Open Journal of Leadership
2013. Vol.2, No.4, 106-109
Published Online December 2013 in SciRes (
Open Access
When All Roads Lead to Rome: The Catholic Hospital Dilemma
Impacts Entire US Healthcare System
Mary Ann Keogh Hoss1, Kevin S. Decker2
1Department of Urban Planning Health and Public Administration, Ea stern Washington University,
Spokane, USA
2College of Arts, Letters & Education, Eastern Washington Univer sity, Spokane, USA
Received September 7th, 2013; revised October 7th, 2013; accepted Oct ob er 15th, 2013
Copyright © 2013 Mary Ann Keogh Hoss, Kevin S. Decker. This is an open access article distributed under the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
With the stripping of 2 Catholic Hospitals of their status as Catholic in 2010, much information has come
forward on the 72 Ethical and Religious Directives (ERDs) of the Catholic Hospital Association of the
United States (CHA). With this, the authority of the bishops of the Catholic Church in relationship to de-
livery of health care has been called into question. The decision of the bishop in Phoenix has raised clini-
cal, ethical and operational concerns which are explored. CHA claims that 1 in every 6 patients in the US
is in a Catholic Hospital. The questions related to the public on the impact of the ERDs for their health-
care are staggering. Is one’s healthcare in the hands of a bishop? Should some ethical dilemma occur?
These questions are explored.
Keywords: US Healthcare System; Catholic; Ethical and Religious Directives; Bishops
When All Roads Lead to Rome
The Catholic Hospital Association of the United States
(CHA, 2011) claims one in six patients in the United States is
cared for in a Catholic Hospital. The December 2010 decision
of Bishop Thomas J Olmsted of Phoenix, Arizona to strip St.
Joesph’s Hospital of its Catholic status creates additional chal-
lenges for Catholic Hospital administrators in healthcare today.
This is the second Catholic hospital to lose Catholic status in
2010. St. Charles Medical Center in Baker, Oregon lost its sta-
tus in February (Mann, 2011).
Phoenix Action
The Phoenix action arose over the following incident. In
2009, a woman 11 weeks pregnant presented at the hospital
with deteriorating pulmonary hypertension hat had begun to
seriously threaten her life. Doctors informed her that risk of
death was close to 100% (Tenety, 2011). An abortion was per-
formed to save the live that could be saved. Bishop Olmsted
stated,”…the baby was healthy and there were no problems
with the pregnancy; rather, the mother had a disease that
needed to be treated. But instead of treating the disease, St.
Joseph’s medical staff and ethics committee decided that the
healthy, 11 week old baby should be killed. This is contrary to
the teaching of the church” (Tenety, 2011: p. B02). It should be
noted that Bishop Olmsted’s bio does not include any clinical
training. It does include numerous years of service in Rome
(Roman Catholic Diocese of Phoenix, 2011).
Catholic Hospitals
According to the Catholic Hospital Association, there are
more than 600 Catholic hospitals in the United States with as
many as 45 of those being the sole providers of hospital care in
their communities. The total number of community hospitals in
the US according to the American Hospital Association is 5008
(AHA, 2010). Of those 2918 are nongovernmental not for profit
hospitals. The Catholic affiliated hospitals make up roughly one
fifth of that number. The parent company for St. Joseph’s Hos-
pital is Catholic Health Care West, the eighth largest healthcare
company in the US (Mann, 2011) The CHA (2011) fact sheet
based on AHA 2009 data shows 16.7% of care for Medicare
patients is received in Catholic Hospitals as well as 13.5% of
care for Medicaid patients. Catholic Hospital administrators
struggle with complex issues; among those challenges are
community trust, governance, damages in human capital, fi-
nance capital and quality of care. But the overriding issue of
community trust presents as the most serious of these chal-
lenges especially as this decision has been communicated
throughout the US. In a world of “perception is reality”, the
message take away from this incident is not positive to say the
least. This leaves a lingering after taste for women and indeed
any community member seeking care and treatment in Catholic
hospitals who may fear for their lives as this denunciation sug-
gests, follow doctrine not clinical indicators in matters of live
and death.
