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Resident physicians Brooke Jemelka, Gavin Puthoff and Alexis Simon stand around Carmen Hinze as the proud father, Dan, looks on in her recovery room after she delivered her new son, Thaddeus, at Mercy Hospital in St. Louis. (CNS photo/Lisa Johnston, St. Louis Review) (April 5, 2012) See NFP April 5, 2012.

Should Catholic hospitals stand out for how much health care they provide for the poor relative to secular systems? Does the kind of spiritual and pastoral care they offer signify their unique religious identity? Or should they be defined by the procedures their physicians will not offer and the drugs they will not prescribe?

These kinds of tricky questions about the nation’s vast Catholic health care landscape are not new. Since the 1970s, a document published by the U.S. Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, has sought to provide some clarity and insight. The 30-page document draws from Catholic theology and church teaching to create a comprehensive set of ideals and rules relating to Catholic health care ministry.

But with rapid advances in medicine and sweeping changes in the U.S. health care landscape, some are suggesting that the document needs a complete overhaul, setting up a potential battle over the future of one of the church’s largest and most storied ministries.

According to a 2018 summary of the directives published by Catholic Health and Catholic Medical Partners, the guidelines have three main goals. First, they affirm the church’s vast teaching about human dignity. Next, they offer “authoritative guidance” on moral issues confronting health care practitioners operating in Catholic systems. Finally, they offer patients and medical professionals “principles and guides for making decisions.”

With rapid advances in medicine and sweeping changes in the U.S. health care landscape, some are suggesting that the U.S. bishops’ Ethical and Religious Directives needs a complete overhaul. 

On June 16, 2023, the U.S. Conference of Catholic Bishops voted to begin a process of updating a section of the directives in order to prohibit a set of medical procedures sometimes referred to as gender-affirming care. Those include hormone therapy and certain surgical interventions, including elective hysterectomies related to gender transitions.

Following the vote, controversy ensued, with pro-L.G.B.T. Catholics decrying what they view as another salvo in the culture war and other Catholics applauding bishops for articulating Catholic principles on human sexuality.

In recent years, especially as Catholic health systems merge with once-secular hospitals, the directives have also been in the news because they prohibit Catholic hospitals from carrying out elective abortion and sterilization procedures.

Controversy is nothing new, however, when it comes to the guidelines.

“They’re helpful, and they provide good moral guidance,” Ron Hamel, a former senior ethicist for the Catholic Health Association, told America. “There are a few neuralgic issues, but, by and large, they do provide helpful guidance.”

M. Therese Lysaught, professor at the Neiswanger Institute for Bioethics and Health Care Leadership at Loyola University Chicago, agrees.

“A lot of the directives are actually very positive,” she told America.

The directives, for example, call on Catholic health care systems to “work to ensure that our country’s health care delivery system provides adequate health care for the poor” and to promote “the good health of all in the community.”

But Dr. Lysaught said much of the attention given to Catholic health care by bishops seems to focus on what are traditionally called pro-life issues, such as contraception, abortion and euthanasia. More recently, she said, the conversation has evolved to include how the directives do—or do not—address health care decisions for transgender patients.

Dr. Lysaught sees the recent decision by bishops to begin a revision process of the directives as part of the larger “culture wars” playing out in the United States.

She pointed to similar ethics documents published by Catholic leaders in Canada and Australia as potential models if a more thorough revision is on the table.

“They just have a very different approach,” she said. “We are very legalistic.”

First approved by bishops in November 1971, the directives were met immediately with criticism from within the church. Dr. Hamel chronicled the history of the directives in a 2019 article in Health Progress, a journal published by the C.H.A.

Dr. Hamel wrote that during the 1960s, Catholic hospitals were grappling with difficult questions related to contraception and sterilization and applied an existing code with little uniformity from diocese to diocese. The Catholic Health Association asked what was then called the National Conference of Catholic Bishops to create a set of guidelines that could be applied universally.

“The hope was that such an authoritative document would resolve the problem of what some perceived as ‘geographical morality.’”

