A Response to Rev. Richard A. McCormick's Article On the Preservation of Catholic Hospitals
Fr. O'Rourke is director of the Center for Health Care Ethics, Saint Louis University Health Sciences Center, St. Louis.
Summary
In "The Catholic Hospital Today: Mission Impossible?" (Origins, March 16, 1995, pp. 648-653), Rev. Richard A. McCormick, SJ, STD, questions whether Catholic hospitals can continue their missions in a society with so many factors and influences that seem to oppose efforts to perpetuate the healing ministry of Christ.
As Fr. McCormick states, the matrix of good medicine is centered on the good of the individual. But too often, the patient has been considered an individual isolated from others. The rights of families, people who belong to the same insurance program, and the society funding much of healthcare must also be considered.
Fr. McCormick points out that an obstacle to the healing mission arises because healthcare is often treated as a business instead of a service. If not-for-profit healthcare facilities come to exist for the well-being of the shareholders, as do for-profit healthcare facilities, then a perversion of values results. This should lead us to renounce for-profit healthcare and the behavior that some Catholic health organizations have borrowed from the for-profit sector.
In addition, Fr. McCormick calls attention to our society's denial of death and tendency to call on medicine to cure personal, social, or economic problems. This denial-of-death phenomenon helps us realize the need for the mission of Catholic hospitals.
Continuing the mission of Catholic hospitals will require the attention of all involved in them — physicians, trustees, nurses, administrators, and ancillary personnel. These healthcare providers must not be distracted from the mission by joint ventures and economic issues.
Everyone even remotely involved in the mission of Catholic healthcare should read the thoughts of Rev. Richard A. McCormick, SJ, STD, in regard to the problems facing Catholic hospitals ("The Catholic Hospital Today: Mission Impossible?" Origins, March 16, 1995, pp. 648-653). Fr. McCormick questions whether Catholic hospitals can continue their missions in a society with so many factors and influences that seem to oppose efforts to perpetuate the healing work of Christ. Echoing the words of Charles Dougherty of Creighton University, Fr. McCormick questions whether we can save the souls of Catholic hospitals "as they maneuver through a competitive minefield" (p. 653).
Fr. McCormick's article has two distinct parts. Part one explains the importance of forming a culture for any common endeavor. For Catholic hospitals, Fr. McCormick describes the culture in this way: "The Catholic hospital exists to be Jesus' love for the other in the health care setting" (p. 649). More specific descriptions of the Catholic culture have been offered by the National Conference of Catholic Bishops' recent revision of Ethical and Religious Directives for Catholic Health Services (1994) and by recent documents, such as Setting Relationships Right (1994), published by the Catholic Health Association. Hence, people in Catholic healthcare have an adequate knowledge of the goals and objectives that pertain to creating a Catholic culture in hospitals.
The more challenging aspect of Fr. McCormick's thoughts is contained in the second part of his article. There he describes the context in which healthcare is delivered and lists some key characteristics of this context (see "The Context in Which Healthcare is Delivered" at the end of this article). He then questions whether continuing the mission of Catholic hospitals is possible. Surprisingly, he does not mention the difficulty that arises from the moral code of Catholic hospitals.
Reaction
Fr. McCormick's summary of the threats to the Catholic healthcare mission is challenging, even frightening. How should we in Catholic healthcare react? Some people say Fr. McCormick's summary is overdrawn or of doubtful merit because he is an academic instead of a person involved in the everyday delivery of healthcare. In my opinion, however, Fr. McCormick's observations are accurate. Indeed, I could cite even more glaring trends in society and in the provision of healthcare. Moreover, Fr. McCormick's position as a concerned and objective commentator on moral issues in America is beyond challenge.
The question remains, however, in light of the characteristics he has outlined: Is the mission of Catholic hospitals possible? In this article I consider factors that underlie the various observations contained in Fr. McCormick's article and thus offer a different perspective in regard to Catholic hospitals' viability.
Changes in Financing and Provision of Care
Many of Fr. McCormick's concerns spring from changes in the financing and provision of healthcare. Thus, when he discusses healthcare's depersonalization and secularization, Fr. McCormick cites the changes that:
- Have occurred and will occur in technology
- Arise from efforts at cost containment
- Occur in the patient-physician relationship
My response to these observations is straightforward. I agree that depersonalization and secularization are dangers, but I do not agree that the dangers are anything new to the healthcare context, nor are they a result of changes in the provision of medical care.
Fr. McCormick and many people he quotes imply that in the recent past there was a "golden age" of medicine, characterized by fee-for-service payment. During this golden age, concern for the patient as an individual was a result of physician autonomy. Physicians were kind and compassionate and did not allow technology or other entities to interfere with patient relationships. Finally, compensation for physician services was of minor importance.
I do not believe medicine ever had a golden age. Many of the changes being introduced, such as managed care, the loss of physician autonomy, and involvement of third parties, are not necessarily harmful.
Managed Care If one reads between the lines, the experts Fr. McCormick quotes seem especially incensed with managed care as a means of financing and providing healthcare. But managed care per se need not lead to patient neglect or physician dissatisfaction. It has not in most managed care cases with which I am familiar. Moreover, most managed care systems have more built-in safeguards for patient satisfaction and high-quality care than the so-called golden age's fee-for-service model. Finally, some of the changes associated with managed care — such as an emphasis on preventive care, outcome studies to set therapeutic standards, and use of outpatient procedures — are long overdue and should not be considered as deterrents to Catholic healthcare.
Physician Autonomy I also question the article's various statements that bemoan the loss of physician autonomy. Many of the shortcomings of today's U.S. healthcare system can be traced to physician autonomy. Setting priorities for healthcare without regard for the common good is the result of physician autonomy. Consider, for example, that 40 million people in the United States do not have adequate access to healthcare, yet the medical profession places top priority on the development of organ transplant technology.
