Why a Habit of Discernment Is Crucial for Catholic Health Care

Summer 2022

SCOTT KELLEY, PhD, MA, HEC-C
Mission Leader, Loyola University Medical Center, Trinity Health

DAVID NANTAIS, DBe
Mission Leader, St. Joseph Mercy Ann Arbor/Livingston, Trinity Health

Why a Habit of Discernment Is Crucial for Catholic Health Care -a
Illustration by David Senior

Discernment, a deliberative process long used by Christian religious communities, has been increasingly used in business settings because of its capacity to broaden the discussion beyond technical frameworks that shape business disciplines. At the same time, however, the assumptions and practices that were foundational for religious communities in the past need to be critically reexamined to allow the tradition of discernment to enrich decision-making in contemporary Catholic health care. For this reason, Trinity Health recently updated and revised its framework and guidelines for discernment, helping to further actualize its mission and values in service to the common good.1

FRAMING THE PROBLEMS
The study of decision-making is a complex, evolving and crowded field ranging from cognitive neuroscience to psychology to management. Although its study has grown considerably over the last few decades, management scholars have also noted that increasing specialization within business disciplines has led to fragmentation, leaving executives and managers poorly prepared to make the kind of decisions that effectively respond to complex challenges. Business decisions can be hampered by premature commitments; an overemphasis on or misuse of analytic evaluations; insufficient search/investigation and innovation; investment in the wrong things; and use of failure-prone decision-making practices. The events of 2020, including the COVID-19 pandemic and the increased awareness of racial injustice, have highlighted that many of the challenges in the health care landscape can be described as "wicked" problems because they are complex, open-ended and seemingly intractable. Often there are unintended harmful consequences to any intervention, regardless of how noble the intent.2

The insight from management scholars is not that business leaders can be flawed, myopic or self-interested at times. Rather, there is humble recognition of what good decision-making requires of today's leaders who operate under great scrutiny. As the preamble to the Ethical and Religious Directives for Catholic Health Care Services describes, health care in the United States is marked by changes in clinical practice due to technological advances and by changes in the institutional and social conditions that shape the health care landscape. Furthermore, developments within the Catholic Church — including changes in religious orders and congregations, the increased involvement of lay men and women and a heightened awareness of the Church's social role in the world — complicate business decisions in a mission-driven environment. Today's health care landscape, professionally and institutionally, is far more complex than it has ever been.3 As such, strategic plans require not only a "vision" for the core business of an organization and its key business practices, but also a more "holistic assessment" of complex business environments. "When there is no vision, the people perish … ." (Proverbs 29:18 MEV) It is increasingly more difficult for today's health care leaders to connect the dots and to chart a path forward.

Pope Francis has voiced a critique similar to that of management scholars, recognizing specifically the harm to the poor and to the environment when leadership vision becomes technocratic and fragmented. For the Pope, today's problems call for a leadership vision "capable of taking into account every aspect of the global crisis" because of the deep interconnections that exist between economic, social and environmental systems.4 Today's leaders, often inundated with information, can lack wisdom that "demands an encounter with reality,"5 particularly when those encounters conflict with deeply held assumptions. Reality is bigger than ideas.6 In Let Us Dream: The Path to a Better Future, Pope Francis warns of an "existential myopia" that encourages us to defensively select what we see and to hold on to things we are afraid to release. Coupled with information pathologies such as disinformation, defamation and fascination with scandal, facts can become subservient to incomplete or misguided narratives. We must remove the log in our own eye, before attempting to "remove the splinter" from the eye of someone else. (Matthew 7:5)

Today's Catholic health care leaders navigate a fine line between the rhetorical aspirations of a Gospel vision of healing and the extraordinary demands of successfully managing health care in the 21st century. There is no blueprint or decision-making toolkit for our collective work in health care; we must "discern" what our mission requires of us in response to the particular challenges and opportunities that present themselves in the course of our ministry.

WHAT IS DISCERNMENT, AND WHY BOTHER?
Popular definitions and descriptions note that discernment can be an "individual" or a "collective" endeavor. Although there are important distinctions to be made between these different decision-making contexts, there are significant similarities worthy of consideration. First and foremost, discernment is not another decision-making tool, algorithm, technique or process alongside others. It should not add to an already crowded toolbox. Rather, discernment is best understood as a "habit of mind and practice" to better understand what our health care mission requires of us in response to the particular challenges and opportunities that emerge in the course of organizational life. Discernment can enhance a decision-making lens, tool or process by constantly inviting those who discern into a deeper, broader and more reflective relationship to the evidence gathered, the people engaged in the process and the good that is imagined.

