WASHINGTON — Throughout the summer, critics used town hall meetings to stir fears regarding the proposed health-care reform bill. They’ve warned of possible medical “rationing” and “death boards” designed to withhold care for the elderly and the disabled.
Back in Washington, however, Dr. John Morrissey, director of critical care for Providence Hospital, a Catholic institution that primarily serves inner-city patients, views the heated public debate on end of life issues with a mixture of hope and exasperation.
All things being equal, Morrissey, who annually treats about 1,000 patients — many poor, uninsured and homeless — would welcome proposals designed to fund primary health care for the poor before untreated medical conditions bring patients into his ICU. But he also knows that health-care reform can’t easily solve perhaps his thorniest problem: patients who arrive ill-prepared to address the spiritual, emotional and intellectual challenges posed by a terminal condition.
Morrissey and his partner in the ICU struggle daily to help overwhelmed patients and families weigh the benefits and burdens of aggressive treatment. Yet his labors also underscore the vitality of Catholic biomedical ethics during an era that has witnessed the advance of both technical innovations to prolong life and utilitarian equations designed to withhold care to those deemed undeserving of precious medical resources.
“Patients increasingly fear that care will be withheld,” observed Morrissey, who also chairs Providence Hospital’s ethics committee. “The poor feel this deeply. They also have a strong belief that they don’t need to fill out advanced directives: their people will know what to do. But their families often don’t know what to do when the time comes.”
Morrissey is grateful that the U.S. bishops have provided a strong, well-written document that guides his interaction with patients in crisis: “Ethical and Religious Directives for Catholic Health Care Services” (ERDs). Based on a series of Vatican documents that address moral absolutes as well as general ethical principles, the ERDs cover a range of issues, from assisted suicide and feeding tube decisions to pain management and patient autonomy.
“The greatest strength of the ERDs is that they are very reassuring for our patients and encourage trust,” he said. “The directives give comfort. Patients know that the Church defends the sanctity of life, while it endorses the view that patients can dictate what is to be done, such as withdraw from further care.”
The ERDs say, in part: “While every person is obliged to use ordinary means to preserve his or her health, no person should be obliged to submit to a health-care procedure that the person has judged, with a free and informed conscience, not to provide a reasonable hope of benefit without imposing excessive risks and burdens on the patient or excessive expense to family or community.”
While Americans often view end-of-life conundrums in black-and-white terms, Morrissey notes that the more typical ICU issue is the incremental treatments that ultimately result in aggressive efforts to keep a dying patient alive. Ultimately, the process can place family members in the position of making deeply painful choices with little preparation.
“Most end-of-life decisions turn on the guidance offered by doctors, nurses and the hospital ethics committee,” said Jim Towey, president of Saint Vincent College in Latrobe, Pa., and the author of “Five Wishes,” an advanced care-planning document used by many dioceses and Catholic hospitals.
“Catholic families should have these discussions well in advance of a crisis. They should communicate their wishes to their physician and identify someone who can legally speak for them when they can’t speak for themselves,” said Towey.
Recently, Towey criticized the Department of Veteran Affairs for distributing end-of-life guidelines that asked disabled veterans to consider whether they may have become a burden to their families. Such practices, he wrote in The Wall Street Journal, reveal how a preoccupation with “cost containment” leads administrators on the slippery slope toward “a systematic denial of care.”
Morrissey is the first to acknowledge that the daily effort to assuage patients’ fears and confusion can be exhausting. Over decades of working with patients in crisis, he has learned to step in and provide clear guidance that helps dying patients accept palliative treatment, thus avoiding weeks of aggressive but fruitless medical procedures. His partner, by contrast, “may spend an hour and a half with patients establishing trust and weighing treatment outcomes.”
Morrissey confirms that patients are in agreement. If not, he encourages them to seek another opinion.
Matt Lukasiak, vice president for admissions at Providence, believes that Morrissey “has a fluency for dealing with patients who are new to the health-care system and don’t know how to deal with it.” But Morrissey also gets help from a larger cohort of health-care providers and counseling staff.
“We offer a significant pastoral presence, including a number of women religious,” said Lukasiak. “Patients are regularly visited during their stay. When we bring in new physicians, nursing staff and new members of the board of directors, we share the ‘Ethical and Religious Directives’ with them. There is a mindfulness of what we do. You could find it in a lot of hospitals, but it’s a deliberate choice we make here.”
Providence is part of Ascension Health, the largest Catholic health-care system in the country and one that earns ready praise from Catholic bioethicists and industry experts.
“Ascension Health is good about handling end-of-life concerns, in part, because they deliberately look for outside assistance to both evaluate tough moral issues and critique their practices. They go the extra mile,” noted Paul Danello, a Washington-based health-care and canon lawyer who has worked with the Catholic health-care system for 35 years.
By contrast, says Danello, many Catholic hospitals that operate with thin margins at the forefront of uncompensated health care are losing the struggle to shore up their religious mission.
“Some Catholic hospitals give lip service to the ERDs, but look for some way to ‘get around’ them,” he contended. These hospitals have been hollowed out and are led by administrators “who don’t have a real grasp of Catholic ethics as a lived commitment,” Danello said. Shaped by the larger materialistic culture, they may even contend that religious and spiritual values should not intrude into medical decisions, he said.
Morrissey remains guardedly optimistic about the future of Catholic heath care. But he notes that Providence’s ethics committee has begun to address a much broader array of concerns — from an undocumented alien who ran up a $500,000 bill to a new law that mandates federal subsidies for abortion in the District of Columbia.
Health-care reform, including proposals for a national board of advisors that would establish new treatment guidelines for Medicare and Medicaid, is also likely to pose a challenge for a Catholic hospital that seeks to safeguard human dignity and patient autonomy.
Said Leonard J. Nelson III, author of Diagnosis Critical: The Urgent Threats Confronting Catholic Healthcare, “If health-care reform passes, it may become more difficult for Catholic hospitals to preserve their distinctive Catholic identity and persevere in their commitment to operating under the norms contained in the ERDs.”
Joan Frawley Desmond writes
from Chevy Chase, Maryland.