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BY: RON HAMEL, Ph.D., and MICHAEL PANICOLA, Ph.D.

Dr. Hamel is senior director, ethics, Catholic Health Association, and Dr. Panicola is corporate vice president, ethics, SSM Health Care, both in St. Louis.

Is it morally permissible for Catholic health care organizations (CHCOs) to be involved with and support the activities of philanthropic organizations (POs) such as Susan G. Komen for the Cure, the March of Dimes, and the Juvenile Diabetes Research Foundation? This question arises frequently these days, especially during those times of the year when many such POs conduct fundraising activities. The question itself may seem strange to readers not familiar with the issue given that these POs and many others have praiseworthy mission statements, often aligned with those of CHCOs, and accomplish enormous good by way of advocacy, education, community outreach, funding for local programs, and for research directed toward the prevention and treatment of devastating illnesses.

However, the POs noted above and several others have also been accused of supporting in various ways procedures that are contrary to church teaching, such as pre-implantation genetic diagnosis; prenatal testing followed by abortion; research using aborted fetal tissue; human embryonic stem cell research; contraception; sterilization; and physician-assisted suicide. So much variation exists among the POs regarding their association with morally prohibited activities; it is not possible to give a univocal response to the question above. Each situation must be evaluated. However, it is possible to offer a general moral assessment, as well as a tool that can be employed to evaluate specific instances of a CHCO's involvement with a particular PO.

Since what is at issue in these situations is a claim of "cooperation in wrongdoing," we begin by offering a general description of the principle of cooperation. Then, we consider the Susan G. Komen for the Cure and assess the nature of a CHCO's involvement with Komen in light of the principle of cooperation. We conclude with a brief discussion of the larger theological issue at stake in these situations, namely, the relationship of the church to the modern world.

The Principle of Cooperation
The principle of cooperation is a time-honored principle in the Catholic moral tradition used to assess the moral permissibility of one party's involvement or cooperation (the cooperator) with another party engaged in serious wrongdoing (the principal agent). In this context, "wrongdoing" refers to various actions prohibited by the church as those outlined above. Some types of cooperation are morally permissible when there is sufficient moral distance and serious enough reasons, while others are not. When the person cooperating intends or approves the wrongdoing of the other, the cooperation is said to be "formal." Formal cooperation is never morally permitted because it is essentially a willingness to do what is judged to be morally wrong (e.g., approving of human embryonic stem cell research). The occurrence of the wrongdoing ought never to be the object of one's choice. It is unlikely that a CHCO would be involved in formal cooperation with any given PO because typically its involvement is centered on the good objectives.

When the person cooperating contributes something to the wrongdoing — whether directly or indirectly — the cooperation is said to be "material." Whereas formal cooperation occurs at the level of intention, material cooperation occurs at the level of action. If the cooperator's contribution to the wrongdoing of the principal agent is indistinguishable from or essential to it, the cooperation is said to be "immediate" (e.g., providing funding for human embryonic stem cell research). Immediate material cooperation is generally not morally permissible. In such instances, the cooperator is intimately involved in the wrongdoing of the principal agent. It is unlikely that a CHCO would be involved in immediate material cooperation with any given PO because typically a CHCO does not contribute in essential ways to the wrongdoing itself.

If the cooperator's contribution to the wrongdoing of the principal agent is distinguishable from it and not essential to its occurrence, the cooperation is said to be "mediate," which can be morally permissible for a proportionate reason¹ (e.g., funding educational programs related to a particular disease that have nothing to do with a PO's support of human embryonic stem cell research). If a CHCO is involved in any level of cooperation at all with POs, it would most likely be at this level of mediate material cooperation, whether it is proximate or remote.

Another element must be considered in any assessment of cooperation and that is what is referred to as "scandal," which is a technical theological term. It does not mean offending someone's ideological positions or moral sensibilities or tender conscience. Rather, as defined by the Catechism of the Catholic Church, "scandal is an attitude or behavior which leads another to do evil" (#2284). It is an attitude or action that leads another to engage in wrongdoing. It is conceivable that a CHCO's involvement with a PO that publicly and strongly supports physician-assisted suicide or human embryonic stem cell research, for example, could lead to confusion about the church's teaching or could diminish the importance of the church's teaching for some individuals, thereby contributing to their own wrongdoing. A more likely consequence might be a weakening of the CHCO's witness to life and the impact that it could have on people in the community and within the organization it. This is a matter for careful discernment and much vigilance among the leaders of the organization. Very often, though, scandal can be avoided with good communication regarding the nature of the CHCO's involvement with the particular PO.

