Catholic Healthcare Providers Must Refashion Their Identity As Actors and Advocates in the World

Fr. Hehir is a professor at the Harvard Divinity School, Cambridge, MA. This article is adapted from his address at the 80th Annual Catholic Health Assembly, June 1995.

The fashioning of one's identity in an ecclesial institution like the Catholic Health Association is a theological task, but one that must be carried out in the context of the rational demands, the secular setting, the pluralistic context, and the scientific requirements of the world of healthcare. If we do not have a religiously grounded, theologically articulated understanding of who we are and what we are, we will lose our way in this complex context. At the same time, if we specify our identity but we cannot meet the standards of a rational, secular, pluralistic world, then our identity will not be effective.

Catholic Identity and Institutions
In discussing the need to "reclaim our identity," I begin with one fear. One way to understand that subject would be to say that somehow we had, purely and simply, lost our identity. I think that judgment would be too harsh, indeed inaccurate. My premise, rather, is that the identity of a complex community and institution must be continually rewoven and renewed. Identity must be maintained over time; time brings changing circumstances, conditions, and challenges; therefore, while identity has an essential element of continuity to it, it must also include a dynamic of development leading to a deeper understanding and expanding sense of what our identity is. Identity must be refashioned in light of questions that come to us precisely from the rational, secular, pluralistic context in which we function.

Catholic healthcare shares the task of developing its sense of identity with other Catholic social institutions. In these different settings we see a fundamental question about how to preserve identity and still participate effectively in the society of which we are a part.

The Catholic Church is institutional by instinct and by nature. We often think of the institution as a force that hinders, burdens, or creates obstacles. A contrasting perspective emerges from my professional colleagues, social scientists, and political scientists — most of them not Christian, hardly any of them Catholic — who see the institutional structure of Catholicism as a major asset in a society like ours. These people, whose lifework is to examine which institutions carry the potential for public influence, see the structure of Catholic institutions as a great gift to the world we live in.

The Catholic healthcare ministry, as the largest not-for-profit healthcare system in the United States, is joined by the largest social service agency in the country (Catholic Charities) and the largest private educational system in the country. Size never proved anything, but there is something to presence. If one seeks to influence, shape, direct, heal, elevate, and enrich a complex industrial democracy, it cannot be done simply by the integrity of individual witness. It is done by institutions that lay hands on life at the critical points where life can be injured or fostered, where people are born and die, where they learn and teach, where they are cured and healed, and where they are assisted when in trouble.

In a large, complex democracy like ours, institutions ultimately always make a difference for good or for ill. None of that eliminates the irreducible need for individual moral responsibility. None of it takes away from the value of personal witness, heroic as it often is. But in the context of the 1990s — where we have, on the one hand, exploding social problems and, on the other hand, declining public resources and maybe declining public will to address them — the pervasive presence of institutions like ours becomes all the more critical to a society like ours.

I would not be misunderstood. I share no common ground with the proposition that our country's governmental structure has no responsibility to the poor and needy. That idea has neither moral foundation nor religious validity. The fact is that local and national governments must face the necessity of weaving public-private partnerships at the seams of society where people must learn, must be cured, must be healed, and must be supported. Because we have pervasive institutional presence, this challenge confronts us as an opportunity.

We stand institutionally at strategic places in this society. When the questions come up — What are we going to do about children? What are we going to do about AIDS? What are we going to do about the fabric of the family? What are we going to do about the future intellectual health of this country? — we are already there. The question is how we understand who we are at those strategic intersections, and how we marshal limited resources, often under institutional pressures placed on us by society, in an effective witness. That is the task which faces Catholic social institutions as a whole.

The challenge is clear, but we do not pay enough attention to this question strategically. We ought to convene a well-chosen, representative body of Catholics who can think systematically about our strategic presence. The potential exists for a "Catholic summit meeting" that would cut across healthcare, social service, and education and look at where we stand in this society and in service of the Gospel. Because we have specialized functions, complicated lives, and busy schedules, we may miss the possibility of coming together for reflective assessment of where we stand in the country, what we have to say, and what we might do across the Catholic social spectrum.

The Identity of Catholic Healthcare
In its journey toward reclaiming its identity, Catholic healthcare stands at a third stage of development. The three stages are the immigrant model, the Vatican II model, and the model that is being catalyzed today by the conditions of the 1990s.

The Immigrant Model The immigrant model of healthcare, like that of Catholic education and Catholic social service, was a product of both ecclesial impulse and social necessity. Catholic healthcare, rooted in the middle of the nineteenth century and developing through the first 60 years of the twentieth century, was driven by an ecclesial impulse to heal, to teach, and to serve, and by a social impulse to serve specifically the needs of the Catholic community. We feared that this community would not be well instructed in a total vision of life or well cared for if we did not create our own institutions. Thus from the mid-nineteenth to the mid-twentieth centuries, the immigrant model focused on the Catholic community.

The Vatican II Model The Vatican II model is a product of ecclesial initiative; it arises from the Church's conciliar vision to take the essential tasks rooted in the Gospel — teaching, healing, and social service — and to think about them in terms of a Church at the service of society as a whole.

It is possible to trace in all our institutions over the past 30 years a definable trend toward serving a much broader constituency and thinking about ourselves as specifically Catholic in identity and broadly catholic in scope. The necessities of the immigrant model tended to exhaust care and ministry almost totally within the Catholic community. But the Vatican II model was a conscious choice to move beyond the bounds of the ecclesial community to demonstrate what it meant when we said the Church should be a sacrament of unity in the world.

The Catalyst of Social Forces The Vatican II model still drives our conception of ministry and identity, as it ought to. But the catalyst of the 1990s is rooted not so much in ecclesial initiative as in the imperatives and the challenges posed by social forces. These forces are not unique to Catholic healthcare, but the Catholic health ministry must face them along with everyone else. The forces, a product of events that are both beneficial and threatening, come together to create the context for ministry.

In American society, healthcare is a product of our science and our technology, and it is an overwhelmingly positive asset and a success story. But technology has produced a certain style of healthcare, a certain logic in the economy of healthcare, and a certain set of demands and possibilities that require wise social policy to ensure the system accomplishes both useful human purposes and valid moral purposes.

In the midst of this highly complicated social and technical environment, we have just been through the sixth try for systemic healthcare reform in the United States. The attempts go back to 1910 and continue through the most recent debate in the U.S. Congress; each time, we seem not quite to make it.

The recent healthcare struggle was the most consequential social policy debate we have faced since the New Deal. It was precisely because the New Deal did not address the healthcare question, and the Fair Deal tried but failed, that in the 1990s we were back again to our discussion of whether healthcare is a right, who has responsibility for it, and how we shall fund it.

By anyone's assessment, the sixth try at systemic reform clearly came to a dead end. Now we still stand in need of reform, but few initiatives for systemic reform are being proposed. Enormous change is going on, but one ought not to equate change with reform. Indeed, a movement is under foot in which powerful market forces seem to be the only forces at work. We are still without comprehensive healthcare coverage, and the one victory from the fifth try at comprehensive reform in medical care — the Medicare and Medicaid programs of the 1960s — is now under threat. These clearly not perfect but useful programs may be rolled back also.

As we look at the debate that surrounds not just healthcare, but also social policy, it is important to see that the argument now being launched raises the most fundamental moral questions, as well as technical and secular questions. Anyone who listened to the recent debate about tax reform in the U.S. Congress found people on both sides saying they spoke in the name of moral values. Anyone can claim to speak for moral values, but that claim is the beginning of an argument, not the end of it.

We need to understand what is at stake in the debate that follows the collapse of the healthcare reform efforts of the 1990s. It involves first defining precisely the state's moral responsibility in society. This is a different question from what the state's empirical capabilities are. That is an entirely legitimate question, but in Catholic terms, it is never the only question. The moral responsibility of the governing authority of a society, in Catholic terms, carries a positive responsibility. That question is now up for grabs: What is the content, scope, and extent of the state's moral responsibility?

A second question is: What is society's responsibility for the poor and the vulnerable? The option for the poor may be possible only as a product of a religious vision, but even without this vision one could say that any secular society has moral responsibility for the poor and the vulnerable. We have no settled view on that in the United States today.

Third, what is the moral role of the market? The market clearly has an empirical role in social policy. But the first pope to highlight the value of the market — John Paul II — immediately followed his commendation with a discussion of the moral limits of the market. If healthcare reform is to be driven only by the market, we clearly will not reach even minimal moral standards.

Finally, what is the connection between healthcare and the common good? Can you sustain the common good without a minimal level of healthcare for each person in society? Precisely because health is an irreducible human need, it never can be defined purely as a commodity; it is also a social obligation for the morally good society.

Ministry within a Context
The complexity of the Catholic healthcare struggle is that it is committed to be a ministry, but it must be a ministry within a context. The context is shaped by the market, which in turn fits within a broader political and economic structure. Thus the Catholic healthcare ministry is both an actor in the system and an advocate for those least able to protect themselves. When we try to be both an actor and an advocate — when we try to represent effective, efficient action as well as the vision and voice of the prophets — we have defined a role filled with tensions. Actors must survive; but actors who fulfill a ministry cannot survive at any cost. The question of identity brings together both the place we hold in the system and who we think we are as we hold that place.

Reclaiming our identity is a process of development, of reflective evolution in our understanding of ourselves, faced with the demands of healthcare in late twentieth-century America. Defining one's identity as a ministry roots it in both ecclesial and moral soil.

It is interesting that the final document of Vatican II, "The Pastoral Constitution on the Church in the World" (1965), discusses the Church's identity and ministry in terms of the Church in the world — not the Church and the world, never the Church apart from the world, nor simply over against the world. The Church is to locate itself precisely in the context from which the challenges to our ministry arise. It wants to be tested because being tested means living in the midst of the fabric and fiber of life where real decisions are being made. And so the framework for the ongoing process of reflection on our specific identity is set: Be in the world.

Second, the anchor of our presence in the world is radically human. It is the service of the human person, the service of human dignity. In the language of Vatican II, the Church is to stand as the transcendent sign of the dignity of each human person. To quote Pope John Paul in Redemptor Hominis (1979): "The person is the way for the ministry of the Church." Our identity is tested by how our ministry contributes to human dignity and human rights.

Third, we are to be in the world by dialogue with the world. The Council says this is how the Church shows it love for the world — by being willing to be in dialogue about all the issues that touch the human person.

This role raises the critical notion of what our posture ought to be as institutions strategically located in society. The posture of Vatican II is what I would call "confident modesty." It is a Church that believes it has something to learn from the world and something to teach the world. It is a ministry of both collaboration and criticism, for we are never to be simply of the world. In the world as we know it, there is much to criticize. But it is also a ministry in which we seek to find common ground where the dignity of the person can be served.

You are faced now with choices, from social policy to institutional identity, that raise the questions of how much one can collaborate, where one must draw the line, and what criteria one should apply. These eminently tactical choices are never purely tactical. They are rooted in the idea that the Church willingly locates itself in the world, striving to make the right choices about maintaining our identity, but not preserving our identity by taking ourselves out of the flow of human history.

The result of the Council's vision — in the world, for the person, in dialogue with the world — is a Church that is more open to the secular, is universal in its conception of service, and defines itself as a servant. This was the ecclesial initiative which spawned the second stage of Catholic healthcare identity. It moved us purposely out into the wider community, defined the ministry precisely as service, and kept it universal in focus. Moreover, this legacy of Vatican II gives us the criteria to assess the changes we face in the 1990s. But times have changed and the tension may be greater today in the Church-world relationship.

Increasing Tensions
Several years ago, at the beginning of the healthcare debate, the Church had three essential objectives: justice for each person, symbolized by universal coverage; bioethical concerns in terms of the basic minimum package of healthcare benefits; and institutional pluralism, meaning that religiously based institutions would continue to contribute to society.

In the late 1990s, each of these objectives is much more difficult to achieve than it was in 1993. Precisely because of the failure of a debate about systemic reform, we are further away from the social justice criterion than before. We are in danger of dismantling a fabric of social service and protection for the most vulnerable, which will make us a disgrace among industrialized nations. We face on the bioethical front intensification of the struggle from the beginning of life to the end. Finally, the question of institutional pluralism is not so much threatened by governmental regulation as it is by the logic of market forces and the role of very large private actors in that competition.

Pope John Paul II's encyclical of 1995, Evangelium Vitae ("The Gospel of Life"), moves us from focusing on identity as our place in society to how we engage a set of specific issues. It moves us from ecclesiology to moral argument.

The accent of John Paul II's text tends to fall on the increasing tension of being the Church in the world. There is no call here to leave the world, but simply to recognize the complexity of what we face. Indeed, the encyclical is best understood as a passionate call for defense of a specific moral vision. It is a passionate call to defend the sacredness of life at the end of a murderous century, a century that has consumed 160 million lives in warfare alone. It is a cry of the heart, and I think the personal history of the pope is not irrelevant here. This is a person who has lived at the vortex of the major social traumas of this century: the rise of totalitarianism, the Holocaust, the Cold War, and the strange lack of peace that has followed the collapse of the Cold War. He casts the moral argument in cosmic categories, arguing that there is competition between a culture of life and a culture of death.