The rest of the nation must closely watch what is happening
with the Catholic Healthcare systems. A much larger picture
emerges with this type of news that travels the nation. While
bishops have long been silent most likely because of the nu-
merous scandals plaguing the Church, they now have an avenue
for visibly and vocally asserting their authority. This quote
from Bishop Olmsted says it all “It is my duty as the chief
shepherd in the diocese to interpret where 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
(ERD)” (Hendershott, 2010). How safe does the American
public feel in having a bishop of the Catholic Church with no
known clinical background deciding their fate while in a Catho-
lic hospital? The Catholic Hospital United States Conference of
Catholic Bishops Association (CHA) with the United States
Conference of Catholic Bishops (USCCB) announced that they
have agreed on the following after much discussion:
… Archbishop Dolan of New York goes on to say “any
medical case, and especially one with unique complications,
certainly requires appropriate consultation with the medical
professionals and ethical experts with specialization in the
teaching of the church. Still, as you have reasserted, it is the
diocesan bishop’s authentic interpretation of the ERD’s that
must govern their implementation. Where conflict arises, it is
again the bishop who provides the authoritative resolution
based on his teaching office. Once such a resolution of doubt
has been given, it is no longer a question of competing moral
theories or the offering of various ethical interpretations or
opinions of the medical data that can still be legitimately es-
poused and followed. The matter has now reached the level of
an authoritative resolution” (Zenit News Agency, 2011: p. 1).
The implications for this are staggering.
The Ethical and Religious Directives for the
Catholic Health Care Services
In November 2009, the USCCB issued the 5th edition of the
ERD. These are 72 directives which direct Catholic Health Care
Services. The updated ERD has 2 purposes. These are “to reaf-
firm the ethical standards of behavior in health care that flow
from the church’s teaching about the dignity of the human per-
son and to provide authoritative guidance on certain moral is-
sues that face Catholic health care today” (USCCB, 2009: p. 4).
These directives are guided by 5 principles for the Church’s
healing ministries. As stated by Archbishop Dolan, the author-
ity of the bishop supersedes the rights of patients and individual
doctors. What does the stripping of Catholic status really mean?
A hospital may no longer refer to itself as Catholic, mass can’t
be said and the diocese where it resides will not support it (Ge-
rardi, 2010). It is unclear what types of support that includes
and whether or not communion may be received by patients.
US Healthcare Crisis
With a US healthcare system in crisis, having one fifth of the
system engaged in this type of controversy is onerous. The
American Hospital Association report on the economic reces-
sion shows that 74% of hospitals reported reduced operating
margins. Half of hospitals are reporting decreased non-operating
income. 89% of hospitals report back that they have not added
back staff or increased staff hours and 98% have not restored
services or programs previously cut (AHA, 2010). Medicare
and Medicaid fact sheet show that” payments continue to fall
below costs and the shortfall is growing” (AHA, 2010: p. 2).
Is there trust in the bishop’s of the United States to fairly and
justly deal with the very serious issues pertaining to healthcare
in each and every community where a Catholic hospital resides?
Based on the most recent scandals is there faith in their judg-
ment based on the nation’s view of how the sex abuse issues
were handled? In the large hospital systems residing in multiple
states where the consistency of thought may not go across bi-
shops, who decides and how is that transmitted throughout the
Where do these issues become the issues for the nation fac-
ing a crisis in healthcare? Catholic healthcare administrators
and leaders should now be required to respond to the following.
