The ERDs: Part One – The Social Mission of Catholic Health Care Services

Abstract

The Ethical and Religious Directives for Catholic Health Care Services (ERDs) exist to guide administrators, providers, and patients regarding the Church’s principles for maintaining human dignity while providing ethical patient care. A brief history of the document itself is presented followed by a discussion of selected portions of Part One of the ERDs, which relate directly to the mission of Catholic healthcare and why this is important as the secular culture becomes increasingly hostile to religious beliefs.

With 668 hospitals and 1589 continuing care facilities nationwide, Catholic institutions comprise the largest group of non-profit health care providers in the United States. In fact, about one in every seven patients is cared for in a Catholic hospital every day (Catholic Health Association 2021). To assure that the mission of carrying on the healing ministry of Jesus is continued in a manner worthy of His Name, especially in a time when Catholics and the Church herself are feeling immense pressure to conform to the secular culture’s practices, the Ethical and Religious Directives for Catholic Health Care Services (ERDs) (United States Conference of Catholic Bishops (USCCB) ²⁰¹⁸) exist to guide administrators, providers, and patients regarding the Church’s principles for maintaining human dignity while providing ethical patient care. ¹

The scope of this article is not to present the entire text of the ERDs, but rather a pointed focus on the document regarding its relation to the mission of Catholic healthcare. Part One of the ERDs focuses on mission, beginning with an introduction expounding upon the responsibility of Catholic institutions and professionals to promote and defend human dignity, to concretely care for the poor, to contribute to the common good, to be responsible stewards of resources, and to stay true to the moral teachings of the Church. The remainder of Part One consists of nine Directives. These address the need to be witnesses to the Gospel, to treat all with mutual respect, and to serve and advocate for the marginalized. Furthermore, any medical research should adhere to Catholic moral principles. The Directives in Part One also state that adoption of the ERDs by institutions and all affiliated staff and employees is required. (However, this article will later discuss that the local bishop does have to promulgate these Directives within his diocese for the ERDs to be in effect.) A brief history of the ERDs is presented here followed by a discussion of selected portions of Part One of the document, which relate directly to the mission of Catholic healthcare in a culture that is increasingly hostile to religious beliefs.

History of the ERDs

In 1915, the Catholic Hospital Association (now called the Catholic Health Association) was formed in response to a desire to provide patients access to increasing technological advances in medicine while maintaining Catholic mission and identity (Catholic Health Association 2004). What was needed was a written set of directives regarding moral issues. In 1921, the Archdiocese of Detroit created a one-page list of norms, mostly regarding prohibited surgical procedures. As healthcare became more complex, a more detailed document was necessary. First published in this journal over 70 years ago, the ERDs were created by moral theologians and health care professionals from the United States and Canada (Catholic Physician’s Guild 1948) based on natural law understood in the light of revelation. However, since any directives are ultimately up to the individual diocesan bishop to accept, they were not universally promulgated. Over several decades, this led to confusion and marked differences in medical care in various locations within the United States, a sort of geographically differentiated moral doctrine. In response, a request was made of the National Conference of Catholic Bishops, the organization now called the USCCB, to revise and approve a new set of ERDs. This was completed in 1971, and while these revised Directives were more universally adopted, there were still some outstanding issues, especially concerning sterilizations to avoid future disease or pregnancy-induced medical conditions. In 1994, a major revision occurred with a focus on the importance of human dignity. Unlike earlier versions, the document not only proscribed certain practices, but it positively expounded the Church’s moral doctrine with more social justice issues along with the clinical conditions (O’Rourke, Kopfensteiner, Hamel 2001, 18-20). The content was furthermore sub-divided into six sections that have been maintained for the most part in subsequent editions that were released in 2001, 2009, and the most recent 2018 version. ²

Compassion Can Lead to Conversion

Unfortunately, whenever the Church comes into conflict with the secular world, her teachings are viewed as restrictive and antiquated. In the case of the ERDs, it is no different. However, by consistently following the spirit, not just the letter, of the Directives, we can promote the Catholic case for the importance of human dignity.

“Catholic health care should be marked by a spirit of mutual respect among caregivers that disposes them to deal with those it serves and their families with the compassion of Christ, sensitive to their vulnerability at a time of special need.” (USCCB 2018, No. 2)

The chief medical officer at my hospital once received a letter from a transgender patient’s significant other. The author, who was also transgender, explained that the patient usually obtained medical care at other institutions for a recurrent condition; however, one night an acute event happened, and our emergency department was the most convenient. Knowing that Catholic teaching does not support transgender lifestyles, they fully expected to be treated poorly. However, the couple was happily surprised that all caregivers were very respectful while administering good medical care. In fact, they stated that they were treated better in our emergency department than they had been in secular facilities. That is a great testimony to how Catholic health care providers should care for their patients, “mutual respect… with the compassion of Christ, sensitive to their vulnerability” (USCCB 2018, No. 2). Our mission is to show our love for souls; it should be evident in our actions wherever we practice medicine and to whomever we serve, even if we have completely contrasting moral viewpoints. “By this shall all men know that you are my disciples, if you have love one for another (John 13:35).” ³ Our caring witness may be what is necessary to convert hearts lost in darkness to the Truth of Jesus Christ, bringing their souls into a right relationship with their Creator.

Making a Case in the Courtrooms

“…within a pluralistic society, Catholic health care services will encounter requests for medical procedures contrary to the moral teachings of the Church. Catholic health care does not offend the rights of individual conscience by refusing to provide or permit medical procedures that are judged morally wrong by the teaching authority of the Church.” (USCCB 2018, 8)

Catholic institutions can and should provide compassionate care that is consistent with Truth. Towards that end, there will be times that morally illicit procedures will not be permitted. This refusal is not an abandonment of the patient. If the patient persists in desiring the illicit treatment and chooses to seek that treatment elsewhere, then a transfer of care to a new provider selected independently by the patient is permissible. However, the patient should not simply be referred to another provider who will perform the illicit treatment and then returned to the Catholic institution for follow-up care, as this referral would constitute formal cooperation with evil.

