BY: FR. MICHAEL D. PLACE, STD
Fr. Place is president and chief executive officer, Catholic Health Association,
St. Louis.
In a previous column ("A
Tale of Two Reports," Health Progress, May-June 2004), I reflected
on two Institute of Medicine reports, Insuring America's Health and Crossing
the Quality Chasm, pointing out the essential relationship between the issues
of access and quality.1 I also pointed out
how, as ministry gathered and engaged, we are addressing both of these topics.
Finally, I highlighted some of the ethical resources that are available to assist
and guide us in our efforts.
After writing that column in early February, I joined our then board chair,
Rich Statuto, in making visits to and engaging in discussions with the leadership
of several of our systems. As always, I was impressed by the passion and vision
of these ministry colleagues. I also was struck by how, in one way or another,
the issues of access and quality were raised. And, as regards quality, I was
struck by how each system was taking its own unique approach to advancing the
quality agenda. Clearly, the history, philosophy, and resources of each system
influenced what its leaders determined to be their approach to advancing the
quality agenda.
In several of these discussions, a new theme or topic for reflection emerged.
Though expressed in different ways, the theme went something like this: How
should our being Catholic distinguish our quality efforts? There was a concern
that our efforts needed to be pursued for more substantial reasons than merely
preserving market share or avoiding legal and regulatory sanctions. This line
of reflection was taken to a new level when, on several occasions, it was suggested
that what was needed was a theology of excellence. To be honest, I was
a bit taken aback by the proposal. The proposal appealed to me at an intuitive
level, but, at a rational level, it was not at all clear to me how one might
begin to construct such a theology.
As a result of this perceived complexity, I put the matter on the "back
burner." However, over the course of the intervening months the question
has surfaced again and again in various venues: Is there anything distinctive
about our quality efforts?
The question of distinctiveness is not a new issue. For example, Cardinal Joseph
Bernardin addressed it nine years ago this October in his pastoral letter, A
Sign of Hope. When viewing the question of distinctiveness from the perspective
of the patient, he proposed that: "Our distinctive vocation in Christian health
care is not so much to heal better or more efficiently than anyone else; it
is to bring comfort to people by giving them an experience that will strengthen
their confidence in life."2
I continue to believe that, from a theological perspective, providing the possibility
of hope in the midst of the chaos that is so much a part of sickness and dying
should be a distinctive aspect of Catholic health care. Our public perception
research also indicates that those we serve appreciate this differentiation.
People describe Catholic hospitals as "more caring" in their approach
to patients. In a 2003 nationwide phone survey, six out of 10 respondents listed
compassionate care as a top-tier quality-care issue — and added that the
primary difference they perceived between Catholic hospitals, on one hand, and
community or university hospitals, on the other, was the compassion offered
at Catholic facilities. As one focus group participant put it, "[Catholic
hospitals] also care about you as a person, not just as a patient." And
when focus group participants consider other aspects of the care continuum,
they immediately connect Catholic care at nursing homes or long-term care facilities
with greater compassion and a more caring staff. They describe a nurturing environment
that tends the emotional and spiritual needs of individuals as well as their
physical needs.
One might well ask, however, Can a sense of hope be provided if patients, their
families, and our communities cannot trust that the health care we provide is
safe and effective? In other words, without a bond of trust can we be a "sign
of hope"?
Bond of Trust
As I move into the reflection that follows, I want to emphasize its tentativeness.
In many ways, what follows is an attempt at "first impression" theologizing.
My hope is that these reflections might encourage others to a richer and more
helpful theological grounding — or, to say it another way, to a better appreciation
of the theological imperatives that should guide and inform us as we build and
nurture a bond of trust between patient and provider, whether that provider
be a single clinician or the health care institution.
In organizing a response to the question "Can we be a sign of hope without
a bond of trust," I would suggest that it will be helpful to return to a distinction
I introduced in my column in our last issue.3
Reflecting on ministerial leadership, I proposed that the "how" of Catholic
health care can be distinguished from its "why," even though these two dimensions
are essentially interrelated. The "why" of the ministry — its purpose — is
noted by the transcendence of proclaiming the presence of the Reign of God through
healing. The "how" of being about that healing is quite incarnational: It is
practicing both the art and science of 21st-century health care. I introduced
this distinction because I wanted to propose that the theological grounding
for creating and maintaining a bond of trust might not be the same for both
the "why" and the "how" of Catholic health care.