What is the average consumer to do? If there is only one pro-
vider of hospital care in a geographic area what does a con-
sumer do? Do the ERDs impact all healthcare arenas where
Catholic services are provided-subacute care, skilled nursing,
home health, adult day care/assisted living/residential care and
hospice? Are all potential clients notified in writing of what
constitutes the ERDs and the possible impact on them? Are
physicians with admitting privileges aware of the 72 directives
and their impact on care. Are providers educated on the 72
ERDs? Do patients and providers understand what rights re-
garding privacy and confidentiality may be violated when a
bishop becomes involved in individual healthcare decision
making? Do all providers and their patients understand the
implications of this and are they advised in writin g?
As a nation, healthcare is taking more and more of a toll on
the US public. Health care systems are trying desperately to
meet the demands of a nation unclear on how to proceed with
the delivery of services. The Phoenix decision is evidence that
patient rights and clinical judgment appear to be secondary to
the authority of a bishop. Would the government refuse to pay
for care based on a decision made? Who is liable? Who pays?
All of these issues could be pushed based on the fact that seri-
ous dilemmas will arise as technology and constant change in
healthcare continue to occur. Is the patient at risk and does he
or she know it based on Catholic doctrine?
Biomedica Ethics Involved
Some of the reportage of the case of Bishop Olmsted and St.
Joseph’s Hospital has mischaracterized the issues at stake by
ignoring the fact that the debate over the correctness of care at
St. Joseph’s (or, indeed, any hospital or care facility) should be
evaluated in terms of plural cultures within a democratic setting
that legally and morally values an individual’s autonomous
decisions. One should not be surprised, for example, that Ben-
jamin Mann, staff writer of the Catholic News Agency, toes the
Olmstedian party line when reporting on the controversy. More
worrisome, however, is his citing of John Brehany, executive
director of the Catholic Medical Association, who puts the onus
for the excommunication of St. Joseph’s on the hospital itself.
“We don’t want you in our life”, was the message that St. Jo-
seph’s sent to the Church by their actions, Brehany claimed.
Brehany further went on to compare “the situation between the
bishop and St. Joseph’s to a child who decides to break off
contact with his parents” (Mann, 2011). Taken at face value,
this seems to derogate the clinical and ethical claims of the St.
Joseph’s staff, supported by the arguments of theologians and
bioethicsts, to the whining of teenagers. Is this a morally ac-
ceptable way to characterize one’s opponents in an argument?
Framing the Issu e
In a more insidious example of framing in the issue, Anne
Hendershott (2010), uncharitably portrays the claims of Lloyd
Dean, president of Catholic Healthcare West, the hospital’s
Open Access 107
parent company. Hendershott parses Dean’s opposition to Olm-
sted’s decision in this way: “… Mr. Dean appeared to suggest
that the teaching authority of the Phoenix Bishop was just one
more ‘opinion’ on a ‘complex matter’.” In fact, Dean said that
“this is a complex matter on which the best minds disagree,”
and cited the expert opinion of M. Therese Lysaught, Associate
Professor of Theology at Marquette University, whose training
includes an MA in Theology from Notre Dame and a PhD in
Religion and Theological Ethics from Duke University. But
Hendershott has clearly made her mind up in advance about the
results of a disagreement between, say, Olmsted and Lysaught
when she writes: “Many theologians … 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.” She apparently ignores that fact that many “alter-
native” church fathers, including Saint Clement, Origen, Ter-
tullian, and Saint Jerome, never held any formal position within
the church hierarchy. And as guilty as Dean was in omitting the
considered views of ethicists who disagreed with him in his
communications with Olmsted, Hendershott herself is as guilty
in failing to consider the Bishop’s complete lack of clinical
To cast the issue, as Hender shott and many Catholic com-
mentators do, as a failure to heed prescriptive authorities is to
cede the controversy to Bishop Olmsted without debate and,
further, to ignore the opportunity for moral deliberation and
transformation that might ensue. From the perspective of med-
ical care within a pluralistic democracy such as the United
States, there are at least two key issues at stake in the St. Jo-
seph’s Hospital case: clinical competence and conscience. As
can be shown, these are not necessarily at odds with each other,
either in this case or in such cases in general.
