BY: CLARKE E. COCHRAN, PhD
Dr. Cochran is professor of political science, Texas Tech University, Lubbock,
TX. He serves as a deacon for the Diocese of Lubbock and is a member of Hope
Ministries, a public juridic person within Catholic Health East.
There Are Practical Steps Catholic Health Care Facilities Can Take to
Emphasize Their Religious Roots
Identity and mission are central concerns of every Catholic health system.
Although there are many ways to approach these concepts, "sacramentality" is
an essential constituent. A sacramental way of life lies at the very roots of
the faith. "No theological principle or focus is more characteristic of Catholicism
or more central to its identity than the principle of sacramentality,"
according to theologian Fr. Richard McBrien.1
My purpose here is to suggest strategies to enhance Catholic sacramental identity
through ritual, art and design, personal presence, and visible witness.
Although American Catholics readily remember the old Baltimore Catechism definition
("an outward sign instituted by Christ to give grace"), the church today understands
sacrament more personally. Grace is a relationship between the human person
and God. Grace is the gift of divine life itself, the gift of friendship with
God, as the Catechism of the Catholic Church puts it (paras. 1,468 and
1,997). Thus understood, grace is an essential part of the wholeness and healing
of body, spirit, and relationships essential to health care.
Catholic sacramental identity grows from the Incarnation. The man, Jesus,
who is at the same time God the Son, reveals the transcendent God as a Father
of love and compassion. One way to say this is that Jesus is the sacrament of
God. Jesus is the perceptible sign of God's love, the embodiment of God's compassionate
grace. Because he has ascended to his Father, Jesus commissions the church to
be the visible sign, the sacrament, of his salvation. Persons, actions, and
objects of the church, therefore, are sacramental when they signify the presence
of God's grace. This picture of the world is the heart of sacramentality, an
insight as necessary for health care as for other dimensions of Catholic life.2
Because God took on human flesh, the divine can become present in physical
things; matter touches spirit. "The sacraments are perceptible signs (words
and actions) accessible to our human nature. By the actions of Christ and the
power of the Holy Spirit they make present efficaciously the grace they signify"
(Catechism, para.1,084). Catholic theology does not limit the scope of
sacramentality to the seven sacraments; it recognizes many "sacramentals" (medals,
statues, prayers, and holy cards) that extend the sacramental perspective into
the routines of daily life. There is, moreover, a sacramentality that "blesses
and enhances what the world, through God's grace, already has"; for example,
the healing arts.3 Therefore, if the church
is to be fully sacramental, its health care (and other) institutions are to
be places where patients, employees, physicians, and visitors experience God's
grace—places of personal encounter with God.
Symptoms of Loss, Symptoms of Hope
"Payment arrangements must be made in advance." If this is the first sign
visible in a physician's office or an emergency room, what does it communicate?
When the material environment emphasizes finances, it erects a barrier between
the person and the experience of grace. Of course, employees must be paid; supplies
cost money; capital improvements cannot wait indefinitely. Nevertheless, when
an experienced nurse of my acquaintance, who is now working in a for-profit
specialty hospital, describes leaving her previous job in a Catholic hospital
"because the first item on the agenda of any meeting was cost saving instead
of patient care," there is a danger to Catholic identity.
Modern medicine itself is another barrier to signs of grace. Health care today
is often "high tech, not high touch." It is more difficult to experience God's
grace in a machine than in the warmth of a doctor's voice or a nurse's hand.
As important as medical invention is for the healing mission, the current prominent
idea of infinite medical progress subtly undermines Catholic identity. Medical
progress points toward success in this world, rather than toward God. When trust
is placed in the latest pharmaceutical or the latest medical device, hope in
the divine becomes obscure. Moreover, some medical "progress" (embryonic stem
cell research, in vitro fertilization, contraceptive devices) conflicts with
Catholic teaching.
