BY: JOHN A. GALLAGHER, Ph.D.
Dr. Gallagher is corporate director, ethics, Catholic Healthcare Partners, Cincinnati.
This essay is dedicated to the memory of Mary Kathryn Grant, friend, colleague, and mission leader.
The Catholic health care ministry is about mission, and the role of organizational ethical reflection is to encourage people in the ministry to think about the institutional performance and practice of medicine within a ministry of the Catholic Church.
By engaging a creative process that identifies the needs of people served by Catholic health care, institutions are able to mediate the healing and redeeming power of Jesus, thereby creating virtuous organizations.
To depict the mission of Catholic health care as an extension of the healing ministry of Jesus is to evoke explicitly Catholic theological language, and such language is appropriate because Catholic health care is a ministry of the Catholic Church. The church itself is the embodiment of the healing and redeeming ministry of Jesus, and the institutional ministries it has created over time need to bear witness to this fundamental reason for their existence.
The world is charged with the grandeur of God,
It will flame out, like shining from shook foil;
It gathers to greatness, like the ooze of oil
— Gerard Manley Hopkins
In the course of his presentation on "Identity and Institutions" at the 1994 Catholic Health Assembly, Fr. Bryan Hehir commented that "The Catholic Church is institutional by instinct and by nature."1 I intend, in the course of this article, to reflect on what is sometimes described as the "virtuous organization." There are a number of reasons why such a reflection should begin with some thoughts about so self-evident a comment as Fr. Hehir's.
Those reasons have to do with the connotations associated with the word "institution." In Models of the Church, Cardinal Avery Dulles, SJ, refers to the institutional model of the church as pertaining to "its visible structures, especially the rights and powers of its officers."2 The institutional structures of Catholicism provide continuity to the church over time as well as identity within a social community to its members.
Moreover, the health care ministry is, from both a theological and a sociological perspective, a preeminent example of a social institution. The health care ministry is an institutional ministry of the church. And health care delivery in the United States is itself organized in a web of complex social institutions. The provision of health services requires a corporate structure to ensure its continuity and to provide identity and purpose for its associates. The collaborative skills of physicians, nurses, technicians, and a host of other professionals and paraprofessionals are required to support the practice of contemporary medicine.
In current medical practice, the autonomy of individual providers has been altered by the demands of organizations. "Individual decision makers increasingly are being supplanted by the rules, standards, traditions and collective decision-making processes of organizations which instruct and construct institutional actions in shaping health care choices."3 In this context, the ethical performance of the organization, the performance of the system as a whole, becomes as important, if not more important, than that of individual practitioners within it. The "rules, standards, traditions, and collective decision-making process" become grist for ethical reflection.
The contemporary configuration of American health care as complex sociological arrangements is a matter of profound ethical significance. In the past, patients relied on the integrity and virtue of individual caregivers. This is the presumption of the codes of professional ethics for physicians, nurses, and other caregivers. While personal integrity and virtue remain matters of key importance, what is now of at least equal importance is the integrity and virtue of the institution, the institutional structures through which health care is mediated. The contemporary ethical exigency is for virtuous health care institutions. Thus is the stage set for the introduction of organizational ethics.
Organizational ethics is a form of applied ethics that originally was developed as a component within compliance programs by suppliers to the U.S. Department of Defense, then gradually spread throughout the business community and, more recently, within the health care industry. The common thread of such programs has been to ensure that companies were in compliance with federal law and regulation and fulfilling their corporate ethical obligations.
There are several problems associated with the notion of organizational ethics. First, there is no clear consensus concerning what organizational ethics is. For Edwin Hartman, organizational ethics is an issue of corporate culture.4 For Lynn Sharp Paine, organizational ethics is a management issue.5 Or consider this definition: "Organizational ethics is fundamentally concerned with questions of integrity, responsibility and choice."6 Or this: "Organizational ethics is the articulation, application, and evaluation of the consistent values and moral positions of an organization by which it is defined, both internally and externally."7 The other authors in this special section of Health Progress will develop some of these conceptions of organizational ethics and identify the manners in which such conceptions can be of service to the ministry. Each will be an important contribution, but leaders of the ministry need to know that there is no single model of organizational ethics that has demonstrated its superiority over the other models. In other words, there is no established "best practice."
