As part of the Markkula Center's yearlong series of talks on conscience, Ron Hamel, chief ethicist of the Catholic Health Association, discussed the role of conscience in Catholic health care. This is a summary of that discussion.
Hamel began by quickly reviewing some of the places where conscience is relevant in Catholic health care: reproductive health, doctor-patient interactions, the Affordable Care Act contraceptive mandate, and Catholic-secular hospital mergers, to name just a few. He called attention not just to these vexed issues, but also to several levels of conscience at work: Individuals, institutions, and government are all involved in health care. Hamel drew attention to three crucial relationships that emerge from these interactions: 1) physician-patient, 2) physician-institution, and 3) institution-institution.
Hamel then situated American Catholic health care. Most Catholic hospitals were started by religious orders in the 1700s and 1800s. Over time they grew into multimillion dollar businesses. The Catholic Health Association has 14 percent of the hospital beds in the U.S., with 600 hospitals and 1,400 other health-related facilities, and 5.5 million patients. But the numbers do not speak to the core of Catholic health care. The core of Catholic health care is a religious enterprise to advance the reign of God by carrying on the healing work of Jesus, following Jesus's command to "go and do likewise," Hamel said. It is an official, formal, ministry of the Church, reporting to the local bishop and subject to the Ethical and Religious Directives of the U.S. Conference of Catholic Bishops. What is so complex here? Trying to fit a specifically religious ministry into a secular and pluralist society, in a context where the hospitals are now managed by laypeople or non-Catholics, and the employees and patients may be mostly non-Catholic as well. Under these conditions, people may disagree on moral issues, and therefore conscience becomes a major concern.
Given these complexities, we must ask "what is conscience?" Hamel said that conscience has two parts: our personal identity and our integrity of action. At the most basic level, conscience dictates that we must pursue good and avoid evil. People must never violate their consciences, and must be able to follow their consciences even if to do so may be wrong.
That pertains to individual conscience. Hamel suggested that, by analogy, institutions also have consciences. Organizations are more than the sum of their parts. Institutions have identities and perform actions; Catholic health care institutions, he said, are in health care because Jesus commanded it. The missions of Catholic institutions articulate their identity and purpose—aspects of their conscience—and actions counter to the mission violate their moral integrity. Individuals acting on behalf of their institutions should have respect for the mission and follow it, Hamel argued, and yet institutions should also have respect for individuals whose consciences may be put in conflict by following this mission.
At this point Hamel returned to three of the relationships he mentioned earlier. In the case of physician-patient conflicts of conscience, the right of conscientious objection of the health care provider is generally accepted, with the caveat that the patient must be respected and should not be belittled for asking for something the physician does not want to do.
In the case of physician-institution tensions, some procedures may be legal yet not allowed at a Catholic hospital, even if they are considered to be standard of care. A hospital needs to be able to stay true to its identity, Hamel said. A hospital can conscientiously object to providing certain types of services, but it needs to be open and transparent about that. Employees are bound by the practices of their institutions. If a physician objects, he or she ought to work somewhere else, Hamel argued. Patients should also not expect to receive such services and can go elsewhere, he said. Laws cannot change the morality of an act.
In the third case of institution-to-institution relationships, partnerships vary in their specifics. Many fear the imposition of Catholic values, which may stop the partnership, or require "carve outs" around certain services. The principles here surround cooperation in evil – moral distance should be maintained, Hamel argued. Other institutions need to have their own identities too, so compromises must be carefully negotiated and consciences respected.
Overall, Hamel provided key insights into how conscience and Catholic health care form a complex territory for moral analysis.
Brian Green is assistant director of Campus Ethics Programs at the Markkula Center for Applied Ethics.