Viagra and the Political Genius of Mary Lou Marzian

Most readers have probably heard about a bill Kentucky State Representative Mary Lou Marzian proposed in response to Kentucky's most recent intrusion on a woman's right to choose:

A health care practitioner shall:
(1) Require a man to have two (2) office visits on two (2) different calendar days before the health care practitioner prescribes a drug for erectile dysfunction to him;
(2) Prescribe a drug for erectile dysfunction only to a man who is currently married;
(3) Require a man to produce a signed and dated letter from the man's current spouse providing consent for a prescription for erectile dysfunction; and
(4) Require a man to make a sworn statement with his hand on a Bible that he will only use a prescription for a drug for erectile dysfunction when having sexual relations with his current spouse.

Representative Marzian, a retired nurse, wanted to expose the hypocrisy behind Kentucky's new law requiring a women to receive "counseling" 24 hours before having a legal abortion, in hope that Kentucky women would join her in saying "enough is enough." Not surprisingly, her proposal has gone viral. It's an act of political genius. Rather than offering another rant, she takes the precedent of legislative intrusion into medical care to its logical extreme - but focused on men.

In addition to being hilariously funny, her bill represents a philosophical argument Socrates would have been proud of. His distinctive technique was to take an inadequately thought through position and show how it leads to conclusions his interlocutor cannot accept. If a picture is worth 1,000 words, a spoof like the bill Representative Marzian proposed is worth 10,000 or 100,000.

Hats off to a Kentucky legislator with the guts, wisdom, and delicious sense of humor to come up with the proposal she made!

(See here for an op ed by Representative Marzian in the Kentucky Courier Journal.)

Nicholas Kristof on "Tussling Over Jesus"

Readers who have followed the controversy within the Catholic Church over the abortion done at St. Joseph's Hospital in Phoenix to save a pregnant woman's life should read Nicholas Kristof's powerful op ed in today's New York Times.

Kristof correctly locates the St. Joseph's controversy in the struggle in every faith group between dogmatic fundamentalists and compassionate humanists. "Faith group" is not limited to religions. The controversies about the U.S. Constitution between strict constructionists and those who - correctly - recognize that the Constitution was designed to be a living document, rests on the same dynamic.

Here are the key paragraphs from Kristof's piece:

To me, this battle illuminates two rival religious approaches, within the Catholic church and any spiritual tradition. One approach focuses upon dogma, sanctity, rules and the punishment of sinners. The other exalts compassion for the needy and mercy for sinners — and, perhaps, above all, inclusiveness.

With the Vatican seemingly as deaf and remote as it was in 1517, some Catholics at the grass roots are pushing to recover their faith. Jamie L. Manson, the same columnist for National Catholic Reporter who proclaimed that Jesus had been “evicted,” also argued powerfully that many ordinary Catholics have reached a breaking point and that St. Joseph’s heralds a new vision of Catholicism: “Though they will be denied the opportunity to celebrate the Eucharist, the Eucharist will rise out of St. Joseph’s every time the sick are healed, the frightened are comforted, the lonely are visited, the weak are fed, and vigil is kept over the dying.”

Hallelujah.

(My own posts about St. Joseph's can be seen here, here, here, and here. My most recent post on the topic shares Kristof's admiration for the noble Catholic traditions of commitment to the poor and to social justice.)

Catholic Social Vision and the Diocese of Phoenix

With regard to the abortion done for a patient who was 11 weeks pregnant and on a rapid trajectory towards death from pulmonary hypertension at St. Joseph's Hospital in Phoenix, I wondered if Fr. John Ehrich wanted to stand by the comment he made on May 21, 2010:

"She consented in the murder of an unborn child" said the Rev. John Ehrich, the medical ethics director for the Diocese of Phoenix. "There are some situations where the mother may in fact die along with her child. But - and this is the Catholic perspective - you can't do evil to bring about good. The end does not justify the means."

I went to his website to find the answer. He does.

Fr. Ehrich graduated from college in 1998, so he's probably in his 30s. A Fox News video from December 23 shows a young man pontificating with great certainty about complex existential issues involving theology, ethics, the patient's personal morality, and medical practice. Fr. John evinces what to my eye was smug assurance, not the loving humility one hopes to see in religious leaders.

What I find most painful about the St. Joseph's controversy is that by what many - including committed Catholics - see as a reasonable interpretation of directive 47 of the Ethical and Religious Directives for Catholic Health Care Services, the care at St. Joseph's hospital was religiously, ethically, and medically the right course of action:

Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

If what the caretakers at St. Joseph's saw as a nearly one hundred percent certainty of maternal and fetal death caused by the increased cardiovascular demands of the pregnancy is not "a proportionately serious pathological condition of a pregnant woman," it's hard to imagine what would qualify as "proportional."

The controversy about St. Joseph's is not a replay of the all-too-familiar "pro-life" and "pro-choice" stalemate. It's about interpretation of Catholic teachings themselves. An excellent 2008 article in the American Journal of Public Health by Lori Freedman and colleagues - "When There’s a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals" - reports on interviews with physicians who practice at Catholic hospitals. At some hospitals ethics committees forbid doing an abortion procedure if the fetal heart is still beating, however tenuously, even if other facts make it clear that the fetus cannot survive to birth. At others, such as St. Joseph's, directive 47 is interpreted as being focused on saving the life of the mother when the fate of the fetus is already sealed.

In the research and teaching I've done in India, I met many Catholic volunteers and health professionals working in NGOs serving patients with HIV who were abandoned by others. Mother Theresa is only the tip of the iceberg for the Catholic social mission. Catholic individuals and institutions committed to caring for the poor embody the best ideals in health care. The moral and religious perspective of the caretakers motivated by the Catholic vision of health ministry would not bless the decisions of the Diocese of Phoenix that condemn an otherwise dying patient who reluctantly agreed to terminating her pregnancy as a murderer!

The Wall Street Journal Weighs In about St. Joseph's Hospital

I've been following the controversy between Bishop Olmsted of the Phoenix Diocese and St. Joseph's Hospital in Phoenix and its parent organization, Catholic Healthcare West. (See here, here, and here for previous posts.) I'm not Catholic, but I"m moved by the moral seriousness of Catholic healthcare ethics, and have admired the church's strong traditions of social justice since learning about the Berrigan brothers during the Vietnam era.

In an op ed in today's Wall Street Journal, Professor Anne Henderschott of The King's College in New York weighs in with strong support of the Bishop. I've taken the liberty of reprinting the op ed, with my own comments interlaced in bold italics:

Catholic Hospitals vs. the Bishops
Administrators shop for theologians to support practices that conflict with church teachings.
By ANNE HENDERSHOTT

The severing of ties last week between the Catholic Church and St. Joseph's Hospital in Phoenix, Ariz., is the latest example of the fraying relationship between the bishops and Catholic hospital administrators. In recent years, some Catholic hospitals have taken greater liberties, authorizing abortions and sterilization procedures that the church strictly prohibits. Earlier this year, for instance, Rev. Robert Vasa, bishop of the Diocese of Baker, Ore., ended the church's sponsorship of St. Charles Medical Center in Bend over the hospital's performance of tubal ligations.

But the Phoenix case breaks new ground. In explaining his decision, Rev. Thomas Olmsted, bishop of the Phoenix Diocese, was the first to explicitly point to the role played by Catholic theologians in providing theological cover for "a litany of practices in direct conflict with Catholic teachings."

The terms "shop for theologians" and "theological cover" are catchy journalism, but cheap shots of this kind are demeaning to what has thus far been a thoughtful, respectful deliberation. The terms presuppose the correctness of the Bishop's position, which is exactly what is being questioned.

