROURKE, OP, STM, JCD; REV. THOMAS KOPFENSTEINER, STD; and RON HAMEL, PhD
A Summary of the Development of the Ethical and Religious Directives
for Catholic Health Care Services
Fr. O'Rourke is professor of bioethics, Stritch School of Medicine, Loyola
University, Chicago; Fr. Kopfensteiner is associate professor, Theology Department,
Fordham University, Bronx, NY; and Dr. Hamel is senior director, Ethics, CHA.
Catholics engaged in health care throughout the centuries have always sought
to minister in the spirit of Christ and in accord with the teaching of the church
as they carried on their ministry of healing. In the 16th century, theologians
began to treat issues arising in the practice of medicine more frequently. Thus,
such questions as how to determine that death had occurred and which medical
methods to prolong life were mandatory and which methods were optional were
discussed.1 Professionals engaged in Catholic health care applied
treatment norms agreed upon by theologians as well as general norms for compassionate
health care. No formal set of directives was issued for any country in the centuries
immediately following, but a common teaching in the Catholic Church concerned
the ethical practice of medicine and patient care.2
In the United States and Canada, the ministry of Catholic health care grew
and flourished during the late 19th and early 20th centuries. Hospitals and
long-term care facilities multiplied, usually under the sponsorship of religious
communities, but always under the jurisdiction of the diocesan bishop.
The Catholic Hospital Association (the former name of the Catholic Health
Association [CHA]) was founded in 1915 to improve the effectiveness of patient
care and to protect the rights of Catholic health care facilities.3
One of the expressed needs of the various health care facilities, the sponsors,
and administrators — as well as the physicians and nurses more directly involved
in patient care — was a written statement of ethical directives that concerned
serious moral issues.
The first written set of medical ethical norms seems to have been compiled
by Rev. Michael Burke in 1921 for health care facilities in the Archdiocese
of Detroit.4 Most of the norms concerned surgical procedures, prohibiting
anything that resulted in the destruction of fetal life or the sterilization
of men or women. Exceptions to the latter situation were instances in which
the sterilizing effect followed as the indirect and undesired result of necessary
interference for the removal of diseased structures. Burke's one-page set of
directives, accepted verbatim by many dioceses and slightly modified by others,
hung on the operating room walls of many Catholic hospitals in the United States
These first regulations concerning ethical medical practices in the Catholic
tradition did not consider the scriptural and theological teaching underlying
the ministry of healing, but rather listed "dos and don'ts" that were considered
most significant at the time. As time went on, however, and as the ministry
of health care became more complicated and extensive, a new and more complete
document was needed.
Work on a uniform set of directives was begun in 1947 by a committee of theologians
and health care professionals from the United States and Canada. This document,
under the title Ethical and Religious Directives for Catholic Hospitals,
was first published in the July-October 1948 issue of Linacre Quarterly.
A brochure version was published in 1949, and a French translation for use in
Eastern Canada was published in 1950.5 This set of directives was explicitly
understood to not be an official code for any diocese unless adopted by the
bishop.6 Rev. Gerald Kelly, SJ, CHA's consulting theologian at the
time, remarked: "It seems that it was so adopted by a majority of dioceses,
but by no means all."5 Of course, not all dioceses had Catholic hospitals,
and some had only one. Hence, every diocese did not need to promulgate the Directives.
After World War II, the government of Canada adopted a system of universal
health care, financed and organized by their federal government and the various
provinces. This system, so different from that of the United States, prompted
Canadian hospitals to form their own association. In October 1954, the Canadian
hierarchy officially adopted a Code of Ethical Directives for the hospitals
under its jurisdiction.7 About the same time, CHA decided that a
more succinct expression of the 1949 Directives was needed for convenient
printing on charts placed in the surgical suites of Catholic hospitals. To satisfy
this form of promulgation, the Code of Medical Ethics for Catholic Hospitals
was published in 1954 and was referred to as "the Code" to distinguish it from
the more extensive "Directives."8 The Code did not contain
anything different from the Directives, but it could be hung on the operating
room wall or in prominent places in the health care facility, replacing the
documents that had been used in various dioceses since the 1920s. Thus, it became
known as the "U.S. Code." The U.S. Code was also published in booklet form.