There is a second reason to exercise caution with regard to organizational ethics programs. Organizational ethics was spawned by compliance programs. The Office of the Inspector General of the U.S. Department of Health and Human Services has co-opted the ethical term "integrity" and has applied it to settlement agreements with health care organizations. "Integrity," an attorney colleague has assured me, does not appear in Black's Law Dictionary. In a similar vein, the Sarbanes-Oxley Act of 2002 has codified in legal terms what constitutes a "conflict of interest." In both instances legal categories have supplanted those of ethics. The subtle message is that legal compliance can produce integrity and ensure ethical performance. In fact, ethics is about creating and sustaining a good order in communities that can foster the human dignity of all its members. Ethics and law ought not to be conflated or confused. Law and compliance are no substitute for ethical reflection on either the personal or organizational level. Although they are not necessarily the same thing, "organizational ethics" has a tendency to be linked in people's minds with compliance and thus with legal categories.
Finally, the Catholic health care ministry is about mission, not ethics. Ethical reflection's role in the ministry is to compel associates and leaders to think about the institutional performance and practice of medicine in Catholic health care. That is an enormous and complex task. Ensuring that patients are given authentic informed consent, resolving ethical concerns associated with end-of-life care, to say nothing of addressing issues of fairness to associates and multiple stakeholders — these are time- and energy-consuming tasks.
Engaging dialogue on ethical issues, however, also provides one with an opportunity to enter into more profound levels of human experience. Ethical reflection can heighten the awareness within the ministry of the human suffering, fears, and vulnerability that the mission strives to address. The identification and specification of such suffering and the recognition of fear and vulnerability in contemporary society are creative processes that reveal the existential needs of people in the communities served by Catholic health care. Only when that creative process is fully engaged, can the power of the healing and redeeming ministry of Jesus be mediated through institutional structures of the church. Only then can Catholic health care institutions be truly virtuous institutions. Practical theology is a resource with which the mission may be more fully articulated into the activities of the organization.
The German theologian Karl Rahner made several comments about practical theology that are immediately germane to this discussion. First, he said, practical theology is concerned with the manner in which the church orders charity through its institutional ministries.8 Practical theology is not concerned with the proper order of love in the lives of individual Christians, the subject matter of moral theology. Practical theology is in the service of the church's institutional ministries and is concerned with the manner in which the mission — the ministry as an expression of charity — is ordered to the service of people in the world.
Practical theology is "theological reflection upon the entire process by which the Church as a whole brings her own nature to its fullness in the light of both her own nature and also of the contemporary situation of the world and the Church today from a theological point of view."9 The nature of the church is to be the extension through time of the healing and redeeming mission of Jesus Christ. The ordered love of the church's institutional ministries is the expression, the mediation, of that healing and redeeming ministry. The task of articulating that mission in light "of the contemporary situation of the world and the Church" is the task of practical theology.
The work of the contemporary American theologian David Tracy aids a more detailed understanding of how reflection on the church and the world results in an articulation of the church's institutional ministries.10 Tracy begins by identifying the "Christian fact" and "common human experience" as the two sources of theology. By the "Christian fact," he means the life of the church, its theological traditions, classical texts, and the witness of the saints. He means all that is part of the history and contemporary life of the church. "Common human experience" refers to nothing other than life as it is lived in communities by women and men in the contemporary world.
Practical theology strives to identify the manner in which the healing and redeeming ministry of Jesus and the church correlate with the limit situations — experiences of finitude, sin, and ecstasy — latent within common human experience. Practical theology's goal, therefore, is to discover the ways the healing ministry can be mediated though institutional structures to correlate with the fears, anxieties, and threats of an empty existence as experienced by persons in community as well as their moments of ecstasy.