The break began more than a year ago, when a Catholic nun and longtime administrator of St. Joseph's Hospital gave permission for doctors to perform an abortion. She claimed the pregnancy was terminated to save the life of the mother. Sister Margaret McBride's decision drew sharp criticism from Bishop Olmsted. After excommunicating Sister McBride, the head of the diocese then turned his attention to the role of the hospital itself.

In the phrase "She claimed..." the op ed again substitutes rhetoric for analysis. "Claim" is defined as "demanding one's due." Guilty parties claim innocence. Children claim the toy is really theirs and doesn't belong to the true owner. A proper description is that Sister Margaret "concluded" that the procedure was morally justified. We might end up thinking she was wrong, but we shouldn't treat her as making an unreasoned "claim."

In a Nov. 22 letter to Lloyd H. Dean, president of Catholic Healthcare West, the hospital's parent company, Bishop Olmsted wrote that he would be moving to revoke the Catholic status of the hospital unless certain conditions were met by hospital administrators. Among other things, the bishop demanded that hospital officials acknowledge in writing that the abortion performed was a violation of Catholic directives for health-care institutions.

But hospital officials have defied the bishop and refused to meet his conditions. Rather than acknowledge that an illicit abortion had been performed at his hospital, Mr. Dean attempted to support Sister McBride's decision by pointing out that "many knowledgeable moral theologians have reviewed this case and reached a range of conclusions."

Once again, the op ed assumes that the procedure was "an illicit abortion" without engaging with the substantive questions at stake.

In a July 6 letter to Bishop Olmsted, Mr. Dean asserted that "this is a complex matter on which the best minds disagree." Citing the opinion of Marquette University Professor M. Therese Lysaught on the permissibility of the abortion performed at St. Joseph's, Mr. Dean appeared to suggest that the teaching authority of the Phoenix Bishop was just one more "opinion" on a "complex matter."

I've had the opportunity to read Professor Lysaught's analysis. In its careful attention to (a) the medical facts of the situation and (b) the complex ethical issues the patient, family, and caretakers were dealing with, it's (c) a brilliant, persuasive analysis. I hope it becomes widely available - I would like to use it in my class on medical ethics as an example of careful reasoning about a topic that is too often drowned in strident rhetoric.

This case points to the real problem in the church. For too long, the authority of bishops has been limited to issuing mere opinions. This is especially true at Catholic colleges and universities, where bishops have little affect on the culture and curriculum.

In the recent health-care debate, it was these same Catholic theologians who joined Sister Carol Keehan, head of the Catholic Health Association, to defy the bishops over the legislation in Congress. Cardinal Francis George, president of the United States Conference of Catholic Bishops, criticized Sister Keehan and her organization for supporting a bill that did not contain provisions to protect life. President Obama was so grateful for Sister Keehan's help in shepherding the bill through Congress that he awarded her one of the 20 pens used in the law's signing ceremony at the White House.

Many theologians, like Prof. Nicholas Healy of St. John's University in New York, write that theologians comprise "an alternative magisterium" to the teaching authority of the bishops. And in cases like the one at St. Joseph's, the alternative magisterium often trumps the true Magisterium of the church. Catholic colleges and hospital administrators now "shop" for theologians who will support their decisions.

As an interested observer of the Catholic tradition, my hunch is that the choice for the church is finding ways to live with the "alternative magisterium" or lose Catholics to other denominations (or to "unaffiliated" status). As I've written in a previous post, the Bishop's conclusion about the Phoenix case is not likely to persuade many of the faithful. The fetus and mother were both in the process of dying. There was no medically imaginable scenario that would have led to birth of a living child. The Bishop's position would appear to have required the caretakers to wait until the fetus had died, hoping that the mother would still be alive and that a D & C could then be done to save her life. Even to those who regard abortion as an evil to be forbidden, I believe the Bishop's position will seem like a tortured effort to hold to an orthodoxy that simply makes no sense by criteria of (a) "common sense," but also (b) by Catholic theology and ethics, seen in the light of Professor Lysaught's analysis.

Bishop Olmsted has refused to allow this to continue. In his letter responding to Mr. Dean, the bishop wrote: "You have only provided opinions of ethicists that agree with your own opinion and disagree with mine."

Concluding that "there can be no tie so to speak in this debate," Bishop Olmsted said, "it is my duty as the chief shepherd in the diocese to interpret whether the actions at St. Joseph's meet the criteria of fulfilling the parameters of the moral law as seen in the Ethical and Religious Directives."

For faithful Catholics, there is relief that the tie between the theologians, the administrators and the bishops seems finally to have been broken. But there remains a sadness that yet another Catholic institution has been lost.

I have no expertise about the theological understanding of the role of the Bishop within the church, but I believe Bishop Olmsted is correct in claiming positional authority to declare what is true church teaching. The problem with regard to the St. Joseph's Hospital situation is that his analysis is not likely to be persuasive. Since the fetus, as well as the mother, was in the process of dying, there was no way to protect the unborn life. The choice was between two deaths, or one.

The comments in response to newspaper articles on the case often invoke the pedophile scandals. This is psychologically understandable, but not relevant to the merits of the Bishop's argument. The pedophile scandals have dealt a severe blow to trust in the church heirarchy, just as the scandals about sex with patients and corruption of medical judgment by commercial interests have diminished trust in the medical profession. Trust is easy to lose and very difficult to regain.

In a previous post I encouraged readers to watch the press conference in which Bishop Olmsted explained his decision. Although I was not impressed by his reasoning, I was moved by his moral passion, as expressed in his response to a question he was asked about being vilified in the media:

I really don’t read the blogosphere. I try to pray each day to find my identity in Jesus Christ… My identity comes from Christ. Christ is present in his living body, the church… That’s my identity, it comes from there. If I am unfaithful to that, then whether I’m looked at one way or another, if I’m given praise or given ridicule doesn’t matter. What I’m called to be is faithful to Jesus Christ and his church.

To my reading, paragraph 47 in the Ethical and Religious Directives for Catholic Health Care Services exactly describes the situation the patient, family, and caretakers faced:

Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

Had the caretakers postponed the intervention they made, both mother and fetus would have died. In concluding that it was ethically and theologically correct to terminate the pregnancy the patient, family, and caretakers were acting in accord with Jesus's teaching "I was sick, and ye visited me." I was sad to see Bishop Olmsted attach his moral passion to a conclusion that appears to be erroneous within his own theological and ethical tradition.

In Praise of St. Joseph's Hospital and the Sisters of Mercy

Although I believe that Bishop Olmsted was wrong from the perspectives of both secular and Catholic medical ethics when he decreed that St. Joseph's Hospital "no longer qualifies as a 'Catholic' entity...[and] may not use the name Catholic or be identified as Catholic in the Diocese of Phoenix," the moral seriousness and dignity of the conflict has much to teach. (See here and here for previous posts on the topic.)

Here's how St. Joseph's Hospital explained its views about the clinical circumstances:

A woman in her 20’s with a history of moderate but well-controlled pulmonary hypertension found out she was pregnant. There was concern for her health, because pregnancy with pulmonary hypertension carries a serious risk of mortality. Because of the severity of her disease, the woman’s risk of mortality was close to 50 percent. In November 2009, the woman was admitted to St. Joseph’s Hospital and Medical Center with worsening symptoms. Tests revealed that she now had life threatening pulmonary hypertension. The chart notes that she had been informed that her risk of mortality was close to 100% if she continued the pregnancy. The medical team contacted the Ethics Consult team for review. The consultation team talked to several physicians and nurses as well as reviewed the patient’s record. The patient and her family, her doctors, and the Ethics Consult team, agreed that the pregnancy could be terminated, and that it was appropriate since the goal was not to end the pregnancy but save the mother’s life.