The pope's description of the threats to life can be divided into three categories, which bear upon the tests we face in the healthcare ministry today. The synthetic sweep of the letter addresses ancient, modern, and postmodern threats to life.

The ancient threats to life include hunger, poverty, famine, and genocide. They arise from our inhumanity to each other, and they have been with us a very long time. What is surprising is that they are still so very much with us at the end of this century, in Central Africa, Central Europe, and our own inner cities. Any healthcare ministry clearly must be committed to mitigating the ancient threats to life.

The modern threats to life are more complicated. They arise not from the worst that is within us, but often from the best. This paradox is central to the story of this century: that enormously significant human insights, inventions, and creativity have often produced choices we seem unable to make or to control. In American society, the world's laboratory, in the last 50 years we have split the atom, cracked the genetic code, pierced the veil of space, and extended life far beyond the expectation of any generation before us. Who would describe any of this as unfortunate, much less evil? When we cracked the atom, we penetrated the center of the universe and unlocked its energy; who would not see in that the fulfillment of what we were called to do in Genesis?

But the modern threats to life arise out of the ambiguity that is in the best of us. We split the atom, created the nuclear age, and then struggled with the Cold War for half a century. We cracked the genetic code, and now face choices in which our scientific insights outpace our moral capacity to make judgments about preserving human dignity. We extend the life span of everyone and then find ourselves wondering whether we contribute to the dignity of the patient or erode it.

Healthcare is at the heart of the ambiguity of the modern threats to life. Once again, just as the Catholic style is never to leave the world to avoid its risks, the Catholic moral style is never to deny what was done or wish that it had not been done. When human intelligence reaches toward the truth, it is always a grace, but we are left with the task of bringing our moral vision to match our intellectual insight.

I believe that is what the pope describes as the postmodern challenges to life. They are rooted not in what we do, but in how we think. The fear that runs through the encyclical is that we do not know how to think well about protecting human dignity and promoting human rights in a world framed by the ancient and modern threats to life.

A Framework for Identity
These challenges are at the heart of what we confront when we ask about Catholic identity. If we combine the basic structure of "The Pastoral Constitution" with the principal argument of "The Gospel of Life," key themes emerge that can provide the framework to address who we are and where we should stand today. Those themes are a commitment to sacredness, an understanding of stewardship, and a deep conviction about the social fabric of life.

A commitment to sacredness entails not only a philosophical statement that life is sacred, but the development of a personal attitude that is evident in the way we approach every human person who comes to be healed and cured; a development of a social attitude that radiates from institutions; and a development of a professional sense of awe when we stand in the face of the mystery of every human person, well or ill. This is not automatically cultivated in an age of much technology and great complexity.

A sense of stewardship involves maintaining a conviction that life is a gift and not simply a product. Such a conviction means that we stand in the face of a mystery that is larger than we are, that comes to us and will be taken from us. In the Catholic tradition such a conviction yields a posture personally, professionally, and institutionally that we are entrusted with life — we do not own it. Such a posture provides direction for methods of healthcare and sets definite limits that should not be transgressed.

This, too, is hard to sell in a culture like ours. For if we do not own our own life, what else escapes our grasp? But that is just the point: The principle of stewardship in Catholic thought guides our approach to economics, as well as to bioethics. For the goods of the earth are entrusted to us and, while we can legitimately claim we own some, how we use them is as much a moral question as how we understand stewardship at the beginning and end of life in a medical setting.

The social fabric of life involves a conviction that we are bound together in a single destiny, that we are social by nature and not by choice. From this conviction flows the understanding that being human means accepting accountability, personally, professionally, institutionally, for the lives of others. This sense of social fabric is not a vague, nice-sounding theme. For example, if the euthanasia debate is viewed with the understanding that we are socially bound together, one gets a different perspective than if society is seen as a series of atomized individuals all in possession of their own lives and disconnected from each other in their choices.

This sketch is far from a finished product, but convictions about sacredness, stewardship, and the social fabric of life give us the kind of moral vision that allows us to be a Church in the world, for the person, and capable of dialogue about the interaction of science, technology, and social policy.

Institutional Choices
Fashioning an identity always requires institutional strategy; that is, in the end we have to make choices and apply tactics in the face of challenges.

The first step in a strategy is to be aware of the value of institutional presence. Today, our institutional instinct is a social asset; in this society, institutions will not do everything, but they will fundamentally shape the quality and character of life. How we keep alive that institutional presence is an ecclesial theme, a social challenge, and a human necessity.

Second, strategy requires an integrated witness, that is, horizontal and vertical integration in the Church. Horizontal integration means that the multiple Catholic social institutions need to conceive of ministry in an integrated fashion; health, education, and social service should form an interlocking presence for the Church in American society. Strategic vision needs to be developed across the range of Catholic institutions in the United States. It is going to take multiple insights from the social sciences, from ethics, and from ecclesiology to do this well, but we will never do it adequately by thinking about institutions separately. Vertical integration means that institutions like hospitals and healthcare facilities can be related in the future to parishes, for example, in whole new ways. This is a leading edge of where we need to go in changing forms of healthcare.

Finally, we must hold together our understanding of identity and values, of viability and integrity. This imperative takes me back to the beginning of this address: Catholic institutions must survive, but with a distinctive posture and presence in society. It is clear that the logic of healthcare reform, whether it comes by systematic planning or purely by market forces, includes the reduction of the number of healthcare institutions. The maintenance of institutional presence becomes a strategic challenge, particularly where viability must be preserved within the ambit of ecclesial and moral integrity. A person without identity and integrity is a threat to himself or herself. But an institution that loses its moral compass and its sense of identity is a much larger threat to society.

The 1990s is no time for Catholic healthcare to lose its way. The stakes are too high and potentially too great: to make a difference for sacredness, stewardship, and the social fabric of this country.

Copyright © 1995 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Summary

Nowadays many religious institutes are asking questions about sponsorship. The issue is usually phrased as the sponsoring of institutions. But it might be useful to ask about the institution of sponsorship instead.

In The Good Society, Robert Bellah and his associates say that, on one hand, institutions are created by human beings; on the other hand, because we draw our sense of identity from them, institutions create us too. Bellah et al. also say that institutions, being human creations, are susceptible to corruption, especially when great wealth and power are involved.

Since hospitals and healthcare systems obviously do involve wealth and power, we sponsors now have many questions, as well as some ambiguity about our sponsorship capability. One might even say that a moral debate is raging in our collective subconscious: Is loss of corporate influence something we would do something about if we could, or have we chosen some other value, such as ministerial diversity, instead?

My institute, the Sisters of Mercy, has decided to continue our sponsorship of such organizations. As an institution, sponsorship is an essential bearer of our ideals and meanings. We need this institution to announce, to the world and to ourselves, that whatever power and wealth we possess are committed to mercy and justice.

The Sisters of Mercy have in recent years been giving much thought to the concept of sponsorship. We have asked ourselves: How can we, as an institute, most effectively use our sponsorship capability to address our enduring concerns in ministry?

In addressing that question, we have found ourselves raising others, such as:

• Who are we, as an institute and as the subgroups we call "regional communities"? How inclusive shall we make that "we"? Do we include associates? Colleagues in ministry?
• How extensive is our agreement about the meaning of sponsorship? Can we invest sufficient shared meaning in the term to have a reasonably fruitful conversation about it?
• How much--or how little--common ground would we find in the phrase "sponsorship capability"? How many of us would see that glass as half full? How many would see it as half empty?
• Where shall we focus our attention when questioning the effectiveness of our sponsorship? On the quality of service delivered? On our ability to advocate systemic change? On the priority given to unmet needs?

I realize, of course, that other religious institutes are asking themselves similar questions. In the hope that others may find them useful, I offer the following thoughts on sponsorship and institutions. I will begin by turning the usual phrase on its head: Let us discuss, not the sponsoring of institutions, but the institution of sponsorship.

Sponsorship as an Institution
In taking this tack, I draw on the work of Robert Bellah and his associates, especially their book The Good Society (Alfred A. Knopf, New York City, 1991). Bellah et al. write:

There is an ambiguity about the idea of institutions that is hard to avoid but that we will try to be clear about. Institutions are normative patterns embedded in and enforced by laws and mores (informal customs and practices). In common usage the term is also used to apply to concrete organizations. Organizations certainly loom large in our lives, but if we think only of organizations and not of institutions we may greatly oversimplify our problems. . . . Individual corporations [for example] are organizations that operate within the legal and other patterns that define what a corporation is. If we do not distinguish between institution and organization, we may think that our only problem with corporations is to make them more efficient or more responsible. But there are problems with the way corporations are institutionalized . . . with the underlying pattern of power and responsibility. . . . [To solve those problems,] we have to reform the institution itself. . . .

While we in concert with others create institutions, they also create us: they educate and form us. . . . [Institutions] are the substantial forms through which we understand our own identity and the identity of others as we seek cooperatively to achieve a decent society. (pp. 10-12)*

*From The Good Society by R. Bellah et al.
Copyright 1991 by Robert N. Bellah, Richard Madsen, William M. Sullivan, Ann Swidler, and Steven M. Tipton. Reprinted by permission of Alfred A. Knopf, Inc.

If we think of sponsorship as itself an institution (a normative pattern embedded in and enforced by rules, informal customs, and practices) — if we think of sponsorship the way we think of the family or public education or religious life — then we shall want to ask, for example:

• Whether and how we can make sponsorship the sort of force in our works that can hold them to their purpose of relieving misery and addressing its causes
• Whether and how sponsorship can provide for our works stability but not rigidity — that is, just enough structural shape to hold up through chaotic times but not so much as to hasten their obsolescence

Furthermore, if we believe (with Bellah et al.) that to understand what institutions are is to know that we form them and they in turn form us, then we shall also want to ask:

• Whether and how the institution of sponsorship is for us an enabler of life and progress
• Whether and how the sponsoring of works is for us a source of both organizational coherence and flexibility and adaptability
• Whether and how the sponsoring of works (and not just the works themselves) gives sense and purpose to the lives of our members and to our life as institute

Yet, even this growing list of questions does not present the whole picture. Bellah et al. remind us that "all institutions . . . are necessarily involved to some degree with wealth and power. These means all too easily become ends in themselves. Institutions become corrupt" (pp. 40-41). In The Good Society, the authors employ institutionalized sports to exemplify the moral drama of institutions:

The enormous amount of money at stake in professional sports has introduced an element of corruption so profound that many fans are deeply cynical about the sport that at the same time they also deeply love. Indeed, it is just at the point where the relative clarity of the game is clouded over by purely business considerations and power conflicts that disillusionment sets in. Suddenly an institution we thought we understood well begins to look like the institutions we don't understand at all. What seemed morally clear is now morally ambiguous. It is no wonder that Americans have an often-noted allergy to large institutions--though, as in the case of sports, even in our cynicism we continue to depend on them. (p. 41)

A Moral Drama
There are elements of our tussle with the notion of sponsorship that have this character of moral drama about them. Certainly, we have raised questions about the institutions we sponsor. In the healthcare arena, for example, we vacillate between seeing ourselves as part of the problem and seeing ourselves as, potentially at least, part of the solution. We worry about the extent to which assets amassed in hospitals and health systems represent a kind of corporate greed. We worry that our resultant power may be more attuned to maintaining the institutions themselves than to serving the medically underserved. Most of all, we question whether we have the will and the wisdom to apply our institutional power to help solve our society's dilemma over the costliness of healthcare.

What I see, though, in addition to all those questions, is a moral quandary with respect to the institution of sponsorship itself. This quandary is fed in part — but only in part — by the diminishing presence of women religious in institutional settings. It is also fed — but still only in part — by the desire of many women religious to be more clearly identified with works that serve the poor directly. A November 1994 survey of my own institute, for instance, showed that members were experiencing a "loss of influence" within large complicated organizations, a sense of loss growing larger and more complicated with the emergence of systems and mega-systems. Yet, at the same time, survey respondents decried our "lack of clear vision about mission, diversification of ministries, individual ministries, and desire to do new ministries."

Such responses suggest an ambiguity in our collective consciousness about sponsorship capability. Perhaps, one might even say, a moral debate is raging in our collective subconscious — a debate that might be illustrated by just one question: Is loss of corporate influence something we would do something about if we could, or have we chosen some other value, such as ministerial diversity, over influence?

Most of us recognize, at least from time to time, that ambiguity about the use of power is a central moral dilemma — maybe even the central moral dilemma. Thus Paul wrote to the Romans: "I cannot even understand my own actions. I do not do what I want to do but what I hate. . . . I do, not the good I will to do, but the evil I do not intend" (Rm 8:15ff).

In our individual lives, we are sometimes so afraid of our power to do a harm we do not intend that we are inhibited from acting at all. But is this not true of our collective life as well, perhaps even more so? Do we name our concerns about the degree of influence over works we sponsor more readily than our concerns about gathering our power, or, to use the phrase of the day, our concerns about institutionalizing our sponsorship? The extent of our sponsorship capability is not even a known quantity. But, whatever it is, exercising it makes demands on us not only individually but corporately as well.