In an effort to make the church teachings in regard to health care even more
accessible and useful, Fr. Kelly and CHA published a second, revised edition
of the 1949 Directives in 1956.9 However, the 1956 edition
did contain new material on professional secrecy, ghost surgery, psychotherapy,
and spiritual care for non-Catholics as well as an index, reference material,
and consecutive numbering of the paragraphs. Fr. Kelly, the main author of the
1949 and 1956 Directives, commented on them in various articles in Hospital
Progress (the former title of Health Progress) in the 1950s. These
articles were later published, along with additional chapters, in book form.9
The various editions of the Directives were published with the intention
that all Catholic hospitals in the United States would follow the same regulations
with the same interpretations. They did not become official, however, for a
particular hospital or locale until they were approved by the diocesan bishop.
The local ordinary also had the right to officially interpret the Directives
for his diocese. In the 1950s and early 1960s, the interpretation of the Directives
was fairly uniform; no apparent difficulties regarding uniformity existed.
But in the late 1960s, as a result of a new method of moral reasoning known
as proportionalism proposed by many influential theologians, the Directives
relating to direct sterilizations and the distribution of contraceptives in
Catholic hospitals began to be interpreted more liberally in certain dioceses.10
This led to the phenomenon known as "geographical morality," meaning that a
practice that was prohibited because of immorality in one diocese might be allowed
in another. As a result of "geographic morality," the executive committee of
the CHA board of trustees requested that the National Conference of Catholic
Bishops (NCCB; the former name of the United States Conference of Catholic Bishops)
compose and promulgate a set of Directives that would be uniform for
the entire country.11 The executive committee hoped that, if the
Directives were composed by a conference of bishops and promulgated by
individual bishops, "geographic morality" would disappear.
This request led to the publication of a new set of Directives in November
l971.12 Although these Directives were overwhelmingly approved
by the NCCB, they were not greeted with acclaim by many theologians.13
Actual promulgation in each diocese was encouraged, however, by the response
of the NCCB to the Roe v. Wade decision of the U.S. Supreme Court in
1973, which legalized abortion in the United States, and to an injunction granted
by a federal court in Montana against the prohibition of sterilizations in Catholic
hospitals. Cardinal John Krol of Philadelphia, then NCCB president, pointed
out to the bishops that they might have a difficult time using the federal conscience
clause allowing hospitals to prohibit abortions and sterilizations in accord
with "religious teaching" unless they were on record as prohibiting such procedures.14
The 1971 Directives, however, did not settle all issues of interpretation,
especially regarding the practice of sterilizations that might be indicated
to avoid a future disease or medical condition arising from pregnancy.15 — Because
of questions and doubts surrounding this issue, the NCCB submitted the matter
to the Vatican Congregation for the Doctrine of the Faith (CDF).16
In 1975, the CDF issued a response to the matter entitled Quaecumque Sterilizatio,
which indicated that sterilizations performed to avoid pathological medical
conditions that might result from future pregnancies were contraceptive sterilizations
and could not be performed in Catholic hospitals, no matter what theological
opinion might be put forward to justify such procedures.17
In 1977, the NCCB issued a commentary on the CDF document of 1975. The commentary
agreed with the Vatican document but enlarged upon the interpretation of material
cooperation as contained in Quaecumque Sterilizatio.18 To
show that the sterilization issue was not easily settled, the NCCB, at the instigation
of the CDF, issued another statement in 1980 offering the traditional interpretation
of the principle of totality.19
The 1971 Directives were rather legalistic; they did not attempt to
explain the reasons for church teaching, but merely stated rules. Moreover,
some new ethical issues in health care — such as informed consent for research
projects, the use of advance directives, and cooperation with other-than-Catholic
health care facilities — had arisen.