The Bishop's condemnation and St. Joseph's defense both draw on a component of Catholic tradition that I, a non-Catholic, especially admire - the preferential option for the poor and vulnerable. This commitment to social justice comes from Jesus, as in this passage about the last judgment from Matthew (King James version):

34 Then shall the King say unto them on his right hand, Come, ye blessed of my Father, inherit the kingdom prepared for you from the foundation of the world:

35 for I was ahungered, and ye gave me meat: I was thirsty, and ye gave me drink: I was a stranger, and ye took me in:

36 naked, and ye clothed me: I was sick, and ye visited me: I was in prison, and ye came unto me.

37 Then shall the righteous answer him, saying, Lord, when saw we thee ahungered, and fed thee? or thirsty, and gave thee drink?

38 When saw we thee a stranger, and took thee in? or naked, and clothed thee?

39 Or when saw we thee sick, or in prison, and came unto thee?

40 And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.

I encourage readers to watch the press conference in which Bishop Olmsted explained his decision. Although I was not impressed by his reasoning, I was moved by his moral passion. Here's the Bishop's response to a question he was asked about being vilified in the media:

I really don’t read the blogosphere. I try to pray each day to find my identity in Jesus Christ… My identity comes from Christ. Christ is present in his living body, the church… That’s my identity, it comes from there. If I am unfaithful to that, then whether I’m looked at one way or another, if I’m given praise or given ridicule doesn’t matter. What I’m called to be is faithful to Jesus Christ and his church.

The Bishop sees himself as defending the vulnerable fetus, since the life-saving intervention used the same medical technique that is applied in most abortions. What he fails to recognize, however, is that the fetus was not simply vulnerable - it was in the process of dying. The choice the family and the caretakers faced was whether to stand by and let the mother die as well, or terminate the pregnancy, which gave the mother a chance to live. There was no scenario by which the fetus would become a living child.

I'm in no way expert on Catholic medical ethics, but to my reading paragraph 47 in the Ethical and Religious Directives for Catholic Health Care Services exactly describes the situation the patient, family, and caretakers faced:

Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

Had the caretakers postponed the intervention they made, both mother and fetus would have died. In concluding that it was ethically and theologically correct to terminate the pregnancy the patient, family, and caretakers were acting in accord with Jesus's teaching "I was sick, and ye visited me." I am sad to see Bishop Olmsted attach his moral passion to a conclusion that appears to be erroneous within his own theological and ethical tradition.

A Worthy Conflict about Abortion in Arizona

The level of public debate about health care ethics has been in a sorry state in recent years, as evidenced by the Kaiser Family Foundation finding that thirty percent of seniors still believe the health reform law lets a government panel ("death panel") make decisions about end of life care.

In contrast, the Arizona "theological showdown" over abortion that I posted about last week addresses profound ethical issues with admirable clarity.

In November 2009 St. Joseph's Hospital in Phoenix performed an abortion on a patient who was (a) 11 weeks pregnant and (b) terminally ill with pulmonary hypertension, a condition made much worse by pregnancy. The hospital concluded it could not save both mother and gestating child. After consultation with patient, family, caregivers, and ethics committee, the abortion was performed.

Bishop Olmsted demanded that St. Joseph's acknowledge by December 21 that it had violated ethics and Catholic teachings and promise never to repeat what it had done. The hospital refused. In a terse statement the Bishop concluded that St. Joseph's "no longer qualifies as a 'Catholic' entity...[and] may not use the name Catholic or be identified as Catholic in the Diocese of Phoenix."

St. Joseph's response was respectful, but firm:

The leadership of St. Joseph's Hospital and Medical Center in Phoenix is saddened today following Bishop Thomas Olmsted's announcement that he has revoked his endorsement of the hospital as "Catholic." At his direction, the hospital will remove the Blessed Sacrament from the chapel and will no longer celebrate mass there.

Though we are deeply disappointed...St. Joseph's will remain faithful to our mission of care, as we have for the last 115 years...[we] will continue through our words and deeds to carry out the healing ministry of Jesus.

Consistent with our values of dignity and justice, if we are presented with a situation in which a pregnancy threatens a woman's life, our first priority is to save both patients. If that is not possible we will always save the life we can save, and that is what we did in this case...Morally, ethically, and legally we simply cannot stand by and let someone die whose life we might be able to save.

In teaching medical ethics I always encourage the groups I work with to (a) think through what they believe is the right thing to do, (b) explain the rationale for their conclusion, and then (c) ask what the law says. Most of the time law and ethics will coincide.

If our ethical analysis and the requirements of law diverge, the first thing to do is to revisit our ethical analysis. Did we miss something? After all, law is an expression of the body politic's conclusions about how to govern itself.

If we hold to the conclusion we reached, the next question is whether we see the situation as one in which fair-minded people can disagree about right and wrong. The Bishop spoke to this in his November letter to Catholic Healthcare West, parent organization to St. Joseph's:

...you stated in a letter to me "As you know, many knowledgeable moral theologians have reviewed this case, and reached a range of conclusions. If we may assume that these individuals are motivated by their faith and desire for justice, one must at least acknowledge that this is a very complex matter, on which the best minds disagree." Thus, it would appear that your intention is to resolve our disagreement by asserting that there is no single "correct" answer to the question of whether the procedure that led to an abortion at St. Joseph's Hospital was morally permissable under the Ethical and Religious Directives of the USCCB. In effect, you would have me believe that we will merely have to agree to disagree. But this resolution is unacceptable because it disregards my authority and responsibility to interpret the moral law and to teach the Catholic faith as a Successor to the Apostles.

Catholic Healthcare West and St. Joseph's Hospital believe their interpretation of the moral law taught by the Catholic Church is correct. The Bishop claims that his position in the Church heirarchy gives him authority to decree the correct answer. It appears that Catholic Healthcare West and St. Joseph's believe that he is not infallible and has, in fact, reached a conclusion they regard as wrong and cannot accept.

To the best of my knowledge, the Bishop's claim that he has authority to decree what the correct answer to the St. Joseph's question is correct under Cannon law. But this "authority" is not persuasive to his flock - a 2009 Gallup poll showed that forty percent of Catholics regard abortion as morally acceptable. Insofar as the Phoenix case draws attention within the Church, the Bishop's action is likely to push more Catholics away from the official teaching, given that this was a situation in which holding to the official position meant death for the mother. The hospital accepted the Bishop's authority to take away their right to say Mass in the chapel, but claim the authority of Jesus himself to justify their conclusion about the ethical course.

Theological Showdown over Abortion in Arizona

Bishop Thomas J. Olmsted, the Catholic Bishop of Phoenix, has thrown down a theological gauntlet to St. Joseph's hospital. If the hospital does not acknowledge that he was right in his condemnation of a medical procedure that involved abortion he will revoke it's status as a Catholic hospital.

The story goes back to November 2009. All that is publicly known is that a patient at the hospital (1) had pulmonary hypertension, (2) was pregnant, a combination associated with a high rate of fatality, and that (3) Sister Margaret McBride, vice president of mission, was a member of the hospital ethics committee that was consulted about the case.

On May 14, 2010, Bishop Olmsted made the following statement:

I am gravely concerned by the fact that an abortion was performed several months ago in a Catholic hospital in this Diocese. I am further concerned by the hospital's statement that the termination of a human life was necessary to treat the mother's underlying medical condition.

An unborn child is not a disease. While medical professionals should certainly try to save a pregnant mother's life, the means by which they do it can never be by directly killing her unborn child. The end does not justify the means.

Every Catholic institution is obliged to defend human life at all its stages; from conception to natural death. This obligation is also placed upon every Catholic individual. If a Catholic formally cooperates in the procurement of an abortion, they are automatically excommunicated by that action. The Catholic Church will continue to defend life and proclaim the evil of abortion without compromise, and must act to correct even her own members if they fail in this duty.