Sponsorship and the Sisters of Mercy
Once again, let me offer as an example my own institute. It was not until 1991 that the Sisters of Mercy, previously a loosely linked confederation of religious institutes, became a single institute. This was not an easy decision. In considering the prospect of coming together, the question we asked most frequently was why. Virtually none of us wanted to discuss "how" to do it until we could be persuaded "why."

We showed some corporate wisdom in our insistence on phrasing the question in this manner. We realized that tinkering with our existence as separate institutes could conceivably do all sorts of harm. On the other hand, we were willing to take that risk, but only if creating a single institute promised some greater good — if, above all, it seemed to strengthen the sponsorship role of the Sisters of Mercy. In the end we were convinced that the institute would strengthen our sponsorship, and so we formed it (leaving a certain amount of autonomy to the regional communities). The "why" was answered, even though the "how" was not yet entirely clear.

We Sisters of Mercy continue to struggle with the "how" of sponsorship. That is because we do not fully know how being an institute that sponsors ministries (rather than a collection of individual ministers) shapes, forms, changes us. But the sense that sponsorship does change us grows clearer and more demanding. As it grows, so too will our need for a sense of purpose equal to the pain of whatever is being exacted from us.

Is there a purpose that large, that motivating? I can only say, I think so. I am thinking now not only of the Sisters of Mercy, but of all sponsors of Catholic ministries. If we did not sponsor ministries, what would take the place of the "institution of sponsorship" as a shaping influence over us, molding us into a people--a people of God, a people for God, a witness to Christ's mission?

I believe that sponsorship as an institution is an essential bearer of our ideals and meanings — even if it is (like the works themselves) inevitably an imperfect embodiment of those ideals and meanings. We need this institution. We need it to announce, to ourselves and the world, how and for what we mean to hold ourselves collectively accountable. We need it to announce, to ourselves and the world, that whatever wealth and power we possess are irrevocably committed to mercy and justice. Without the sort of bold statement that is made by founding, organizing, and taking long-term responsibility for specific works of mercy, how would we make moral sense of our corporate life?

We need the institution of sponsorship because the world of our service and our striving is replete with evidence of dysfunctional and coercive institutions — from the family, to capitalism, to organized religion. We shall either take an institutional stance ourselves or yield the territory. And we need not only to take an institutional stance, but to review and revise that stance constantly, so that sponsorship evokes responsible participation — and makes such participation fulfilling as well as demanding.

The Struggle May Be the Goal
Henry Van Dyke's The Story of the Other Wise Man features a fellow named Artaban, who never caught up with the three Magi who were traveling to Bethlehem. Instead, he spends 33 years searching, meanwhile using his wealth to care for the sick and needy. Even the jewel he had meant to give the King of the Jews, even that goes to help poor people. As Artaban dies, he envisions Jesus, with welcoming arms, saying, "You fed me when I was hungry." "Not so, my Lord," Artaban replies. "For when saw I thee hungry and fed thee? Or thirsty and gave thee drink? . . . Three and thirty years have I looked for thee; but I have never seen thy face, nor ministered to thee, my King."

John Shea, in a commentary on the story, suggests that this is a theme instructive for all searchers (Starlight, Crossroads Publishing, New York City, 1992, p. 138). The search may be its own reward. The struggle may be the goal. The task may be, not to gauge the distance we still have to travel, but to be attentive to what is happening on our journey.

Sr. Amos is president and chief executive officer, Mercy Medical Center, Baltimore. This article is adapted from a talk she gave to the Mercy Sponsorship Conference in Daytona Beach, FL, in January 1995.

Copyright © 1996 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

BY: LAWRENCE E. SINGER, JD

Mr. Singer is assistant professor of law and director, Center for Catholic Health Care and Sponsorship, Loyola University Chicago School of Law.

Catholic healthcare is at a crossroads. At a time when its mission—providing high-quality, spiritually based care, particularly to the poor—is needed more than ever, it finds itself threatened. Managed care, together with the refusal of sophisticated purchasers to pay for inefficiency, has radically altered the healthcare landscape. Sharp competition is forcing venerable Catholic organizations with "blue-blood" pedigrees to reexamine their place in the market, and some are deciding to substantially alter their institutional presence, if not to leave the market altogether. Through the New Covenant process, the ministry is moving to reposition itself to meet oncoming competitive challenges.

Catholic sponsorship is also in a period of flux. The emergence of a strong, highly visible for-profit sector has changed healthcare's dynamics. For the first time, for example, sponsors are facing takeover offers. Catholic healthcare leaders are forming partnerships with physicians, but these partnerships often do not mesh with the leaders' old methods of governance and control. Lay boards of directors are beginning to challenge sponsors openly, in some cases going so far as to file lawsuits against them. And sponsoring religious institutes are themselves challenged by declining growth, an aging membership, and a shortage of potential leaders.

These pressures are real. But they are not entirely negative. Sponsors can in fact use the pressures as an impetus to provide strong, innovative leadership for Catholic healthcare. Now is the time for sponsors to exercise such leadership. Indeed, now is the time for them to exercise an even higher degree of leadership than they have in the past.

The Strength of Sponsorship
Catholic healthcare sponsors have long led the development of innovative management, governance, and delivery techniques. Sponsors were among the first, for example, to recognize the efficiencies that could result from system organization, both for governance and management. The ministry's traditional approach to healthcare—which began with Christ's healing ministry and was later reinforced by women religious's practice of treating a patient's spiritual, physical, mental, and social needs as a whole—long foreshadowed the current movement toward integrated delivery systems and holistic treatment modalities.

Although faith-based healthcare may be discounted by the current market, it is likely to regain its luster as patients grow increasingly alienated from for-profit care. Certainly the survival, even strengthening, of Catholic care in this era of competition and diminishing reimbursement is due in large part to the mission, philosophy, and values inculcated in it by its sponsors.

Sponsors continue to be a viable partner of the Catholic health ministry because they provide leadership that can see the big picture and address the greater good. Precisely because they are "above the fray," sponsors have an obligation to help develop the innovative solutions Catholic healthcare so sorely needs. Put another way, a healthcare organization without a sponsor is one without an outside force that constantly challenges the organization to improve.

The Challenges of Sponsorship
Consider the following events, each of which has actually occurred:

• A facility's board of directors, unwilling to pay an assessment to a sponsored healthcare system, votes to terminate its membership in the system, thereby terminating sponsorship as well.
• A sponsor removes an institution's board because it has refused to collaborate with the sponsor's system. The former board subsequently files a lawsuit against the sponsor.
• A physician group wants to take control of a Catholic hospital by making it part of an integrated delivery network. However, the new network will not promise to keep the hospital Catholic.
• Two cosponsors end their partnership because they cannot agree on a common vision.

Although they otherwise differed, these situations are similar in that each demonstrates the need for strong sponsor leadership. Too often sponsors assume that their needs and goals will be immediately understood by the agents involved—board members, executives, attorneys, consultants—not realizing that such understanding can only come after sponsor and agent have developed a relationship. Too often sponsors assume that the interests of their member systems and organizations are identical with their own, forgetting that they bear a responsibility to ensure that a vision serving the higher calling of Catholic healthcare is developed and implemented. Sponsors also are obliged to ensure that their work is a means of facilitating public service (in keeping with Catholic values), not as a way to stymie beneficial initiatives.

Much has been written about the competition offered to Catholic providers by investor-owned organizations. Although proprietary systems do pose formidable challenges in some markets, the larger challenge is from within: inculcating in everyone—employees, physicians, and the community at large—the continued value of Catholic sponsorship.

In this era of multimillion, even multibillion, healthcare systems, it is all too easy for employees and community members to view such organizations as big business, not as a ministry of service. Many physicians, not understanding what Catholic sponsorship means, are wary of partnership proposals from Catholic hospitals. And, on the other hand, religious institutes tend to get wrapped up too often in institutional or system politics—or at least are perceived as wrapped up in it—thus obscuring the unique leadership capital they might bring to a difficult business transaction.

In short, the current era of sharper competition and declining reimbursement challenges sponsors to define the essence of their sponsorship and to choose the tools they will need to stay true to their visions. The era demands clear answers to basic questions: What does it really mean to be a Catholic healthcare provider? How do we remain true to the ministry in the face of lowest-cost pricing and managed care incentives? How can we sponsor organizations when they affiliate with other-than-Catholic partners, partners who may not understand or appreciate our values? How can we retain a sense of ownership in a ministry whose organizations seem to grow inexorably larger? And, finally, can we let go—of our control and our traditional, comfortable way of doing things—in order to respond to the needs of others?

The Responsibilities of Sponsorship
The Catholic Health Association, Consolidated Catholic Health Care, and other groups have tried to identify the "core competencies" required by sponsors. In theory, they can be taught. Unfortunately, some competencies have nuances that make them difficult to teach. Others—for example, leadership and vision—cannot be quickly taught. Their inculcation requires years of mentoring and on-the-job experience.

Since this is the case, it might be better for sponsors to identify core responsibilities they can either carry out themselves or delegate to others. They would do well to accept ownership of the following—by no means exhaustive—list of responsibilities:

Planning Sponsors have an obligation, in order to determine an appropriate future course, to assess themselves and the healthcare organizations they sponsor. Although businesses routinely engage in strategic planning, many religious institutes, unfortunately, do not. Yet a careful assessment of its resources will help a sponsor make decisions that strengthen both the religious institute and the healthcare ministry.

Marketing Religious institutes are generally uncomfortable with what they see as self-promotion. Unfortunately, we live in a world of information overload—one in which, if things are not screamed at you, they must not have occurred. But a happy medium lies somewhere between these two extremes. Religious institutes must quietly—but creatively and persistently—tell their stories to the public. If they do not, they will have little influence in the major decisions that affect both their own ministry and society at large.

Few members of the public understand the scope, duties, and responsibilities of religious sponsorship in the modern world. Because this is so, sponsors must clearly communicate both their own identities and the value of institutional Catholicity. Sponsors must consistently emphasize their interconnectedness not only with the organizations they sponsor but also with other sponsors. Then everyone involved—board members, employees, and the public at large—will understand that the ministry itself is more important than any single organizational piece of it.

Relationship Building A few sponsors have paid dearly, in adverse publicity and unwanted litigation, for using their reserved powers to ensure compliance from member organizations. In sponsorship, never having to use these powers is the name of the game. Sponsors should certainly exercise their powers when necessary, but they can accomplish more through relationship building. Unfortunately, many sponsors delegate the appointment and orientation of new board members because they fail to see how important such activities can be in building positive relationships. A sponsor's connectedness with member organizations will obviously be affected by the number involved, the distances between them, and similar factors. Nevertheless, sponsors have spent too little time ensuring the allegiance of their board members, executives, and medical staff leaders. Trust goes a long way when the chips are down.

Doing Your Homework Sponsors must take the time to understand, and stay in touch with, the organizations they sponsor. For religious institutes with leaders well versed in healthcare, this may be easy to do. Others, after taking a hard look at the number and location of their organizations, may need to create structures through which they can delegate certain functions. (And even then, in my experience, leaders of religious institutes often feel they are shirking religious community responsibilities when they attend board meetings, membership meetings, or negotiation sessions involving the organizations they sponsor.)

Sponsors also have an obligation to seek out the expertise they need to guide them in decision making. I have seen many instances in which leaders of religious institutes undertook activities they were not well-equipped to deal with and did not have appropriate advisers. In doing so, they put themselves in a negotiating stance or business transaction they did not understand.

A Valuable Tradition
The new healthcare environment, competitive and cost constrained, is a challenge to religious institutes, many of which face their own internal changes. Such institutes must remember that, in sponsoring healthcare organizations, they are stewards of a rich, honorable, and valuable tradition. Sponsors are called to a new day of vigorous involvement as they move to fill a role for which they are uniquely qualified.

Copyright © 1997 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

BY: SR. KELLY CONNORS, pm, JCD, PhD

Illustration from the St. John's Bible

Life in the church changes and evolves. So do the ministries of the church, for the church's works must remain relevant as the times change and evolve. Thus the relationship between the church and the Catholic health care ministry has been adapting to a modern era in which founding congregations gradually relinquish control of the entities they created.

Historically, religious women and men sought to respond to the needs of the people in ways that were not or could not be carried out by individuals or the infrastructures of the day. Although they did the work, they also prepared others to be able to assist and continue the work. Ideally, the freedom of the apostolate is to be flexible enough to respond to the greatest needs, and once a particular need is met or can be assumed by others, the religious (usually sisters) would move to address the next need.

Throughout the United States, the hospitals that congregations of religious founded and administered were, automatically, entities of the Catholic church that had canonical status as well as the accompanying mandate to act in the name of the church. They received goods, land and money to sustain their work, to use for the benefit of the people they served, and to provide for those who carried out the mission in the name of the congregation and, therefore, the church.

