Cases in Genetics: Commitment to the Poor and Business Development

November-December 2003

This is the sixth of a series of case studies, prepared for Health Progress by the staff of CHA's Theology and Ethics Department.

St. Francis Medical Center is a 400-bed community hospital in an affluent suburb of a major city. The hospital also serves a rather large and quite poor Hispanic population on the outskirts of its service area. Most members of this community are uninsured or underinsured. Hence, it has been very difficult to get them to make use of the services of the hospital and of the associated physician group in a timely way. Because of poor preventive care and delays in receiving needed care, patients from this community tend to be more seriously ill when they finally see a physician or come to the emergency department.

Two family practice physicians from the hospital have had informal conversations with community leaders and the mayor about starting up an outreach clinic in the community. The idea was received enthusiastically, and the mayor offered city funds for the start-up and operation of the clinic, provided that the hospital also committed resources. The two physicians have drawn up a proposal and submitted it to the hospital CEO. Among other things, they request that they each be allowed to work part-time at the clinic and that the hospital contribute $200,000 to the clinic's start-up and $300,000 annually to its support.

The CEO is moderately interested. Such a project, after all, would be in line with the organization's much publicized mission statement: "We answer God's call to foster healing, act with compassion, and promote wellness for all persons and communities, with special attention to our neighbors who are poor, undeserved, and most vulnerable."

However, he also has another proposal on his desk—from the oncology group and genetics department at the hospital. It wishes to start up, in collaboration with the hospital, a specialty oncology hospital that would not only provide the latest technology but also conduct cutting-edge genetics research and offer a very active program of susceptibility testing for various forms of cancer, in particular, breast, ovarian, and colon cancer. The oncologists believe that an aggressive testing program would attract many individuals in the region (especially private-pay individuals and those whose insurance covers susceptibility testing) for the testing itself and also for follow-up care and possible treatment down the road for those who develop cancer. They see this as potentially very lucrative for themselves and an excellent investment for the hospital. The hospital would be part owner and share in the profits.

The other pressing reason for the specialty hospital is that another oncology group in the region apparently is considering doing the same thing. The St. Francis group has several advantages: Most of its oncologists trained at a very prestigious university, they are very active researchers and tops in their specialties, they are doing a large number of experimental protocols, and they tend to admit a high proportion of their patients to the hospital; and St. Francis itself has a very capable genetics department. The group is looking for considerable capital from the hospital to build the specialty clinic. Its leaders have insinuated that if the hospital chooses not to participate in this venture they will look elsewhere.

Questions for the Board
What factors would go into making a decision about this situation?

How would the organization's mission and values enter in?

How much weight would be given to the organization's mission and values?

Which consideration(s) would be decisive in resolving the situation?

What course of action would you—as a board member concerned with fidelity to the organization's mission and values as well as with strategic planning and good business development and the organization's bottom line—recommend? Why?

Questions for Executive Management
What factors would go into making a decision about this situation? How would the organization's mission and values enter in?

How much weight would be given to the organization's mission and values?

Which consideration(s) would be decisive in resolving the situation? Why would you consider them to be decisive?

What course of action would you recommend? Why? How does this course of action fit with the organization's mission and values?

How would you explain your decision to the relevant parties? To management and staff?

Questions for the Ethics Committee
How would you describe the ethical issues in this situation?

What moral values/principles have relevance in addressing this case? How would the organization's mission and values be relevant?

If the CEO were to request the ethics committee's guidance regarding how to deal with this situation, what would you recommend? Why? What would be potential of the option(s) not chosen? Are they acceptable from an ethical perspective? From a mission perspective? From a business perspective?

Does your organization have criteria or a process for addressing these kinds of situations?

Guiding Ethical Principles
The following principles are intended to provide some moral guidance to discussions of the questions above. They are not exhaustive of the principles that might be relevant to the case and to the various questions raised. They should, however, be of some help.

A statement of the mission and values of the organization should play a central role in these discussions as well.