We always must remember that when a difficult medical situation involves a pregnant woman, there are two patients in need of treatment and care; not merely one. The unborn child's life is just as sacred as the mother's life, and neither life can be preferred over the other. A woman is rightly called 'mother' upon the moment of conception and throughout her entire pregnancy is considered to be 'with child.'

The direct killing of an unborn child is always immoral, no matter the circumstances, and it cannot be permitted in any institution that claims to be authentically Catholic.

As our late Holy Father, Pope John Paul II, solemnly taught in his encyclical 'The Gospel of Life,' a 'direct abortion, that is, abortion willed as an end or as a means, always constitutes a grave moral disorder, since it is the deliberate killing of an innocent human being' (The Gospel of Life #62).

The Ethical and Religious Directives for Catholic Healthcare Institutions (ERDs) are very clear on this issue: 'Catholic health care ministry witnesses to the sanctity of life from the moment of conception until death. The Church's defense of life encompasses the unborn and the care of women and their children during and after pregnancy.' (ERD, Part Four, Introduction) The ERDs further state that 'Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. Every procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion.(ERD 45)"

Here's the statement St. Joseph's hospital had made:

At St. Joseph's Hospital and Medical Center, our highly-skilled clinical professionals face life and death decisions every day. Those decisions are guided by our values of dignity, justice and respect, and the belief that all life is sacred.

We have always adhered to the Ethical and Religious Directives for Catholic Health Care Services as we carry out our healing ministry and we continue to abide by them. As the preamble to the Directives notes, 'While providing standards and guidance, the Directives do not cover in detail all the complex issues that confront Catholic health care today.'

In those instances where the Directives do not explicitly address a clinical situation - such as when a pregnancy threatens a woman's life - an Ethics Committee is convened to help our caregivers and their patients make the most life-affirming decision.

In this tragic case, the treatment necessary to save the mother's life required the termination of an 11-week pregnancy. This decision was made after consultation with the patient, her family, her physicians, and in consultation with the Ethics Committee, of which Sr. Margaret McBride is a member.

In a subsequent interview Suzanne Pfister, vice president of communications for the hospital, added: "We believe that all life is sacred. In this case, we saved the only life we could save, which was the mother's."

On November 22 Bishop Olmsted sent a remarkable four page letter to Lloyd Dean, president of Catholic Healthcare West, the large not-for-profit system with 40 hospitals - including St. Joseph's - in Arizona, California and Nevada. (The letter was made available to, i.e., leaked to, and published by, the Arizona Republic.)

The Bishop quotes from a letter from Catholic Healthcare West as saying "many knowledgeable theologians have reviewed the case, and reached a range of conclusions. If we assume that these individuals are motivated by their faith and desire for justice, one must at least acknowledge that this is a very complex matter, on which the best minds disagree."

The Bishop will have none of it. Here's his response - "There cannot be a tie in this debate. Until this point in time, you have not acknowledged my authority to settle this question. Your actions communicate to me that you do not respect my authority to authentically teach and interpret moral law in this diocese. Failure to fulfill these requirements will lead me to decree the suspension of my endorsement of St. Joseph's Hospital, forcing me to notify the Catholic faithful that St. Joseph's Hospital no longer qualifies as a Catholic hospital..." He gives Catholic Healthcare West until Friday December 17 to capitulate by acknowledging in writing that they have made a grave error and that he is correct.

I do not know the particulars of the clinical situation, but from the Bishop's letter I infer that the patient's physicians concluded that there was no way to save the lives of both mother and baby-to-be. The choice was two deaths, or one.

The Bishop is correct that Canon Law decrees him to be the "decider." But if I am correct in my inference about the clinical facts, he will not be regarded - including by many Catholics - as having moral, as opposed to legal, authority. He will not be seen as a true arbiter of what is right in the situation.

(See here and here for two excellent articles by Michael Clancy in the Arizona Republic. The second article has a brief quotation from me - I'm grateful to Mike for contacting me about the situation.)

The New Abortion Providers

Today's New York Times Magazine features a superb article about "The New Abortion Providers." But before I write about it I have to acknowledge a conflict of interest. The author, Emily Bazelon, is my daughter in law.

Emily describes how young physician leaders, mainly women, are training residents and fellows in abortion procedures and family planning. Their aim is to offset the retirement of current abortion providers and to bring abortion services back into mainstream medicine.

I was blown away by the reflectiveness and moral courage of the physicians who were interviewed for the story. Providing abortion services requires tremendous courage. "Pro-life" terrorists have murdered 8 Americans and assaulted 153. If Al Qaeda did the same in a foreign country we would probably bomb or invade! If I were a newly trained OB/GYN physician I don't know if I would have the guts to include abortion in my practice.

Despite terrorism and the hate-laden rhetoric of the "pro-life" protesters who surround abortion clinics, the new abortion providers show respect for colleagues who oppose abortion in a civilized manner. One physician who does abortions only up to nine weeks explained “It was a way of being respectful, because I know that not everyone agrees with me and what I do.” Another handles all the arrangements and does the billing himself for the abortions he provides in his general OB/GYN practice because of the views of the beloved nurse who works with him:

When I talked to Ann [the nurse] — Ray [the physician] offered her his office chair while he saw a patient — she said that when Ray took over the practice, she and the office manager, another woman in her 60s, weren’t sure if they would stay. “We didn’t want a young doctor with attitude,” Ann said. “We’re too old for that. But we gave him a chance. And he has exceeded our expectations wildly. I thank God every day, because he’s so good with the patients. I’m just blessed. Other than the little termination thing — ” she made a small box with her fingers and then moved her hands to her left, as if to set the box aside.

The New York Times piece mentioned an extraordinary article by Dr. Lisa Harris - "Second Trimester Abortion Provision: Breaking the Silence and Changing the Discourse" - that I would never have seen otherwise. Dr. Harris describes the experience of doing an abortion for a woman who was 18 weeks pregnant when she was herself 18 weeks pregnant with her first child, and moves from her personal experience to broad moral reflection:

I went about doing the procedure as usual, removed the laminaria I had placed earlier and confirmed I had adequate dilation. I used electrical suction to remove the amniotic fluid, picked up my forceps and began to remove the fetus in parts, as I always did. I felt lucky that this one was already in the breech position – it would make grasping small parts (legs and arms) a little easier. With my first pass of the forceps, I grasped an extremity and began to pull it down. I could see a small foot hanging from the teeth of my forceps. With a quick tug, I separated the leg.

Precisely at that moment, I felt a kick – a fluttery ‘‘thump, thump’’ in my own uterus. It was one of the first times I felt fetal movement. There was a leg and foot in my forceps, and a ‘‘thump, thump’’ in my abdomen. Instantly, tears were streaming from my eyes – without me – meaning my conscious brain - even being aware of what was going on. I felt as if my response had come entirely from my body, bypassing my usual cognitive processing completely. A message seemed to travel from my hand and my uterus to my tear ducts. It was an overwhelming feeling – a brutally visceral response – heartfelt and unmediated by my training or my feminist pro-choice politics. It was one of the more raw moments in my life.

...What do we do when caught between pro-choice discourse that, while it reflects our values, does not accurately reflect the full extent of our experience of abortion and in fact contradicts an enormous part of it, and the anti-abortion discourse and imagery that may actually be more closely aligned to our experience but is based in values we do not share?...I want to make the case that honesty about abortion work can be the basis for a stronger movement – one that makes it easier for providers and the teams they work with to do all abortions, especially second trimester abortions."