Early on, by the very nature of health care, religious women and men collaborated with lay women and men in carrying out the healing ministry of Christ. As mutuality and greater leadership were assumed by and given to people who were not members of the founding congregations, the role of the religious congregations needed to be clarified. The resulting understanding of the relationship of the religious congregation to the ministries that they founded, or assumed on behalf of another, is that of sponsor.

Our understanding of a sponsor finds its connection here — the religious congregation was the sponsor of its hospital or health care entity, and the sponsor's resources were used for the mission, that is, to promote and assure the healing ministry of Jesus. Sponsorship is a formal relationship between an authorized Catholic organization and a legally formed system, hospital, clinic, nursing home, etc., entered into for the sake of promoting and sustaining Christ's health ministry to people in need.¹

As long as a health care ministry is connected to the religious congregation, it remains Catholic and a work of the church. But how much of a connection between the religious congregation and the ministry is enough to call the hospital or other entity Catholic? What elements of the health care ministry need to be accountable to the sponsor in order to maintain Catholic identity? Fr. Francis G. Morrisey, OMI, JCD, PhD, addressed those elements this way:

As various theological and historical studies have shown, the term "sponsorship" is relatively new in church circles. It originally was given wide circulation as part of a threefold approach to health care works: ownership, sponsorship, control. Ownership referred to holding title to the property; sponsorship usually referred to the body under whose name it operated; and control referred to the internal governance.

With time, though, the distinctions among these three dimensions have become more and more blurred. For instance, we can have sponsorship with or without ownership; ownership with or without control, or with very little control; and degrees of control with various forms of sponsorship.

It is rather advantageous that canon law does not define "sponsorship," because we are not bound by any special legal parameters. Through the course of time, various forms of sponsorship in the church have been tried and tested. No one form has proven to be the only correct one; the forms are different, and nothing more.²

Ownership, sponsorship and control are terms applied to what evolved organically. They refer to the function of ministry, not the essence of the mission — carrying on the healing ministry of Jesus Christ, founded on the Gospel and followed in communion with and in the name of the church.

As the dynamics of society and a post-Vatican II church continue to change, the relationships between church entities and Catholic works have evolved. There have been and continue to be wonderful opportunities to internalize and model the ecclesial ideal of communio as well as challenges to put this into practice with freedom and dynamism. It has called those involved in Catholic health care to step back and focus on why we do what we do, what makes our doing this work different from what others are doing. Good works can be and are carried out by good people. What is the value in doing the same thing in the name of the church?

Hopefully we, as ministers of health care, come to the realization that we are a part of something bigger than ourselves. We recognize that the mission of Jesus Christ in the building up of the kingdom of God precedes us and will continue long after us.

"Indeed, by starting from the mission — to imitate Christ who was doing good for others (see Canon 577) — we could then look at what are some of the issues at stake, not forgetting that here we will have some messy elements that don't seem to fit into place, but that should not stop us from trying to move forward," Fr. Morrisey wrote.3

The post-Vatican II church continuously calls members of the faithful to return to the Gospel, return to our origins and remember why we do what we do, not only why we did what we did. The founding of religious institutes was borne of responses to the needs of people and communities, and no two were or are the same. The establishment, growth and maintenance of the many institutions was wrought through hard work and sacrifice, choices and priorities. Can we expect that the next iteration of Catholic works would be realized any other way?

Similarly, as members of the faith community, we cannot expect that there will be one form of sponsorship of Catholic works, with or without members of religious congregations.

Today, as we in Catholic health care grow and need to evolve in our understanding and expression of sponsorship, it is critical that this Gospel-centric response to the needs of our world and society be identified as a Catholic response, unique among the many responses. It is equally critical that this Catholic identity be a priority. It is no longer sufficient to let the implicit indicators — the saint's name on the door or building, crucifixes in hallways or rooms, chapels and chaplains — passively speak for us.

Maintaining a Catholic identity is challenging on many levels; it is a multiplicity of relationships, with some being more difficult than others — church bureaucracy, societal misconceptions, unhelpful media and politics, just to name a few. Health care in the United States is demanding enough without the added layer of it being a work of the church.

But this is not a one-way relationship. The founding charism and particular mission of the ministry, within that of the church, is a gift to the church and reveals an aspect of the face of Jesus the Healer that would otherwise remain unseen. In this relationship, the health care ministry is a work of the church, but it also is a ministry to the church.

As religious congregations acknowledge the need to place these works of the church into the capable hands of the laity, it is not easy to create or implement comprehensive models that facilitate mission and Catholic identity. It is tempting to allow a sponsored ministry to transition to a private work of Catholics. In some instances, that might be an appropriate response for the common good and the service of the ministry, but such a decision must be made through dialogue, discernment and integrity. It is not easier; the challenges are just different.

At this time in history, Catholic health care is so very important. Pope Francis has characterized his ideal of the church as a field hospital. What greater role can we play in carrying out the mission of the church than reflecting back to her what she is striving to become? Our Catholic identity reminds us that we are part of something bigger than ourselves, we carry on the ministry of Jesus, we are not the saviors. Simultaneously, we bear the gifts of the Spirit and the witness of the Gospel to the people we serve as well as the church in whose name we minister. By our sharing in the public identity of the church, we contribute to the holiness of the church.

When people witnessed the dedication, work and holiness of social activist Dorothy Day, she would insist: "Don't call me a saint. I don't want to be dismissed that easily."

She meant that if people classified her as a saint during her life, they would be liberated from bearing the same kind of responsibility she demonstrated. If Catholic works abandon their Catholic identity because maintaining Catholic identity is too much work, or has too many layers, or "it won't be the same as when the sisters ran things," then the impact that the ministry has on the church and the people of God can be too easily dismissed.

Just as we speak of sponsorship as influence, maintaining our Catholic identity is influence, too. The same Spirit that founded the church, religious congregations and the Catholic ministries is alive and well in our time. Will we have the radical faith, as witnessed by the founding religious institutes who risked all for the Gospel, to allow the Spirit to lead us into unknown territory?

SR. KELLY CONNORS, pm, is senior director, sponsor services, the Catholic Health Association, St. Louis.

NOTES

1. The Catholic Health Association, "Sponsorship Overview," www.chausa.org/sponsorship/overview."
2. Francis Morrisey, "Our Sponsors: Yesterday, Today and Tomorrow," Health Progress 94, no. 4 (July-August 2013): 63.
3. Morrisey, 65.

Copyright © 2017 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3490.

Illustration from the St. John's Bible

Since the very beginning of his papacy, Pope Francis has provided a field day for the media. With well over 10 million people following him on Twitter, it is no wonder that many of his statements have become quotable quotes. One in particular has garnered much attention: "I see clearly that what the Church needs today is the ability to heal wounds and to warm the hearts of the faithful; it needs nearness, proximity [to the people]. I see the Church as a field hospital after a battle."

The concept of field hospital generated a tremendous amount of excitement throughout the Catholic health ministry. Ever since the Holy Father's 2015 homily at Casa Santa Marta when he gave us this vision of the church, there have been many interpretations and elaborations on how the church is like a field hospital, and it continues to be a common theme in programs, presentations and articles developed by the Catholic Health Association.

Most will agree that the fundamental message communicated through the field hospital image is that the church's mission is to care for and heal the wounds of society.

Maybe it's my age, but the thought of a field hospital reminds me of the 4077th mobile army surgical hospital on television's "M*A*S*H." For those who never watched the show, which ran from 1972-1983, it was about a team of men and women serving in a MASH unit during the Korean War. Described as a dark comedy, the weekly episodes were filled with both laughter and sorrow. One could not help but often be moved to tears by the courage and commitment the characters depicted in their response to tragedies of war and their care for those physically, mentally and spiritually wounded, whether friend or enemy.

Although set in South Korea, "M*A*S*H" reflected the political and social conflicts related to the Vietnam War. By airing significant issues of the era, the show about a mobile army surgical hospital — a field hospital — made for one of the most socially relevant television series ever produced.

"M*A*S*H" reminds sponsors — and us — that to care for and heal the wounds of the day, the Catholic health ministry must remain socially relevant. The Second Vatican Council called the church to such relevancy as it considered the role of the church in the modern world. Society was changing rapidly in the 1960s, and if the church was to be leaven in the world, it also needed to change.

"Thus the church, at once 'a visible association and a spiritual community,' goes forward together with humanity and experiences the same earthly lot which the world does. She serves as a leaven and as a kind of soul for human society as it is to be renewed in Christ and transformed into God's family."¹

Since the opening of the first U.S. hospital after the 1727 arrival of the French Ursulines in New Orleans, the Catholic health ministry has experienced momentous change. From the simple beginnings of providing care for poor people, there have developed multibillion-dollar health systems, innovative technologies and advances in the provision of care. These changes have given way to new and evolving models of sponsorship ensuring the ministries remain relevant for the times.

Throughout this issue of Health Progress, readers are invited to consider the many ways sponsors are ensuring the relevancy of the Catholic health ministry today. For example, Anthony Tersigni, Ascension's president and CEO, describes sponsors' prophetic action as "bridging the gap between the Gospel and contemporary realities" as we respond to contemporary needs. Melanie Dreher, PhD, RN, and Sr. Linda Werthman, RSM, from Catholic Health Ministries, sponsor of Trinity Health, provide an in-depth look at the relationship between sponsorship (canonical) and governance (civil), and the lessons learned from a "mirror board." SSM Health Ministries' Sr. Rose Mary Dowling, FSM, along with ethicist Ron Hamel, PhD, describe one congregation's inspiration for creating a new model of sponsorship and the journey of its development.

The authors give us a lens through which sponsorship is perceived and experienced, and their various perspectives and new interpretations have come a long way since the founding congregations sponsored these ministries of the church. Chris Lowney's invitation to think more broadly about "small s" sponsorship brings us back to Sister of Mercy Concilia Moran's understanding of sponsorship: "support of, influence on and responsibility for." That's a vision that encompasses far more than canonical sponsorship.

In the current health care environment, the impact of market demands has resulted in some Catholic hospitals being sold to secular or other faith-based systems. Lisa Gilden, JD, CHA's vice president, general counsel and compliance officer, analyzes such arrangements as how "the Catholic health ministry continues to seek new ways to carry on its mission of providing services to those in need in an evolving U.S. health system."

Today, amid so many challenges, the Catholic health ministry strives to remain relevant. At times the pressures seem insurmountable, particularly with the uncertainty surrounding health reform. In their article, Sr. Catherine O'Connor, CSB, Congregational Leader of the Sisters of St. Brigid, and Thomas H. Morris, senior vice president, sponsorship and theology at Bon Secours Health System, remind us of the vital role formation plays in preparing and providing guidance to members of juridic persons as they navigate these challenges.

Perhaps more than ever, sponsors need to heed the call of Mother Odilia Berger, the founder of the Sisters of St. Mary, to "Continue courageously, for the love of God." The stories of the fictional 4077th mobile army surgical hospital staff demonstrate how courage and commitment allow any and all of us in the health care ministry to be relevant and remain true to our call.

By the way, if you haven't watched an episode of "M*A*S*H" lately, check your local TV listings. It's a story you don't want to miss.

SR. MARY HADDAD, RSM, is vice president, mission services, the Catholic Health Association, St. Louis.

NOTE

1. Paul VI, Gaudium et Spes, paragraph 40. www.vatican.va/archive/hist_councils/ii_vatican_council/documents/vat-ii_const_19651207_gaudium-et-spes_en.html.

Copyright © 2017 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3490.

BY: BRIAN SMITH, MS, MA, MDiv

Illustration from the St. John's Bible

I have a confession to make: I was a mission leader for seven years before I had a good understanding of what sponsorship in Catholic health care is all about. I used to be embarrassed by it, until I discovered that many other senior leaders and middle managers also have no idea what sponsorship is. Many leaders are not able to tell you the names of the individuals who make up their sponsoring board or PJP. And the term PJP — public juridic person — is understood by even fewer leaders within Catholic health care. Unfortunately, for many leaders and front-line associates, sponsorship and the individuals who make up our sponsoring boards are shrouded in mystery. One of the goals of this Health Progress issue is to pull back the curtain and begin to demystify sponsorship. This article will show the relationship and connections between sponsorship, governance and mission integration.

A DEFINITION
According to one CHA definition, a sponsor's primary role "is to ensure that the mission of Catholic health is carried out, now and in the foreseeable future. A sponsor is a steward, accountable to the church for the organization's Catholic identity and ministry, as well as its financial health and property ownership."¹

In short, sponsors are responsible and accountable for the integrity and perpetuity of the healing ministry. The members of the sponsoring board or PJP, therefore, must first themselves understand what that means. It is never assumed that anyone — even a person in a religious congregation or with a strong Catholic education — who serves as a sponsor member, understands what the role and responsibilities of sponsorship entail. Sponsors go through a formation process that prepares them by providing the theological, ethical, canonical and spiritual resources they need to shepherd the ministry entrusted to them.

The Catholic Health Association and its members developed a sponsorship formation program that identifies key competencies for sponsors, as well as a core curriculum of formation. The program's purpose is to root sponsors in the tradition of the Catholic Church so that the identity and integrity of Catholic health care are maintained, while, at the same time, the emerging needs of the community are assessed and addressed.