When Tracy discusses theological statements embodying Christian beliefs about the significance of Jesus for life in the world today, he refers to them as "re-presenting." Representational statements connect the healing and redeeming mission of Jesus in a language that correlates with the manner in which contemporary women and men experience finitude, suffering, sin, and ecstasy. What theology says about Jesus needs to address and engage the existential anxiety, fear, and threat of an empty existence, or to be expressive of ecstatic moments. Practical theology within the health care ministry is charged with the creation and maintenance of systems of care that mediate — re-present — Jesus' healing and redeeming mission in a manner that engages the total range of needs experienced by patients and residents.
Now all this may be elegant theology, but how does it provide concrete guidance for leaders, especially mission leaders? How, concretely and specifically, can a CEO ensure that his or her organization is prepared to effectively mediate the healing and redeeming ministry of Jesus? These issues are especially important for sponsors. The men and women who founded Catholic health care in the United States were not primarily concerned with physical healing, but, rather, with works of ordered or organized charity that may have provided health benefits to the sick but always provided the possibility of spiritual healing. The healing narratives in the Gospels, we should recall, are not primarily about physical healing; the healing narratives in the Gospels demonstrate the spiritual healing of Jesus' ministry.
Ethics, Compassion, and Mission
Catholic health care has a long history of intentional ethical reflection. In recent years, that reflection has expanded beyond narrowly clinical issues and extended into social ethics, business ethics, and organizational ethics. The most recent CHA Theology and Ethics Colloquium engaged the topic of diversity of treatment. Health Progress has recently published a series of articles on the ethical implications of genomic medicine.11 The more than 46 million Americans without health insurance have been identified by the ministry for years as an ethical issue. Hospice and palliative care programs have dedicated themselves to the identification and development of ever more adequate ways of providing for the human dignity of the dying within communities. Each of these issues can be discussed in the conventional language of ethics. They can be described as issues of justice and injustice, fairness and inequity. The sinful social structures of American health care become increasingly evident as one delves deeper and deeper into such questions. Ethical reflection frequently takes one beyond the cognitive categories of justice/injustice and fairness/inequality into the realm of human finitude, the realization of personal mortality, and concern for the meaningfulness of human existence. The human realities of suffering and vulnerability that such ethical reflection reveal can threaten to impugn human dignity.
The danger arises from allowing the consideration of ethical issues to remain on the cognitive level, thereby avoiding the sometimes painful transition to the affective and experiential levels.
There is another level of ethical reflection that, while not abandoning the cognitive, ascends to a higher level — the level of compassion or fellow-feeling. Ethical reflection reserves an important role for emotion. Emotions need not be blind passions; they can be "discriminating responses closely connected with beliefs about how things are and what is important."12 The ordered love or the healing and redeeming mission of Jesus that ought to permeate the life of the ministry are not just ideas; they do not pertain primarily to the cognitive level of human activity. Emotions link persons to what they love; they enrich human experience by revealing what is important and significant in life. When emotions such as compassion drive ethical reflection, they reveal what ethical reflection is ultimately all about — ordered love for a creation of God, the human dignity of a fellow sojourner in life, a person redeemed by Jesus Christ. Ethical reflection intensified in this manner rises to the level of religious thought and becomes theological reflection.
When people engage in compassionate ethical reflection, they risk entering vicariously into the suffering sustained by injustice. The experience of the indigent mother who fears taking her asthmatic child into an emergency room is perhaps a case in point. Does she have the communication skills that will enable her to cope with the system? Can she read? Can she comprehend a consent form? How fearful is she of a bill? Whom does she trust? Is her anxiety unfounded? Is there some sense, some meaning for her in this experience?
Or consider the experience of the vulnerable. "Vulnerability means that one is controlled by, rather than in control of, the world."13 When residents of a long-term care organization are deprived of their right to drive, or are moved to a level of care that imposes greater monitoring upon them, their vulnerability simultaneously becomes a crucial part of their experience. Compassionate ethical reflection allows one to enter into and understand some level of another person's experience of vulnerability. Whom does one trust? It is only when one vicariously enters the suffering generated by human finitude and sinful social structures — and thereby experiences the impact of finitude and sinful structures on human dignity — that one begins to truly see the specific human needs that the mission strives to address. If Catholic health care does no more than meet the physical needs of the vulnerable — but fails to minister to the person who is a bearer of human dignity — it has failed in its mission.
