CNS PHOTO/JOSE LUIS AGUIRRE, CATHOLIC SAN FRANCISCO
WHEN WE HEAR the term
Catholic health care, we may
think of the last time we visited
someone in the hospital.
Perhaps we imagine a
chaplain visiting patients or
a parish minister bringing the Eucharist
to a bedside. Or maybe we remember a
crucifix in front of the hospital or hanging
on the walls in patients' rooms. I
would bet, however, that the images we
associate with social justice have nothing
to do with our images of Catholic
When we think of social justice, we
might have historical images of the
civil-rights era, or contemporary images
of those advocating for immigrants or
protesting the war in Iraq. Some might
think of a family working in a soup
kitchen or student volunteers helping
the poor here and abroad. Seldom do
we think of health care as social justice.
Yet social justice and Catholic health
care cannot be separated.
From the very beginning of Catholic
health care in this country through to
the present, one of the important reasons
for the very existence of Catholic
hospitals has been the care of the sick
poor. In this article, I would like to
reflect on this connection between
health care and social justice, first in a
practical way, then by looking at some
official guidelines that shape Catholic
health care in this country today.
The Church is concerned about health-care
reform in this country today
because the Church has been part of
health care in this country from the
In fact, the Church's involvement
in health-care systems long precedes
the United States, going back to the
Middle Ages. During those years, various
religious groups—vowed and lay,
composed of women or men—cared
for the needs of the sick and often lived
among the sick poor.
This happened in many ways. Let's
take a look at the Franciscan movement
as an example. Even the early
history of the Franciscan Order shows
that the brothers considered care for the
sick as part of their vocation. Soon,
care for the sick poor also became a
special task for those lay members of
the Franciscan family called the Third
Order (or more commonly today, the
Secular Franciscan Order).
St. Elizabeth of Hungary, the patroness
of the Third Order, is often singled
out as a special example of a person
who embodied concern for the sick.
As more people followed St. Elizabeth's
example, the task of caring for the sick
poor came to be seen more as an individual
vocation rather than a communal
This changed again in the 18th and
19th centuries as more and more religious
communities of women were
founded to carry out particular apostolic
activities. Caring for the sick once
again became a communal vocation.
When these religious communities
came to the United States, hospitals
were among the institutions that they
In 1727, the Ursuline sisters became
the first Catholic congregation of
women to come to America. Their apostolic
works included the care of the
sick. They were involved in the founding
of New Orleans' Charity Hospital,
the second-oldest hospital (by six
weeks!) in the United States. It was originally
called Hospital of St. John or The
Hospital for the Poor. In the 1800s
came more Catholic sisters who saw
their task as caring for the physical and
spiritual needs of the Catholic immigrant
The explicit mission of many of these
communities was care for the sick poor.
Education and health care became the
hallmarks of these congregations. About
five of the 16 religious communities of women that were in the United
States in 1849 were involved in health
care. By 1875 there were 75 Catholic
hospitals. By the beginning of the 20th
century there were almost 400.
Many of the hospitals founded by
these religious communities served a
dual purpose. On the one hand, they
were founded to serve where social
institutions discriminated against
Catholic immigrants. On the other
hand, Catholic hospitals were open to
all, providing not only for their
patients' medical but also for their spiritual
needs. They even arranged for visits
from Protestant clergy if so requested
by patients—at a time when Catholic
clergy were often not welcome in many
public or private hospitals.
This tradition of care for the poor
has continued to the present day. It is
expressed in the mission statements
and the lists of core values that are
now part of Catholic health care.
In these mission statements, one sees
a strong relationship between health
care and a commitment to social justice.
These core values are similar across
Catholic health-care systems. They
emphasize human dignity, care for the
poor, the sacredness of life, service,
integrity, justice and compassion.
Almost invariably the mission and/or
vision statements of the various
Catholic health-care systems articulate
that the work of the system is a participation
in the healing ministry of
Christ, which includes a commitment
to the poor and vulnerable.
As Catholic health-care systems worked
more closely with other health-care
institutions over the years, a need arose
for some guidelines on how our faith
informs practice in a Catholic facility.
This need became especially pressing in
modern times, as U.S. health care began
taking on increasingly complex ethical
issues. The U.S. Catholic bishops created
such guidelines and revised them over
the years. Their latest version, issued in
1994 and revised slightly several times
since then, was updated last fall in areas
related to end-of-life issues.
These guidelines are published in
the Ethical and Religious Directives for
Catholic Health Care Services. The aim: to
help guide Catholic hospitals and other
Catholic health-care facilities as they
serve in the name of the Church.
The Ethical and Religious Directives (ERDs) should not be seen simply as a
list of do's and don'ts for Catholic
health care. Rather, they primarily do
two things: First, they attempt to
explain the Catholic identity of hospitals
and other such facilities as part of the
health-care ministry of the Church.
Second, they seek to clarify how these
institutions act with ethical integrity.
Various editions of the ERDs have appeared over the past 60 years. They
have addressed pertinent ethical issues
facing Catholic health care at the time,
especially those concerning the prolongation
of life for dying patients and
procedures relating to procreation.
The current guidelines begin with a
section devoted to the social responsibility
of Catholic health-care institutions.
This section offers specific
directives for Catholic hospitals regarding
the Church's social teaching. But
first it lays out five values regarding
the social responsibility of Catholic
The five values that relate Catholic
health care to the Church's justice tradition
are: human dignity, care for the
poor, common good, responsible stewardship
and rights of conscience. Two
of these values, human dignity and the
common good, are the very foundation
of Catholic social teaching. And
those two values are actually two complementary
aspects of the Catholic
understanding of human nature.