CHURCH RELATIONS
Although sponsors have the ultimate responsibility for maintaining Catholic identity and addressing the needs of the community, they work in partnership with the church and the diocesan bishop, as well as the health system's functions of governance and mission. Sponsors serve as connectors between the Vatican and the local ministries. Sponsoring boards and PJPs are required to submit an annual report to the Vatican and make an in-person visit every three years to the Congregation for Institutes of Consecrated Life and Societies of Apostolic Life. Staff have told CHA that although the financial reports demonstrating viability are important, the Vatican is more interested in how the needs of the poor and marginalized are being addressed and how the lay leaders and associates of Catholic health care are receiving ongoing formation so the ministry endures.

Similarly, sponsors meet regularly with local bishops to share how Catholic health care facilities within the diocese are continuing the healing ministry of Jesus. Catholic identity, ethical issues, proposed partnerships with other-than-Catholic entities and formation of lay leaders are the typical areas discussed. Because the CEO and mission leader of the Catholic health organization also routinely meet with the diocesan bishop, it is essential that there be a mutual understanding between sponsors, governance and mission about how Catholic identity and integrity are being demonstrated within the organization and how that message is being communicated.

RELATIONSHIP TO GOVERNANCE
The relationship between sponsorship and governance has not always been easy to define. One of the reasons is the variety of models of how sponsors and governance share the responsibility for oversight of the ministry. Some systems have a distinct sponsorship board, or PJP, and a board of trustees. Others have a "mirror board" whose members act both as sponsorship board and board of trustees or directors.

The sponsorship role is focused on carrying forth the healing ministry of Jesus and preserving Catholic identity. Most models agree that finance, operations, management, quality and strategic planning are traditional roles of governance. However, most systems recognize that sponsors also must be included in the strategic planning process. Part of the responsibility of sponsorship is to ensure that the ministry will endure, and it is critical for the sponsors to know what the future looks like and how the organization will respond in a manner consistent with Catholic tradition.

CHA's members have asked for a task force to clarify the emerging role of the sponsor and the relationship between sponsorship and governance. The goal is to explain and distinguish the roles and responsibilities of these two aspects of ministerial stewardship. The task force will be composed of CEOs, sponsors and trustees and will begin meeting in 2017.

PROPHETIC ROLE
From the Industrial Revolution, when religious congregations emerged to deal with the health and social needs of the poor and vulnerable, to today, when sponsors are clear voices in the call for basic health care for everyone, sponsors have been prophetic. For example, they recognized that religious congregations would one day no longer oversee the health care ministry and that it was time to invite and form lay leaders to first partner, then one day lead the ministry.

Their vision resulted in the creation of PJPs — each composed of religious and laypersons, although some now are made up entirely of lay members; formation programs for senior leaders; and the creation of mission leadership departments that help other leaders learn how to integrate mission, ethics and spirituality within their departments.

More recently, sponsorship boards and PJPs have taken a prophetic role by directing their system leaders to become more involved in caring for vulnerable populations, including immigrants and refugees, victims of human trafficking and persons with mental illness. At times the sponsors have challenged us by asking why our systems have not eliminated disparities in care delivered to minorities and the poor; why our boards and senior leadership teams are not as diverse as the populations we serve; and what we are doing to address the social determinants of health in our area.

Some sponsors have become advocates for protecting the planet and have asked governance and senior leaders to adopt environmental sustainability practices.

Although the prophetic role of sponsorship is central to stewarding the church's health ministry, leaders and associates don't usually see the sponsors, which may contribute to some of their mystique and the misperception that sponsors deliver oracles from on high. It is crucial for senior leaders and sponsors to maintain a relationship.

SPONSORSHIP AND SENIOR LEADERS
Sponsors are responsible for keeping the mission and ministry of Catholic health care vibrant. Senior leaders are responsible for operationalizing it. Sponsors create the vision and inspire others to share in the mission of Catholic health care, steward the ministry and maintain accountability to Rome and the diocesan bishop. Senior leaders, including the mission leader, are responsible for creating the policies, procedures, practices and culture to make sure the vision is being realized. For vision and practice to come together, sponsors, senior leaders and mission leaders must establish working relationships.

Operationalizing mission, or mission integration, is the day-to-day work of leadership. It occurs not only in formative moments like new-hire orientation, but more importantly in the day-to-day work of caring for the sick, infirm and those who are most vulnerable. Mission integration takes place when a manager or a senior leader pauses to reflect and use a values-based decision-making process rather than making a quick decision.

Leaders operationalize mission when they help create an environment that invites the spiritual dimension of holistic healing to be experienced by patients, families and staff. These are the hands-on, daily moments when leaders connect associates to the higher calling of the mission and ministry. Such nuts-and-bolts work is not the role of sponsorship, it is the work of senior leaders — but obviously there is a connection.

SPONSORSHIP AND FRONT-LINE STAFF
I believe we have an opportunity within our ministries to make the connection between sponsorship, senior leaders and front-line staff more visible. Recently, I facilitated a retreat for members of a PJP. While discussing the relationships between sponsorship, governance, senior leaders and front-line staff, one of the members stated, "Our leaders and associates don't know the name of our public juridic person, much less the names of the individual members. How can we help them see they are a part of something bigger than the facility where they work? That the work they do is rooted in a tradition and charism that ultimately goes back to the ministry of Jesus?"

One person thought the answer was in educating leaders and staff, publicizing the name of the PJP and showing pictures of the members of the PJP board.

But another said, "It is our responsibility as sponsors to go to the facilities where ministry is taking place. It is not enough for us to read reports that tell us all the good things that are going on. We should be seen by leaders and associates, and we should be out on the floors thanking them for partnering with us in this ministry. They need to know us, and we need to know them."

That certainly would go a long way toward demystifying who and what sponsorship is.

BRIAN SMITH is senior director, mission integration and leadership formation, the Catholic Health Association, St. Louis.

NOTE

1. Karen Sue Smith, "Overview of Sponsorship: A Supplement to CHA's Sponsorship Video, 'Go and Do Likewise. Sponsorship of the Catholic Health Ministry'." www.chausa.org/docs/default-source/sponsorship/overviewofsponsorship-karensuesmith.pdf?sfvrsn=0.

Copyright © 2017 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3490.

BY: ZENI FOX, PhD

Illustration from the St. John's Bible

"Spirituality" names an important domain of human experience that has contours influenced by varied religious traditions, but it is not always tied to any religious tradition in particular. It is influenced by the vast array of individual experiences of inner life, especially as transformed by the transcendent.¹ These individual expressions sometimes become part of religious traditions, spiritual classics handed on from generation to generation.²

"Sponsorship" names an aspect of Catholic institutional ministerial life that has been evolving over a period of about 30 years. It is a term widely used in Catholic health ministry circles, and Catholic educational ministries and Catholic social service ministries speak of sponsorship, as well. The spirituality of sponsorship is a rich, complex concept, with dimensions that are relevant for individual sponsorship entities and for the members of the sponsor.

Among the Oxford English Dictionary's definitions, sponsor is "one who answers for an infant at Baptism; a godfather or godmother." The dictionary indicates that the word first was used in a religious sense, tied to a very important Christian ritual, and later it held significant social and political meanings. Among them: "one who enters into an engagement, makes a formal promise or pledge, on behalf of another." One of the dictionary's examples of how the word is used is particularly evocative for today's understanding of sponsorship: "It knits them unto me, and me to them, that bond of sponsorship."³

The Catholic Health Association's definition of sponsorship gives us a contemporary understanding:

Sponsorship of a health care ministry is a formal relationship between an authorized Catholic organization and a legally formed system, hospital, clinic, nursing home (or other institution) entered into for the sake of promoting and sustaining Christ's health ministry to people in need. Sponsorship of Catholic health care involves promoting and assuring Jesus' healing mission. Those who sponsor are responsible for the continued viability of the health care ministry, promoting its ongoing mission and animating its life.⁴

These definitions offer several points relevant to a spirituality of sponsorship. In an effort to provide ways of deepening spiritual understandings and lived experience, we can explore the relevant points for the individual sponsor and for the individuals who are members of the sponsor entity.

THE SPONSOR
The ritual of Baptism creates a personal and ecclesial relationship between the infant and sponsor. The relationship of godchild and godparent is larger than a juridical relationship; it is deeply interpersonal. Various Christian cultures emphasize this role as operative throughout the lives of the individuals.

In a similar way, a sponsor has a personal and ecclesial relationship with the entity it serves. The role can be cast in juridical terms, but at the heart of spiritual life in every religious tradition is relationship — with a transcendent reality and with "the neighbor." Creating the relational bonds, both among the members of the sponsor and with the sponsored ministry, is a spiritual task. It contributes to the deep collaboration and reverent regard of the other (whether individual person or corporate entity) that mark a spiritually alive group.

The godparents' responsibility "is to show the candidates how to practice the Gospel in personal and social life, to sustain the candidates in moments of hesitancy and anxiety, to bear witness and to guide the candidates' progress in the baptismal life."⁵

Applied to a corporate entity, this spiritual charge is central to the work of sponsorship. Attention to the institution's "personal and social life" supports the importance of social justice teachings as a guide for the life of the institution. It echoes the sense that the sponsor attend to the vision and tasks inherent in this mandate. Attention to hesitancy and anxiety describes a compassionate approach to the concerns of the institutional ministry; it is an approach that places the sponsor within the circle in a position of support, not outside in a position of judgment. Bearing witness in an institutional setting calls for an agenda of emphasizing hope and love and faith within the sponsor itself and as its work of sponsorship unfolds.

A focus on the task of the sponsor — "promoting and assuring Jesus' healing mission"⁶ — emphasizes the story of Jesus within the sponsor's spirituality. The focal point for spiritual reflection should be the image of the reign of God that Jesus proclaimed and inaugurated more than the story of the founders of a particular ministry. The reign of God is a larger reality than the church, and as such it reminds us that the fullness of life, peace and justice it promises will never be completely achieved until the Second Coming. That reality leads to a stance of humbly placing all we do in the hands of God, even as we actively work "for the continued viability of the health care ministry."⁷

Another way of conceptualizing the role of the sponsor is to say that it has a primary responsibility for fostering the spiritual life of the institution it serves. Sr. Regina Bechtle, SC, writes: "Organizational consultants and religious writers alike affirm that institutions do have a collective spirit, a spirituality that is more than the sum of the individual spiritualities of persons affiliated with them."⁸ The first step in being able to foster this life is to believe that it is possible. A profoundly Christian belief underlies it:

Our religious heritage orients us to view institutions as spirits embodied, as places of graced possibility... They are open to the action of grace and of evil. They act, for good or ill, with more or less freedom, to influence the world around them. By words and deeds, policies and behaviors, institutions translate their deepest dreams and desires into real time and space. By what they do and fail to do, they can evoke blessing or blame.⁹

Community is central to this enterprise, and so is the conviction that God already is among us. God, who created all that is and holds all that is in being, is always here — as psychiatrist Carl Jung once said — bidden or unbidden.

... (T)he spirit/Spirit in a community or institution is always already there. It may need to be uncovered, pointed to, coaxed forth, led out, articulated explicitly. But it was there before us. We may need to name and claim it, stretch it, push it, strengthen it, make room for it to deepen and grow. But the spirit/Spirit was and is always already there.¹⁰

This conviction is lived out (or, more precisely, lived into) when meetings allow time for human connection (community-building) and practices of reflection (prayer, yes, but also modes of decision-making that invite the participation of all, and proceed centered on mission and values). "God's Spirit shows Herself, embodies Himself, in the way the groups act to make their best intentions real ... The Spirit is present in the community's honest efforts to live its commitments faithfully, even if the results are not successful according to the world's standards."¹¹

MEMBERS OF THE SPONSOR
The individuals who are part of a sponsoring entity come to their role, to the spiritual task entrusted to them, with their personal spiritualities. Certainly, service as a member of a sponsor becomes part of each one's spiritual path. But, it is important for these individuals also to pay attention to the path they have walked before taking on this responsibility.

Allowing our path to "speak to us" can be quite revealing. In a course for Catholic-school principals, I invited participants to prepare for a class by tracing the influences that had brought them to being part of the class and illustrating their journey in a way that could be shared. They noted many different experiences as part of the story — from childhood, adolescence, adult life, both gifts and challenges. Doing the assignment, then sharing the story with others, often brought a realization: My path is, indeed, a path, and it was informed by grace. For many, it was a case of "bringing to the level of conscious awareness that which was already present by grace."¹² This awareness heightens the ability to truly bring one's personal spiritual gifts to the world, and, therefore, of course, to the work of the sponsor.