In an effort to prepare a more complete, effective, and theologically nuanced
set of Directives, the NCCB's Committee on Doctrine was commissioned
to prepare a new set of Directives. Over a six-year period, the Committee
on Doctrine, working in the initial stages of the project through a subcommittee,
enlisted the help of several Catholic organizations and centers, theologians,
and ethicists in composing these new Directives. After 11 major drafts,
the Revised Ethical and Religious Directives for Catholic Health Care Services
were approved by the NCCB in November 1994 with a new title, once again with
the understanding that they did not become the law for any particular diocese
until promulgated by the diocesan bishop.20
The 1994 Directives were composed of six sections, each introduced
by a theological basis for the directives in that section. They also contained
an appendix that sought to explain the principle of "cooperation in evil," a
principle that is significant in the matter of relationships with other-than-Catholic
health care facilities (Directive 69). Although the CDF had reviewed the Directives
before the bishops' vote, they had not reviewed the appendix. The appendix was
still being revised shortly before the vote. Although it was approved by the
bishops, the Appendix immediately caused consternation, especially among some
theologians. In the spring of 2000, the CDF instructed the NCCB to revisit the
appendix as well as their 1977 commentary. Both were viewed by the CDF as sources
of misinterpretation and misapplication of the principle of cooperation with
A number of points should be mentioned regarding the 1994 revision. First,
the 1994 revision expands the area of medical ethics beyond clinical issues
to include issues of social justice. In this way, the Directives were
revised in light of the U.S. bishops' Pastoral Letter On Health and Health
Care (1981). The issue of access to health care services also became a pressing
moral concern. The Directives recognize the social obligations of Catholic
health care services to serve the poor, to be responsible stewards of limited
resources, and to collaborate with other providers to improve the health of
Second, the Directives moved beyond proscriptions to describe Catholic
identity in more positive terms. The Directives were no longer displayed
in surgical suites; they now aimed to create a culture in health care that focused
on the promotion of human dignity in a way that was animated by the spirit of
the Gospel and guided by the teachings of the church. In this way, the 1994
Directives were more than a mere "updating" of earlier editions in light
of magisterial teaching.
Third, this positive focus on Catholic identity did not diminish the importance
of clinical issues. The Directives were expanded to include issues such
as advance medical directives, surrogate decision making, reproductive technologies,
and the provision of nutrition and hydration to patients in persistent vegetative
states. They also offered more nuanced guidance for the treatment of victims
of sexual assault. Rather than merely list negative norms, the Directives
provided a theological backing for all moral claims made.
Finally, the Directives addressed the issue of partnerships with other-than-Catholic
health care providers. The U.S. Bishops recognized the growing phenomenon of
partnerships as a way of promoting the church's social teaching and influencing
the health care profession. The bishops also recognized that such partnerships
might prevent Catholic providers from implementing the Directives in
a consistent way. To address this dilemma, the bishops detailed the traditional
principle of material cooperation in an appendix to the Directives. After
consultation with the Vatican, the U.S. Bishops unanimously approved the main
text in November 1994.
In the spring of 2000, the CDF requested Bishop Joseph A. Fiorenza, president
of the Bishops' Conference, to undertake a review of Part Six of the Directives,
the appendix, and the NCCB commentary on Quaecumque Sterilizatio. The
CDF viewed these texts as contributing to misinterpretation of the principle
of cooperation and to misapplication of the principle to partnerships with other-than-Catholic
health care organizations.
In response to the request of the CDF, Bishop Fiorenza asked Archbishop Daniel
Pilarczyk of Cincinnati, chair of the Bishops' Committee on Doctrine, and Bishop
Donald Wuerl of Pittsburgh, chair of the Ad Hoc Committee on Health Care Issues
and the Church, to serve as leaders of a review of the materials in question.
Over a two-year period, the bishops consulted with health care administrators,
theologians, other bishops, and CHA staff. In the course of this process, three
different drafts were composed. The third draft was sent to the CDF for review.
In February 2001, a response was received approving the draft in substance but
offering a few observations that were incorporated into the draft sent to the
United States Conference of Catholic Bishops for consideration. The new version
of the Directives was approved June 15, 2001, by a vote of 209 to 7.
Thus, the 2001 version of the Directives, like its predecessors, becomes
the official statement of ethical directives for the provision of health care
in Catholic facilities, provided the local bishop promulgates the document.
All the revisions to the 1994 Directives occur in Part Six, "Forming
New Partnerships with Health Care Organizations and Providers." There are four
- A new directive (Directive 70) forbids Catholic health care organizations
from engaging in immediate material cooperation in actions that are intrinsically
evil, such as direct sterilization.
- The appendix of the 1994 Directives was deleted; it was judged to
be a source of confusion.
- A footnote states that the new directive, Directive 70, is viewed as superceding
the 1977 commentary on Quaecumque Sterilizatio.
- The notion of "scandal" is more precisely defined, using the definition
contained in the Catechism of the Catholic Church.
The 2001 revision was a two-year process marked by collaboration among the
bishops, Catholic health care leaders, theologians and ethicists, and the Holy
See. Patience and a commitment to ongoing dialogue, to the teaching of the magisterum,
and to the good of the ministry and the people it serves led to a text that
addressed the concerns of the CDF while minimizing unintended consequences to
Catholic health care.
- Francisco de Vittoria, On Homicide, John P. Doyle, editor, Marquette
University, Milwaukee, 1997, p. 95, 103.
