On the USCCB’s revised “Ethical and Religious Directives” for Catholic hospitals

The Plenary Assembly of the United States Conference of Catholic Bishops’ (USCCB) meeting in Baltimore, November 10-13, is probably most widely known for its “Special Message” on immigration.

But another important document came out of that gathering: the seventh edition of the bishops’ “Ethical and Religious Directives for Catholic Health Care Services” (ERD).

What is the ERD?

The ERD expresses the moral principles governing Catholic health care facilities—primarily hospitals — in the United States. They date back to the late 1940s, when the first set of ERDs was published by an association of Catholic moral theologians and physicians. Because they were not an official issuance by the bishops, they depended for their force on promulgation in individual dioceses. It was not until 1971 that the ERDs were formally adopted by the National Conference of Catholic Bishops (the predecessor of the USCCB) to provide a Catholic national standard.

Over time, the ERD has evolved. What began basically as a list of procedures Catholic hospitals would not perform, fitting on a single page, is today a little 35-page booklet. The ERD has also grown from a simple list to a six-part document whose 77 directives are arranged under specific topics, preceded by “introductions” articulating the rationales—primarily theological and mission-driven — that underlie those directives.

The six topics around which directives are now arranged are: Catholic health care’s social responsibilities; its pastoral and spiritual responsibilities; the patient-professional relationship; issues at the beginning of life; issues with death and dying; and collaboration with non-Catholic health care. The bishops periodically revise the ERD to take account of new issues in medical ethics, especially around life and the changing nature of the American health care system, of which Catholic health care is part.

What’s new?

To the degree the larger media took account of the new ERD, it focused on the addition of new directives prohibiting Catholic facilities’ participation in the whole range of “gender” interventions, especially by chemical/hormonal administrations and physical mutilation. Proponents of such interventions sell them as “gender-affirming healthcare,” ranging from efforts to delay the onset of puberty to “surgical reassignment.” The latter is colloquially branded in some circles as “top” and “bottom” surgery, i.e., mastectomies to amputate healthy breast tissue or constructive surgery to “create” pseudo-breasts, amputation of a penis or construction of simulacrum genitalia (that don’t generate). The latter also necessarily involves rerouting egress for the urinary system.

While gender issues took the lion’s share of limited public attention to the new ERD, they were not the only changes.

Other changes included taking account of Church documents issued since the ERD’s last major revision in 2018. Some newly-referenced documents, primarily Dignitas infinita, seek to incorporate the evolving concept of “dignity,” particularly pressed in the late Francis pontificate. ERD footnotes are supplemented with additional references to the Church’s “life” magisterium, primarily from Pope St. John Paul II. One addition broaches the possible place of AI in Catholic health care. A sentence was added banning “genetic engineering” not oriented to “medical treatment,” that is, efforts by some scientists to produce the “better human” eugenically.

Editorially, revisions also did some reformatting of the document, primarily consolidation or splitting up of paragraphs and the rearrangement of some directives to maintain the previous cap of 77.

Gender

The bishops’ directives on gender are found in two new directives (28 and 29), sandwiched between previous directives (26 and 30), which are expanded.

The new directive 28 prohibits “medical interventions, whether surgical, hormonal, or genetic, that aim not to restore but rather to alter the fundamental order of the body in its form or function. … [including those] that aim to transform sexual characteristics of a human body into those of the opposite sex (or to nullify sexual characteristics of a human body.”

The directive frames the prohibition in light of Catholic theological commitments. Quoting Pope Francis, it states that “creation is prior to us and must be received as a gift.” As such, man’s humanity, incarnated in a given sex, must be “’accept[ed] … and respect[ed] … as it was created.” Failure to do so is to respect the human person as “a unity of body and soul,” i.e., not a mind with a body attached. That theological anthropology is precisely what separates the Catholic understanding of the person from various secular notions of who man is, not just those of trans ideologues but of the Cartesian heritage of mind/body dualism that has affected the West for four centuries.

Directive 29 reminds Catholic health care facilities that their vocation is to care for all the ill. That care includes “mitigat[ing] the suffering of those who experience gender incongruence or gender dysphoria….” This perspective is in keeping with the Church’s call to accompany everyone, especially the marginalized. To ensure, however, that this language cannot be used as a backdoor to sneak in “gender affirming care,” the directive explicitly limits itself to “employing only those means that reflect the fundamental order of the human body.”

This directive provides an important perspective, one likely to be contested: that Catholic health care seeks to provide authentic care for human persons consistent with the full truth of their humanity. Directive 29 should not be seen as “we care for gender dysphoric people to the degree the Church does not prohibit us.” It instead contends that genuine care for the whole person does not encompass interventions that deny the full truth of “the fundamental order of the human body.” Directive 29 endorses holistic care of the person; it just does not accept what secularism calls “holistic care” (which arguably involves dissecting the whole).

The two new directives are inserted between two pre-existing ones whose content and context are both directly relevant. No. 26 deals with informed consent. No. 30 explains the proper and improper use of the “principle of totality” as it applies to “remov[ing] or suppress[ing] the function of one part of the body.”

Revised Directive 26 addresses the right of a patient or his “surrogate” to be able to give fully informed consent to proposed courses of medical intervention, including access to moral and pastoral resources necessary to form a correct conscience about the ethics of those interventions. It makes clear, however, that Catholic medical care is not wish fulfillment: a Catholic health care facility will honor decisions made by the free and informed consent of a patient or his surrogate, provided that they do “not contradict Catholic teaching (including that specified in these Directives).”