  • Care for Poor and Vulnerable Persons ýecause Jesus had a special affection for poor and vulnerable persons, Catholic health care should "distinguish itself by service to and advocacy for those people whose social condition puts them at the margins of our society and makes them particularly vulnerable to discrimination" (Directive 3, Ethical and Religious Directives for Catholic Health Care Services1). Catholic health care is characterized by its efforts to alleviate the conditions that perpetuate the structures of poverty and vulnerability in society.
  • Act on Behalf of Justice Because justice is an essential component of the Gospel, Catholic health care strives to create and sustain right relationships both within the ministry and with those served by the ministry. Toward this end, Catholic health care attends to basic human needs for all (including accessible and affordable health care) and seeks structures that enable the full participation of all in society, the equitable distribution of societal resources, and the contribution of all to the common good.
  • Solidarity Because we are made in the image of a triune God, we are social by nature. The fundamental relationality with others implies responsibilities to others. At minimum, we should not harm them. Optimally, we ought to seek their good.
  • Distributive Justice Societal goods and resources should be distributed equitably.
  • Common Good Because of our social nature, we ought to contribute to the creation of "conditions of social life which enable individuals, families, and organizations to achieve complete and efficacious fulfillment."2 In this light, health care organizations ought to contribute to the public good in part by seeking to improve the health status of the community.
  • Respect Human Dignity Because we believe that each person is made in the image and likeness of God, we ought to treat others with profound respect and utmost regard.
  • Beneficence Our decisions and actions ought to contribute to the well-being of others.
  • Nonmaleficence Our decisions and actions should not harm others.
  • Economics in the Service of People While seeking profit is certainly a legitimate goal of economic decisions, policies, and institutions, they must ultimately be in the service of all people, especially the poor.
  • Stewardship Health care resources should be delivered and used prudently, efficiently, effectively, equitably, and in a manner that reflects professional standards of quality.

NOTES

  1. Ethical and Religious Directives for Catholic Health Care Services, U.S. Conference of Catholic Bishops, Washington, DC, 2001, pp. 9-10.
  2. "Gaudium et Spes," in Austin Flanery, ed., Vatican Council II: The Conciliar and Post-Conciliar Documents, vol. 1, Costello Publishing, Northport, NY, 1975, section 74.

RESOURCES

Cahill, Lisa, "The Genome Project: More Than a Medical Milestone," America, August 12-19, 2000, pp. 7-13.

Cahill, Lisa, "The New Biotech World Order," Hastings Center Report, March-April 1999, pp. 45-48.

Emmanuel, Ezekiel, "Justice and Managed Care: Four Principles for the Just Allocation of Health Care Resources," Hastings Center Report, May-June 2000, pp. 8-16.

Hamel, Ron, "Genetic Research: Putting Justice to the Test," Chicago Studies, November 1994, pp. 240-251.

Hofmann, Paul, and Nelson, William, eds., Managing Ethically: An Executive's Guide, Health Administration Press, Chicago, 2001.

Lebacqz, Karen, "Fair Shares: Is the Genome Project Just?" in Ted Peters, ed., Genetics: Issues of Social Justice, Pilgrim Press, Cleveland, 1998, pp. 82-107.

Mehlman, Maxwell, and Botkin, Jeffrey, Access to the Genome: The Challenge to Equality, Georgetown University Press, Washington, DC, 1998.

National Conference of Catholic Bishops, Economic Justice for All, U.S. Catholic Conference, Washington, DC, 1986.

> 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

  1. Richard P. McBrien, Catholicism,Orev. ed., HarperCollins, New York City, 1994, p. 1,196. Emphasis in original.
  2. See Catholic Health Association, "The Dynamics of Catholic Identity in Healthcare: A Working Document," St. Louis, 1987.
  3. Dennis M. Doyle, Communion Ecclesiology, Orbis Books, Maryknoll, NY, 2000, p. 22.
  4. Clarke E. Cochran and Kenneth R. White, "Does Catholic Sponsorship Matter?" Health Progress, January-February 2002, pp. 14-16, 50.
  5. Wayne Ruga, "A Healing Environment, by Design," Modern Healthcare, October 23, 2000, p. 24.
  6. Loring W. Batten III, letter to the editor, Commonweal, April 21, 2000, p. 36.
  7. 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.

 

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