Dr. Harris is spot on. Dodging the moral complexity of abortion will weaken the feminist "pro-choice" perspective. Recognizing that complexity makes for a more mature, small "c" catholic moral position.

If Ann, a "pro-life" grandmother who goes to Mass every week, and Ray, a young physician who includes abortion in his practice, can work together in mutual respect, there's hope for ameliorating our national nightmare about abortion policy!

Abortion and Health Reform

The current clash about abortion and health reform is a tragedy. It reflects the breakdown of civil national discourse.

Although I'm a strong supporter of accessible abortion services, I see abortion as a a sad human event, to be avoided as much as possible.

And I respect the views of the majority of the "pro-life" community who oppose abortion in a thoughtful, conscience-driven manner and who respect those who hold the "pro-choice" position in an equally thoughtful, conscience-driven manner. Unfortunately the hate-laden screamers and the madness of committing murder on behalf of purported "reverence for life" has tainted the anti-abortion position, just as suicide bomber-murderers have tainted the noble traditions of Islam.

If Representatives Stupak and Pitt, their supporters, and the Conference of Bishops, were simply trying to ensure that health reform would continue the 33 year history of the Hyde amendment in prohibiting direct federal funding of abortion, I would be with them. (See here for the wording of the Stupak-Pitt amendment.) Abortion is currently an unresolvable moral conflict in the U.S. about which people of conscience cannot agree. Protecting access to abortion when states wish to fund the services or private insurance contracts include them while not allowing federal tax money to pay for abortion is a fair resolution. It won't leave anyone fully happy. That's something a mature democracy must be able to accept.

But Stupak-Pitt appears to have a much wider scope than the Hyde amendment, including prohibiting abortion in private insurance sold through any "exchange" created by the legislation. If the amendment is trying to extend constraints on abortion by hijacking health reform to achieve that aim the supporters ought to put their cards on the table and acknowledge that blackmail is their aim: "We think further restraint of abortion is more important than reforming our health system, so unless we get our way we'll block any legislation." If that's not their intent they should work with leadership to achieve a fair resolution.

Threatening to kill health reform unless abortion constraints are extended would be a misguided way of witnessing one's conscience. If abortion opponents take this path "pro-choicers" will take an equally hard line. The U.S. would miss a rare opportunity to tip toe towards greater social justice in health care.

The Murder of Dr. George Tiller (2)

By good luck I was in my car shortly after noon yesterday and heard the NPR program Here and Now. Host Robin Young interviewed Miriam Kleiman, who nine years ago had a late term abortion at Dr. Tiller's clinic. The interview is very worth listening to, and could be used as a trigger for discussion in a mature high school class, a college or health professional class, or a discussion group.

The baby Ms. Kleiman was carrying was found to have a rare brain anomaly that would lead to death. She and her husband decided to seek abortion. When she spoke with the head of her obstetrical practice he looked her in the eye and said "we call that murder!" This was a serious lapse of medical ethics. It would have been acceptable for the physician to have spoken about his personal values, but not to use "we" for a personal perspective or to use the word "murder" for a legal procedure.

By contrast, Dr. Tiller and his clinic were professional, kind and considerate. I've read more about him. He appears to have been a true moral hero. Here's part of what I learned from an article in USA Today:

As a late-term abortion doctor, George Tiller knew he had chosen a dangerous career, one that made him a lightning rod. His Kansas clinic was a fortress, his days marred by threats, but he refused to give up what he saw as his life's mission.

"He never wavered," says Susie Gilligan, who knew Tiller as part of her work in the Feminist Majority Foundation. "He never backed away. He had incredible strength. When you spoke to him, he was a soft-spoken man, a very gentle man. He said, 'This is what I have to do. Women need me. I know they need me.'"

When thousands of protesters gathered at the Women's Health Care Services clinic in 1991 for the 45-day "Summer of Mercy" demonstration staged by Operation Rescue, he was again unbowed.

"I am a willing participant in this conflict," he said at the time. "I choose to be here because I feel that it is the moral, it is the ethical thing to do."

He told The Wichita Eagle newspaper in 1991 that prayer and meditation helped him through hard times. "If I'm OK on the inside," he said, "what people say on the outside does not make much difference."

Reading about Dr. Tiller's deeply grounded moral strength reminded me of an experience I had during my first year at college. A roommate from Dr. Tiller's part of the country (Kansas/Oklahoma) and I, wanting to earn some extra money, participated in what I later learned was a classical social psychological experiment - the Asch Conformity Experiment.

The ostensible task was making visual judgments about the length of a line. All of the other "subjects" were confederates in the experiment, and after a few correct judgments made a consistent systematic error. The research question was - what was the impact on the one true subject?

I remember a feeling of dis-ease and gradually beginning to question my judgments. The confederates were making a consistent erroneous choice, and sometimes that choice actually looked correct to me.

But my roommate, who I now associate with Dr. Tiller in his inner confidence, never noticed what the confederates were doing. We had 80 judgments to make. He disagreed 80 times. For me, the contrast between his reaction and mine was a learning opportunity I've never forgotten.

I hope at least some opponents of abortion will be able to recognize and respect Dr. Tiller's moral seriousness.

The Murder of Dr. George Tiller

In order to assert the sanctity of life, an abortion opponent murdered Dr. George Tiller, one of only three physician providers of late term abortion in the U.S., as he served as an usher of his church yesterday.

Sadly, as shown in a New York Times article this morning, at least one anti-abortion spokesman, while intending to condemn the murder, showed how deeply entrenched hate-laden rhetoric is:

Opponents of abortion, including those here who have been most vociferous in their protests of Dr. Tiller and his work, also expressed outrage at the shooting and said they feared that their groups might be wrongly judged by the act.

Troy Newman, the president of Operation Rescue, an anti-abortion group based in Wichita, said he had always sought out “nonviolent” measures to challenge Dr. Tiller, including efforts in recent years to have him prosecuted for crimes or investigated by state health authorities.

“Operation Rescue has worked tirelessly on peaceful, nonviolent measures to bring him to justice through the legal system, the legislative system,” Mr. Newman said, adding, “We are pro-life, and this act was antithetical to what we believe.”

Of course a group that is "pro-life" must oppose murder. Sadly, Mr. Newman's statement about "bring[ing] him to justice" pours gasoline onto the fire of hatred. "Bring[ing] him to justice" states as a fact that Dr. Tiller was a criminal. Operation Rescue is entitled to believe that. But Newman should have said something like "Operation Rescue has worked tirelessly on peaceful, nonviolent measures to make a practice we abhor illegal..." The murderer, who may already be in custody, will probably claim that he was "bringing Dr. Tiller to justice."

When I use the terms "pro-life" and "pro-choice" I always put them into quotation marks. For almost 400 years the King James translation of Deuteronomy 30:19 has told us that choice and life go together:

I call heaven and earth to record this day against you, that I have set before you life and death, blessing and cursing: therefore choose life, that both thou and thy seed may live

I don't know the Qur'an well enough to identify a similar teaching, but I'm sure it's there.

Abortion deserves to be controversial. I believe that abortion should be legal, safe and available. But I have friends and colleagues who I respect who believe abortion is evil and should be banned. In my view, "therefore choose life" says it all. In three words it unites the pro and anti abortion believers in the tent of humanity.

This effort to find an overarching principle of unity is what President Obama did with such eloquence in his graduation speech at Notre Dame. Here's part of what he said:

In this world of competing claims about what is right and what is true, have confidence in the values with which you've been raised and educated. Be unafraid to speak your mind when those values are at stake. Hold firm to your faith and allow it to guide you on your journey. Stand as a lighthouse.

But remember too that the ultimate irony of faith is that it necessarily admits doubt. It is the belief in things not seen. It is beyond our capacity as human beings to know with certainty what God has planned for us or what He asks of us, and those of us who believe must trust that His wisdom is greater than our own.