- Almost every manual of moral theology published from the 17th to the 19th
century has a section concerned with medical practice.
- C. J. Kauffman, Ministry and Meaning: A Religious History of Catholic
Health Care in the United States, Crossroad Publishing, New York, 1995.
- Michael P. Bourke, Surgical Code for Catholic Hospitals, Archdiocese
of Detroit, 1921.
- Gerald Kelly, SJ, "Review of Existing Codes," Hospital Progress,
March, 1956, p. 53.
- Ethical and Religious Directives for Catholic Hospitals, 1949, Catholic
Hospital Association, St. Louis, foreword, page iv.
- Three other collections have been published by the Catholic Health Association
of Canada, Ottawa, Ontario: Medico-Moral Guide, 1971, Health Care
Ethics Guide, 1991, Health Ethics Guide, 2000.
- Kelly, p. 53.
- Ethical and Religious Directives for Catholic Hospitals, second
edition, 1956, Catholic Hospital Association, St. Louis, preface, p. iv.
- The principal of totality allows excision of a bodily organ if its malfunction
may endanger the life of a person, but it prohibits the excision of an organ
for other purposes. Thus, a uterus may be removed if it is cancerous, not
to prevent conception. Proportionalism was popular among many Catholic theologians
who proposed that the ultimate purpose of a moral action was more significant
than the action performed. The encyclical Veritatis Splendor by Pope
John Paul II taught that Catholic moral theology recognizes that some actions
are "intrinsically evil," that is, morally wrong no matter what the motivation
that prompts them. Origins, October 14, 1993, vol. 23, p. 18.
- Letter of Monsignor Edward Michelin, CHA president, to Most Rev. John Whealon,
chair, NCCB Committee on Doctrine, May 17, 1971 (private papers of Rev. Kevin
- Catholic Hospital Association, Ethical and Religious Directives for
Catholic Health Care Facilities, St. Louis, 1971. Slight revisions were
made in 1975, but these revisions were considered a second editing, not a
- Kauffman, p. 290ff.
- "Toward a Federal Conscience Clause," Origins, June 14, 1973, vol.
3, no. 3, letter of John Cardinal Krol, president of the NCCB, March 7, 1973
(private papers of Rev. Kevin O'Rourke, OP); cf. Taylor v. St. Vincent's
Hospital, Billings, MT, c-1090, U.S. District Court, Montana, October 25,
- CHA Board of Trustees Meeting, November 3-4, 1975. On-going problems with
interpretation of Directive 20 (private papers of Rev. Kevin O'Rourke, OP).
- Archbishop John Quinn, "Catholic Hospitals and Sterilization; The State
of the Question" (private papers of Rev. Kevin O'Rourke, OP). Archbishop Quinn
was chair of the NCCB Committee on Doctrine at the time, and it seems that
this document sought to explain to the CDF the situation in the United States.
- Quaecumque Sterilizatio, CDF Reply on Sterilizations in Catholic
Hospitals, March 13, 1975, United States Catholic Conference, Washington,
- Commentary on the Reply of the CDF on Sterilizations in Catholic Hospitals,
National Conference of Catholic Bishops, Washington, D.C., 1977. The reason
for the delay in publishing the response of the CDF and the commentary on
this response seems to have been the thought that the response was simply
a repetition of the traditional theological interpretation of Directive 20.
- "Statement on Tubal Ligation," National Conference of Catholic Bishops,
Origins, August 20, 1980.
- "Ethical and Religious Directives for Catholic Health Care Services," United
States Catholic Conference, Origins, December 15, 1994, vol. 24, p.
The chronology of the various collections of ethical norms published for Catholic
health care facilities in the United States is as follows:
- Surgical Code for Catholic Hospitals, Archdiocese of Detroit, 1921.
- Ethical and Religious Directives for Catholic Hospitals, Catholic
Hospital Association, St. Louis, 1948 (brochure, 1949).
- Ethical and Religious Directives for Catholic Hospitals, second
edition of 1949 Directives, with some additions, Catholic Hospital
Association, St. Louis, 1956.
- Ethical and Religious Directives for Catholic Health Care Facilities,
Catholic Hospital Association, St. Louis, 1971.
- Ethical and Religious Directives for Catholic Health Care Services,
National Conference of Catholic Bishops, Washington, DC, 1994.
- Ethical and Religious Directives for Catholic Health Care Services,
United States Conference of Catholic Bishops, Washington, DC, 2001.
Copyright © 2001 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.