An assessment of the possibility of scandal, however, should not be limited to the wrongdoing in question. Scandal, in the true sense, can occur not only from cooperating with another engaged in wrongdoing, but also from refusing to cooperate, thereby sacrificing other important goods. This flip-side of the coin is generally not considered in assessments of scandal. Yet, sacrificing certain goods can also lead others into sin, whether sins of omission or commission. This consideration is critical to any balanced assessment of a CHCO's cooperation with a given PO. In some instances, what the Catholic provider does not do can be even more subject to scandal than what it does do. Too often, it seems, the possibility of scandal is exaggerated. Instead of taking steps to avoid the possibility of scandal by offering public explanations (if, in fact, they are needed at all), the CHCO is forbidden from being involved with and supporting the PO with little or no consideration of unintended consequences.

Susan G. Komen for the Cure
Having briefly described the principle of cooperation, we now want to use an example to illustrate how the principle might be applied to the issue at-hand. Before doing so, when using the principle of cooperation in assessing a CHCO's cooperation with a PO, it is necessary to address two levels of concern: whether the PO is cooperating in the wrongdoing of another organization, and, if so, how and to what extent; and whether the CHCO's cooperation with the PO is morally acceptable. Typically one need not address these two levels of concern when assessing cooperation because one need only consider the relationship between the cooperator and the principal agent. However, we really have three parties: the CHCO which is a cooperator; the PO that is also a cooperator because it is not itself engaged in wrongdoing but supporting another's wrongdoing; and the wrongdoer or principal agent who is actually carrying out the wrongdoing. Thus, with this issue CHCO's, unlike traditional cooperators, are already one step removed from the wrongdoing.

One of the POs most targeted of late is Susan G. Komen for the Cure, which is said to have ties to Planned Parenthood, one of the nation's primary providers of abortion services. For example, it is claimed that in 2003, 21 local Komen affiliates awarded grants to Planned Parenthood chapters for a total of $475,000 (out of $38.4 million raised across the country for community grants).² The further claim is that grants given to Planned Parenthood are used to "support Planned Parenthood's agenda of death and deception" and to "swell bloated Planned Parenthood's bulging 'not for profit' coffers."³ In response to such claims, some bishops have forbidden CHCOs and other Catholic organizations within their dioceses from participating in any activities associated with Komen.

Established in 1982, Komen has become the largest grass-roots network of breast cancer survivors and activists worldwide. The organization is dedicated to: promoting earlier detection through breast health education and breast cancer screening; funding research to prevent and treat cancer; advocating at the local, state, and federal levels for increased funding for breast cancer research, treatment, and prevention; and providing support and assistance to women with breast cancer.

Much of Komen's fundraising and programming is done locally. One hundred twenty-five affiliates across the country and more than 100,000 breast cancer survivors and activists promote the organization's goals. The affiliates sponsor fundraising events and provide non-duplicative, community-based grants for education, screening, and treatment of breast cancer, especially for the medically underserved. Each affiliate works with local medical experts and community leaders to conduct a comprehensive community needs assessment. The resulting community profile establishes the grant application and review processes.

Two types of grants exist that are awarded at the community level. STEP grants are awarded to organizations within the community for screening, treatment and education, especially for medically underserved populations. CRAFT grants fund clinical research in the local area, particularly projects that employ effective strategies to overcome barriers to enrollment and retention in clinical trials. Preference is given to research protocols aimed at racial and ethnic minorities not adequately represented in cancer research efforts.

It is at the affiliate level that Komen has some connection to Planned Parenthood. The national office has no known relationship to Planned Parenthood. Some local affiliates, in some calendar years, do fund grant proposals submitted by Planned Parenthood. These grants are awarded on the basis of the criteria established by the local community and affiliate. Generally, they are directed at providing breast health services for underserved women. In some areas, Planned Parenthood may be the only source of free or low-cost women's health screening services (e.g., pap smears, mammograms, etc). All the Planned Parenthood grant proposals that are funded are concerned with breast health education and screening, or with the prevention and treatment of breast cancer. In addition, several other factors need to be considered in any moral assessment of cooperation between Komen and Planned Parenthood:

• Planned Parenthood must submit grant proposals like any other organization
• Planned Parenthood proposals must meet the established criteria
• Some grant proposals are funded, others are not
• Grants are highly restricted; the funding must be used for the purposes stated in the grant proposal
• Bi-annual reports must be submitted to the local affiliate to provide an accounting that the program goals are being met
• Grants awarded to Planned Parenthood are a very small percentage of the total number of grants awarded by any local affiliate in any given year
• The relationship of the local Komen affiliate to Planned Parenthood is no different than its relationship to other community organizations, including CHCOs which often receive funding for specific programs.