Yet there are grounds for hope. Technologically advanced Catholic hospitals
are also leaders in personal forms of health care, such as hospice services,
pain management, health promotion, and disease prevention.4
Catholic health care leaders define mission as healing, service to the poor,
advocacy for justice, and respect for human dignity. These mission commitments
do not exist only in frames on hospital walls. They permeate the culture of
Catholic institutions. Every day, doctors, nurses, and technicians place the
good of patients ahead of reimbursement. Every day, medical vans visit those
without insurance in homeless shelters, poor rural communities, and church parking
lots. Yet, a richer sacramental identity is possible.
Ritual
There are a number of ways Catholic health care organizations might renew
their sacramental dimension. Ritual is one. Rituals communicate and embody meaning.
Take a simple example: two alternative rituals for arriving home from work.
(1) I enter the door, go to my study to unpack my briefcase, check the mail,
and turn on the computer. Then I head for the family room where I greet my wife.
(2) I enter the door, go to the family room, and greet my wife. We talk for
awhile, and then have a glass of wine and dinner. Later, I go to the study,
unpack my briefcase, check the mail, and turn on the computer.
Rituals are not limited to church settings; they evolve naturally in all areas
of life. Medicine is full of them: taking vital signs, narrating the history,
admitting patients to the hospital, and discharging them. Standard ways of doing
things evolve; and they communicate a—sometimes intended, sometimes unintended—meaning.
Rituals can be profound (those surrounding death) or ordinary (tooth brushing).
Leaders can plan rituals, or they can allow rituals to evolve without direction
or purpose. Rituals directly shape the character of the people involved (worshipers,
for example), but they affect others indirectly (the way parishioners interact
with fellow citizens after Mass, for example).
Health facilities have dozens of rituals that subtly communicate messages
to employees, patients, and visitors. Most of the time management and staff
are not consciously aware of such rituals, but the rituals suffuse the institution
nonetheless. Think about the words and actions that surround direct medical
care: the choreography of the operating room, the physical examination, or the
movements and gestures in the imaging center. Think about the rituals of hospital
routine: shift changes, announcements, record dictation. Think about the rituals
of staff and management meetings, celebrations of employee arrivals and departures.
Most often we work with rituals already embedded in our institutions, striving
to shape them more closely to mission and identity. However, some can be consciously
designed. A Catholic hospital in the southwestern part of the country broadcasts
a short prayer service by mission leaders at fixed times each day. Hospitals
(Catholic and other-than-Catholic) have begun to "script" regular interactions.
For example, a mandatory question on leaving a patient's room: "What else can
I do for you now?" A Catholic hospital system on the East Coast suggests scripts
for its senior managers for their regular rounds. These scripts embody core
values. One CEO, for example, after asking of a harried nursing supervisor the
scripted question, "Is there anything else I can do to help you do your job?"
was surprised by the answer: "Yes, you can feed Mrs. Smith in Room 326." The
hour that CEO spent feeding an elderly and demented patient communicated mission
more effectively than any number of pronouncements from on high. That hour was
the result of a rounds ritual devised by the CEO's system.
Mission leaders might well spend a couple of weeks simply observing ritual
interactions throughout their facilities, taking inventory, and discerning meaning.
What do the interactions communicate? Do the rituals affirm positive Catholic
identity? Do they detract from mission? Do these rituals distance staff from
patients and family, or do they bridge distance? Do they assert control by staff
over patients or by one part of the staff over others? Do they communicate hope
or indifference?
The answers to these questions and the responses to these answers by mission
leaders and senior management can begin a sacramental renewal of Catholic health
care.
Art and Design
With its "smells and bells," Catholicism understands that environment
communicates meaning. Statutes and sculptures, crucifixes and posters, tapestries
and mosaics can be profoundly therapeutic for spirit and body, as recent research
documents.5 It does not matter whether the
visual elements of a health facility are relatively spare or relatively ornate;
what matters is that they are designed to be healing, expressive of identity,
and beautiful.
Lobbies and waiting rooms in Catholic facilities typically feature art and
design to fulfill these purposes. However, even these locations are too often
sterile and visually unappealing. Patient rooms typically have a cross or crucifix,
but often little else. Admitting and discharge offices, corridors, recovery
rooms, and intensive care units (ICUs) vary widely in their visual detail. Some
facilities devote a good deal of attention to them; others equip them with nothing
beyond the functional elements necessary for administrative or medical efficiency.