Discernment functions like a pair of scissors that has an upper blade in ideas, language, values, mission and narrative, and a lower blade in the data.7 Its power to arrive at insights comes from its distinct capacity to collect, analyze and synthesize a broad range of ideas and facts and to interpret them in light of a common vision. At its core, discernment is about openness to experience, others, data, ideas and solutions that are often dismissed, ignored or overlooked. It serves as a contrasting optic to decision-making that is closed off prematurely in a rush to judgment. In a fast-paced, time-constrained environment, discernment invites participants into a different frame of reference. As Pope Francis described, it is a choice of courage to go out of the world of one's convictions and prejudices, to expose one's assumptions to scrutiny and to seek what we are called to do in a specific set of circumstances.

In the Catholic tradition, an "individual" discernment often refers to one's decision-making process of whether or not to enter a religious community. Religious communities in the Catholic tradition have well-established protocols so that a candidate and the community can mutually determine if entrance into the community is authentic or if there is something else driving the decision: family pressure, a mistaken notion of the realities of religious life, grief or other motivations that are not conducive to the free and generous spirit that animates communal life. Discernment is, simply put, the exercise of prudence, which Thomas Aquinas describes in the Summa Theologica as "wisdom concerning human affairs"8 or a "right reason with respect to action."9 In the context of today's workplace, individual discernment is best understood as a habit of mind and practice relevant to many aspects of work life: how to engage colleagues, how to lead a team and how to address the challenges that surface daily. In this regard, discernment does not sit alongside other tools, protocols or practices. Rather, it deepens and enriches them through the wisdom that comes from the critical reflection of experience.

"Collective" discernment refers to the decision-making process of a team that is animated by a shared vision and set of values. Inherited from decision-making models in religious life, collective discernments have been used to make significant organizational decisions.10 In Catholic health care specifically, collective discernments have been used to carefully evaluate the merits of mergers and acquisitions, the sale of property, the creation or termination of new lines of service and many other types of decisions that have a significant impact on the future of the organization. In each of these types of decisions, leadership decision-making brings into being the mission of the organization. How such decisions are made, how they are communicated and how they are implemented embody the actual values of the organization relative to the espoused values found in mission statements. Business ethics scholars have long recognized the gap that can exist between operative and espoused values, a rift that can lead to the demise of the organization itself.

In its collective context, discernment follows a set of practices that ensure multiple perspectives have been sufficiently considered and, most importantly, that the decision-making rationale is consistent with the espoused values of the organization. The more consequential the decision for the organization, the more intentional and collective the decision-making process should be. The aim of collective discernment is to ensure that stakeholder perspectives have been sufficiently considered, that the proposed course of action is supported by available evidence and that the decision is aligned with the organization's values in ways that can be clearly articulated and credibly presented. Communal discernment is useful not only for considering a new endeavor, but also for improving existing practices or operations. A habit of discernment in this context describes the ongoing effort to align vision, strategy and tactics or operations.

CONCEPTUAL FOUNDATIONS OF DISCERNMENT IN THE CATHOLIC TRADITION
Discernment has many roots in the Catholic tradition, but in the context of health care decision-making, three are most notable: it is a development of the wisdom tradition in Judeo-Christian scripture, a spiritual practice and part of the Catholic moral tradition.

Like many traditions in the ancient Near East, the Hebrew tradition included a genre of wisdom literature that collected statements by sages and wise elders about the nature of the divine and human virtue, often presenting them in narrative form, as for example, in the Book of Job. The Wisdom figure, personified as a woman, revealed the mysteries of God, made all things new, and was superior to "scepter and throne." (Wisdom 7:8) The wisdom tradition complemented the law and the prophets as part of the revealed Word of God. Christian scripture describes Mary, the mother of Jesus, as the seat of wisdom. The Gospel writers positioned Jesus in the wisdom tradition, who frequently notes that wisdom is much more than sensory data or sense perception: "Do you have eyes and not see, ears and not hear?" (Mark 8:18) The wisdom tradition describes a way of seeing reality, of conducting oneself in relation to others and of engaging the Divine.11