The common good, as the Church
has taught in many places, refers to
human flourishing. The Second Vatican
Council, for example, explained that
the common good is the sum total of
those conditions needed for the well-being
of individual persons and the
groups of which they are a part.
From these two pivotal values, the
guidelines derive three other principles
of our social-justice tradition and
apply them to health care: care for the
poor, responsible stewardship and the
rights of conscience. The ERD document
recognizes care for the poor as a
biblical mandate. In the document's
introduction, there is an important reference
to the Gospel parable of the
Good Samaritan (Luke 10:29-37—see
box), which the ERDs call an
example of "authentic neighborliness to
those in need."
In this spirit of "authentic neighborliness,"
they challenge Catholic health
care to give particular attention "to the
health care needs of the poor, the uninsured,
and the underinsured."
The next value that the document
discusses is that of responsible stewardship.
Here, the bishops acknowledge
that care for the poor needs to be
carried out mindful of an institution's
limited resources. They explain that
"responsible stewardship of health care
resources can be accomplished best
in dialogue with people from all levels
of society...with respect for the moral
principles that guide institutions and
Emphasizing this value shows the
realism that is part of the Catholic social
tradition. Catholic health-care institutions
continuously need to find the
proper balance between genuine care for
the poor and an appropriate use of their
financial resources. On one hand, care
for the poor should not bankrupt a facility
or system; on the other hand, the
institution ought not hoard resources.
Hoarding has never been the mark of
genuine Catholic health care.
This section of the guidelines ends by
acknowledging the pluralism of American
society. Again, the guidelines try to
strike a balance. They acknowledge the
rights of individual conscience but at
the same time maintain that the
Catholic hospital itself has what might
be called an "institutional conscience,"
safeguarded by its leaders.
Catholic health-care institutions take
into consideration the consciences of
both their employees and the patients
they serve. Catholic health care asks
that its employees respect the fact that
the institution's leaders, too, must follow
their consciences and the moral
stance of the Catholic Church. That
issue of conscience has generated lots of press recently in the health-care
From the five values, the Ethical and
Religious Directives then articulate in
greater detail several specific areas of
Catholic health care's social responsibility.
For example, one directive speaks
about the need for a "spirit of mutual
respect" that helps caregivers serve the
sick "with the compassion of Christ."
Another further describes this respect as
involving "advocacy for those people
whose social condition puts them at
the margins of our society and makes
them particularly vulnerable to discrimination."
The ERDs also challenge Catholic
health-care institutions to be workplaces
of justice. For example, one directive
states straightforwardly that a "Catholic
health care institution must treat its
employees respectfully and justly."
For most Catholic health-care systems,
these values, and the dedication to the
Church's social-justice tradition that
they represent, are not simply marketing
tools; they really represent what
Catholic hospitals aspire to be.
I have heard time and time again
from hospital administrators that the
mission of their institution is to provide
health care to all in need, regardless of
the ability to pay. Especially in the current
economic recession, stories abound
about the amount of charity care undertaken
by Catholic hospitals. I've also
heard about creative ways which
Catholic health care found to ensure
Through prevention and wellness
programs, Catholic health care has partnered
with other groups to work toward
better community health, especially
for the poor and vulnerable. Returning
to the founding vision of the first
sisters who came to the United States,
many Catholic hospitals have even
looked beyond the borders of the
United States to enhance the delivery
of health care in developing countries.
This attention to the Catholic social
tradition, however, has not been without
conflict. The needs of the community
are likely always to be greater than
the capacity of Catholic health care to
satisfy those needs.
In some situations hospitals find that
the values from the Church's directives
are in conflict with one another. The
call to be responsible stewards, for
example, limits the amount of charity
care a hospital can give. The hospital
must, along with ensuring care for the
poor and vulnerable, pay its employees
a just wage.
Although Catholic health care aspires
to embody the Catholic social-justice
tradition, it is not always successful.
Critics often point to Catholic health
care's resistance to unionizing as one
example where its actions have not
lived up to its words.
The Ethical and Religious Directives conclude by suggesting that "Catholic
health-care services rejoice in the
challenge to be Christ's healing compassion
to the world." Yes, Catholic health-care
institutions face limits and value
conflicts. Catholic health care, like individuals
all through the Church, is not
perfect. In spite of it all, though,
Catholic health care continues to be a
sign of Christ's justice and compassion
[A scholar of the law] said to
Jesus, "And who is my neighbor?"
Jesus replied, "A man fell victim
to robbers as he went down
from Jerusalem to Jericho. They
stripped and beat him and went
off leaving him half-dead. A
priest happened to be going
down that road, but when he
saw him, he passed by on the
opposite side. Likewise a Levite
came to the place, and when he
saw him, he passed by on the
"But a Samaritan traveler who
came upon him was moved with
compassion at the sight. He
approached the victim, poured
oil and wine over his wounds
and bandaged them. Then he
lifted him up on his own animal,
took him to an inn and
cared for him.
"The next day he took out two
silver coins and gave them to the
innkeeper with the instruction,
'Take care of him. If you spend
more than what I have given
you, I shall repay you on my way
"Which of these three, in your
opinion, was neighbor to the robbers'
victim?" He answered, "The
one who treated him with
mercy." Jesus said to him, "Go
and do likewise."
Thomas Nairn, O.F.M., is the senior director of ethics
at the Catholic Health Association of the United
States. He holds a Ph.D. from the University of
Chicago Divinity School and has given lectures and
workshops on five continents.