Catholic health care in the United States finds itself at a startling point of convergence with non-Catholic health care. On the one hand, after the Supreme Court overturned Roe v. Wade, other health-care systems across the country have suddenly had to become more like Catholic health care in restricting abortion. (As of January 2023, thirteen states ban abortion with next to no exceptions; similar bans are pending in several other states.) On the other hand, in the context of fierce competition and dwindling margins, some Catholic health-care systems appear nearly indistinguishable from their most ruthless, for-profit counterparts. The economists Anne Case and Angus Deaton, famous for their research on the rise of midlife morbidity and mortality in the United States over the past twenty-plus years, have claimed that “[t]he American healthcare industry is not good at promoting health, but it excels at taking money from all of us for its benefit. It is an engine of inequality.” The New York Times recently published two shocking stories about the Providence health-care system and about Bon Secours Mercy Health—both officially Catholic—showing that they have taken money from the poor and vulnerable to benefit themselves. In an inversion of Catholic social teaching, the poor received special attention not to be served, but to be shaken down.

It would be both ungenerous and inaccurate to suggest that those cases are the rule rather than egregious exceptions to it. At bottom, the mission of Catholic health care remains to tend the sick and proclaim the Kingdom of God. Nonetheless, these examples remind us that Catholic health care in the United States—comprising more than six hundred hospitals that employ more than half a million people and see one out of every six patients—is a very big business and therefore subject to the same market forces and trends characteristic of U.S. capitalism at large. Catholic health care also has to contend with the pitfalls of U.S. politics, as it did a decade ago in the uproar over the Affordable Care Act’s contraception-coverage mandate, and as it will likely have to do in the coming backlash against abortion restrictions. A Catholic hospital’s refusal to perform an abortion for a woman who is miscarrying, but whose nonviable fetus still has heart tones, means one thing when a non-Catholic hospital is willing to step into the breach. It will mean something else when a non-Catholic hospital declines transfer so that it won’t have to negotiate a poorly written state abortion law, and a woman dies of hemorrhage and sepsis in a Catholic hospital’s care.

Enter Todd Salzman and Michael Lawler’s Pope Francis and the Transformation of Health Care Ethics. Salzman and Lawler are moral theologians at Creighton University who have often collaborated. They present their book as a “critical commentary” on the sixth and most recent edition of the “Ethical and Religious Directives for Catholic Health Care Services” (ERDs), issued by the United States Conference of Catholic Bishops (USCCB) in 2018. In fact, their book is an extended polemic against the USCCB. A representative sentence begins, “Unfortunately, most bishops in the United States and the USCCB as a body….” Exhortation and excoriation follow. According to Salzman and Lawler, the 2018 ERDs, as they’re typically called, are “problematic anthropologically, methodologically, ecclesiologically, and pastorally.” Their book’s second thesis is that “Francis’s…contributions and shift in emphases invite a substantial revision of the ERD and the formulation of new directives.”

There is much that is just about Salzman and Lawler’s polemic, but there is also much that is misguided. They inveigh against authoritarianism in the Church with a righteous passion that sometimes sounds a little too, well, authoritative. Their book prompts the question of whether Catholic health care can find a viable middle way—a center that can hold, so to speak, against strident voices on both the Right and Left.

The ERDs, to quote from the sixth edition’s preamble, “provide authoritative guidance on certain moral issues that face Catholic health care today.” They must be observed for a Catholic health-care service to be recognized as Catholic. Violations may result, at the local bishop’s discretion, in a service losing its Catholic status.

The ERDs originated in 1948, but they took a hard legalistic turn in 1971, partly in response to changing medical norms with respect to abortion in the United States and partly in response to variations in practice in Catholic hospitals in the 1960s with respect to sterilization and the distribution of contraceptives. In 1994, the bishops significantly expanded the document with the aim of ensuring uniformity. As the Jesuit ethicist Kevin William Wildes observed in a 1995 commentary, “In contrast to the complexity of traditional Catholic morality, the [1994] directives seek to remove areas of ambiguity and leave little room for judgment.” Wildes went on to suggest that “[o]ne way to understand the Directives is to see them as an effort by those in authority [e.g., bishops] to restrict the space and liberty of those who are an authority [e.g., moral theologians].”