Discernment can also be viewed as a spiritual practice of self-integration and self-transcendence in response to ultimate values.12 Religious communities throughout Christian history have practiced discernment as a model for authentic decision-making. Among the most notable figures in this regard is Ignatius of Loyola, whose framework for discernment in The Spiritual Exercises became foundational for the development of the Society of Jesus (the Jesuits) in 16th-century Spain as part of a reform movement in early modern Catholicism.13 Many other communities of religious women and men rely on the habit of discernment to ensure that communal decisions reflect the core mission and identity of the organization. In the Quaker tradition, practices such as interior and exterior silence highlight the value placed on personal and collective experience in the context of authentic decision-making.

Discernment is also part of a complex, dialogical, dynamic and evolving Catholic moral tradition shaped by the ongoing engagement with people and ideas both inside and outside of the tradition. Over the course of many centuries, the Catholic moral tradition has critically examined the notions, intuitions, sentiments, consequences and principles that form a communal life that shapes — and is formed — by values.14 Many contemporary thinkers have been increasingly critical of the Enlightenment project justifying such moral norms relying exclusively on conceptual principles or on the rational analysis of consequences. Ethics in the Catholic tradition requires much more than adherence to universal principles or an examination of consequences in a particular situation. Modern neuroscience has reaffirmed the centrality of emotion in brain function, which contributes to the renewed focus on virtue and narrative in the field of ethics. This renewed focus points to the enduring wisdom of Thomas Aquinas, who integrated the work of Aristotle, Augustine of Hippo, the Muslim philosopher Ibn Sina and many others into a Christian worldview that positioned the virtue of prudence as an irreplaceable foundation for moral discernment. The virtue of prudence illuminates the single course of action that is most appropriate for achieving a goal through an examination and selection of available and most appropriate tools, and their faithful application.15 The cultivation of virtue is particularly relevant to organizational life.

Communities of trust are not formed on the basis of explicit rules and regulations, but out of a set of ethical habits and reciprocal moral obligations internalized by each of the community's members.16 Such an internalized sense of reciprocal moral obligation is a form of virtue that ought to guide decision-making. Discernment carefully examines the moral dimensions of business decisions and leadership recognizing that rules and principles are necessary but not sufficient for determining the right course of action.

IMPERATIVES FOR A GOOD DISCERNMENT
Express Hopes and Fears Honestly
Communal discernment is best achieved when participants are open to ideas and resist coming to conclusions prematurely. One way to approach this subjective dimension and to grow freely is for individuals to identify and discuss their hopes and fears about the issue being discerned. This exercise encourages transparency and self-reflection and will assist the discernment group in understanding the data and information more objectively. By listening to the hopes and fears of other group members, each participant will better understand the assumptions everyone brings to the process. This exercise will ideally encourage participants to keep one another accountable during the deliberation.

An effective facilitated discernment process requires reliable, current information and sound data. Establishing a prediscernment work group is a constructive mechanism for collecting the necessary data and verifying that the most important information is available to the discernment group. It will be helpful for those preparing for the discernment to ensure that all the relevant data is collected and that any information gaps are named and addressed.

Take Adequate Time
All discernment participants must be willing to set aside ample time for a facilitated discernment to work well. Two or more meetings may be required, depending on the potential impact of the decision on the ministry. The time between meetings can offer opportunities for reflection as the group prepares for the next gathering. During the discernment, the facilitator should offer time for brief mindfulness exercises and for participants to pause and reflect on what has been discussed.

Invite Diverse Perspectives
Gathering a diverse group of colleagues will broaden the spectrum of ideas and perspectives to serve the ministry better by discerning the best options. Implicit bias that is often present in all of us can be corrected through multiple ideas representing different perspectives, and a diverse group more effectively represents the reality of our ministries. Additionally, no one's experience encompasses the complete truth; we can all learn and grow from each other.

Imagine Multiple Possibilities
While it may seem that a discernment is focused on two possibilities, an effective process may result in several possibilities for conversation. Discernment will ideally encourage participants to tap into their creative imaginations and express ideas that are new and exciting.