The "How": Our Service
In recent years, we have come to speak of Catholic health care as having two
foci: service and transformation. In many ways, our service is provided through
the "how" of modern health care delivery, characterized by its many technological
and pharmacological advances. When reflecting theologically on how health
care is provided and on what is necessary for there to be a "bond of trust,"
the Catholic tradition has much in common with secular ethics. For example,
the imperative "Do no harm," expressed theologically as "beneficence," would
"involve the obligation to present and remove harms and to promote the good
of a person by minimizing the risks incurred to the patient and maximizing the
benefits to them and to others. Beneficence includes nonmaleficence, which prohibits
the infliction of harm, injury, or death upon others."4
Similarly, the virtue of justice would require that each person be given his
or her due as well as that they be treated fairly and equitably. Clearly a patient
would expect that, in health care delivery, he or she is "due" (entitled
to receive) safe, high-quality services. A grounding for these requirements
would be the inalienable dignity of each person.
As rich as the categories of beneficence, justice, and human dignity are, the
Catholic tradition would enrich them further with the category of the common
good, which is understood as the sum of these conditions necessary for individuals
(and communities) to flourish. Similarly, the categories of distributive justice
(the fair, equitable, and appropriate distribution of resources) and social
justice (the establishment and defense of economic, political, and social structures
that uphold the dignity of all) would be considered.5
In a way, these theological categories provide the ethical building blocks
for what is necessary if the "how" of Catholic health care is to make
possible a sense of trust: doing no harm, treating fairly, empowering dignity,
making possible human flourishing, distributing resources equitably, and advocating
just social structures.
However, I and many others would argue that these categories are not uniquely
Catholic, but, rather, are "natural" to the proper provision of health
care wherever and by whomever it is provided. In a way, they are essential to
providing well-ordered health care; without them, trust is not possible.
As true as that assertion might be, it also is true that in a way these categories
can be seen as being somewhat minimalist. Returning to Crossing the Quality
Chasm, I note that one of its most provocative observations is that the
higher quality of care it proposes cannot "be achieved by further stressing
current systems of care."6 "In some cases,"
the report goes on, "achieving this ideal will require crossing a large chasm
between today's system and the possibilities of tomorrow."7
This proposition invites us to wonder whether these ethical elements just outlined
are sufficient to motivate or compel the crossing of that chasm. Similarly,
can there be a real bond of trust without crossing the chasm?
I believe one could argue that the answer to both of these questions is a resounding
"no." As important and helpful as these categories are, they lack
a sense of moral urgency. In a sense, they are liable to be viewed as isolated,
distinguishable categories that compete for moral ascendancy. Absent coherence
of vision, there is reason to fear that the fundamental change and systemwide
reform for which many are calling — reform that results in safe, high-quality
health care delivery — will not be achieved.
Perhaps part of what is being asked for under the title "a theology of
excellence" is the coherence of ethical vision about the "how"
of health care delivery necessary to propel us across the quality chasm. To
excel is to go beyond. What will take us beyond the minimal, essential though
it is, to establish the bond of trust necessary if we are to be signs of hope?
Covenant
To be honest, I am somewhat at a loss as to what that "excellence,"
that coherence might look like. As I write, I am reminded of a similar struggle
Cardinal Bernardin had when preparing his 1995 address to the American Medical
Association House of Delegates. What image could serve as a foundation for a
renewal of physician practice?
His answer was to propose "renewing the covenant with patients and society."8
He chose the image of the covenant because it speaks of "moral obligations — as
opposed to legal and contractual obligations — because they are based on
fundamental human concepts of right and wrong."9
(See also Sr. Juliana M. Casey, IHM, and Richard F. Afable, MD, "Contract
or Covenant?")Without reviewing the specifics of how Cardinal Bernardin
developed this insight, I would suggest that he was seeking to provide a much-needed
depth to the understanding of the relationship of the physician with patients
and society. It is this same type of depth, of beyond-ness, of excellence, that
it seems all of health care delivery is in need of today.
I am not certain the image of covenant is the sole answer. But it might be
helpful. Where Webster defines covenant as "a formal, solemn, and binding agreement,"
the Old Testament provides a much richer understanding. Though in the Hebrew
Scriptures "covenant" does signify a legal agreement between
two persons or parties, it also has a theological meaning, signifying the relationship
of the people of Israel to God. One definition of this aspect of covenant, speaking
of the relationship of Yahweh and Israel at Mount Sinai, calls it a "divine
constitution given to Israel with promises on conditions of obedience and penalties
for disobedience."10 While "covenant" appears
hundreds of times in the Old Testament, perhaps three examples from the Pentateuch
will advance our reflection.