Salzman and Lawler couldn’t agree more. The passage in the 2018 ERDs that bothers them the most—to judge from how often they refer to it—appears toward the end of the document’s introduction:

While the Church cannot furnish a ready answer to every moral dilemma, there are many questions about which she provides normative guidance and direction. In the absence of determination by the magisterium, but never contrary to church teaching, the guidance of approved authors can offer appropriate guidance for ethical decision making.

Unsurprisingly, the criteria to qualify as “approved” are not articulated. For it goes without saying that an approved author is someone who never disagrees with Church authorities: in Wildes’s terms, the people in authority.

The 2018 ERDs are a direct descendant of the 1994 ERDs, with some subtractions and additions. Salzman and Lawler focus on the 2018 ERDs not only because they are the most recent but also because, they claim, it is “perplexing and even scandalous” that the USCCB did not revise the ERDs in light of Pope Francis’s “anthropological and methodological contributions.”

Salzman and Lawler are correct that the ERDs reflect a “hierarchical ecclesiology.” As they write with a touch of snark, “[t]he revised ERD reads as if its composers never heard of” Lumen gentium, Vatican II’s constitution on the Church. The model of Church in the ERDs is top-down, heavily invested in the authority of bishops, which, as Salzman and Lawler rightly note, has been badly damaged by the Church’s sexual-abuse scandal. Furthermore, the ERDs show no interest in the sensus fidelium and do not acknowledge that experience might be, as Salzman and Lawler propose, “a source of ethical knowledge.”

Here the case that Salzman and Lawler discuss at length is illuminating. In November 2009, the ethics committee, chaired by Sr. Margaret McBride, RSM, of St. Joseph’s Hospital in Phoenix, Arizona, permitted the abortion of an eleven-week-old fetus. The pregnant woman was suffering from acute pulmonary hypertension, which her doctors judged would prove imminently fatal for both her and her child. After the fact, Phoenix’s then-bishop, Thomas J. Olmsted, criticized both Sr. McBride and the hospital, which he stripped of its Catholic status after it refused to repent of its decision in the case. As Salzman and Lawler comment, “There is no indication [in the 2018 edition of the ERDs] that this case had any impact on the recognition of the possibility of conflicts in interpreting and applying the ERD, resolving such conflicts, or formulating new directives in light of such conflicts.” I have argued elsewhere that the Phoenix case indicates the need for the ERDs to incorporate a principle of lesser evil, but the bishops seem to have drawn neither this lesson nor any other.

Salzman and Lawler are on shakier ground when they discuss their theory of ethical knowledge (their “metaethics”), the authority of individual conscience, and some of Pope Francis’s pronouncements. Their “metaethical epistemology” is perspectivism, which they explain by observing that although the view from a first-story window is different from the view from a twenty-story window, neither is false. Both are “partial and particular.” That’s certainly fair enough for views from windows, but it’s a far leap to argue, as they go on to do, that “[p]erspective is also what accounts for different moral judgments. Seeing and judging from different perspectives accounts for the different judgments on the morality or immorality of abortion and of removing [artificial nutrition and hydration] from a [persistent vegetative state] patient.” In short, the rightness or wrongness of these practices depends, they seem to suggest, on one’s point of view: proponents and opponents can both be partially right. It is hard to imagine that Salzman and Lawler would make a similar claim about, for example, an act of sexism or racism.

Along similar lines, they also write that “[t]he morality of an action is largely controlled by the subject’s motive.” This may not seem controversial—after all, doesn’t the Church teach that the morality of an act depends partly on one’s intention? But intention is a quite different concept from motive. I may intend to rob a bank with various motives, some of them better than others; perhaps I want to distribute the money to the poor. But a worthy motive doesn’t make my intention right. The deeper confusion here has to do with how to specify an action for the purpose of moral evaluation. In brief, it is a mistake to reduce the so-called object of an action to what is physically done—Pope John Paul II is right in his encyclical Veritatis splendor that “the object of a given moral act” is not just “a process or an event of the merely physical order”—but it is equally a mistake to reduce the object of an action to the agent’s purpose. As the philosopher Elizabeth Anscombe remarked in 1982, “Circumstances, and the immediate facts about the means you are choosing to your ends, dictate what descriptions of your intention you must admit.”