One major problem today is that areas that once welcomed patients and visitors
often are no longer the customary places of entrance. Because hospital expansions
have added emergency rooms (ERs), clinics, and parking garages, patients and
visitors now enter from many directions into different parts of the facility.
The old lobby, once the visual center of the hospital, now may be off the beaten
path. The new entrances may be cramped, disorienting, and devoid of religious
symbols.
It does not have to be this way. For example, the bridge from the garage of
a Catholic hospital in a major eastern city leads directly to a spacious lobby
with large and prominent tapestries communicating the history of its founding
congregation in that city. This hospital designed a creative solution to the
prominence of the parking garage.
What about the garage itself? What does it communicate? Does it welcome visitors
and patients, or is it merely utilitarian? My own university, faced with the
need to construct its first parking garage, spent extra money to make it (astonishingly)
both attractive and compatible with the surrounding architecture. The only Spanish
Renaissance parking garage I have ever seen, it communicates visually the identity
of our university as fully as do the academic buildings.
Presence and Touch
People, not things, communicate sacramentality best. Even ritual, although
always embodied in persons, is by its nature general. The ritual is the same
no matter who participates. Presence and touch, however, are always particular
and personal. The secular world today realizes the importance of presence. Wal-Mart
has its "greeters" in every store.
Presence and touch communicate the care of one particular person for another
particular person. They speak of God's presence and the assurance of grace.
Consider the CEO story above from this perspective. A letter to Commonweal
magazine testified eloquently to the sacrament of presence. According to the
letter's writer, a recent Commonweal article
reminded me of the special care I received at Saint Francis Hospital in
Roslyn, New York. Here are two examples. . . .
I was checking in at dawn for surgery when a Brother John greeted me: "How
about this: Here's an Old Roman going to pray for an Episcopalian being operated
on by a Jewish surgeon." I replied, "Here I would hope we are all one." Brother
John said, "Of course we are," and I went upstairs with a lighter heart. .
. . Another year, I was lying in a corridor waiting for an angiogram, and
feeling twitchy. A young nurse walked past, then turned and started to talk.
"You'll get in soon," she said. "The process isn't as bad as some may have
told you. . . . You live in Port Washington? That's a nice town." This sustained
me through a time when I needed help. The nurse did not have to take time
for me. She gave more than duty called for."6
The machinery of modern health care threatens to relegate personal presence
to the margins. In the physical examination, the CAT scan too often replaces
the stethoscope and the physician's diagnostic (and healing) touch. Intravenous
equipment, tubes, and electronic monitors restrict movement and communication.
Medical facilities, therefore, must work especially hard to ensure personal
presence and physical interaction.
We might take a tip from Wal-Mart. How about recruiting volunteers (or part-time
employees) with the requisite interpersonal skills to simply be present (and
not behind desks!) in such high-anxiety areas as ERs, ICU and cardiac care unit
waiting rooms, and neonatal intensive care units? Most fitting would be retired
religious women and retired physicians and nurses, who could offer not only
presence and a comforting word but also reassurance and information about confusing
and frightening medical procedures.
Visible Witness
The three forms of sacramentality I have mentioned are primarily internal,
focused on the life and structures of the medical facility itself. Sacramentality,
however, also looks outward; it represents the mission and identity of Catholic
health care. In this representation, it connects with Catholic social teaching
and the church's responsibility to be a transforming presence in the community.
Catholic health care must be a visible witness to the society that "here
is healing; here is hope; here is a passion for justice." CHA's Fr. Michael
D. Place, STD, refers to this aspect of sacramentality when he describes Catholic
health care's lived faith as built and sustained by "its public icons and
symbols."7
Sacramental witness links public and private life, often through individual
heroic actions of health care workers that become public knowledge, or through
institutional decisions (for example, refusal to perform certain procedures
or decisions to keep open an unprofitable but crucial community service).