Revised Directive 30 explains the proper and improper use of the principle of totality. Catholic medical ethics recognizes that a body part should not be mutilated nor its normal function suppressed except under specific conditions where necessary for the good of the whole. Totality means that a diseased organ or even a properly functioning one, which by that function causes a serious pathology elsewhere, thereby damaging the “life or well-ordered functioning of the body as a whole,” can only be suppressed or removed under particular conditions to save the overall life and proper functioning of the body. As written, Directive 30 incorporates considerable parts of the Principle of Double Effect, e.g., no other remedy to a serious pathology and proportionality. The Principle of Totality is abused when, in the name of some “overall” or “comprehensive health,” healthy body parts are sacrificed or the normal “functioning of the body”—understood as a body-soul union is suppressed, temporarily or permanently.

The Principle of Totality is traditionally associated with the Catholic prohibition on mutilation because it provided the ethical justification for when mutilation might be permitted. Mutilation was the category under which Catholic medical ethics traditionally treated both permanent contraceptive sterilization (e.g., vasectomy, tubal ligation) and the removal of healthy body parts in “gender reassignment surgery.” It is this discussion and tradition that make the insertion of the new gender intervention directives logical at this point in the ERD.

Totality plays into the discussion of both sterilization and gender interventions because both eliminate fertility. Fertility is certainly not a disease. It is not even just a mere “feature” without value “in” the body. Fertility is part of the reality of the human person, as God created him male and female. Fertility’s presence in a person’s life is not, therefore, just some “biological rhythm” whose temporary suppression and/or permanent elimination is devoid of moral significance. Respect for both the person as well as for creation—as Popes John Paul II and Francis respectively would have pointed out—means accepting the whole truth of the person as male and female, capable of giving life and of creation as expressing the design and order intended by God.

The Bigger Picture

Given the Trump Administration’s policies against chemical castration and genital mutilation of minors, as well as taxpayer funding of those procedures in adults, Catholic hospitals should generally feel at least temporarily secure in abiding by their vision of the person as the subject of Catholic health care. Two other concerns, however, should be kept in mind.

An administration like Biden-Harris’s potentially could try to pressure Catholic facilities into providing prohibited services by invoking the “non-discrimination” provisions of federal law pertaining to health care: if you are willing to remove a cancerous breast or testicles, are you not discriminating against “trans people” if you refuse to remove those body parts when they “cause” gender dysphoria? Remember: in gender ideology, “sex” and “gender” are separate and distinct—until they are not. They are not when the Biden-Harris administration attempted to interpret the bans on “sex” discrimination in civil rights laws from the 1960s and 1970s to mean “sex and gender,” even though there is no evidence that, when those laws were passed, anybody in Congress thought that there were more than two sexes or that their distinction was fungible. Expect such “non-discrimination” claims to be lashed to “equity” arguments: if Catholic facilities are the primary or even sole health care providers in a given area, they should be compelled to provide such “services,” their institutional consciences notwithstanding.

That leads us to a broader threat: attempts to brand the ERDs as mandating “substandard” medical care. The argument is that the “full range of medical services” offered in a secular hospital constitutes the accepted standard of “patient care.” When Catholic health care facilities do not provide them—even for “ethical” reasons—it means their care does not meet accepted “medical standards.” That, in turn, could open Catholic health care facilities to a range of threats, from bureaucratic regulators that license hospitals to lawyers alleging “medical malpractice” because these “services” are unavailable. Such threats serve an ideological purpose: requiring the universal “mainstreaming” of “sexual and reproductive health services” regardless of a facility’s moral commitments.

These issues came to the fore during the last major revision of the ERDs in 2018. Seven years ago, the issue was hospital mergers: if a Catholic hospital acquired a secular one, how would the ERDs apply? Could that part of the formerly secular, now nominally Catholic facility be exempt from the ERDs, by continuing to provide abortion or contraceptive (or now, ‘trans”) services? The answer in 2018, reaffirmed in the current ERD revision, was no: there are no “non-Catholic ethical zones” in Catholic facilities. That, in turn, has generated pushback from the “sexual and reproductive services” lobby, especially when the new Catholic institution is the primary health care provider in a region. It has already generated a spate of books (for example, Lori Freedman’s Bishops and Bodies, which pushes the argument that pluralistic America is threatened by the narrow moral strictures of Catholic hospitals).

At root here is an effort to paint Catholic medical ethics—a long tradition in medical ethics predating secular bioethics—as some kind of esoteric, religious dogmatism, akin to Jehovah’s Witnesses’ prohibitions on blood transfusions or fundamentalists’ rejection of traditional medicine in the name of “faith healing.” Current vaccine skepticism furthers this caricature of Catholic health care.

It is a caricature Catholics need to push back against, lest Catholics find themselves pushed out of the medical and health care professions. Catholic medical ethics are not built on bizarre private revelations but on natural law, which is a basis common to all human beings. That all human beings do not acknowledge natural law’s requirements does not render them void. And Catholics were in the health care field long before the modern state: hospitals (like universities) were institutions born from the heart of the Church.

The Catholic vision of healthcare is built on an integral vision: the whole truth about man. That includes the truth of his embodiment and of his moral obligations. His duty to “do good and avoid evil” is a truth that binds, even if he does not admit it, including binding institutions that assist him in caring for his health. Catholic healthcare does not deem the person merely a consumer who can specify his wishes and expect healthcare personnel and institutions, independently of their own professional ethics, to provide wish fulfillment.

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