Tuesday, April 9, 2013

re: "A Theological Reflection on the Principle of Cooperation & the Catholic Health Care Ministry" (Health Care Ethics USA — Winter 2013 Issue)

John A. Gallagher, Ph.D.
Corporate Director, Ethics
Catholic Health Partners
Cincinnati, Ohio

Dear Dr. Gallagher,

The fourth edition of the USCCB's Ethical and Religious Directives for Catholic Health Care Services (2001) removed "the appendix concerning cooperation [Emphasis added.], which was contained in the 1995 edition....the brief articulation of the principles of cooperation...did not sufficiently forestall certain possible misinterpretations and in practice gave rise to problems in concrete applications of the principles....as a rule, Catholic partners should avoid entering into partnerships that would involve them in cooperation with the wrongdoing of other providers" [Emphasis added.].  In a 2005 communication, the Pontifical Academy for Life provided clarity on the term, "cooperation":
  • "The first fundamental distinction to be made is that between formal and material cooperation. Formal cooperation is carried out when the moral agent cooperates with the immoral action of another person, sharing in the latter's evil intention. On the other hand, when a moral agent cooperates with the immoral action of another person, without sharing in the intention, it is a case of material cooperation.
    Material cooperation can be further divided into categories of immediate -- direct -- and mediate -- indirect -- depending on whether the cooperation is in the execution of the sinful action per se, or whether the agent acts by fulfilling the conditions -- either by providing instruments or products -- which make it possible to commit the immoral act.

    "Furthermore, forms of proximate cooperation and remote cooperation can be distinguished, in relation to the 'distance' -- be it in terms of temporal space or material connection -- between the act of cooperation and the sinful act committed by someone else. Immediate material cooperation is always proximate, while mediate material cooperation can be either proximate or remote.

    "Formal cooperation is always morally illicit because it represents a form of direct and intentional participation in the sinful action of another person. Material cooperation can sometimes be illicit -- depending on the conditions of the 'double effect' or 'indirect voluntary' action -- but when immediate material cooperation concerns grave attacks on human life, it is always to be considered illicit, given the precious nature of the value in question.

    "A further distinction made in classical morality is that between active -- or positive -- cooperation in evil and passive -- or negative -- cooperation in evil, the former referring to the performance of an act of cooperation in a sinful action that is carried out by another person, while the latter refers to the omission of an act of denunciation or impediment of a sinful action carried out by another person, insomuch as there was a moral duty to do that which was omitted.

    "Passive cooperation can also be formal or material, immediate or mediate, proximate or remote. Obviously, every type of formal passive cooperation is to be considered illicit, but even passive material cooperation should generally be avoided, although it is admitted, by many authors, that there is not a rigorous obligation to avoid it in a case in which it would be greatly difficult to do so" (Bishop Elio Sgreccia (President of the Pontifical Academy for Life), Moral Reflections on Vaccines Prepared From Stem Cells Derived From Aborted Human Fetuses, 7/26/05).

In contrast to the USCCB (particularly Directive 71 of the ERDs), Dr. Gallagher, you write of the "danger of an exclusive focus on the principle of cooperation when discerning the moral appropriateness or justifiability of transactions between Catholic providers and their secular counterparts."  Your article, A Theological Reflection on the Principle of Cooperation and the Catholic Health Care Ministry (Health Care Ethics USA — Winter 2013 Issue), is featured prominently on the web site of the Catholic Health Association of the United States:
  • "Since the publication of the Third Edition of the Ethical and Religious Directives for Catholic Health Care Services in 1995, the principle of cooperation has become the primary lens through which potential partnerships, mergers or joint ventures between Catholic health care organizations and secular health care organizations have been assessed. Directive 70 stipulates that 'Catholic health care organizations are not permitted to engage in immediate material cooperation in actions that are intrinsically immoral, such as abortion, euthanasia, assisted suicide and direct sterilization'
      [71. The possibility of scandal must be considered when applying the principles governing cooperation.  Cooperation, which in all other respects is morally licit, may need to be refused because of the scandal that might be caused. Scandal can sometimes be avoided by an appropriate explanation of what is in fact being done at the health care facility under Catholic auspices. The diocesan bishop has final responsibility for assessing and addressing issues of scandal, considering not only the circumstances in his local diocese but also the regional and national implications of his decision.
      72. The Catholic partner in an arrangement has the responsibility periodically to assess whether the binding agreement is being observed and implemented in a way that is consistent with Catholic teaching (ERDs (5th ed), 2009).]
  • ....I will argue in this paper that there are inherent limitations to the use of the principle of cooperation in evaluating transactions with non-Catholic organizations where direct sterilization is the major obstacle....