It is relatively easy to see how individual persons can embody sacramentality;
institutions have a more difficult, but not impossible, task. Location is one
clear way that institutions walk with the poor and neglected. The choice of
a Catholic hospital to remain open in a medically underserved inner city instead
of relocating to a more lucrative suburb is a clear case. Institutional commitment
to its surrounding culture is another way; that commitment might be shown in,
for example, the ease with which an illiterate, Spanish-speaking person can
enter a hospital and find someone to talk to, someone who empathizes with her
problem and attends to the ensemble of her financial, personal, medical, emotional,
and spiritual needs.
Two engagements constitute sacramental witness. The first is with those social
groups whose wounded humanity reveals the presence of Christ; for example, persons
with AIDS, immigrants, the uninsured, residents of colonias, and the
neglected aged. This recognition is vital for sacramental identity, for it establishes
members of those groups not as victim groups (the temptation of the political
left) or as irresponsible individuals (the temptation of the political right)
but as alter Christi (other Christs). Such discernment calls forth personal
caring and medical attention. Yet the fact that particular social groups tend
repeatedly to have unmet needs prompts institutional creativity. This may take
the form of residential centers for the mentally ill, clinics in the colonias,
mobile primary care vans sent to visit immigrant neighborhoods, new religious
communities committed to staffing new forms of elder care centers, and so forth.
The second engagement is advocacy that flows from this solidarity. First of
all, the fact that particular groups, rather than simply random individuals,
have unmet health care needs signifies a failure of the common good and, most
likely, a violation of principles of justice and human dignity. Solidarity is
the virtue of commitment to the common good. Therefore, Catholic institutions
and activists will involve themselves in lobbying, opinion formation, and other
forms of public activity to redress wrongs and to include all people fully in
the life of the community. This will mean support for universal health insurance
coverage, programs that provide continuity of care for the elderly, and public
outreach to enroll all eligible people in Medicaid.
Both of these engagements make the church's witness visible in the community,
witnessing the core principles and commitments of mission and identity.
Ask the Hard Questions
Catholic health care is sacramental. Catholic health care can be more sacramental.
Sponsors, boards, and management must ask hard questions of their institutions.
Are there standard medical or institutional rituals that distance and dehumanize
patients and families (and staff)? What can we do to make our facilities more
personal, more human?
In the area of the visual, there are many opportunities for making Catholic
facilities more sacramental. Sponsors, boards, and management should tour their
facilities, walking in the shoes of first-time patients and families. What do
they see, hear, and smell? Do these sights and sounds draw them into a community
of healing, or scare them away?
Finally, in the arena of visible witness, Catholic health care already does
a great deal to identify unmet needs and promote social justice, but this identity
is never complete. New needs, new marginal groups, and new challenges regularly
emerge. Taking stock of the institution's visible witness to mission and identity
is a ceaseless task.
NOTES
- Richard P. McBrien, Catholicism,Orev. ed., HarperCollins,
New York City, 1994, p. 1,196. Emphasis in original.
- See Catholic Health Association, "The Dynamics of Catholic
Identity in Healthcare: A Working Document," St. Louis, 1987.
- Dennis M. Doyle, Communion Ecclesiology, Orbis Books,
Maryknoll, NY, 2000, p. 22.
- Clarke E. Cochran and Kenneth R. White, "Does Catholic
Sponsorship Matter?" Health Progress, January-February 2002, pp. 14-16,
50.
- Wayne Ruga, "A Healing Environment, by Design," Modern
Healthcare, October 23, 2000, p. 24.
- Loring W. Batten III, letter to the editor, Commonweal,
April 21, 2000, p. 36.
- Michael D. Place, "Faith and Public Policy" (the inaugural
Cardinal Bernardin Lecture), Elmhurst College, Elmhurst, IL, October 26, 1998.
See also Michael D. Place, "Elements of Theological Foundations of Sponsorship,"
Health Progress, November-December 2000, pp. 6-10.
Copyright © 2003 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.