The Good of the Community
The involvement of other groups, such as insurance companies and government agencies, in the provision of healthcare also need not be feared. In some sense, the vocal presence of other entities is a beneficial sign that the nation is beginning to realize the social nature of humans and of healthcare.
As Fr. McCormick states, the matrix of good medicine is centered on the good of the individual. But too often, the patient has been considered an individual isolated from others. The rights of families, people who belong to the same insurance program, and the society funding much of healthcare must also be considered.
Should funds be expended on keeping an anencephalic infant alive indefinitely when thousands of young children cannot afford to be immunized against contagious diseases? As a society, we are just beginning to debate whether those who fund healthcare should have some say in determining how funds are expended. Our resources are limited; individual care will therefore be limited. Fundamentally, a limitation to an individual's right to healthcare is not an injustice. Rather, it is a recognition of our finite power and finite existence.
Business Versus Service
Although some factors Fr. McCormick mentions may not weaken the mission of Catholic healthcare, others cause intense concern. Fr. McCormick points out that an obstacle to the healing mission arises because healthcare is often treated as a business instead of a service. In an attempt to drive down prices through competition, a new concept of healthcare was instituted during the 1980s: Hospitals became profit centers, patients became consumers, and healthcare professionals became providers. For-profit hospitals and physician groups became popular. However, if not-for-profit healthcare facilities come to exist for the well-being of the shareholders, as do for-profit healthcare facilities, then a perversion of values results. A healthcare professional working in a for-profit facility can still provide Christlike care as an individual, but the organization's goals and objectives are simply contrary to the mission of healthcare.
Fr. McCormick's observation, along with Card. Joseph Bernardin's statement on for-profit healthcare ("The Case for Not-for-Profit Health Care," Origins, January 26, 1995, pp. 538-542), should lead us to renounce both for-profit healthcare and the behavior that some Catholic health organizations have borrowed from the for-profit sector.
Denial of Death
In accord with other observers, Fr. McCormick calls attention to our society's denial of death and tendency to call on medicine to cure personal, social, or economic problems. These observations are true and could have been drawn out even further. Induced abortion, for example, does nothing for a woman's bodily health, yet the U.S. Supreme Court determined in Roe v. Wade (1973) that a woman has a legal right to abortion only if a physician approves it.
The denial-of-death phenomenon in our society helps us realize the need for the mission of Catholic hospitals. As the newly promulgated Ethical and Religious Directives state: "A Catholic health care institution will be a community of respect, love, and support to patients or residents and their families as they face the reality of death."
A Dedicated and Energetic Effort
Fr. McCormick has posed a challenging question. Many of the characteristics he mentions arise because of needed changes in the financing and provision of healthcare. Others are seriously detrimental and, although not new, more prevalent than in the past.
Continuing the mission of Catholic hospitals will require a more dedicated and energetic effort. Moreover, this effort will require the attention of all involved in hospitals — physicians, trustees, nurses, administrators, and ancillary personnel. They must not be distracted from the mission by joint ventures and economic issues. Such a challenge brings to mind the words of French novelist Leon Bloy: "The great gift of the present time is that no one can afford to be lukewarm."
THE CONTEXT IN WHICH HEALTHCARE IS DELIVERED
The mission of Catholic hospitals is threatened by certain characteristics of our society, Rev. Richard A. McCormick, SJ, STD, maintains in his recent article, "The Catholic Hospital Today." These characteristics include:
- A depersonalized atmosphere that springs from a dependence on technology and efforts to control costs.
- Secularization of the medical profession, resulting from the emphasis on such factors as competition and financial gain. These factors contradict the values that make healthcare a human service.
- The emergence of public partnerships and public morality in the provision of healthcare. This development, Fr. McCormick claims, will lead to the demise of patient-centered healthcare. As other institutions and organizations become involved in healthcare, hospitals' objectives and priorities are likely to be confused and misdirected. Society at large and groups such as health maintenance and preferred provider organizations will bring different values and goals to the provision of healthcare. Writes Fr. McCormick: "It requires no stretch of the imagination to see how deleteriously such values can impact the professional culture of medicine" (p. 651).
- The market-driven healthcare system. By market driven, Fr. McCormick means "institutions whose existence and policies are heavily dictated by the economic factor" (p. 651). The goal of some hospitals, as well as the vocabulary used in making decisions (e.g., downsizing, market share, networking, acquisition, capitation), bespeaks a purely economic ethos.
- The cultural denial of mortality, that is, the effort to organize healthcare in such a way that it implies the denial of death. This denial of death can be seen in, for example, the overuse of intensive care units and the prolonged maintenance of patients in a persistent vegetative state by means of artificial hydration and nutrition.
- A perverted notion of health and healthcare, with an emphasis on curing, or acute care, to the detriment of compassion, or palliative care. Moreover, the notion of disease or illness has been expanded to classify as a medical problem any inability to function well in society. Medicine historically has been concerned primarily with bodily function.
In our day, medicine becomes responsible for manipulating the body to alleviate or eliminate any social and creative dysfunction. Fr. McCormick notes that a good deal of surgery is performed to remove wrinkles, enlarge breasts, "in brief, to conform to someone's notion of the attractive and eventually of the tolerable" (p. 652).
- Hospitals' loss of status as the center of healthcare. Many procedures formerly performed in hospitals are now provided through outpatient centers or home health programs. Fr. McCormick sums up this phenomenon (p. 653) by quoting American Medical News: "In virtually every area of medicine, the hospital is becoming less and less necessary. A growing number of services are being delivered just as well or better on the outside, and it's cheaper to boot" (January 9, 1995, p. 11).
Copyright © 1995 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.