This doubt should not push us away from our faith. But it should humble us. It should temper our passions, and cause us to be wary of self-righteousness. It should compel us to remain open, and curious, and eager to continue the moral and spiritual debate that began for so many of you within the walls of Notre Dame. And within our vast democracy, this doubt should remind us to persuade through reason, through an appeal whenever we can to universal rather than parochial principles, and most of all through an abiding example of good works, charity, kindness, and service that moves hearts and minds.

For if there is one law that we can be most certain of, it is the law that binds people of all faiths and no faith together. It is no coincidence that it exists in Christianity and Judaism; in Islam and Hinduism; in Buddhism and humanism. It is, of course, the Golden Rule - the call to treat one another as we wish to be treated. The call to love. To serve. To do what we can to make a difference in the lives of those with whom we share the same brief moment on this Earth.

(See here and here for recent posts about President Obama's leadership on the abortion controversy.)

Abortion and Conscience

Here's the assignment I developed for today's section of Harvard Medical School's required first year course on "Medical Ethics and Professionalism":

Drawing on the articles by May and Aulisio ["Personal Morality and Professional Obligations] and Curlin ["Religion, Conscience, and Controversial Clinical Practices"], discuss how you would respond to a respected colleague who is strongly against abortion and feels he cannot in good conscience refer a patient to a potential abortion provider and should discuss his moral perspective with his patients.

All 13 students (and I) believed that abortion should be legal, available and safe. My aim for the class was not to have yet another repetitive discussion of abortion ethics, but to engage with the question of whether and how our divided society can reduce the level of rancorous conflict and collaborate despite deep moral differences.

We conducted a segment of the class as a dialogue/role play. One student and I took the role of the anti-abortion physician envisioned in the assignment. The rest of the group was assigned the role of chief of the practice. Here's a summary of the dialogue, written as if it occurred between two people:

Chief: I've been told that you are refusing to refer patients for potential abortion services and are telling them about your personal moral outlook. Is that true?

Physician: It is. I know that abortion is legal and that a majority of the population believes it should be. But it seems so clear to me that abortion is killing a baby-in-the-making that there's no way of not seeing it as a profound wrong. I can't possibly support that - even by referring a patient to someone else.

Chief: Medical ethics is built around patient autonomy - that people have a right to make their own medical choices among legal alternatives. People can refuse life-saving treatment, and two states allow physician assisted suicide!

Physician: I know what the law says. In the country I came from female circumcision was legal and widely practiced, but I refused to do it or refer for it because I saw it as a deep moral wrong. The fact that the law allows abortion or female circumcision doesn't make these practices right or morally acceptable.

Chief: If you can't bring yourself to provide information patients are entitled to maybe you should have gone into a different profession!

Physician: I love medicine, and the feedback we get shows that my patients feel respected and well treated by me. Abortion is the one area where there's a problem for me in the practice.

Chief: It would be better to steer patients who want to consider abortion away from you in the first place.

Physician: That's a good idea.

Chief: Another thing. When you talk with patients about your views, we don't want you using terms like "evil" or "murder." You're entitled to your own views. But people who I regard as just as morally serious as you - including myself - disagree. You can say what you want in a political discussion, but not when you're a doctor dealing with patients.

Physician: I can live with that...

My aim in the class was to challenge us to respect a colleague we deeply disagreed with and not to demonize him because John Salvi and James Kopp felt called upon to murder abortion providers.

As I wrote in a post a few weeks ago, I think the best we can hope for is a gradual reduction of the virulence of the pro and anti abortion debate. (I don't like to use "pro life" and "pro choice" - all decent human beings value both life and choice!) President Obama has made a promising start with the working group he convened and his speech at Notre Dame (see here). And versions of the class experience my students and I had today - if repeated in a few million settings - may make a difference as well.

Obama at Notre Dame

Dear readers - if, like me, you did not see President Obama's graduation speech at Notre Dame University yesterday, watch it now. I'll be surprised if it doesn't bring tears to at least some eyes. I'm still a bit teary. (See here for the text of his speech and a video.)

Obama spoke at length about the virulent way the abortion controversy has played out in the U.S. He acknowledged that ultimately the "pro life" and "pro choice" perspectives are irreconcilable. But with his remarkable rhetorical force he conveyed a small "c" catholic perspective of acceptance among those who hold different faiths, including no faith, which he referred to as "humanism."

For me, the most moving moment occurred when a heckler began to shout. The student audience drowned him out by chanting "yes we can," and gave the President a standing ovation.

Every religion, including "humanism," includes a hate-laden minority, eager to demonize, and sometimes to kill, those who don't share their convictions. Here's what the president had to say about that stance:

But remember too that the ultimate irony of faith is that it necessarily admits doubt. It is the belief in things not seen. It is beyond our capacity as human beings to know with certainty what God has planned for us or what He asks of us, and those of us who believe must trust that His wisdom is greater than our own.

This doubt should not push us away from our faith. But it should humble us. It should temper our passions, and cause us to be wary of self-righteousness. It should compel us to remain open, and curious, and eager to continue the moral and spiritual debate that began for so many of you within the walls of Notre Dame. And within our vast democracy, this doubt should remind us to persuade through reason, through an appeal whenever we can to universal rather than parochial principles, and most of all through an abiding example of good works, charity, kindness, and service that moves hearts and minds.

For if there is one law that we can be most certain of, it is the law that binds people of all faiths and no faith together. It is no coincidence that it exists in Christianity and Judaism; in Islam and Hinduism; in Buddhism and humanism. It is, of course, the Golden Rule - the call to treat one another as we wish to be treated. The call to love. To serve. To do what we can to make a difference in the lives of those with whom we share the same brief moment on this Earth.

The key thing here isn't the words, which are familiar, though eloquent. It's the fact that the President was speaking at one of the world's leading leading Catholic institutions. This kind of leadership won't persuade convinced haters, but it can and will make a difference in our public attitudes over time.

(Ten days ago I wrote a post about the working group on abortion the White House has convened. You may want to look at it as well.)

Good Politics and Good Ethics about Abortion

An article in yesterday's Wall Street Journal described how President Obama has convened a group of abortion rights opponents and supporters to help develop policies both sides can get behind.

This is probably smart politics. It may lead some pro lifers to see the President more favorably. But it's definitely good ethics.

Some years ago, when medical ethics was taught as an elective at Harvard Medical School (it's a required course now), my colleague & friend Lachlan Forrow (president of the Albert Schweitzer Fellowship) and I co-taught the course together. We didn't see how a course on ethics could avoid discussing abortion, but we feared that simply discussing it pro and con would get nowhere, since most people would just be repeating fixed opinions. We decided to approach the issue from the side, through discussing the pros and cons of "selective reduction" in triplet pregnancies, where reducing the pregnancy from three to two increases the likelihood of survival. We also discussed whether an OB/GYN program that included training in abortion should accept or turn down an otherwise well qualified candidate who opposed abortion and refused to participate.

In retrospect I wish we'd asked President Obama's question - how might we create some rapprochement between the pro life and pro choice camps? The issue of whether and how it is possible to promote constructive dialogue in intensely polarized situations should be part of ethics education.

The ideas being discussed in the White House process are constructive but predictable - reducing the frequency of unwanted pregnancies, as by making contraception more available and improving sex education, and making it easier for new mothers to keep their babies and making it easier to adopt.

But the most important outcome could be a greater readiness for the "camps" to appreciate each other's human decency.