Before considering whether the cooperation between CHCOs and Komen is morally licit, it is first necessary to consider the cooperation between Komen affiliates and Planned Parenthood. What is the moral object in this instance of cooperation? It would seem that the moral object in these situations is to fund a project that will provide breast health services to underserved women. The moral object would seem to be "good." In fact, it has no relationship to the wrongdoing itself, though some would argue that by providing funds to Planned Parenthood for breast health services, Komen is "freeing up" money for abortions. No evidence exists that this is the case.

Is Komen's cooperation formal, that is, does it approve the wrongdoing of Planned Parenthood, namely, abortions? Evidence is not available to prove this. Komen has taken no public stands with regard to abortion or the claimed right to an abortion. Is the cooperation, then, material? It is surely not "immediate material." The nature of the Komen affiliate's relationship to Planned Parenthood is such that it is not involved in or providing anything essential to the performance of abortions. Might the cooperation, then, be "mediate material" cooperation? The Komen affiliate does not provide any non-essential elements to the provision of abortions, thus there does not seem to be even mediate material cooperation, at least not proximate. If anything, there might possibly be some remote mediate material cooperation (e.g., women who go to Planned Parenthood for breast services might pick up information on abortion services). In fact, the Komen affiliate is not cooperating with wrongdoing, but is cooperating with a wrongdoer in the pursuit of something good.

Having determined Komen's level of cooperation in wrongdoing, we now need to consider whether it is morally licit for a CHCO to cooperate with Komen. The moral object here will vary depending on the nature of the involvement. For the purposes of this analysis, let us assume that the moral object consists in sponsoring a team to run in Komen's Race for the Cure, which takes place in various locales to raise funds for Komen affiliates. The moral object is at least neutral, if not good. Is there formal cooperation? This is highly unlikely. The CHCO is not intending or approving any wrongdoing on the part of Komen (or Planned Parenthood for that matter). Is the CHCO engaged in material cooperation with the Komen affiliate, either immediate or mediate? No cooperation exists in wrongdoing at all, primarily because the Komen affiliate is not involved in any wrongdoing, at least knowingly. Hence, the CHCO is contributing nothing to wrongdoing, because there is no wrongdoing. The fact that some Komen affiliates, at times, provide funding to Planned Parenthood specifically and solely for breast health services cannot on the face of it is construed as wrongdoing. This is all the more true in those cities where the local Komen affiliate has not funded and does not fund Planned Parenthood projects. If there is any cooperation at all (and we do not believe there is), at most, it would be remote material cooperation which, as the Catholic tradition teaches, can be justified for a proportionate reason. The good that Komen does and the harm that would come to so many women if Komen ceased to exist or ceased to be funded would seem to be a sufficiently proportionate reason.

If there is no cooperation with wrongdoing on the part of the CHCO, what about the possibility of scandal? Would the fact that a Catholic provider collaborates with an organization some of whose local affiliates sometimes fund a community project by Planned Parenthood, aimed at breast health services for poor women, likely lead others into sin? This is truly difficult to imagine! What seems more likely is that a public decision not to collaborate with Komen because of its very loose and remote connection to Planned Parenthood would itself create scandal. It could lead to a misunderstanding of the Gospel and diminish faith in the church and its leadership.

The Church in the World
Beyond the question of whether CHCOs can be involved with POs that may support another in wrongdoing is a much broader theological issue with far-reaching implications. That issue is the relationship of the church to the modern world and the responsibility individual Catholics, Catholic organizations, and the church itself has to work for the transformation of the social order. It seems that an underlying presupposition of those who argue against CHCOs cooperating with POs like Komen is the belief that the church and its members ought not to be involved with others (individuals or institutions) who support or engage in actions judged to be seriously immoral. Not only does this seem unrealistic, but also contrary to the spirit of the Gospel. The fact is the church exists in a sinful world. The only way Christians would be able to keep their hands totally clean and attain the level of moral purity that some seem to be calling for is to retreat from that world. This is not the Catholic tradition, nor is it the Gospel.

Jesus did not isolate himself or walk away from wrongdoers. His mission was precisely to wrongdoers (which is all of us in various ways and to various degrees) as is so well exemplified in the Parable of the Lost Sheep (Luke 15:1-7). Jesus was known to eat with tax collectors and sinners (Matthew 9:10-11; Mark 2: 15-16; Luke 5:30; 7:34). And his talking with the adulterous Samaritan woman at the well and accepting a drink of water from her was, ultimately, transformative of her (John 4:1-29). The instances of Jesus associating with wrongdoers are numerous. This is what Jesus was about. It was core to his mission and is core to the mission of his followers.