The Decree on the Apostolate of Lay People (Apostolicam Actuositatem) from Vatican II provides official teaching that emphasizes such a perspective. The Holy Spirit gives laypeople "special gifts" . . . "so that each and all, putting at the service of others the grace received, may be "good stewards of God's varied gifts." Special gifts, grace received, are concepts too seldom explored as part of the reality of laypeople's lives. Furthermore, "From the reception of these charisms, even the most ordinary ones, there arises for each of the faithful the right and duty of exercising them [italics added] in the Church and in the world."¹³ Charisms! It is in the ordinary life of everyday that these gifts are received and used.¹⁴

This lay spirituality will take its particular character from the circumstances of one's state in life (married and family life, celibacy, widowhood), from one's state of health and from one's professional and social activity. Whatever the circumstances, each one has received suitable talents and these should be cultivated, as should also the personal gifts (s)he has from the Holy Spirit.¹⁵

In addition to the contours of one's personal spirituality defined by the parameters of each one's everyday life, the Second Vatican Council gives guidance to the social dimension of spirituality, which has particular relevance for sponsorship.

That men and women, working in harmony, should renew the temporal order and make it increasingly more perfect: such is God's design for the world ... Lay people ought to take [this] on themselves as their distinctive task. … [T]hey must bring to their cooperation with others their own special competence, and act on their own responsibility; everywhere and always they have to seek the justice of the kingdom of God.¹⁶

In these teachings, there is a mandate for laypersons to recognize their gifts, ordinary gifts received in the living of their lives, and their charisms, special gifts of grace that give them wisdom, or vision, or prophetic voice. As members of the sponsor, it gives them the right and responsibility to use their gifts for the entity they sponsor, but also for the larger world beyond the immediate circumference of the sponsored work.

CONCLUSION
A characteristic of the Catholic community of the East and the West is that there are many varieties of historically developed spiritual paths. Catholic institutional ministries often have been deeply influenced by one of these great traditions — Vincentian, for example, or Ignatian. Today, members of a sponsor often are laypeople whose spiritual paths may have developed idiosyncratically, as well as having been influenced by one or more of the great traditions. This calls for a new honoring of diversity in the spirituality of sponsorship, as different spiritual gifts, different charisms, are present because of the shaping forces of the individual circumstances of the states of life of lay members. There is an invitation here to all members of a sponsor to "Let Your Life Speak."¹⁷

ZENI FOX is professor emerita of pastoral theology, Immaculate Conception Seminary School of Theology, Seton Hall University, South Orange, New Jersey. She is a member of the Ascension Sponsor.

NOTES

1. James Fowler, Stages of Faith: The Psychology of Human Development and the Quest for Meaning (San Francisco: Harper and Row, 1981), 276. In his study, Fowler explores the human side of faith. He posits that all people relate to "centers of value that give our lives meaning." In religious terms, this references the experience of the divine or ultimate reality, by whatever name a particular tradition calls it.
2. From the Jewish tradition, the Psalms, and from the Christian tradition, the songs and prayers of St. Francis, are well-known examples.
3. Oxford English Dictionary, under the word "Sponsor."
4. The Catholic Health Association, "Sponsorship Overview," www.chausa.org/sponsorship/overview (accessed Feb. 9, 2017).
5. Rite of Christian Initiation of Adults, n. 11.
6. The Catholic Health Association, "Sponsorship Overview."
7. The Catholic Health Association, "Sponsorship Overview."
8. Regina Bechtle, "Giving the Spirit a Home: Reflections on the Spirituality of Institutions," in Called and Chosen: Toward a Spirituality for Lay Leaders, ed. Zeni Fox and Regina Bechtle (Lanham, Maryland: Rowman & Littlefield, Inc., 2005), 99.
9. "Giving the Spirit a Home," 100.
10. "Giving the Spirit a Home," 103; italics in the original.
11. "Giving the Spirit a Home," 105. Bechtle offers further suggestions for leaders as "tenders of the Spirit in organizations," which have implications for the work of a sponsor. Compare: 105-10.
12. A guiding principle in the work of theologian Karl Rahner.
13. Decree on the Apostolate of Lay People (Apostolicam Actuositatem), article 3.
14. A clarification is needed here about the definition of laypersons informing this article. It is not the canonical definition, which includes vowed religious, but a sociological one, which describes all other laypeople.
15. Decree on the Apostolate of Lay People, article 4.
16. Decree on the Apostolate of Lay People, article 7.
17. The title of Parker Palmer's book, Let Your Life Speak: Listening for the Voice of Vocation (San Francisco: Jossey-Bass, 2000).

Copyright © 2017 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3490.

BY: SR. CAROL KEEHAN, DC

EDITOR'S NOTE: So much that affects health care for vulnerable populations is swirling around us in the news. For instance, this Health Progress issue on mental health care was well underway before the shootings in Newtown, Conn., precipitated a national debate on mental illness that made it timely in a way we could never have imagined, and certainly would never have wished.

Our next issue, May-June, will focus on health care for veterans at a time when suicides among active military and veterans alike are rising at an alarming rate. And as we go to press with this issue, immigrants are coming to the forefront, as Congress and President Obama put forth proposals aimed at helping potentially millions achieve legal status.

Each of these — people with mental illness, U.S. veterans, illegal immigrants — is a vulnerable population of deep concern to many in our nation, but particularly so to those in Catholic health care.

Meanwhile, health reform moves forward, poten­tially offering help and hope to millions within these populations. Yet, in many states, the expansion of Medicaid — a key component in making reform work — hangs in the balance.

With that in mind, Health Progress invited Sr. Carol Keehan, DC, to write in this space about CHA's ongoing efforts to ensure health reform's success. We can't think of anyone better able to make the case for those people in our nation who have too long been denied a basic human right.

— Pamela Schaeffer

____________

On October 1, 2013, the world will be different for millions of people who are currently uninsured. As a result of the Affordable Care Act (ACA), new health coverage options will be available for low-income, vulnerable persons; for working families whose income isn't enough to cover insurance costs; for children who will become eligible for coverage their parents couldn't previously afford.

Getting out the word about these new benefits will be a big task. Public opinion research shows that the majority of people who will be eligible for new benefits are unaware of that fact. To move the education and awareness work forward, CHA joined Enroll America as a founding partner.

Enroll America is a Washington-based non-profit that counts civic groups, philanthropies, doctors, pharmaceuticals, health insurers and labor and consumer groups among its other partners. The organization is ramping up to launch a major national public relations and education campaign that will include advertising, social media and community-based events to get information directly to hard-to-reach target groups.

CHA is working closely with Enroll America leadership, staff and other partners and will share resources with members of the ministry as they become available. These materials will assist with enrollment outreach, education and even procedures to actually sign people up for coverage.

MEDICAID: A VITAL OPPORTUNITY FOR STATES
When the U. S. Supreme Court affirmed the constitutionality of the Affordable Care Act, it was a win for the uninsured, for working families, for seniors and for others the law was designed to protect. As a ministry we supported the ACA because it represented the first opportunity in years to begin creating an equitable, affordable health care system in the U.S. The Supreme Court reviewed the health care law in its entirety and found the crux of the law — the individual mandate that everyone carry insurance or face a penalty — to be permitted by the Constitution.

The court's ruling, however, included a surprise few, if any, observers saw coming.

First the background: Many people will obtain new coverage as a result of the Medicaid expansion envisioned by ACA. The current threshold for Medicaid eligibility is 100 percent of the federal poverty level income, which is about $23,000 per year for a family of four. ACA adjusted the threshold so that those earning 138 percent of the poverty level will be eligible. This means a family of four may qualify for Medicaid if the annual household income is about $31,000. The net effect: many more working families who cannot currently afford health coverage will gain access through Medicaid.

In its ruling on the ACA, the Supreme Court said the federal government cannot compel states to expand the program, even though the expansion is mostly federally financed. Instead, the court decided, states have the option of expanding their Medicaid program as called for in the ACA. Governors can take new federal money to expand the population they serve with Medicaid. But they do not have to.

Be that as it may, governors most definitely should accept the federal money to expand their Medicaid programs. For Catholic health care, Medicaid represents part of an important promise to care for persons who are poor, vulnerable and have no other option for their health care. Every person is created in God's image. Every life is sacred. Medicaid matters a lot in making these words a reality on the ground.

Ever since the court issued its ruling, CHA and our members have been making the case for governors to do the right thing for the people in their states. With so many uninsured families standing to benefit from Medicaid, governors should carefully consider the implications before saying no to the expansion. Once they have considered the issues, I believe it will be clear that broadening the reach of Medicaid makes sense. It makes sense from the standpoint of protecting human dignity. It makes sense in terms of public health. And it makes sense economically.

To begin, the federal government will pick up 100 percent of the cost of expanding Medicaid until 2016, at which point the government will pay 90 percent of the cost of coverage for newly eligible enrollees. In other words, states can significantly expand their Medicaid program without paying very much for it. If I were running a state, I would find this deal impossible to turn down. This is especially true given that states and their residents would end up paying the cost of care for the new Medicaid population in other ways. When uninsured people receive care in a hospital emergency room or require an extensive stay, someone has to pay for it — and often it is the hospital in the form of uncompensated care. When large numbers of people need care but have no insurance, all of us pay in the form of higher premiums, co-pays and deductibles. We also pay a price in public health when millions of people are unable to receive appropriate routine and preventive care.

As of this writing, 22 states and the District of Columbia have said they will expand their Medicaid population as called for in the ACA, and 13 states have said they definitely will not, including Texas and several in the South. The remaining 15 states are undecided. To refuse hard-working families the opportunity to have health insurance for preventive and sick care absolutely has to be challenged.

In addition, all hospitals took significant reimbursement cuts predicated on getting 30-32 million more people insured. If that does not happen, our ability to serve communities — and especially the uninsured — is seriously jeopardized.

In January 2013, Gov. Jan Brewer (R-Ariz.), a critic of the ACA, announced her state has opted to expand Medicaid, arguing that "with this move, we will secure a federal revenue stream to cover the costs of the uninsured who already show up in our doctor's offices and emergency rooms." (Los Angeles Times, Jan. 15, 2013, "Arizona Gov. Jan Brewer Opts to Expand Medicaid.") Other governors on the fence need to hear Brewer's logic. The best reason to do the expansion is the opportunity to provide health care to vulnerable, working families. But the economic reasons matter as well, and some reluctant governors are obviously beginning to see how the Medicaid expansion is in everyone's best interest.

Catholic health care has a long and admirable history of leading the way on health reform, coverage initiatives and education campaigns. We must step up again to help persuade governors, which is sometimes best done through grassroots communication. If community voices are loud enough about demanding the Medicaid expansion, the legislative machine will respond. The people in Catholic health care should be those voices. We have done it in the past, and I'm quite confident we can and will do it again.

This is a tremendous opportunity for our nation and those who cannot currently afford meaningful, reliable health coverage. Medicaid is at the heart of our mission as a ministry — a program designed to provide health care for those who need but cannot afford it, often working families whose lack of coverage is no fault of their own. Of course this also includes children in low-income families who are often left on the sidelines of our health care system, but no longer have to be.

I am always amazed by and proud of the ministry CHA represents. And I am confident that once again, we will together stand up in favor of health care that works for everyone. There is lots of work still to do. Working together, I know we can do it.

SR. CAROL KEEHAN, DC, is president and chief executive officer of the Catholic Health Association.

Copyright © 2013 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

BY: JEFF TIEMAN

Mr. Tieman is communications director, Covering a Nation, Catholic Health Association, St. Louis.

"Health care reform" is hardly a phrase that gets people excited. Although there can be no doubt that our health care system leaves many outside its boundaries and is in dire need of repair, the topic is just not as sensational as many we see on TV. In a media-saturated world, distractions are close and constant. Even people with a strong sense of social conscience can easily fall victim to the 24-hour news cycle and its tendency to skim over complexities and nuances.

When television producers and news directors decide what is important, even stories as serious as increasing poverty and diminishing access to health care are often ignored on the page and screen. With the war in Iraq, the journalism motto "If it bleeds, it leads" is employed on a daily basis. Other important topics often take a back seat to the story that sells.

This phenomenon, of course, is nothing new. But when we ask ourselves why there is no national movement to reform the broken health care system, no concerted cry for action—despite the evidence that people are marginalized and even harmed by the current system—we must also ask how to engage people on the issues within a broader context than is allowed by a brief newspaper account or MSNBC report.

Quite simply, health care is not a topic of community conversation, particularly as it relates to the poor and vulnerable. No one has made the issues compelling or personal enough to get people talking or to help them make important connections with related social problems that conflict with our moral and democratic values. No one has created the language and the images that will resonate with the public and prompt a call for change. The health care system is profoundly important to us all, even to the healthy and wealthy, but that message has not been effectively broadcast.

As members of a ministry long committed to promoting social justice and defending human dignity, Catholic health care providers can create the images and the words that will be needed. Those working on the front lines of health care are in a uniquely powerful position to spark the conversation and humanize the problem.

Describe the Connections
One way to accomplish that is to embrace complexity rather than hide behind it. We need to describe important connections between related issues and how those connections affect real people in real ways. The problems with access to health care and the growing poverty ranks are two excellent examples. These two social dilemmas are clearly related, but not everyone will think about how or why, and what that means.

