Even at a Distance, Catholic Hospitals' 'Cooperation with Evil' Disturbs Some Ethicists

DETROIT—Care Choices, owned by the country's fourth-largest Catholic health care system, faces an ethical dilemma about whether it enables abortions or not.

Of course, they don't provide abortions directly. None of parent company Mercy Health Services' 39 hospitals or dozens of clinics will abort a baby or provide contraceptive devices. But the Michigan-based Care Choices will contract with another insurance company when an employer requires that family planning be a covered benefit.

“It may not be something everyone enjoys,” said Steve Shivinsky, Mercy's associate vice president for corporate communications. “But it's a fact of life that we have to provide certain services through a third party.”

The solution Mercy arranged is as follows: an employer will send its premium to an independent entity (usually a bank), which will then channel the funds. Most of the money will go to Care Choices for the bulk of the health care offered: check-ups, operations, x-rays, vaccinations, etc. The rest will be sent to another health insurance company contracted by Mercy to provide abortion and other “family planning” services.

“It's a practice found in any Catholic HMO [Health Maintenance Organization] because sometimes it is the only way to obtain a contract from employers,” said Shivinsky.

According to Sister Jean DeBlois, vice president for mission services for Catholic Health Association, “The reality is that when Catholic HMOs do contracting for managed care, most organizations try to eliminate reproductive services from the deal,” she said. “Some are not as successful as others. That's the reality of doing business today in the marketplace.”

Sister DeBlois said that generally, the Catholic organization states that these services are unacceptable and would prefer not to have any dealings with them. If that doesn't work, they take the next step to preserve their integrity from an ethical standpoint by distancing themselves legally and financially as far as possible from the offensive procedures. “Sometimes,” she added, “that's the best they can achieve.”

The United Autoworkers, for instance, requires that any health insurance company it deals with cover family planning, said Shivinsky. “If we can't contract with autoworkers in Detroit we don't have a health plan. If we want to have a viable product, we have to maintain that while providing a moral framework that the sisters can approve.”

Sister Gretchen Elliott, president of the regional community of the Sisters of Mercy that owns the health care network, called the matter a “delicate ethical decision.” Without subcontracting reproductive services out, the contracts with Detroit-area corporations and unions would have been “seriously at risk,” she said, adding that “life is lived in gray areas” and “we take the ethical and moral principles very seriously.”

The ethical and moral principles involved have been treated by the National Conference of Catholic Bishops in a document called Ethical and Religious Directives. The document particularly treats questions involving the beginning and end of life. It also deals with permissible and impermissible forms of cooperation with secular institutions.

One important aspect of the Catholic approach to cooperation, as embodied in the Directives, is the distinction between material and formal cooperation in evil. Formal cooperation in evil occurs when someone intentionally helps another person do wrong. Material cooperation helps another person do wrong but without intending the evil. (See sidebar “Formal vs. Material”)

In December 1994, Bishop John Myers of Peoria, Ill., also issued guidelines for his own diocese about affiliations of Catholic health care institutions with other groups. His statement referred to the bishops' directives, and for Catholic institutions he clearly stated, “Material cooperation with abortion is completely prohibited.”

Bishop Myers' directives also illustrate how the Catholic approach has its most fundamental basis in the dignity of the human person: “The growth of healthcare as a purely ‘for profit’ enterprise is a recent and worrisome phenomenon. Healthcare is not a business, but a profession of service to the human person.”

Even though the Catholic teaching about formal and material cooperation in evil is well established, there is still disagreement about its application in today's healthcare world.

Father Richard McCormick, a professor of Christian ethics at Notre Dame University in South Bend, Ind., said that a Catholic health organization clearly cannot provide abortions or birth control. However, sub-contracting such services may not be wrong. He reasons that a company or a union will easily find another HMO to provide them, but that the other HMO probably will not counsel women to keep their babies.

“It could be defended,” said the priest. “Where abortion is concerned, if you provide counseling services, you may be in the business of saving lives.”

However, many ethicists and moral theologians including Msgr. William Smith, professor of moral theology at St. Joseph's Seminary in Yonkers, N.Y. say that even though some of these types of arrangements are not specifically prohibited in the bishops' directives, “the principles [for disallowing them] are certainly clear enough.”

Catholic Health organizations talk of preserving Catholic identity and viability, but what they are doing falls into an “unacceptable zone” between formal cooperation with evil and material cooperation, said Msgr. Smith. For instance, a nurse may take care of a patient before or after an abortion, but must not participate in it, he said. HMOs like Care Choices, are “horses of a different color” because it is not the individual but the institution that sets the policy.

“It's an odd thing,” Msgr. Smith said. “They're saying that just by doing something that the Church teaches, they lose money. They are comparing moral evil with financial loss.”

HMOs like Care Choices may not be running the abortion money through their cash registers, he added, “but you have to wonder how they avoid scandal.”

Franciscan Father Germain Kopaczynski, director of education at the Boston-based Pope John Center for the Study of Ethics in Health Care says Catholic hospitals in all their activities must be certain they are not cooperating in evil. Catholic health care companies should not be involved in setting up companies that provide abortion or contraception or that make linkages to them, he added.

“They say they're a Catholic health care agency and cannot do abortions, but with winks and nods they say ‘this is how you get around it,’” he said. “It's very problematic from a moral point of view.”

Too many Catholic health services feel pressured by the marketplace and, with the excuse that they cannot compete in the marketplace, align themselves with deep pockets, said Father Kopaczynski. Instead, the companies should draw a line, inform potential customers that they stand with the Church, and be prepared to lose some business because of that stand. “It's not an easy task to come up with an arrangement to satisfy what the Catholic Church is teaching and fiscal realities,” Father Kopaczynski acknowledged.

Germain Grisez, professor of medical ethics at Mount St. Mary's College and Seminary in Emmitsburg, Md., likened some agreements between Catholic hospitals and outside contractors to a Mafia deal.

“If I contract with a Mafia hitman because I am reluctant to do the murder myself, it does not matter how reluctant I am, because I am intending that someone be killed,” said Grisez, author of the book Difficult Moral Questions. “If the Catholic entity says we don't want to do sterilization procedures or do abortions, but arranges that someone else does it, the Catholic entity is enabling that the thing be done.”

Of course, the Catholic HMO does not desire the abortion as a Mafia boss desires a murder, but it facilitates it just the same, he explained.

Grisez called it a “form of cooperation” that makes the health service a responsible partner in the abortion. It's even problematic when a Catholic hospital gets too closely involved with another entity in which unethical things are being done, for instance, an HMO that offers abortion at another facility.

To compete in the modern marketplace, Catholic hospitals and health maintenance organizations are faced with issues of cooperation that did not exist a generation ago, particularly in partnerships with for-profit institutions.

Dr. John Haas, president of the Pope John Center for the Study of Ethics in Health Care, said, “One problem in assessing whether a Catholic facility or organization is collaborating too closely with others who are involved in evil is that we no longer have a sense of moral revulsion toward some of those evil acts because they have come to be so broadly accepted in society. That is certainly the case with contraception, and acts of mutilation such as tubal ligations.

“Regrettably,” he said, “it is coming to be the case even with abortion.”

Lisa Pevtzow is based in Skokie, Ill.

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