    "Analytic Limitations of Cooperation 

    "To begin, the principle is analytically act centered and functions optimally in retrospective review....

    "When the principle of cooperation is used to assess a merger or joint venture the principle is being used in a prospective manner....

    "The prospective use of the principle needs to engage the issues of scandal and sufficient reason. The moral danger associated with scandal should not be readily dismissed, but in a culture such as that of contemporary America the likelihood of scandal is extremely difficult to assess prospectively....

    "the prospective use of the principle can influence how a transaction is structured. In partnerships and joint ventures the deals can usually be framed in a manner so that there is no causal relationship between the activity of the Catholic organization and a partner who provides direct sterilizations. Mergers, however, are a more complex issue....Currently, some Catholic organizations are avoiding the problem by creating a corporation which does not have Catholic identity but which manages one subsidiary composed of Catholic hospitals and another subsidiary that operates community hospitals that continue to provide direct sterilizations [Emphasis added.  Note: Many would be appalled to learn of such moral sleight of hand in CHAUSA hospitals.]....

    "Individual and Institutional Moral Agency 

    "....Corporations can be held accountable for moral evils and applauded for engendering moral goods; however, they cannot sin [Clearly individuals working for "Catholic" institutions - especially those in leadership - ARE morally culpable for their roles.]....

    "Decision making, in this context appeals to what is meaningful, what makes sense, what is of significance within the frame of reference created by the horizon. This is a framework for moral decision making that is distinct from that of an act centered morality. The ethical categories of object, end and circumstance are not immediately relevant in this context [Emphasis added.]....

    "These three reasons suggest that the moral agency of corporations should be more closely associated with a social ethic, with a notion of moral agency more closely aligned with efforts to produce change associated with Catholic social teaching than to the act-centered notion of moral agency articulated in the manuals of moral theology.  Issues associated with Catholic social teaching such as access to health care and appropriate immigration/migration policies result from social and political action. Such changes are the product of social discourse and the exercise of power in response to injustices embodied in culture, society and law[Your statements could easily lead to the erroneous conclusion that Catholic social teaching and moral teaching are separate, distinct entities.]....

    "Engaging the Culture 

    "....The tension between what Christians are called to and the sinful social structures define the parameters of the world in which Catholic health care makes decisions regarding merging or partnering with secular organizations that provide direct sterilization....


    "....Neither Catholic health care nor its secular counterparts can function in this environment and keep one’s hands totally clean. The Church teaches that direct sterilization is an intrinsically evil act....Precisely because of issues like this, but also all the other issues surrounding the sacredness of life from conception to natural death, the Church through its institutional health care ministry must be present in American society as both herald and servant....Recognition of the need for the Church through its health care institutions to be engaged in secular-dialogic discourse with the wider practice of medicine within American society may, in some circumstances, lead a bishop to tolerate a merger between a Catholic and secular health care organization that continues to provide direct sterilization.

    "....Ethical decision making regarding the institutional ministries of the Church that are conducted independent of a comprehensive theological discernment fail to consider the broader impact of such decisions on the life and vitality of the Church. This, as noted earlier, is the danger of an exclusive focus on the principle of cooperation when discerning the moral appropriateness or justifiability of transactions between Catholic providers and their secular counterparts."

To be blunt, Dr. Gallagher, your article comes across as nothing more than obfuscation and rationalization.  It is self-serving for the CHAUSA to feature your piece on its web site.  Your piece does nothing more than promote confusion.  My prayer is that archdioceses and dioceses will honestly assess the amoral situations in so many "Catholic" institutions and follow Pope Benedict XVI's guidance:

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