The health care ministry is also a setting for the ecstatic, for celebrating moments of joy and creation. The first cry of a newborn is to be celebrated. So is the moment in a waiting room in which a surgeon tells a family member that a tumor was not malignant. So is the moment when an emergency room physician tells a wife that her husband will be "all right." All these are instants in which the healing and redeeming ministry exceeds description as a physical event and lends credence to the belief that there is "some reality, some force, even some one, who speaks a word of truth that can be recognized and trusted."14
Compassion resulting from the vicarious experience of suffering and joy elicits insights into and sensitivities to how health care organizations ought to be structured in order to re-present the healing and redemptive mission of Jesus. To configure Catholic health care to meet people's fundamental spiritual needs, members of the ministry must engage in practical theology and involve themselves in what Fr. Bernard Lonergan, SJ, referred to as "creating and healing in history."15 "Creating in history" is to re-present the healing and redeeming mission of Jesus in the delivery of health care services. In this instance, creating health care institutions that can authentically and with integrity proclaim themselves instruments of the healing and redemptive mission of Jesus and the church is the goal.
Ethical reflection is not the only path into "creating and healing in history." In an organization, every intentional operation is open to the same depth of feeling that reveals the existential fears and ecstatic moments latent within common human experience. Strategic planning, budgeting,16 operations, purchasing, human resources — all are intentional operations that affect the ability of an organization to re-present the healing and redemptive ministry of the church. These processes can become more intentional and revelatory if those involved in them will simply ask: "Why are we doing this?"
The initial response to this question will likely be couched in terms of industry standards, financial indicators, or labor law. But a second, deeper response to the question "Why are we doing this?" can reveal the manner in which such decisions are (or are not) responsive to the human needs of patients, associates, and the community. Making ministry decisions in this manner is not to jettison business and clinical responsibility; it is, rather, to situate decision making explicitly within the organization's mission and to recognize those decisions' significance in shaping the ministry. Finally, like the persons the ministry would serve, the ministry too is finite, limited, and imperfect. The ministry's goal in its decision making is not the ideal or the perfect, but, rather, concrete instances of the human good that are achievable and sustainable.
The revelatory possibilities of creating an authentic health care ministry can only be made into realities by identifying the manner in which they can serve as instruments of trust, confidence, hope, and joy. The institution as a whole, the system of care — not some part, such as a mission office or pastoral care department — is responsible for re-presenting the healing and redemptive ministry.
"Creating in history" makes "healing in history" possible. Creating leads to the virtuous organization, an organization that is competent and effective in the representation of its mission and ministry. Wherever one encounters a virtuous organization, one encounters the mission. The virtuous organization is prepared to treat both body and soul — to be a healing organization, an extension of the healing ministry of Jesus. Such an organization knows its mission and lives its mission in service to individuals and communities.
To depict the mission of Catholic health care as an extension of the healing and redemptive ministry of Jesus is to evoke explicitly Catholic theological language. Yet the ministry offers its ordered love to people of all faiths and to none in particular. Many of the ministry's associates, staff, and leaders may not respond to such explicitly Christological language.
Such language is appropriate, however, because the ministry is a ministry of the Catholic Church. The church itself is the embodiment of the healing and redeeming ministry of Jesus, and the institutional ministries it has created over time need to bear witness to this fundamental reason for their existence. Further, such language strives to capture what the founders of the ministry were about and what their successors intend to transmit to the next generation. However, there are two other comments that also need to be added.
The Christology that is at the center of the ministry is an inclusivist Christology. It rejects any understanding of the meaning of the Christ that restricts that meaning to the members of any church or set of churches. Such a Christology contends that "the Christian proclamation of Jesus Christ is genuinely disclosive of all reality, is meaningful for our common existence, is central for a human understanding of the limit-possibilities of human existence."17 The Catholic health care ministry offers to all who seek its services a context of care that is responsive to their physical as well as spiritual needs.