Last August the U.S. Census Bureau announced that the number of people without health insurance grew to nearly 45 million in 2003, representing an increase to 15.6 percent of the population. The bureau also reported that between 2001 and 2004 some 4.3 million people fell into poverty. Although these statistics came out at the same time—and from the same source—they were not always conveyed together, or in a way that advanced the public's understanding of the related issues.

It is easy to see how news outlets might cover the poverty and uninsured stories separately or incompletely. Take the example of a daily city newspaper processing the census figures. If an editor decides to run one story addressing both poverty and the uninsured, the article is likely to use up most of its space listing the facts but without exploring in any depth how they are provocative and interrelated. Alternatively, the editor assigns the poverty and health care stories to two reporters who cover these issues under their pre-ordained beats. The reader may not even see both stories in the first place; but even if he does, he's unlikely to find in either story an explanation of how medical problems can lead to poverty and how poverty can exacerbate medical problems.

In a cursory review I did of recent news stories that mention both poverty and the uninsured, I found poverty mentioned only in the context of explaining eligibility thresholds for Medicaid and other public assistance programs. Except for an op-ed piece here and there, most newspapers do not examine the degree to which someone's health and access to care can threaten his or her economic viability.

Whether or not the media make clear and useful connections between the two problems, they are related. A recent Harvard University study offers direct evidence. As many as 2.2 million Americans who filed for personal bankruptcy in 2001 cited medical causes for their financial trouble.¹ More than one quarter of bankruptcy filers cited illness or injury as the specific reason for bankruptcy.

At least one critic has argued that the Harvard researchers must have surveyed only the lowest income earners, whose employers did not provide long-term disability insurance as a safety net. Another claimed that the study authors exaggerated their findings or used nonrepresentative sample populations to bolster their own agendas for a single-payer health care system.

Even if those arguments have any degree of validity, the study still highlights a problem that should be considered and discussed. Even considering the possibility that only half of the 2.2 million cases cited in the study actually filed for bankruptcy because of medical expenses, that still leaves more than one million people who saw their financial and personal stability collapse because they could not afford health care. As Martin Luther King aptly observed, "Injustice anywhere threatens justice everywhere."²

Many of the news stories generated by the Harvard study did not cite its possible limitations or biases, which in this case may not be so bad. If all the study did was teach us how easy it is for a person to lose his or her financial footing because of medical problems, it accomplished something important.

Reaching the Middle Class
The Harvard study is not alone in identifying links between access to health care and economic viability. According to the Commonwealth Fund's 2003 Biennial Health Insurance Survey, two out of five adults—including both people with and without coverage—said they either had problems paying their medical bills or were paying off medical debt.³ Sixty percent of the uninsured reported similar problems, and more than one-quarter of those struggling with medical bills said that they had been unable to afford such basic necessities as food, heat, or rent.

Of course, it stands to reason that poor people would find it more difficult than others to afford health care and that medical expenses can drive even middle class people into poverty. Fr. Robert J. Vitillo, the former executive director of the Catholic Campaign for Human Development (CCHD), recently said, "It does not take a great leap of logic to understand that poor and low-income people are heavily represented among the uninsured in our country and the situation with poor children is especially tragic."⁴ Logical as it may be, the connection is still not clear to many people.

Ninety percent of respondents to the CCHD's most recent Poverty Pulse survey said they are concerned about poverty as a problem in the United States.⁵ An equal number said they are very concerned about health care. In a separate question, however, respondents were asked to identify what they feel are the causes of poverty. Lack of education topped the list, with 27 percent of respondents citing it as the cause. Meanwhile, only three percent of the respondents identified illness or health problems as a cause for poverty.⁶ People who live comfortably tend to spend little time thinking about poverty and exorbitant health costs. Indeed, many of us never have to imagine being unable, because of poverty, to visit the doctor when we are sick.

The CCHD survey bears this out. Only 23 percent of non-low-income respondents said they were concerned they will become poor at some point in their life. It is easy to be complacent when one's own needs are met; people who struggle for basic necessities can be invisible to those of us who have adequate or plentiful resources. Although 97 percent of survey respondents said it is important to reduce or eliminate poverty in the United States, and more than 90 percent said the government should help low-income populations afford health coverage, poverty was not prominently debated or discussed in last fall's presidential and congressional elections.

Although health care reform was featured in the 2004 campaign, it was usually ranked below such issues as national security and the war in Iraq. Concerned as many of us are about our friends and family members fighting overseas and about the threat of terrorism at home, we find it easy to forget about those who are wondering how to meet their daily needs for housing, education, and health care.

"If we guaranteed health insurance for everyone under 200 percent of poverty, 45 million uninsured Americans would probably become five million," observes Tony Garr, director of the Tennessee Health Care Campaign, which works to expand affordable health care to residents of that state through education, outreach, and advocacy.⁷ As Garr and others point out, covering the poorest Americans would also help prevent them from getting sick or needing hospitalization in the first place—which would ultimately save money for the system and the taxpayers supporting it.

A New Rights Movement
How, then, do we summon the public will to acknowledge these facts? How do we create an environment wherein people not only view poverty and health care access as part of the same social problem but are persuaded to give them high priority on the nation's action agenda?

A large part of the answer, as envisioned by CHA's Covering a Nation initiative, involves exchanging ideas community by community and shaping a national dialogue. Until we Americans collectively see related social problems as urgent and begin to engage in a substantive, all-inclusive national discussion of them, true progress will not occur. In this discussion, everyone must be "at the table"—rich and poor, minorities and other ethnic groups, the employed and the unemployed, insurers and hospitals, physicians and lawyers—all the strange bedfellows.

The U.S. civil rights movement was successful because committed activists worked together to persuade local communities of the injustice of segregation, and eventually these local voices helped form a national consensus. Once that consensus was formed, the federal government had no choice but to take action. Something similar occurred with other movements, from women's suffrage to the elimination of apartheid in South Africa. We who serve the Catholic health ministry can help create the same sense of urgency when it comes to health care access, particularly that of the poor and vulnerable.

The challenge is twofold. First, we must help people understand that lack of access to health care touches every aspect of life, offends human dignity, and stifles progress. Second, we must catalyze public interest in the problem and get people everywhere talking about it in a serious and concerted way. Those who are on the front lines of the access issue can and should prompt dialogue in their communities, making it clear that when any person is unable to gain access to health care, it is not only that person who suffers—society as a whole suffers as well.

This work is not new to the Catholic health ministry. But we must now commit ourselves to doing it in a more focused way. In May, the ministry joined other health care providers and organizations nationwide to rally on behalf of health reform during the Robert Wood Johnson Foundation's Cover the Uninsured Week 2005. As was the case last year, ministry participation was substantial, and for at least a week there was an uptick in headlines covering the issue.

Now the challenge is to make Cover the Uninsured Week 2005 happen every week. A discussion among hospital employees would be a good place to start. What are their frustrations and hopes for the health care system? Having launched discussions among health care workers, we might initiate community discussions at local branches of the Rotary Club and Chamber of Commerce. We could organize town-hall meetings in local elementary school gyms. We could put up posters in local grocery stores, reminding shoppers that their neighbors may not be able to afford a visit to the doctor. The smallest steps can encourage conversation and enlightenment.

As we go about this work, we should remember always to put a human face on our message. Statistics, studies, and policy journal articles are all well and good. But one reason people are not attracted to news stories about health care and poverty is that these stories often lack the human touch. They provide little with which the average person might connect or sympathize.

The reason so few people imagine being poor is that they have not seen poverty up close. They have no frame of reference. Let us give it to them, and in the process help make connections that shed light on the series of problems we must face as a nation. If it is indeed easiest not to care, the least we can do is make it a little harder.

NOTES

1. David U. Himmelstein, et al., "MarketWatch: Illness and Injury as Contributors to Bankruptcy," Health Affairs, February 2, 2005.
2. Martin Luther King, Jr., "Letter from Birmingham Jail," April 1963, p. 1, available at www.stanford.edu/group/King/popular_requests/frequentdocs/birmingham.pdf.
3. Commonwealth Fund, 2003 Biennial Health Insurance Survey, chart 16, available at www.cmwf.org/usr_doc/Collins_biennial_hlt_ins_surveycharts.pdf.
4. Catholic Campaign for Human Development, news release of January 2005, available at www.usccb.org/comm/archives/2005/05-006.shtml. Fr. Vitilla is now special adviser to Caritas International, Rome.
5. Catholic Campaign for Human Development, Poverty Pulse Survey Low-Income Survey, January 2004, p. 5, available at www.usccb.org/cchd/LOWINFNL.PDF.
6. Catholic Campaign for Human Development, Poverty Pulse Survey, p. 10.
7. Tony Garr, telephone conversation of February 16, 2005.

Copyright © 2005 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Five Ethicists Help Define and Contextualize an Elusive Topic

What is organizational ethics? Why is it important for the Catholic health ministry? There is no single, universally accepted answer to either of these questions, but there are many ways to describe just how far reaching and pervasive organizational ethics is for Catholic health care. The following commentaries by Catholic health care ethicists are an effort to bring a little clarity to what we mean when we say "organizational ethics," as well as a way of demonstrating the impact this field has on our ministry.

How would you define organizational ethics?

Carol Bayley, Ph.D.
Vice President, Ethics/ Social Justice Education
Catholic Healthcare West, San Francisco

Organizational Ethics is the fancy name we've given to the deliberate reflection an organization undertakes when it has a decision to make that puts its values in conflict with one another. When, back during the Tylenol scare of 1982, Johnson & Johnson took every bottle off the shelves rather than risk hurting someone, in spite of the potential damage to the J & J reputation and the company's bottom line, that was organizational ethics.

When executive teams think carefully about the relationship between what they get in compensation and what the lowest paid workers in their companies get, or when they screen their investments for consistency with their mission, or when they purchase supplies from an environmentally responsible company, that's organizational ethics.

Philip Boyle, Ph.D., STL
Vice President, Mission and Ethics
Catholic Health East, Newtown Square, PA

I think organizational ethics addresses the choices of all who are part of an organizational enterprise — sponsors, board members, executives, managers, employees, organizational partners, and vendors. But, more importantly, organizational ethics also looks at organizations as moral agents.

Other forms of applied ethics, such as business ethics or managerial ethics, focus largely on smaller, discrete sets of decision makers within an institution (e.g., executives), their codes of ethics, and the limited universe of their choices (e.g., conflicts of interest). But these other forms of applied ethics do not focus on the organization itself as a moral agent.

Thus the term "organizational ethics" principally encompasses a broader ethical field than that of attending to isolated sets of decision-making entities within an institution. Organizational ethics focuses upon the moral consistency that should obtain among the numerous sets of decision-making bodies both within and outside (e.g., civil law, corporate vendors, organizational partners) an organization, each of which, when joined together, impinges upon and effectively defines the moral character of the organization. Organizational ethics, then, both examines the formal ways by which an institution ethically structures itself through its policies and practices and explores the informal culture that consciously — or unconsciously — either promotes or degrades its values across all aspects of its operation.

To these ends, organizational ethics must form a structural part of the choices that different moral actors make within an institution, regardless of their particular departments. This structural integration also holds true for the choices that an organization makes through the policies proposed by management, ratified by boards, and carried out by employees.

Jan C. Heller, Ph.D.
System Director, Office of Ethics and Theology
Providence Health & Services, Seattle

Ethics is concerned with the moral criteria that agents bring to bear on the choices they make. Our moral choices can be categorized into three broad, overlapping domains — our conduct (what actions we ought to do or refrain from doing); our character (who we ought to be or become); and, more abstractly, the conditions that influence what we can do and who we can become.

An organization is an example of a condition that influences what we, as individual agents, can do and what we can become. Informally, organizations influence our conduct and character in many ways. They affect how we spend our time and with whom we spend it; and their cultures shape our attitudes, feelings, thoughts, and values. Formally, they influence our conduct and characters through policies and incentive structures.

Organizational ethics reflects on these influences and, being based on moral criteria, asks how they could be shaped to make it easier for individual agents to choose the right actions and be the best persons they can be.

That said, organizational ethics is concerned not only with individual agents but also with the organization itself as a collective moral agent. For organizations, as organizations, also make choices about their conduct in the world and about their character — choices, for example, about the opportunities they will pursue and the kind of culture they want to foster. And they, too, are influenced by conditions that are larger than themselves. For example, health care organizations are influenced dramatically by the markets in which they compete and by regulatory decisions made by government officials. Organizations can, in turn, affect these markets and regulatory decisions, but they cannot entirely control them. So they must make choices about how to deal with them based on some criteria, some of which should be moral.

Patrick J. McCruden, MTS
Vice President, Mission and Ethics
St. Joseph's Mercy Health Center, Hot Springs, AR

Organizational ethics is a purposeful, reflective application of our values to the decisions, policies, and procedures that affect our patients, employees, and communities. Thus organizational ethics is most concerned with those practices that impact people.