Patient’s Right
There is at least a prima facie plausibility to the individual’s
claim that, in a clinical or pharmaceutical setting, their con-
science requires them to “opt out” of a professionally required
duty. However, it is a mistake to think that conscience should
automatically trump such duties, since in any scenario where
treatment or services might be denied, one also must weight in
the pre-commitment of the medical professional to the normal
performance of their duties, as well as the claim of the patient
to their well-being. Claims of conscience, at least in American
legislative history (the Church Amendment, 1973; the Hyde
Amendment, 1976; the Weldon Amendment, 2004) are based
on two principles: 1) the right of an individual to secure his or
her own moral integrity, and 2) the incorrigibility of the dictates
of conscience. While individuals do have the right to their
moral integrity, this is not an absolute right, especially in cases
where it can be shown that an autonomous individual accepted
professional responsibilities that they were aware might im-
pinge on their sense of moral integrity. Especially in such cases
of conscience, the strict burden of proof should be placed on the
individual to indicate the precise reasons for their opting out.
Further, because of a patient’s right to receive therapeutic
treatments or critical care that are not forbidden by law, con-
scientious dissenters and/or their institutions should be obli-
gated to inform a patient where and how they can receive the
treatment or services requested; in other words, the right to
conscientious opting out does not extend to a right to absolutely
deny a patient services and information.
It is also arguable that the dictates of conscience are incorri-
gible; while an individual may have a strong moral intuition in
a given situation, it is not always true that their conscience is
speaking. Particularly in cases where an individual’s moral
intuitions are inconsistent with each other, we have good reason
to believe that at least some of their intuitions are actually giv-
ing voice to habit, woolly thinking, parental or peer influence,
or religious training. It may also be the case that while I do not
doubt that my conscience has “spoken”, I may be wrong about
the fact that such a moral intuition applies in this particular case,
or how it applies in this case. This is another reason why the
presence of biomedical ethicists is still significant in clinical
care settings, and a reminder of the danger of having one indi-
vidual make decisions that directly and irreversibly impact, in a
negative fashion, the fundamental health and well-being of
hundreds or thousands of others.
Claims of Conscience
Claims of conscience in the Catholic healthcare setting are
most likely to be encountered by providers demurring from
providing services that violate principles the ERD That is,
Catholic health professionals may make negative conscience
claims that they should not be compelled to provide services
that impinge on their conscientious moral intuitions. However,
as Mark Wicclair points out, there are also positive conscience
claims that can be made to justify “provid[ing] professionally
permitted medical goods or services (e.g., medications and
procedures) when do so is prohibited by law, institutional rules,
employer policies, and so forth” (Wicclair, 2009: p. 15).
The termination of the pregnancy of the 11-week pregnant
woman at St. Joseph’s that incited Olmsted is best justified as
demanded as a positive claim of conscience. Sister McBride’s
decision in the case was made more difficult, of course, by the
Church’s teaching that the fetus is a person. But at a non-viable
age of 11 weeks old, the fetus could not have been classified as
a disti nct patient, deserving o f patient rights and treatment con-
siderations, at least in non-Catholic hospitals. In these settings,
the standard ethical practice is that “beneficence-based obliga-
tions to the fetal patient should be negotiated in the context of
the beneficence and autonomy of the mother” (Springer, 2011).