Make a Recommendation and Articulate Reasons
If the discernment process has been deliberate, reflective and honest, colleagues will grow to trust one another and understand how organizational values are informing the decision. This does not mean that there will be unanimous agreement, but the trust that the group has cultivated will allow for conversations about personal reservations. A byproduct of a healthy discernment process may well be that participants discover not only new insight into themselves, but also a newfound appreciation for other colleagues along the way.

SCOTT KELLEY is mission leader for Loyola University Medical Center, a member of Trinity Health, and adjunct assistant professor for the Neiswanger Institute for Bioethics and Healthcare Leadership, Stritch School of Medicine, Loyola University Chicago.

DAVID NANTAIS is mission leader for St. Joseph Mercy in Ann Arbor/Livingston, Michigan, part of Trinity Health.

NOTES

  1. This article includes excerpts from two documents related to discernment produced by Trinity Health. The first document outlines conceptual foundations for Catholic health care; the second outlines the process of facilitated discernment. To request a copy of the Trinity Health documents, please email discernment@trinity-health.org. Scott Kelley and Cory Mitchell, "Trinity Health: Building a Culture of Discernment," Trinity Health, November 15, 2021; "Facilitated Discernment: A Guide for Trinity Health Participants and Facilitators," Trinity Health, 2022.
  2. Sumantra Ghoshal, "Bad Management Theories are Destroying Good Management Practices," Academy of Management Learning & Education 4, no. 1 (2005): 75-91; Henry Mintzberg, Managers Not MBAs: A Hard Look at the Soft Practice of Managing and Management Development (San Francisco: Berrett-Koehler Publishers, 2005); Andre' L. Delbecq et al., "Discernment and Strategic Decision Making: Reflections for a Spirituality of Organizational Leadership," in Spiritual Intelligence at Work: Meaning, Metaphor, and Morals (Bingley, England: Emerald Publishing Limited, 2003); Brian W. Head, Wicked Problems in Public Policy: Understanding and Responding to Complex Challenges (Cham, Switzerland: Springer Nature, 2022).
  3. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1982).
  4. Pope Francis, Laudato Si', paragraph 137, https://www.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si.html.
  5. Pope Francis, Fratelli Tutti, paragraph 47, https://www.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20201003_enciclica-fratelli-tutti.html.
  6. Pope Francis, Evangelii Gaudium, paragraph 231.
  7. Fr. Bernard J. F. Lonergan, SJ, Method in Theology (Toronto: University of Toronto Press, 1990), 281-293.
  8. Thomas Aquinas, Summa Theologica, Second Part of the Second Part, question 47, answer 2.
  9. Thomas Aquinas, Summa Theologica, Second Part of the Second Part, question 47, answer 4.
  10. Fr. Ladislas Orsy, SJ, Discernment: Theology and Practice, Communal and Personal (Collegeville, Minnesota: Liturgical Press, 2020).
  11. Richard J. Clifford, The Wisdom Literature (Nashville: Abingdon Press, 1998); Silvia Schroer, Wisdom Has Built Her House: Studies on the Figure of Sophia in the Bible (Collegeville, Minnesota: Liturgical Press, 2000).
  12. Sandra Marie Schneiders, "Religion and Spirituality: Strangers, Rivals, or Partners?" The Santa Clara Lectures 6, no. 2 (February 6, 2000).
  13. Fr. Michael Ivens, SJ, Understanding the Spiritual Exercises (Leominster, England: Gracewing, 1998).
  14. Servais Pinckaers, The Sources of Christian Ethics (Washington, DC: Catholic University of America Press, 1995); John Mahoney, The Making of Moral Theology: A Study of the Roman Catholic Tradition (Oxford: Clarendon Press, 1987); Charles Taylor, Sources of the Self: The Making of the Modern Identity (Cambridge, Massachusetts: Harvard University Press, 1989).
  15. Thomas Aquinas, Summa Theologica, Second Part of the Second Part, question 47, answer 8.
  16. Francis Fukuyama, Trust: Social Virtues and the Creation of Prosperity (New York: Free Press, 1995).

 

Effective Discernment Models Include Similar Elements

NATHANIEL BLANTON HIBNER, PhD

Through the spiritual discipline of discernment, the Spirit guides and influences us to be compassionate and thoughtful in our responses so that we can better our communities. To facilitate this process, many Catholic health care systems have created formal discernment models to assist them when processing difficult institutional decisions. CHA, too, has published a model that outlines key aspects of discernment.1

In the adjoining article, we learn about the why and when regarding discernment. Through the following outlined steps, we examine the central pieces of this process; while not every discernment process is the same, they do often contain similarities.