“The hope was that such an authoritative document would resolve the problem of what some perceived as ‘geographical morality,’” Dr. Hamel wrote. “Instead, the November 1971 publication of the new Directives resulted almost immediately in severe attacks.”

Writing in the same journal in 1972, the late Jesuit priest Thomas J. O’Donnell, S.J., noted that a “storm of criticism” followed the publication of the directives, which were originally just five pages long, consisting of a preamble and 43 bullet points.

“The Directives are criticized as being meaningless for our modern day, as hopelessly ill-suited to the ecumenical dimension of our pluralistic society, of being irrelevant regarding what the Catholic hospital should or should not do, and beyond the scope of what the American hierarchy should or should not teach,” Father O’Donnell wrote.

The 1971 version of the directives were deemed to be overly legalistic, Dr. Hamel wrote, describing it as “a listing of what could not be done in a Catholic health care facility.”

The Catholic Theological Society of America studied the new code and released a report in 1972 criticizing the directives and urging a reformulation of the directives. As Dr. Hamel put it, the commission wanted a new code that was more consultative and that paid “less attention to sex and reproduction” while also “addressing a number of other issues like service to the poor and underserved; end-of-life issues; the necessity of informed consent; transplantation; human experimentation; and genetic counseling.”

Nearly 25 years later, in 1995, a new version of the Ethical and Religious Directives was published. Dr. Hamel said the process was more consultative, taking more than six years and 11 drafts, and spent more time focused on theology, philosophy and social justice.

That revised version of the directives, while still prohibiting certain procedures, speaks to the ideals of Catholic health care, supporters say.

The directives are “filled with the kind of positive ideas that appeal immediately to anyone wishing to provide health care that goes beyond cataloguing and treating disease and seeks to treat the sick person—body, mind and spirit,” John O'Callaghan, S.J., wrote in American Medical Association Journal of Ethics in 2007. “Far from imposing a largely restrictive framework that impedes doing what is needed for the good of our sick, the document provides a resource for guidance to heal people in total accord with their true nature and its moral exigencies—the way Jesus did.”

The 1995 version remains largely intact today, though there have been three revisions since then, most recently in 2018, updating a section about health care mergers and partnerships with non-Catholic health care entities.

That revised version of the directives, while still prohibiting certain procedures, speaks to the ideals of Catholic health care, supporters say.

Critics contend that in some instances, the directives can be harmful to patients, especially women experiencing pregnancy-related complications.

“The ERDs substitute religious doctrine for the standard of care,” Hayley Penan and Amy Chen wrote for the National Health Law Program in 2019. “For example, the prohibition on abortion applies to the termination of any pregnancy, even where the pregnancy is putting the patient’s health or life at risk.”

But the head of the C.H.A., Mary Haddad, R.S.M., told America in an interview last year that Catholic hospitals are fully equipped, from both medical and moral perspectives, to assist women experiencing a pregnancy crisis, including times when “a fetus [is] aborted in order to save the life of the mother.”

“That is not unusual. And that is acceptable,” Sister Haddad said, when applied to the principles articulated in the directives.

Dr. Hamel agrees, saying that the directives allow for indirect abortions during crisis pregnancies. But sometimes, even health care workers are unaware of what the guidelines permit.

“Catholic hospitals are safe,” he said. “Where there have been problems, for the most part, it’s because clinicians have not clearly understood what is permitted by Catholic social teaching and the directives.”

Asked whose responsibility it is to ensure that patients and physicians understand the directives, Dr. Hamel said a combination of bishops and hospital leadership, including system mission leaders.

The kinds of nuanced, medically necessary discussions about pregnancy-related complications are not taking place with the urgency they demand, Dr. Lysaught said.

“Catholic hospitals are safe. Where there have been problems, for the most part, it’s because clinicians have not clearly understood what is permitted by Catholic social teaching and the directives.”

“Because of the polarization around the question of abortion, there has been an inability within Catholic theology and within Catholic bioethics to have nuanced, careful, well-informed and well-thought-out conversations on what exactly is an abortion,” she said. “How is procured abortion different than various kinds of medically necessary interventions to save the lives of women?”