Salzman and Lawler propose their account of the authority of individual conscience in response to another passage in the ERDs that they vehemently dislike—the last paragraph of the introduction to Part 1, which reads as follows:

[W]ithin a pluralistic society, Catholic health care services will encounter requests for medical procedures contrary to the moral teachings of the Church. Catholic health care does not offend the rights of individual conscience by refusing to provide or permit medical procedures that are judged morally wrong by the teaching authority of the Church.

Salzman and Lawler reply:

The prioritization of Church teaching, the institution, and absolute norms over conscience contradicts the long-established tradition on the authority and inviolability of a well-informed conscience and is, therefore, a violation of human dignity and the common good.

Remarkably, they manage to put this point in even stronger terms: “The ERD subordinates the authority and inviolability of patient conscience to the health care institution and, ultimately, to the authority of the bishop. This usurpation reflects an assault on human dignity and a violation of justice.” Citing Dignitatis humanae, Vatican II’s declaration on religious freedom, they argue that “no Catholic is ‘to be forced to act in a manner contrary to his conscience. Nor…is he to be restrained from acting in accord with his conscience, especially in matters religious’ (DH, 3) and also medical.” That’s quite a stretch. They also claim that “it seems to be a violation of human dignity and the authority and inviolability of individual conscience to declare certain acts ‘intrinsically immoral’ without consideration of the perspective of the acting person.” But again, as Anscombe pointed out, what one can say one intends is constrained by the structure of what one is actually doing. Hoary denunciations of “physicalism,” which recur throughout the book, fail to answer this objection.

That said, it is true that accommodating conscientious objection is a challenge for every organization, and it is also true that the ERDs make no provision for it. Yet institutions, too, may be said to have a kind of conscience. Salzman and Lawler dismiss that claim on the grounds that “conscience requires subjectivity, which institutions do not have.” By contrast, the bioethicist Daniel Sulmasy has claimed that conscience requires “a fundamental moral commitment…to moral integrity,” which in fact institutions may have.

The enlistment of Pope Francis in Salzman and Lawler’s argument for the transformation of health-care ethics is also problematic. They claim, for example, that “Pope Francis’s recent statements on marriage and the family that natural methods of fertility regulation are to be ‘promoted’” are “very different from Humanae vitae’s and the ERD’s absolute condemnation of contraception.” According to them, he “does not absolutely forbid contraception and may, in fact, be interpreted to promote it.” They thus write that “Pope Francis and revisionist moral theologians maintain that contraception may be either right or wrong depending on how it impacts human relationships.” This is simply wishful thinking. Francis hasn’t (yet) said any such thing.

Salzman and Lawler are right that ERDs reflecting Francis’s priorities would give much greater attention to “social justice and environmental issues.” And I think they’re also right to consider Francis’s 2016 apostolic exhortation, Amoris laetitia, as potentially of great significance for Catholic moral thought. As they observe, Amoris laetitia, especially in its notorious chapter 8, emphasizes “conscience, discernment, and the virtues.” But the document’s potential is lost if its teaching is reduced to the claim that individuals have the right in conscience to do the good as they see it. As David Cloutier and Robert Koerpel have recently explained at length, conscience in Amoris laetitia is not opposed to law, but is instead the way that persons discern how objective norms apply to them in their concrete, complex circumstances.

Salzman and Lawler close their book by proposing “to shift the ERD from a focus on absolute norms and intrinsically evil acts to principled guidelines for forming consciences.” That sounds reasonable enough, but Catholic health care will need a different, more rigorous book to make progress toward that end.

Pope Francis and the Transformation of Health Care Ethics
Todd A. Salzman and Michael G. Lawler
Georgetown University Press
$34.95 | 240 pp.