- Genesis 9:11: "I will establish my covenant with you, that never again
shall all bodily creatures be destroyed by the waters of the flood."
In essence, Yahweh is making to Noah here a "first-do-no-harm" covenant.
- Genesis 17:7: "I will maintain my covenant with you and your descendants
after you throughout the ages as an everlasting pact, to be your God and the
God of your descendants after you." The Abrahamic covenant defines relationship:
You (Israel) will be my people, and I (Yahweh) will be your God.
- Deuteronomy 7:11: "You shall therefore carefully observe the commandments,
the statutes and the decrees which I enjoin on you today." The Sinai
covenant seals the earlier definition of roles by delineating particular duties
and responsibilities for maintaining the relationship.
So the overall covenantal aspects are, first, do no harm; second, define our
relationship/roles; and, third, outline each other's specific duties and
responsibilities. Viewed in context, these examples provide a definition greater
than the sum of their parts. Ultimately, the Old Testament covenant establishes
an irrevocable bond of trust between unequal parties. Yahweh, the source of
all being and meaning, extends to the previously sinful, unfaithful, and often
weak people of Israel that which they cannot claim or earn: the promise of unwavering
fidelity. Though as God Yahweh can do anything, because of the Sinai covenant
God is no longer able to harm or abandon the unequal partner, Israel. The infinite
One is bound forever in a special relationship that will last until the end
of time.
In the New Testament, "covenant" finds deeper meaning. Through the
mystery of the Incarnation, God freely enters time in order that humanity might
realize its God-given potential. And how is that possible? Salvation is achieved
by another act of generosity, the ultimate generosity of sacrificial love. In
Jesus, human life is given away in order that we might be saved.
What does all this say to Catholic health care? I would suggest that it turns
the focus from what the patient is due to what we are obliged to provide.
One must, without accusing the health care provider of self-idolatry, agree
that he or she is clearly in a "power position" vis-à-vis the
patient, most especially when the patient is ill or dying. Patients come to
us in need of that which they cannot provide themselves. They expose themselves
to us in their vulnerability.
And what response is most appropriate? Clearly, the legal elements of a contractual
relationship are a first step: You will not be intentionally harmed, you will
receive care, and your share of the common good will be made available to you.
Is this response fully commensurate with the vulnerability and risk taken by
the patient? Cardinal Bernardin felt it was not. He proposed that a far deeper
response was required. By analogy, he suggested that our response ought to be
to establish a covenant with those we serve. In a way, we limit our freedom
by binding ourselves to the well-being of those we serve — a bond whose fullest
understanding is achieved through the lens of sacrificial love.
In light of this description of covenant, does it seem unreasonable to propose
that a covenantal attitude of fidelity and sacrificial love would nurture a
bond of trust adequate for us to be a sign of hope? I leave that question to
others to answer, but it does seem that a shift to a covenantal attitude would
be a necessary first step toward creating a theology of excellence. Rather than
ask what our contract requires of us, we ask: How must we act in order that
the well-being of the other might be realized? What does "fidelity"
mean in the provision of health care? And, when it becomes necessary: What must
I sacrifice in order that a patient might be cared for properly?
If this tentative theological musing meets the test of further analysis, then
we would not begin with a discussion of safety and quality, but rather with
the requirement of fidelity that is marked by the radical beyond-ness of sacrificial
love.
The "Why" — Transformation
In discussing what would serve as the elements of a theology of excellence for
the how of our ministry, we have suggested moving from a contractual to a covenantal
perspective. Although the content of that particular discussion was guided by
the Hebrew and Christian faith experience, a covenantal perspective also could
be developed by utilizing more secular categories. In fact, one could argue
inductively that, for most of human history, the ethics of healing or health
care have been more than contractual. Perhaps that is why the AMA House of Delegates
responded to Cardinal Bernardin's remarks with such affirmation. The cardinal
named something that was in danger of being lost when health care becomes a
commodity managed by a contract, rather than a service, a gift, which is in
the context of a unique relationship. Unlike others of good will, who might
resonate with such a "secular" covenant perspective, we are a people
of faith who are called and gifted to be about the healing mission of Jesus
Christ. We are the sacramental presence of the healing touch of Jesus in today's
world.