Pro choicers should acknowledge that abortion does involve sacrificing a (pre natal) life. That's a deeply serious moral choice and a very sad event. They shouldn't see pro lifers in terms of the lunatic and criminal fringe of the movement. And the pro choice folks shouldn't be demonized as promiscuous baby killers. Comparing abortion to the Nazi gas chambers is preposterous logic and grotesque ethics.

But it's important to have realistic expectations about dialogues of the sort the White House has convened. In 1994, after John Salvi murdered Shannon Lowney, receptionist at Planned Parenthood, and Lee Ann Nichols, receptionist at Preterm (both in Boston), Governor Weld and Cardinal Law promoted talks between six prochoice and prolife leaders. The women, with two facilitators, met for more than 150 hours over the course of five years.

The talks did not lead the leaders to change their basic views, but they did promote a change in tone in the public debate. The "sides" came to see their "opponents" as as people of integrity and decency who held wrong views. But heightened recognition of each others' humanity in Massachusetts did not prevent James Kopp from murdering abortion provider Dr. Barnett Slepian in Buffalo in 1998. And if there is a Salvi/Kopp clone skulking about somewhere, the White House talks will not bring him to sanity.

The fact that even the deepest ethical dialogue has finite impact shouldn't dissuade us from promoting the process. For me one point of the Garden of Eden story is that even an omnipotent creator doesn't have full control over what our species will do!

Here's the final paragraph from a superb Boston Globe article written by the participants in the Massachusetts abortion dialogues:

We hope this account of our experience will encourage people everywhere to consider engaging in dialogues about abortion and other protracted disputes. In this world of polarizing conflicts, we have glimpsed a new possibility: a way in which people can disagree frankly and passionately, become clearer in heart and mind about their activism, and, at the same time, contribute to a more civil and compassionate society.

Catholic & Secular Values in the British National Health Service (2)

In December I wrote about conflict over reproductive ethics at "John and Lizzie's," a well-known Catholic hospital in London.

The Hospital of St. John and St. Elizabeth, founded by the Sisters of Mercy in 1856, is known as a celebrity hospital. Cate Blanchett, Emma Thompson, Kate Moss and Heather Mills-McCartney have all had babies there. The media describes John and Lizzie’s as "the poshest place to push." The hospital is under the governance of the Catholic church, but has been operating as an independent entity, funded by the NHS, self-paying private patients, private health insurance companies, and charitable donations.

In 2007, Cardinal Cormac Murphy O’Connor, head of the Catholic Church in England and Wales, had laid down the law to John and Lizzie’s: “There must be clarity that the hospital, being a Catholic hospital with a distinct vision of what is truly in the interests of human persons, cannot offer its patients, non-Catholic or Catholic, the whole range of services routinely accepted by many in modern secular society as being in a patient's best interest."

In February 2008, Cardinal O'Connor asked for, and received, the resignation of the entire Board. Lord Guthrie of Craigiebank, a former Army Chief of Staff, and Vice President and Knight of the Sovereign Military Order of Malta, an ancient Catholic military order that now focuses on medical charity work around the world, was appointed as the new Board chair.

This week the Board adopted a new code of ethics. In accord with Catholic teaching the code specifies that euthanasia, sex change operations, IVF, pre-natal testing by amniocentesis, sterilizations, fitting of IUDs, and direct provision of abortion are forbidden. It does not mention, however, referrals for abortion, prescriptions for contraceptives or the morning after pill. This means that doctors and nurses at the hospital and in the National Health Service practice based at the hospital could refer patients elsewhere for these services without violating the hospital's ethics code.

Nicholas Bellord, of the Restituta Group (named for St. Restituta, who was martyred in the 4th century, but miraculously saved from fire by the intervention of an angel) which has been lobbying hospital officials to retain its Catholic pro-life policies, complained that "It will be possible for a woman to attend this hospital and be counseled to have an abortion and for her to believe, not unreasonably, that she has the blessing of the Roman Catholic church."

Lord Guthrie spoke about how doctors and nurses would operate under the new code as follows:

"The confidentiality of their consultations with patients must be respected, as must the confidentiality of the advice which they offer to patients in accordance with their professional and legal obligation.

The hospital, however, cannot condone or permit practices in its name which conflict with Catholic teaching on the sanctity of life or respect for the human person."

As I understand his comments, Lord Guthrie is doing an admirable piece of ethical balance. His assertion that the hospital cannot "permit practices in its name..." clearly affirms Catholic teachings. But his comments about the staff's "professional and legal obligation[s]" recognizes pluralism.

In the U.S. fundamentalist terrorists have murdered abortion providers and intimidated those who oppose them. If I understand Lord Guthrie correctly I see him as doing God's work. He has found a path to fidelity to his church's teachings without casting those of good conscience who hold different views as murderers. We in the U.S. need more of Lord Guthrie's combination of fidelity to our beliefs and pragmatitic acceptance of of differing moral perspectives. That's what democratic pluralism requires.

Health Worker's Religious Freedom, Patient Rights, and Ethical Deliberation

Today's Washington Post article about a budding Bush administration proposal to extend the rights of health care workers to opt out of participation in a range of procedures that they object to was all over the blogosphere within minutes of publication.

The proposal, which would deny federal funding to any hospital, clinic, health plan or other entity that does not accommodate employees who want to opt out of participating in care that runs counter to their personal convictions, including providing birth-control pills, IUDs and the Plan B emergency contraceptive, is an obvious effort to heat up the abortion debate. Opponents of abortion say the regulations are needed. Supporters of choice see it as another effort to thwart access to legal care options.

Quite apart from the torch the regulations would toss into the abortion debate, they construe society as composed of individuals who look inward to conscience with no need to engage with others. They embody no sense of a moral community that must deliberate and struggle with difficult questions and develop creative ways of living with differences. In a similar vein, observers of the legislative process comment on the trend towards polarization without deliberation, accomodation, and compromise.

This moral solipsism is a major impediment to guiding our health "system" towards better quality and more sustainable costs. Our default moral reflex is that every physician has a "right to autonomy" and every patient has a "right to the treatment he wants." When these moral reflexes are applied to insurance systems they result in the runaway costs and suboptimal quality we see today. When they are applied to individuals they result in ever wider disparities of access and outcomes.

With skillful leadership, communities have shown that they can come to grips with potentially explosive ethical issues. The Oregon Death with Dignity Act shows how over the course of several years a state developed a viable approach to a deeply divisive question. (Read about it here.) The Century Foundation effort to make Medicare a demonstration project for collaborative oversight of health policy reflects the same vision.

Catholic & Secular Values in the British National Health Service

Four days ago I discussed the conflict over reproductive health care at Lutheran Health Center in Wheat Ridge, Colorado. This posting is about a similar conflict currently unfolding at “John and Lizzie’s” in north London.

The Hospital of St. John and St. Elizabeth, founded by the Sisters of Mercy in 1856, is known as a celebrity hospital. Cate Blanchett, Emma Thompson, Kate Moss and Heather Mills-McCartney have all had babies there. The media describes John and Lizzie’s as "the poshest place to push." The hospital is under the governance of the Catholic church, but has been operating as an independent entity, funded by the NHS, self-paying private patients, private health insurance companies, and charitable donations.

Debate about abortion has been much less virulent in the U.K. than the U.S. Last year a British journalist wrote, with some satisfaction, “Over here [in comparison to the U.S.], abortion can be a medical issue and a psychological issue; it can be an issue of social ethics.”

For reasons unclear to me on this side of the Atlantic, the tone of British debate is heating up. Cardinal Cormac Murphy O’Connor, head of the Catholic Church in England and Wales, laid down the law to John and Lizzie’s: “There must be clarity that the hospital, being a Catholic hospital with a distinct vision of what is truly in the interests of human persons, cannot offer its patients, non-Catholic or Catholic, the whole range of services routinely accepted by many in modern secular society as being in a patient's best interest."