In following the ERD, McBride and the staff at St. Joseph’s
attempted to save the only life that was possible to save. The
decision hinged on the mother’s diagnosis of pulmonary hyper-
tension as a near-certain risk of death; The patient realized this
in her decision to abort the pregnancy. What Bishop Olmsted
failed to comprehend, but what St. Joseph’s apparently did, is
that a mother need not suffer from a “grave illness” in order
that both the lives of her and her baby are at risk. The doctrine
of double effect (DDE) clearly allows McBride, in this case, to
make a decision in which the intention is to save the life of the
mother even though she also knows that the fetus’s life will be
ended; the alternative would be that both would die. Whether or
not the reasoning of the DDE is sound, McBride’s case should
be one of a positive claim to conscience. What we then have is
the unusual case of assessing the justifiability of this claim not
from within the structure of a religious institution, but against
it. Which issue should one weight more heavily in this case,
Bishop Olmsted’s lack of clinical competence or the claims of
St. Joseph’s clinical professionals to permissibly dissent, on the
Open Access
Open Access 109
basis of conscience, from Olmsted’s interpretation of Catholic
doctrine? Despite Bishop Olmsted’s diverse background in
Catholic affairs, including his current service as member of the
Catholic Association of Latino Leaders and the USCCB Mis-
sions Committee, as well as various positions dealing in Per-
sonal and Priestly Formation and a stint on the Board of Direc-
tors for the Catholic Legal Immigration Network, appears to
have no formal clinical or documented biomedical ethical
training. With regard to the last of these, it is not enough to say
that Olmsted encountered Catholic bioethics in seminary work
in philosophy and his doctoral studies at Rome’s Gregorian
The pluralistic nature of the field of American bioethics re-
quires that an expert in this field have documented evidence of
having engaged with moral theories, including not only secular
views such as deontology and utilitarianism, but also non-
Catholic religious theories; it further requires lay academic or
advisory committee engagement with argumentative opponents
from a diverse range of ethical perspectives.
Bishop Olmsted’s lack of experience in these regards con-
trasts distinctly with that of Sister Margaret McBride and Lloyd
Dean of Catholic Healthcare West. Olmsted’s repeated claims
that his retributive acts against St. Joseph’s are sanctioned by
his role as “shepherd” and “teacher” seem oxymoronic. His
decision to declare that St. Joseph’s is no longer “Catholic” is
one that will undoubtedly (and unjustifiably) hurt the hospital’s
reputation with many of its more doctrinaire clientele. Faith and
moral claims of conscience have been, and likely will always
be, central to the religious life. If Catholic identity is partly
based on the ability of being faithful to invoke their conscience
against a wider, secular society’s standards, isn’t there hypoc-
risy to denying individuals the right of reasoned, conscientious
dissent within the church (O’Rourke, 2001)? Particularly when,
as in this case, the central Catholic value of life was maximize d
in a case in which the only other alternative was two deaths.
Adherents of freedom of conscience supported (and perhaps
challenged) by a robust debate on ethical and clinical issues
underpinning hard cases should stand with Sister Margaret
McBride and the rest of the hospital administrators and staff.
They—and not Bishop Olmsted—represent the synthesis of
clinical competence and ethical sensitivity required to further
the mission of genuinely Christian hospitals in a pluralistic
American Hospital Association (2010a). Hospitals continue to feel
lingering effects of the economic recession.
American Hospital Association (2010b). Underpayment by Medicare
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Catholic Health Association of the United States (2011). Catholic
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Gerardi, J. (2010). Phoenix’s Augean stabl e s . The Daily Caller.
Hendershott, A. (2010). Catholic hospitals vs. the bishops. Wall Street
Mann, B. (2011). Phoenix hospital’s break with bishop a troubling sign,
health care experts say. Catholic News Agency.
O’Rourke, K. (2001). Catholic hospitals and catholic identity. Christian
Bioethics, 7, 15-28.
Roman Catholic Diocese of Phoenix (2011). Highlights in the life of
Bishop Olmstead.
Springer, S. ( 2 0 11). Fetus as Patient. eMedicine.
Tenety, E. (2011). Bishop says Ariz. Hospital is no longer “Catholic”
after abortion to save mother’s life. The Washington Post.
United States Conference of Catholic Bishops (2009). Ethical and
religious directives for Catholic health care services (5th ed.).
Washington, DC: USCCB.
Wicclair, M. (2009). Negative and positive claims of conscience. Cam-
bridge Quarterly of Healthcare Ethics, 18, 14-22.
Zenit News Agency (2011). Catholic Hospital Association reaches
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