Litigation has been brought forth in several cases claiming that when institutions follow the ERDs, patients receive sub-standard or negligent medical care. In 2013, a woman filed suit against the USCCB, claiming that she was not given appropriate care due to the hospital closest to her following the ERDs, resulting in a miscarriage and post-partum infection. (The appropriate care that the plaintiff (and the ACLU) proffered was to advise the patient of the option to terminate the pregnancy to avoid the post-partum infection.) Were there gaps in the patient’s care? That is a possibility; however, that gap in care was not a result of the ERDs themselves. The judge stated in his motion to dismiss, “This Court is competent to address whether the medical care provided by … physicians, and vicariously provided by [the health system], constitute negligence or medical malpractice. However, the Court cannot determine whether the establishment of the ERDs constitute negligence because it necessarily involves inquiry into the ERDs themselves, and thus into Church doctrine” (Bell 2015, 23). Basically, he admitted that the legal system is not qualified to evaluate or critique Church teachings, including the ERDs. In 2020, an FtM transgender patient sued a state university medical system because a hysterectomy as part of treatment for gender dysphoria was cancelled due to it not meeting hospital criteria for medical necessity. While the hospital system has a separate center for treatment of transgender patients, the patient’s surgeon mis-scheduled the procedure at a Catholic hospital purchased by the secular hospital system that was bound to follow the Directives, a fact of which the surgeon was fully aware as he had agreed to follow the ERDs as conditions for obtaining privileges at that Catholic institution. The patient was ultimately transferred to a non-Catholic hospital within the medical system for the hysterectomy. The defendants argued that the plaintiff “brings this case to have a federal court extinguish the Catholic legacy” that the institution carries on to ensure patients in the region “have access to hospital care they need” [emphasis in original] (Giraudo, Werner, and Matini 2020, 1). The authors of the legal brief further stated, “This case is one of a number of test cases brought by plaintiffs working with the American Civil Liberties Union to prevent Catholic hospitals from abiding [by] the Church’s ethical and religious directives – a.k.a., the ERDs.”

A Right to Conscientious Objection

As more collaborative agreements between Catholic and non-religious institutions occur, and as the secular world strays further into moral quagmires, it is anticipated that the numbers of similar legal challenges will escalate. The emphasis moving forward needs to be reminding society that the right to conscientious objection by a healthcare professional or institution is not secondary to a patient’s right to appropriate medical care, and, in fact, they are currently protected by law. The conscience provisions contained in the documents collectively known as the “Church Amendments” were enacted in the 1970s to protect the conscience rights of individuals and entities that object to performing or assisting in the performance of abortion or sterilization procedures (Office for Civil Rights 2018). The Religious Freedom Restoration Act, signed into law in 1993 by President Bill Clinton, established the exercise of religion is an “unalienable right” (Jipping and Perry 2021, 16). Another point that must be made is that conscientious objection stems from a well-formed conscience – it is not a feeling and cannot be separated from reason (Vélez 2009, 122). Nor can conscientious objection be allowed to be redefined as a refusal to care for the patient. A commentary in a recent issue of this journal stated, “Objection emphasizes the thought behind the action while refusal gives the impression that medical care is not given” (Jones-Nosacek 2021, 1). Furthermore, the more strongly we state our beliefs and do not cower to pressures of the culture, the better we will be able to defend ourselves in court. For example, in 1971, not all bishops had universally adopted the revised ERDs, as any document issued by the Conference of Bishops is not binding unless promulgated by the bishop of each diocese. ⁴ However, after the passing of Roe v. Wade, Cardinal John Krol of Philadelphia, who was then the NCCB president, reminded his fellow bishops that they might not be able to use the federal conscience clause to defend the prohibition of abortions and sterilizations in Catholic hospitals in accord with religious teachings unless they had documentation that such procedures were against their beliefs (O’Rourke, Kopfensteiner, Hamel 2001, 19).

Bravely stating our beliefs that uphold the beauty of human dignity as God created us, obtaining support from local bishops, and being armed to defend against the litigious and moral assaults of the culture are what will allow Truth to ultimately prevail.

Conclusion

In this brief discussion of the history of the ERDs and Part One of the Directives, an overview of Catholic mission in healthcare is presented in a culture that is becoming more and more hostile to religious beliefs. Moving forward, we need to be aware of what the ERDs truly mean – what Catholic health care is for as much as what it is against. Catholic physicians and healthcare professionals should be familiar with and use the Directives as a basis to examine their practices and daily decisions to assure that they are in alignment with the Catholic mission in healthcare. Yet, the ERDs should be used carefully and not blindly without forethought, else we run the risk of not truly providing ethical and appropriate medical care. These Directives are based on sound reasoning and should be promulgated in all dioceses because they can help explain our Catholic perspective to society – and within courtrooms – while helping us to ensure dignity for each person with ethically-sound medical care that promotes the common good and works towards our mission to carry on the healing ministry of Jesus.

Biographical Note

Christine Sybert, PharmD, has over 25 years of experience as a clinical pharmacist and currently practices at Ascension St. Agnes Hospital in Baltimore, Maryland. She and her husband are both cradle Catholics who strive to continually grow in their relationship with Christ and learn the beauty of the Faith. Recently becoming interested in bioethics, she hopes to pursue this field more as her four “almost-grown” children leave home.

ORCID iD

Christine Sybert https://orcid.org/0000-0002-1163-4100