In response, Dr Martin Scurr, founder of the Portobello Clinic in Notting Hill, and a director at the hospital, shot back a strong response: “I am convinced that the Cardinal has been badly advised, as so often has happened with the Catholic Church. Expert advisers have been chosen who give the hierarchy of the church the answers they wish to hear ... in the matter of modern medical care the cardinal has chosen to listen to individuals who have no specific expertise in that arena…we are now in an era where the Catholic Church must withdraw from involvement in frontline healthcare here in the UK, as it appears to be unable to reach the degree of tolerance that has been reached elsewhere in the world." When the hospital adopted the code of ethics demanded by the Cardinal, Scurr and another director resigned. The board chair is expected to join them next week.

Notice two things about the British debate. First, the Cardinal acknowledges that the reproductive services current church teachings preclude are “routinely accepted by many…as being in a patient’s best interest.” He acknowledges that his opponents are seeking to serve the patient’s interests, not to commit murder. And, Scurr insulates the Cardinal, by construing him as having “been badly advised.” Their positions keep the debate at the level of social ethics and leave room for further discussion.

I think the Brits, with their tradition of sharp-edged but civil debate, are likelier to advance the Catholic/Secular standoff than we Yanks are. We oscillate between politically correct vapidity and hate-laden rhetoric that encourages terrorists like James Kopp to commit murder on behalf of “right to life.” An ethically governed health system requires societal ability to debate contentious, value-laden issues, without loss of social cohesion. I hope to come back to the conflicts at Lutheran Health Center and John and Lizzie's in a future posting.

Religious Hospitals, Secular Hospitals, and Democratic Process

A fascinating hospital purchase drama with medieval undertones is unfolding in Wheat Ridge, Colorado.

The Sisters of Charity of Leavenworth Health Systems is seeking to purchase Exempla Lutheran Medical Center. If the Attorney General approves the transfer of ownership, procedures prohibited under Catholic health care rules – such as abortion and tubal ligation – will no longer be permitted at Lutheran. A group of Lutheran doctors, supported by the ACLU, Planned Parenthood, NARAL, and other organizations, are lobbying against the sale.

The contending parties have rich histories. The Sisters of Charity opened the first private hospital in Kansas in 1864. Lutheran was founded in 1905 as a tent colony for tuberculosis patients. Both entities are mission-driven and committed to care of the poor.

The issue of merger between secular and religious hospitals is common enough to be the single focus of an activist organization, MergerWatch. The secular/religious conflict in Colorado is a vintage good vs good ethical dilemma. Catholic health care has a noble history of devotion to the poor and vulnerable. But in our pluralistic society, many do not share Catholic views on reproductive ethics. Lutheran, with its own noble history, has provided these services to its community.

Two days ago the Rocky Mountain News carried a moving plea for compromise from Dr. Lawrence Rust, a retired trauma surgeon who had practiced at Lutheran. Dr. Rust seeks a path whereby “both sides of this dispute can salvage their most important principles.” Specifically “the medical staff at Lutheran needs assurance that they will be free to practice on a daily basis without interference,” and “the Sisters of Charity need to know that the organization that they own faithfully represents their core values.”

I am committed to deliberative discussion as a key process for ethical governance of the health system. I would sorely love to believe Dr. Rust’s proposal could work:

“When a physician disagrees with a policy, the disagreement would be handled openly by peers. The Catholic voice would be joined with other professional voices in committees, and the resulting decisions would be forged from reason and discussion. If the decision disagreed with the Catholic approach (such as allowing tubal ligations) both sides would have had the opportunity to fully present their side, but the consensus approach would prevail.”

Unfortunately, this won't work. The Catholic perspective on reproductive services does not arise from particular facts about individual situations. The Conference of Bishops "Ethical and Religious Directives for Catholic Health Services" prohibit abortion and sterilization under all circumstances. If the Directives are to be followed the hope that "decisions would be forged from reason and discussion" is, alas, entirely quixotic.

Hospitals drop "service lines" all the time, especially if the service in question is a money loser. In Wheat Ridge the issue is principle, not money. It is hard to see how the Sisters of Charity could respect pluralism and allow the prohibited procedures to be done, say, by a nominally independent portion of the hospital. Apart from logistical complexities, the Bishops are clear: "Catholic health institutions are not to provide abortion services, even based upon the principle of material cooperation."

So what should be done? If I were the Sisters of Charity I would not want to be seen as imposing my moral perspective -- even though I fervently believed it was absolute truth -- on those who did not share it. But that is exactly how buying Lutheran and dropping the forbidden services would appear. But if I were a physician at Lutheran I would want to be sure that I was protesting because the purchase would make the services significantly less available to those who want them, and not because, like Martin Luther himself, I was opposing "Catholic power" on principle.

The decision is in the lap of the Attorney General. In my view, if the purchase would significantly reduce access to services that are legal and, by a majority of the population, seen as ethically acceptable as well, I would not allow it to go through. But if I concluded that the services were readily available I would allow it to go ahead.

Pluralism does not come easily. We need to learn all we can about how to respect principles and pluralism from cases like Wheat Ridge. I hope to be able to follow the story, and invite readers to comment.

Gary Wills on Abortion

Gary Wills, one of my favorite writers, has thrown a constructive bomb into the abortion debate.

In a Los Angeles Times column “Abortion isn’t a Religious Issue” Wills argues learnedly that there is no scriptural authority for concluding that religion forbids abortion. He sees abortion as a moral concern that should be thought about in light of “natural law.” To Wills this means “we must turn to reason and science,” and look for insights from philosophers, neurobiologists, embryologists, and others, not scripture.

Here is the heart of Wills’s argument. While I agree with his conclusions, I present the argument as a model of the way we need to conduct thoughtful public deliberation about difficult topics:

"These [abortion decisions] are difficult matters, on which qualified people differ. It is not enough to say that whatever the woman wants should go. She has a responsibility to consider whether and when she may have a child inside her, not just a fetus. Certainly by the late stages of her pregnancy, a child is ready to respond with miraculous celerity to all the personal interchanges with the mother that show a brain in great working order.

Given these uncertainties, who is to make the individual decision to have an abortion? Religious leaders? They have no special authority in the matter, which is not subject to theological norms or guidance. The state? Its authority is given by the people it represents, and the people are divided on this. Doctors? They too differ. The woman is the one closest to the decision. Under Roe vs. Wade, no woman is forced to have an abortion. But those who have decided to have one are able to."

Not surprisingly, Wills has been attacked vehemently, as in ProLifeBlogs:

"Wills, a dissident Catholic liberal, has made a living attacking the church of his parents. In this article he attempts to sound intellectual, all the while presenting false, misleading bits of history along with half-truths designed to give the reader both an intellectual as well as religions reason not to care about the abortion debate."

Wills’s column is lucid and important. I presume the same is true for “Head and Heart: American Christianities,” the recently published book it comes from. His argument has implications for health policy, not just abortion.
The major impediment to serious consideration of a single payer system in the U.S. is the vexing question of whether our political discourse can tolerate the kind of thoughtful deliberation that managing a health system and setting limits would require. As much as I prefer a health system based on universal coverage financed by collective funds, grotesqueries like Senator Bill Frist’s March 17, 2005 speech contesting the diagnosis of Terry Schiavo on the basis of his review of family videotapes make me doubt our potential for rational oversight of the health system.

Wills provides an antidote to the kind of knee jerk moralizing Senator Frist evinced. Perhaps the fact that Frist’s political aspirations have crashed and burned mean that Wills’s brand of thoughtful moral and scientific analysis is not just pie in the sky. Wills’s discussion of abortion provides a model for the kind of public reasoning we must learn to do about health care.