Perhaps the most high-profile case related to the role directives play in patient care came in 2010, when the local bishop stripped a hospital in Phoenix of its Catholic status. Hospital administrators, including a Sister of Mercy who chaired the ethics committee, decided to approve an abortion for a 27-year-old mother of four who was 11 weeks pregnant. Doctors said the woman would almost certainly be unable to survive childbirth due to pre-existing medical conditions.

Bishop Thomas J. Olmsted said the diocese would sever ties with the hospital, and Margaret McBride, R.S.M., who was the vice president for mission integration at the hospital, incurred an excommunication.

The case set off a firestorm of controversy, with many theologians and Catholic health care ethicists arguing that neither Catholic theology nor the directives prohibited the procedure because the intent was to save the mother’s life, not to end a pregnancy. Sister McBride’s excommunication was lifted the following year.

More recently, some Catholic hospitals have faced lawsuits over their refusal to perform procedures related to transgender health care. In 2017, Evan Minton, a transgender man in California sued Mercy San Juan Medical Center, claiming that the Catholic hospital canceled an elective hysterectomy two days after he told a nurse he is transgender. Mr. Minton was able to get the procedure days later at another hospital, but claimed in his lawsuit that his civil rights had been violated. The hospital cited the directives as the basis for why it could not offer the procedure.

Several people interviewed for this article, and other Catholic health care leaders, say the directives are overdue for an exhaustive revision. But there is little agreement on what those revisions may look like.

Michael Rozier, S.J., an assistant professor of health management and policy at St. Louis University, told America that while the directives are binding, “as with any document within the church, the interpretation and the level of enforcement is up to each individual bishop and the ministries within his diocese.”

Father Rozier said that while the directives are sometimes viewed through a legalistic lens, they require interpretation to be applied to concrete situations, especially as advances are made in medical technology.

“As we’re thinking about the E.R.D.s as moral guidance, we need to keep them alongside the other rich moral traditions of the church,” Father Rozier said, citing virtue ethics, the role of conscience and Catholic social teaching.

“Catholic health care at its best cares for everyone who walks through its doors,” he said. “What we’re constantly trying to do is figure out ways to be faithful to our understanding of the human person, and the human community, and move through the world as it really is.”

Several people interviewed for this article, and other Catholic health care leaders, say the directives are overdue for an exhaustive revision. But there is little agreement on what those revisions may look like.

John F. Brehany, the executive vice president for the N.C.B.C., says the revision process provides an opportunity for Catholic health care to reassert a more traditional form of Catholic morality and identity.

For his part, Dr. Hamel said it is time for “a complete revision” of the directives, given the advances in medicine since 1995. Like Dr. Lysaught, he also pointed to the 131-page “Health Ethics Guide,” published by the Catholic Health Alliance of Canada, as a good model and hopes any future revisions of the directives will include a robust discussion about Catholic teaching on conscience. That duty of an individual to follow a well-formed conscience would be helpful to health care workers as they face increasingly complex moral choices, he said.

“Pope Francis has said that moral norms are intended to inform conscience, not to take away conscience,” Dr. Hamel said. “And I think that’s a very, very important lesson for us to learn.”

A series of articles from the National Catholic Bioethics Center newsletter, Ethics & Medics, published in 2021 also called for a complete revision of the directives. The author, John F. Brehany, the executive vice president for the N.C.B.C., says the revision process provides an opportunity for Catholic health care to reassert a more traditional form of Catholic morality and identity.

Dr. Brehany writes that more attention should be given to the role of conscience. But he also suggests the directives should consider restrictions on “new age spiritualities, practices and beliefs,” remind Catholic systems that church-affiliated hospitals “share in the mandate to evangelize” and suggest restrictions on certain medications, including anti-H.I.V. preventatives for gay men and erectile dysfunction medication for unmarried men, because they could “facilitate immoral sexual activities.”

Any changes to the E.R.D.s would need to be approved by the full body of bishops. Then, it would be up to each individual bishop to promulgate the directives in his diocese if he supports them.

For now, the doctrine committee of the U.S.C.C.B. will continue consulting with health care practitioners, hospital administrators, ethicists, theologians and patients as they consider possible changes to the directives.

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