I think we typically worry about how our clinical ethics impacts our patients. But it's our organizational ethics — hiring practices, staffing levels, billing practices, legislative advocacy, and so forth — that probably more keenly impact our patients' experiences in our institutions. Our patients judge us not on our professed beliefs and values but on the quality and compassion of our care. People who work in our institutions come to their own conclusions about what it means to be employed by a Catholic facility. The communities in which we exist come to their own conclusions about what a Catholic institution stands for. None of these people — patients, employees, or community members — read our value or mission statements; they experience them.

Dan O'Brien, Ph.D.
Vice President, Ethics
Ascension Health, St. Louis

Organizational ethics concerns organizational integrity, whereby personal and organizational relationships, structures, behaviors, processes, policies, and procedures reflect and promote human dignity and the common good. It's about fostering a work-life culture that is characterized by integrity, participation, a positive spirituality, and healthy relationships and interactions. An organization with integrity is one in which decision-making processes are consistent with the moral identity and values of the organization, so that the organization, its associates and the communities it serves may be freed to flourish in genuinely human ways. It sounds rather lofty and formal and ideal, but is actually very hard work in the concrete — entailing a willingness to expose our individual biases, preferences, and vulnerabilities. Organizational ethics requires candor and openness to each other, so that we can be truly responsive to human needs, and not just be manipulated by our own fears and hidden agendas.

What do you perceive are the major organizational ethics issues facing Catholic health care?

Carol Bayley
I see one major one, eclipsing all the others. We are in the health care business. In our tradition, health care is so fundamental to human flourishing that all people deserve it, regardless of who they are or whether they work.

But in the United States, health insurance — in effect, access to health care — is seen as a benefit either of employment or of destitution. Two of our deeply held values are in conflict. One is the need to stay afloat as a business in a capitalist system; the other is a need to stay connected to the tradition that informs our identity. How, and whether, our health systems can carry the tension of those two poles requires organizational ethical reflection.

Philip Boyle
Catholic health care faces challenges that are unique within health care because the ministry is informed by the Catholic moral tradition, particularly by Catholicism's long tradition of social teaching. While the Catholic tradition has clear moral prohibitions (e.g., not taking the life of the innocent), it also promotes strong moral obligations concerning, first, care of those who are poor, and, second, the common good, which includes values such as subsidiarity, participation, and association.

As a consequence, the Catholic tradition creates challenges for every level of Catholic health care. The challenges include providing appropriate levels of charity care and community benefit, setting responsible executive compensation and living wages, establishing fair labor practices, setting responsible investment policies, partnering with group purchasing organizations, and marketing itself truthfully. In addition to these issues, which are department specific, Catholic organizations must, as moral agents, be diligent and conscientious about those with whom they partner; and vigilant that, as organizational ministries of the church, they do not give scandal.

Jan C. Heller
The organizations that make up Catholic health care have a long and noble tradition of reflecting on their mission, identity, and purpose as Catholic-sponsored organizations, and on their impact on individuals and on communities — those they serve and those they employ or partner with. They also have a long tradition of advocacy that seeks to affect the conditions that influence their missions.

This is the work of organizational ethics, although it has only recently been called by that name. What needs to be done, going forward, is to help sponsors, leaders, employees, and our partners become more self-conscious about how their work in and for Catholic health care can be understood through the lens of organizational ethics, and about how our organizations themselves can be understood and held accountable as moral agents.

This can be done through education, through ministry leadership formation programs, and by linking formal decision processes to organizational ethics resources.

In addition, however, Catholic health care organizations (along with other organizations that are concerned with ethics) must become more self-conscious about organizational ethics as such, and about its implications for our organizational life in general. We must decide, going forward, which ethics standards we will use to evaluate our leaders, our ethics programs, and their resources and staffs; and how we will integrate ethics processes into other important decisions of the organization. Catholic health care faces many concrete challenges — involving choices about labor relations, staffing ratios, manager salaries, and ethics training for board members, to name just a few — but all these issues will be addressed only in an ad hoc way if we fail to institutionalize organizational ethics. Institutionalizing organizational ethics is our biggest challenge in the long run.

Patrick J. McCruden
I think the major organizational ethics issue facing Catholic health care is its role (or lack thereof) in transforming the American health care system. I think we are all aware of the physical and financial hardships borne by people without health insurance. More than 20 years ago, the U.S. bishops called for the creation of a national health insurance plan, and Catholic health care has affirmed on several occasions our belief in a right to health care. I think we need to grapple with our vision of how the American health care system should be transformed and with our commitment to that vision at the system and local level.

In that regard, at the individual hospital level, a major organizational ethics issue is how we care for the uninsured, and, more generally, how we care for the poor and vulnerable — care for, that is, not only those who end up in our emergency rooms but also poor people in the larger community. How are we working to help expand services to the poor in our communities and act as advocates for them with our legislators?

Other major organizational issues include staffing practices during times of increased budgetary pressure; billing practices towards the uninsured and underinsured; and compensation and benefit practices, especially those for our highest- and lowest-paid employees. Catholic health care is a ministry of the church and must be transformational, transforming individuals and communities. Our practices need to be evaluated in light of our call to transform the world.

Dan O'Brien
In my opinion, the major ethical issues facing Catholic health care are:

• The selection, development, and formation of leaders — they are our future who will shape how we respond to basic human needs.
• Ensuring that the vision and legacy of our sponsors are carried into the future
• Promoting an organizational culture that is transparent, embraces people's spirituality and interacts with the Catholic social tradition and teaching
• Integrating the organizational and physician cultures
• Effectively engaging those internal and external forces that attempt to control our organizations through political, social, and legal mechanisms or hidden agendas, rather than through healthy dialogue and rational discourse

What do you see as some of the challenges in implementing organizational ethics?

Carol Bayley
One challenge is that executives associate "ethics" with the various scandals we read about in the newspaper. Granted, Enron and WorldCom were ethical failures, but most ethical implications of an organization's decisions are not so clear. A bigger challenge in a busy world is cultivating the habit of ethical reflection, of considering the practical implications of honoring one value at the expense of another. Part of the challenge is that we tend to compartmentalize too much. "Care for the poor" is considered a "mission value," whereas the kind of rating we earn on Wall Street is seen as just the business of business. In fact, every business decision is a revelation of our values, either positively or negatively. We just need more practice in using the values language.

Philip Boyle
Two broad problems exist for implementing organizational ethics.

The first relates to developing processes that address it. Many clinical ethics committees realize that they do not have the committee membership, case referral system, or skill set to facilitate organizational ethics problems. To address this void, health care systems have developed a discernment process for all organizational ethics problems. This values-based decision-making process (VBDM), sometimes called "mission discernment," serves as a means of making plain whether the discussion at hand is aligned with an organization's mission and values. Misused, however, the process can act as an after-the-fact justification for predetermined conclusions. Pragmatically, getting all who work for the organization to understand it, adopt it, and become skilled and comfortable implementers of it will be the work of the next 10 years.

The second challenge relates to this last point — making practitioners competent and confident with respect to organizational ethics. In clinical ethics, by contrast, many feel confident about their knowledge of what the issues are and about the adequacy of their analysis in such areas as informed consent, advance directives, and termination of life-sustaining treatment. They do not feel equally confident in organizational ethics. But they might strengthen their sense of self-reliance by examining issues that have been carefully analyzed in business ethics literature. These other areas of applied ethics provide both clues for analysis and the language and concepts needed to tease apart the moral problems of organizational ethics.

Patrick J. McCruden
One challenge is to bring the voice of ethics to the table where decisions are made. We tend to work in "silos" — the finance department develops the billing practices, human resources (HR) develops compensation and benefit plans, nursing works on staffing levels and patient care, and so forth. Since these are not typically seen as areas in which ethics should be consulted or involved, decisions may be made in them without reference to our values. This is not to imply that decisions in these "silos" are made in an unethical fashion; but we have to be more intentional about applying our values and ethical principles in a systematic way throughout our organizations.

Another challenge is a tendency to overlook structures in our systems that may motivate people away from ethical behavior. For example, expansion of services to the poor will almost certainly affect operating margins. If compensation, promotion, advancement, and similar matters are tied too closely to financial success, then there will be little incentive for a leader to expand services to the poor, even if this is a clearly articulated value of the leader's organization.

Dan O'Brien
In a time of intensely limited and competing resources and other pressing organizational priorities, one of our greatest challenges is persuading leaders to devote the time and resources needed to promote and implement organizational ethics and learning among leaders and associates.

What advice or successful practice in this area would you like to share?

Carol Bayley
We learn by doing. Some of the first ethics committees learned how to talk about clinical ethical ethics by reviewing cases that were no longer active, to see how the ethical concepts of autonomy or justice applied. Executive teams that are serious about learning the language of organizational ethics could start by looking backwards, at decisions they've already made, to see what values were at stake and what choices were made, and at what cost.

Or they could dedicate a certain amount of time to reviewing the ethical implications of decisions they are currently making. Sometimes "ethical implications" look forward: If we are going to close this or that program, we had better take this or that step to mitigate harm. At other times, the implications look backward. If we need people whose natural styles of action and leadership are consistent with our organization's values — or, by failing to do so, risk decisions that don't "look like us" — we must hire, orient, and reward people for the right reasons.

Whatever strategy an organization uses — whether a retrospective or a concurrent review of real cases — and whether the implications are for future action or reveal past assumptions, the best way to get better at organizational ethics is the best way to get better at anything: practice.

Philip Boyle
First, my experience in Catholic health care has lead me to conclude that VBDM gains a foothold once an executive experiences the value in doing it. Different executives value it for different reasons. Some see that VBDM offers a systematic way of discerning whether choices are consistent with mission and values. Others value it because it provides transparent evidence to a board or sponsors, for example, that the outcomes of VBDM further the organization's mission. Still others use it as a clarifying device to get everyone on the same page. Whatever the reason, once the merit of VBDM is made clear by its successes, executives begin to implement it among groups that report to them.

Second, it is critical for an organization to be very clear how, when, and by whom VBDM is to be implemented. In some organizations, management is required by policy to use it on all major decisions and then to supply evidence to the board that they have done so. In other organizations, either the mission leader or a mission-effectiveness committee has the authority to invoke the process. Nevertheless, however an organization's leaders decide the circumstances under which a VBDM should be used, they need to be clear about when it should be conducted as a formal process and to reinforce the process once it begins.

Third, the implementation of VBDM can begin with less complex issues that can show the organization the immediate benefit gained from using it — in conceptually simple cases such as those involving conflict-of-interest or vendor-relation issues. Finally, the very process of developing a VBDM can galvanize support for its later use. For a model developed for a health system, see the free downloadable example at http://www.che.org/publications.

Jan C. Heller
There is an ongoing debate in health care ethics about how best to structure organizational ethics vis-à-vis our long-standing clinical ethics programs. In larger organizations, it makes sense to set up separate but related structures to address clinical and organizational concerns. The clinical ethics committee will usually have enough work to do without trying to take on the demanding tasks of organizational ethics as well.

Furthermore, the choices that must be made under the heading of organizational ethics generally require different talents — and, generally, access to different kinds of information — than do those involving clinical ethics. Of course, many clinical issues will have organizational implications, and the two ethics groups can share members or pass requests to each other doing so as appropriate. Nevertheless, we recommend that our organizational leadership teams, supported by professionally trained ethicists and others who gather relevant information on a given issue, constitute themselves as organizational ethics committees when they face a choice that has significant moral implications.

Thinking about organizational issues from an ethics perspective requires preparation and practice on the part of our leaders, and they often find this difficult to fit into their busy schedules. But, as Jack Friedman, CEO of Providence Health Plans, Beaverton, OR, recently said: "If we are too busy to deal with an ethical issue as a leadership team, then we're not doing our jobs as leaders." It is always possible that the pressures that our leaders deal with everyday will cause them to miss significant ethical issues or to "sweep them under the rug" in their rush to deal with many, seemingly more pressing concerns. Still, organizational leaders, including board members, are our organizations' most influential decision makers. They should learn to recognize and respond appropriately to issues with organizational ethics dimensions. If they do not, the long and noble tradition of ethical reflection in Catholic health care may not continue into the next generation.

Patrick J. McCruden
Organizational ethics needs to be fluent in the language of business and management, but it should not allow the precepts of our free-market system to trump the principles of Catholic health care. The "just wage" is, for example, a foreign concept in an economy in which workers' wages are set by the market.

In our health system, Sisters of Mercy Health System, St. Louis, we have worked at the corporate level to work across the "silos" and engage our colleagues in discussions that utilize the expertise of everyone "at the table." For example, to develop a position on just-wage and compensation practices, we brought ethicists together with HR and finance department people to analyze and discuss the ethical principles involved in light of the reality of the employment market and the impact of wage decisions on the system's finances. We ethicists, being educated in such issues, educated the other professionals regarding how justice would apply in these discussions.

Dan O'Brien
My advice is to seek out opportunities that will give leaders the personal, concrete experience of a positive discernment or decision-making process. That experience will reinforce the perception that good ethics and spiritual practices are genuinely worth all the extra effort. The more we can connect ethics to spirituality — as the "horizontal dimension" of spirituality — the more relevance people will find in ethics. They will see that it is much more than a series of abstractions or rules.

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