Define Fundamental Questions
First, the group must identify the primary question at hand. Most tools recognize that when people from diverse backgrounds come together, they might have different perspectives regarding how they see the problem. Some may even completely disagree with one another when attempting to arrive at a decision. Therefore, the group must ask itself: "What exactly will we consider?"

What is consistent in this first step is the importance of everyone being on the same page. We cannot answer a question if we do not name it correctly. This clarity eliminates future confusion and ensures that the question up for debate meets the level of importance needed for such a rigorous discernment process. 

Gather Information
Second, the group gathers facts. CHRISTUS and Providence Health ask succinct questions: Who? What? Where? When? Why? How? These get to the heart of the information required to properly evaluate the situation. Most of the discernment tools urge the group to include various experts in the dialogue, who will be able to enrich the bare data.

The majority of models recommend inclusion of the stakeholders. This upholds our ministries' commitment to subsidiarity. Some questions for the consideration of this might include: Who is most directly affected and how? Who has proper authority? In this step, the stakeholders can share how they believe the different decisions would impact them and their work. The discernment tools recognize that merely discussing facts and figures can make us distant to the people impacted by our work. This attention should be praised as an appropriate way to live out our responsibilities toward our neighbors and fellow ministry colleagues. 

Communal Dialogue
Third, the discerning group is encouraged to turn their discussion toward the relevant values, the mission of the organization, principles of morality, The Ethical and Religious Directives for Catholic Health Care Services and other teachings of the church. Some examples of reflection questions include: Which values relate to or appear to conflict with this issue? What are some key principles? This step filters out those solutions that do not align with our ministry's purpose. What often happens, however, is the need to pick one value over another.

The group must also determine whether more information is required, or if new voices need to be added to the table. This step serves as an assessment on whether the group and the process are moving correctly ahead.

Prayer and Reflection
Fourth, the tools set aside time for meaningful prayer and reflection. After the possible decisions have been filtered through the lenses of mission, values and Church teaching, the group is encouraged to take time and reflect. The group members open themselves to the Spirit moving within them and listen to their hearts. Time for quiet reflection and prayer is encouraged and, in most cases, required. Afterwards, the members come together and share their decision. Through this collective sharing, the goal is that a choice will appear and a consensus will be achieved. 

Assessment and Consensus
The fifth step includes listing tentative decisions. This approach will show the most desired decision by the group but also give an alternate plan/other prospects that can be reexamined should the decision not meet its desired effect. The discussion about alternative solutions might reveal whether the group needs to start the discernment process again should members feel strongly that one option was not given proper vetting. 

Should the group finalize a decision, one more review is required. The group assesses the impact of the decision on the common good and our ministry's commitment to the poor and marginalized.

Communication and Implementation
The sixth stage concerns implementation, as once a decision has been made, its execution must also be well planned. A decision can lose its impact should the execution fail. Therefore, the discernment tools recommend constant updates, periods of review and receptiveness by the group to alter course should their decision fail. It encourages
self-reflection by all as to whether the decision they made is meeting the expected goals.

Ongoing Discernment
As noted in the accompanying article, discernment has been with the Church for centuries. The process continues to guide the faithful on the road to the coming Kingdom of God. Though the process is often done in a group setting, as individuals in the health care ministry we can prepare ourselves for discernment. Those who help lead our organizations should also be encouraged to practice prayer and reflection. It is a skill that needs constant attention, even more so as our days remain filled with complex responsibilities and stress. Our "discernment muscles" need to be stretched so that when we meet in a group, we have the ability to see clearly and to sit quietly, allowing the Spirit to be heard. Regardless of our roles, we should all be encouraged to read the discernment model of the system where we work — or the one provided by CHA — become familiar with the steps, and begin to ask ourselves how we can be better prepared for when the Spirit calls us.

NATHANIEL BLANTON HIBNER is director, ethics, for the Catholic Health Association, St. Louis.

NOTE

  1. Cooperating With the Spirit: CHA Discernment Model and Facilitator's Guide (St. Louis: Catholic Health Association), https://www.chausa.org/store/products/product?id=4653.

 

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