The Second Vatican Council's "Pastoral Constitution on the Church in the Modern World" underscores this mission. In the words of the council: "[T]he Church seeks but a solitary goal: to carry forward the work of Christ Himself under the lead of the befriending Spirit. And Christ entered this world to give witness to the truth, to rescue and not to sit in judgment, to serve and not to be served" (#3). Elsewhere in the same document, it is said that the "Church has a single intention: that God's kingdom may come, and that the salvation of the whole human race may come to pass" (#44) and that "through her individual members and her whole community, the Church believes she can contribute greatly toward making the family of [human persons] and its history more human" (#40).

Contributing to the humanization of all people and helping to bring about the kingdom of God cannot occur by retreating from the world or from those involved in or somehow associated with wrongdoing. Christians must be in the world if they are to have any hope of helping to transform the world; indeed they have a special responsibility to do so. The council made this abundantly clear in stating that Christians "are not only bound to penetrate the world with a Christian spirit, but also are called to be witnesses to Christ in all things in the midst of human society" (43). A posture of retreat, or isolation, or "keeping our hands clean," or "being morally pure" not only leads Christians astray from their true mission as Christians but smacks of a certain degree of arrogance. It fails to recognize that all of us human persons and all of their institutions are at once graced but always in need of redemption and transformation.

Conclusion
As a ministry of the church called to witness to Christ in all things, Catholic health care and the various organizations that make it up must engage the world, and collaborate with others in hopes of transforming the world. This necessarily means that CHCOs will have to rub elbows with those who may not espouse all of its beliefs or may not live up to all of its values in every situation. Without question, CHCOs must avoid unacceptable forms of cooperation and be vigilant about the possibility of scandal. However, by adopting an excessively rigid stance and not cooperating with POs because they may be involved in some wrongdoing on some level, CHCOs would be absenting themselves from efforts to prevent, treat, and cure a host of serious diseases and medical conditions, and assist those affected by them and their families; miss opportunities to witness to their own values and moral convictions; and fail to provide any kind of transformative influence.

NOTES

1. A "proportionate reason" is a sufficient reason. The closer the mediate material cooperation is to the wrongdoing, the weightier or graver must be the reason in order for there to be "sufficient" reason or a proportionate reason. In other words, mediate material cooperation that is proximate to the wrongdoing must have a weightier reason in order to be morally permissible than if it were remote.
2. Eve Sanchez Silver, "The Susan G. Komen Breast Foundation's Affair with Planned Parenthood," Access Presentation: www.stopabortionbreastcancer.org/denver_silver060930.pdf. Produced by Clear Research, www.clearresearch.org.
3. Silver, p. 20. See also p. 44 where Ms. Silver claims that the "Susan G. Komen Breast Cancer Foundation is paying into Planned Parenthood's seek and destroy mission." On p. 49, she claims that between 2002 and 2003, Planned Parenthood's abortions increased by 14,000 while breast exams decreased by more than 141,000.

Reflective Process for Assessing Catholic Health Care Organizations' Involvement with Philanthropic Organizations

The questions below have been designed to help leaders within Catholic health care organizations assess whether it is acceptable to be involved with, and participate in, the activities of a philanthropic organization accused of cooperating in the wrongdoing of another individual or institution. These questions address two levels of concern, namely: whether the philanthropic organization promotes and/or supports the wrongdoing of another individual or institution and if so, how, and to what extent; and the nature of the Catholic health care organization's involvement with the philanthropic organization, the possibility of scandal because of this involvement, and the presence of a proportionate reason that may justify the involvement. The following questions are based on the assumption that the philanthropic organization is not itself performing the wrongdoing. For simplicity, PO = philanthropic organization, CHCO = Catholic health care organization, wrongdoing = actions contrary to Church teaching, and another = individual or institution.

Questions for Reflection

Assessing the PO's cooperation in wrongdoing

1) Does the PO openly and publicly promote or advocate for the wrongdoing? If so, does the PO's advocacy constitute a central part of its mission and does it dedicate a considerable amount of resources toward this end?
For example, the PO has taken an official and very public stance in favor of human embryonic stem cell research and has made this a major part of its advocacy agenda. The more public the PO's support of the wrongdoing and the more central to its mission, generally the more difficult to justify the CHCO's involvement with the PO.