And what is that healing touch? We know that, with rare exception, it is not
the miraculous touch of Jesus experienced by those he healed during his ministry.
It is a much deeper and more profound healing to which we witness — the world
of sin has been conquered and God's reign is in our midst. Rather than seeing
what is not, we see what has already transpired and what, in God's "time," will
be realized. Our Easter/Pentecost faith requires us, in a sense, to read the
Scriptures backward. It is in the almost unintelligible Book of Revelation,
the Apocalypse, that we gain perspective on all that has and will transpire.
Pope John Paul II spoke of this in his September 15, 2004, audience. He said,
"The Lord has established his reign, intervening in history with supreme authority.
Though God has entrusted mankind to be free to generate good and evil, history
has as its ultimate seal the choice of divine providence. No matter what storms,
wounds and devastation are wrought by evil, the book of the Apocalypse celebrates
the end toward which history is guided through the efficacious work of God."11
Our sacramental witness in Catholic health care is, in fact, to transformation;
it is to witness to the "efficacious work of God." Without succumbing
completely to the rhetorical flourish of homiletics, one can well question whether
the way we provide health care, which includes the well-documented quality chasm,
truly witnesses to the "efficacious work of God." This thought might
lead us to ask what — if we were to view Catholic health care from the perspective
of witnessing to God's reign — would we do differently? Obviously, answering
this question would be another Health Progress article (if not several).
I would suggest, however, that the manner in which we would engage in such reflection
could provide much-needed content and depth to a theology of excellence vis-à-vis
the transformational, the "why" dimension of Catholic health care.
Filling the Quality Chasm
In summary, it is possible to construct a foundational theology of excellence
for Catholic health care. As regards the "how" of Catholic health
care, our pursuit of excellence would emerge from a change of perspective from
the what-is-due-the-patient? position to one that causes us to ask, What does
our covenantal relationship require us to provide to the patient? Covenantal
fidelity and sacrificial love would compel us to fill up the quality chasm.
As for the "why" of Catholic health care, because we are a sacramental
witness to God's efficaciousness, our delivery of health care should mirror
that efficaciousness. Again, we would be motivated always to be about more rather
than less. And even when the more we desire cannot be achieved, we always will
experience an unsettledness, a sense of urgency, that will motivate us to continue
searching for the desired goal. A theology of excellence would have the coherence
of a covenantal perspective and the urgency of making real the Reign of God.
In the end, we would pursue quality and safety in a distinctive manner because
we would stand in a different place: a place "beyond" the minimum
expectations of justice. We would look back into the delivery of health care
with an eye of the Reign of God. Could there be anything more excellent?
NOTES
- Institute of Medicine, Insuring America's Health, National
Academies Press, Washington, DC, 2004; Institute of Medicine, Crossing
the Quality Chasm: A New Health System for the 21st Century, National
Academies Press, Washington, DC, 2001.
- Joseph Bernardin, A Sign of Hope: A Pastoral Letter on Healthcare,
Office of Communications, Archdiocese of Chicago, and the Catholic Health
Association, St. Louis, 1995, p. 5.
- Michael D. Place, "Ministry Leadership Development: A New Pilgrimage,"
Health Progress, September-October 2004, pp. 6-9, 57.
- Peter A. Clark, "Medication Errors in Family Practice, in Hospitals
and After Discharge from the Hospital: An Ethical Analysis," Journal
of Law, Medicine & Ethics, vol. 32, 2004, p. 355.
- Clarke.
- Institute of Medicine, Crossing the Quality Chasm, p. 4.
- Institute of Medicine, Crossing the Quality Chasm, p. 5.
- Bernardin, "Renewing the Covenant with Patients and Society,"
in Selected Works of Joseph Cardinal Bernardin, vol. 2, Alphonse P.
Spilly, ed., Liturgical Press, Collegeville, MN, 2000.
- Bernardin, "Renewing the Covenant," p. 246.
- F. Brown, S. Driver, and C. Briggs, A Hebrew and English Lexicon of the
Old Testament, Clarendon Press, Oxford, England, 1951, p. 136.
- Carol Glatz, "Despite
Evil, God's Plan Leads toward People's Redemption, Says Pope,"
Catholic News Service, September 15, 2004.
Copyright © 2004 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.