Finally, the healing and redeeming ministry of Catholic health care stands behind and in the services it provides to individuals and communities. The Christology is not explicit or expressed directly in the touch, the word, or the gesture that offers assurance, trust, confidence, or love. The healing and redeeming ministry of Jesus is re-presented, mediated through an array of health services — at best it shines out like shining from shook foil.
- J. Bryan Hehir, "Identity and Institutions," Health Progress, vol. 76, no. 8, November-December, 1995, p. 18.
- Avery Dulles, Models of the Church, Doubleday, New York City, 1987, p. 34.
- Stanley Joel Reiser, "The Ethical Life of Health Care Organizations," Hastings Center Report, vol. 24, no. 6, 1994, p. 28.
- Edwin M. Hartman, Organizational Ethics and the Good Life, Oxford University Press, New York City, 1996.
- Lynn Sharp Paine, "Managing for Organizational Integrity," Harvard Business Review, March-April 1994, pp. 106-117.
- John A. Gallagher and Jerry Goodstein, "Fulfilling Institutional Responsibilities in Health Care: Organizational Ethics and the Role of Mission Discernment," Business Ethics Quarterly, vol. 12, no.4, October 2002, p. 435.
- Edward Spencer, et al., Organizational Ethics in Health Care, Oxford University Press, New York City, 2000, p. 5.
- Karl Rahner, "Practical Theology and Social Work," in Theological Investigations, vol. 10, David Bourke, trans., Herder and Herder, New York City, 1973, p. 351.
- David Tracy, Blessed Rage for Order: The New Pluralism in Theology, Seabury Press, New York City, 1975.
- Jeffrey G. Shaw, "An Introduction to Genetics," Health Progress, May-June 2005, vol. 86, no. 3, pp. 46-52; Judith Pratt Rossiter, "Obstetrics and Pediatrics: A Medical View, and Carol A. Tauer, "Obstetrics and Pediatrics: An Ethical View," Health Progress, July-August 2005, vol. 86, no. 4, pp. 9-13 and 13-18; Jeffrey G. Shaw, "Cancer and Genetic Medicine: A Medical View," and Carol Bayley, "Cancer and Genetic Medicine: An Ethical View," Health Progress, September-October 2005, vol. 86, no. 5, pp. 31-35 and 35-37; Jessica Blasco, "Genomics and Neurology: A Medical View," and John Paul Slosar, "Genomics and Neurology: An Ethical View," Health Progress, January-February 2006, vol. 87, no. 1, pp. 62-67 and 68-72; Jessie Hastings, "Cardiology and Genomics: A Medical View," and Jan C. Heller and Maria Wallington, "Cardiology and Genomics: An Ethical View, Health Progress, March-April 2006, vol. 87, no. 2, pp. 48-51 and 51-53; and Scott McConnaha, "Genomics and the Ministry: The Executive Perspective," Health Progress, May-June 2006, vol. 87, no. 3, pp. 56-60.
- Martha Nussbaum, Love's Knowledge: Essays on Philosophy and Literature, Oxford University Press, New York City, 1990, p. 41.
- Barry Hoffmaster, "What Does Vulnerability Mean?" Hastings Center Report, vol. 36, no. 2, March-April 2006, p. 43.
- David Tracy, The Analogical Imagination: Christian Theology and the Culture of Pluralism, Crossroad, New York City, 1981, p. 4.
- Bernard Lonergan, "Healing and Creating in History," in Frederick E. Crowe, ed., A Third Collection: Papers, Paulist Press, New York City, 1985, pp. 100-109.
- Patricia Talone, "Budgeting as Theological Reflection," Health Progress, January-February 2004, pp. 14-16; and Michael D. Rowe, "Balancing Act," Health Progress, January-February 2004, pp. 17-18.
- Tracy, Blessed Rage, p. 206.
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