2) Does the PO provide support to another engaged in wrongdoing?
For example, the PO provides grant money to individual researchers or institutions that actively participate in human embryonic stem cell research. Support of individuals or institutions engaged in wrongdoing on the part of the PO is not itself a non-starter but it should raise concerns and lead to further exploration as to the nature of that support.

3) Does the PO's support contribute in essential ways to another's ability to carry out the wrongdoing?
For example, the PO provides a significant amount of funding to individual researchers or institutions for the explicit purpose of conducting human embryonic stem cell research. The more essential a PO's support is of an individual or institution engaged in wrongdoing for this end, generally the more difficult to justify the CHCO's involvement.

4) Does the PO's support contribute in non-essential ways to another's ability to carry out the wrongdoing?
For example, the PO provides grant money to individual researchers or institutions for reasons other than conducting human embryonic stem cell research or any other wrongdoing. The less essential a PO's support is of an institution engaged in wrongdoing for this end, generally the easier to justify the CHCO's involvement.

Assessing the CHCO's cooperation in wrongdoing

5) Does the CHCO's support contribute in essential ways to a PO that promotes wrongdoing and/or supports the wrongdoing carried out by another? (Note: if the PO is not engaged in this type of activity or relationship, then the CHCO's support is not problematic.)
For example, the CHCO contributes monetary funds that the PO uses to advocate publicly for human embryonic stem cell research or to provide grant money to individual researchers or institutions for the explicit purpose of conducting such research. The more essential the CHCO' s support is of a PO that promotes wrongdoing and/or supports the wrongdoing carried out by another, generally the more difficult to justify its involvement, especially if there are not carve-outs for directed contributions that steer money away from the wrongdoing.

6) Does the CHCO's support contribute in non-essential ways to a PO that promotes wrongdoing and/or supports the wrongdoing carried out by another? (Note: if the PO is not engaged in this type of activity or relationship, then the CHCO's support is not problematic.)
For example, the CHCO participates in certain fund-aising activities for breast health services that the PO sponsors but this is in no way connected to the PO's advocacy for human embryonic stem cell research or its grant funding to individual researchers or institutions for the purpose of conducting such research. The less essential the CHCO' s support is of a PO that promotes wrongdoing and/or supports the wrongdoing carried out by another, generally the easier to justify its involvement, especially if there are no links between the support and the wrongdoing.

Assessing scandal and the presence of a proportionate reason

7) Does the CHCO's support of the PO lead to scandal?
For example, people in the community or the organization itself will be led into error in the sense that they will now promote and/or support human embryonic stem cell research. If the CHCO's support of the PO leads to scandal in the true sense, then it is very difficult to justify its involvement.

8) Is there a proportionate reason for the CHCO's support of the PO?
For example, the good the PO is doing (e.g., breast health for underserved women, eradicating birth defects, supporting research for debilitating illness) outweighs its promotion of the wrongdoing and/or its support of another engaged in wrongdoing.

Common Scenarios and General Guidelines

After collecting the information to the questions on page 50, leaders should try to determine which scenario best relates to the situation at-hand. Following each scenario are some general guidelines regarding whether a CHCO can be involved with a given PO.

• The PO openly and publicly promotes and advocates for the wrongdoing (formal cooperation). The CHCO will be hard-pressed to justify its involvement with the PO if its advocacy efforts for the wrongdoing are central to its mission and the PO contributes considerable resources toward this end.
• The PO openly and publicly promotes and advocates for the wrongdoing and provides essential support to another engaged in wrongdoing for the specific purpose of carrying out the wrongdoing (formal and immediate material cooperation). The CHCO will be hard-pressed to justify its involvement with the PO in this type of scenario.
• The PO provides essential support to another engaged in wrongdoing for the specific purpose of carrying out the wrongdoing (immediate material cooperation). The CHCO may licitly be involved with the PO provided that: the PO's support of another engaged in wrongdoing is not central to its mission and it does not direct substantial funds for the carrying out of the wrongdoing; the CHCO's support can be directed away from the wrongdoing and toward the good the PO is ultimately trying to accomplish; the CHCO's involvement does not lead to scandal; and a proportionate reason is present.
• The PO provides non-essential support to another engaged in wrongdoing for reasons other than carrying out the wrongdoing (mediate material cooperation). The CHCO may licitly be involved with the PO provided that scandal can be avoided and a proportionate reason is present.
• The PO is not promoting wrongdoing in any way and does not support others individuals or institutions engaged in wrongdoing (no cooperation). The CHCO may licitly be involved with the PO.

Copyright © 2008 by the Catholic Health Association of the United States.
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