Measure 16: Oregon Confronts Death and Dying; No. 2; Catholic Health Care

[New speaker] During the 1994 election, the Catholic Church campaigned to defeat Oregon's assisted suicide initiative. When Measure 16 passed, Sacred Heart Hospital in Eugene, along with every other Catholic hospital in Oregon, said it would conscientiously object to the law. Catholic doctrine holds that life-ending medical procedures, like assisted suicide, break what the church calls, "the seamless sanctity of life." A federal judge ruled in August that Measure 16 is unconstitutional, but the case is being appealed. If assisted suicide does become legal, residents of Oregon's second-largest city may have trouble taking advantage of it. In the second part of a monthly series on doctor-assisted suicide, Colin Fogarty reports on how the growing influence of the Catholic Church in the health care industry is running up against community values. [Fogarty] Since the mid-1930s, Sacred Heart Hospital has provided health care to the Eugene-Springfield area. Owned and operated by the Sisters of St. Joseph of Peace, the hospital's purpose is to provide what it calls "the healing

mission of Jesus Christ". That mission statement can be found on a small table tent on the desk of Sister Barbara Haas. The former head of Sacred Heart, Sister Barbara's current job is to make sure the hospital services are available to the poor. Lane County's Catholic population, just 4.5 percent, already lives in one of the most unchurched states in the country. But, Sister Barbara says Sacred Heart tries to respect its clients' diversity. [Haas] Not only race and language, or whatever, but also religious diversity. We have always tried to make certain that we were not just here to make Catholics, we were not here to proselytize, but we were here to serve the needs of sick people. [Fogarty] Sacred Heart is part of Peace Health Systems, a Catholic health maintenance organization that owns hospitals and clinics in Oregon, Washington, and Alaska. Like any HMO, Peace Health is responding to market pressures, forcing it to integrate and expand. As the medical industry changes,

patient volume is the only way to ensure financial viability. [Haas] I think by partnering with people we'll be able to spread the few dollars we have much, much farther, and with much more efficacy. And I think we're not building bridges today, we're trying to build for tomorrow. I have a dream that every child, that nine months before they're born and all the way through until they're 18, will have full-kind of coverage, and learning and access to information that they need. [Frances Kissling] Perhaps it's time for Catholic healthcare, or those Catholics who are in healthcare, to return to providing religious services rather than trying to provide something that is a social service. [Fogarty] Francis Kissling is president of the Washington D.C. based group, Catholics for a Free Choice. The group calls for the liberalization of the church, particularly in healthcare issues. Kissling says Catholic orders, which run hospitals, should return to religious ministry just as fire-fighting monks did in the Middle Ages, when that industry was professionalized.

Kissling says, when a hospital like Sacred Heart controls such a big portion of healthcare in a community, the diversity of views within that community is lost. In her words, healthcare is still seen through the lens of the church even though its members are a minority in the community. Kissling says a bishop has ultimate power to dictate what does, and does not occur, in a hospital within his diocese. [Kissling] And, if he chooses to exercise an arbitrary and conservative control, or if he chooses to make these issues - the controversial issues, a hallmark of his term as bishop, then the hospitals have to toe the line. If he chooses to look the other way, the hospitals tend to be liberal. The result is that the consumer has no idea from day to day, and from bishop to bishop, what will be available and what will not be available. [Fogarty] Kissling points to the U.S. bishops' ethical and religious directives for Catholic healthcare services. The bishops' directives, reaffirmed in November of 1994,

placed strict bans on many types of contraceptives and on some medical procedures. The bishops advocate comfort care and advance directives for dying patients, but they say Catholic hospitals will not honor an advance directive contrary to church doctrine. Sister Barbara Haas says Sacred Heart likes to think it follows the spirit of the directives, rather than the letter of the law. She stresses that the archbishop of the Portland diocese, which encompasses all of western Oregon, has no legal or financial responsibility over Sacred Heart. [Haas] He does have a pastoral responsibility, meaning he is the shepherd of the flock in the biblical terminology. And therefore, needs to be concerned that we would not be giving scandal. That we will not be misleading people, whatever. But, I think the directives cover a very small, tiny portion of what a hospital does and what a hospital is all about.

[Fogarty] But one medical procedure covered by the directives is abortion. And, that concerns abortion rights advocates as they look at Sacred Heart's domination of healthcare in Eugene. With 650 beds, Sacred Heart provides 70 percent of the city's hospital services. Some women's groups argue, that as Sacred Heart gobbles up more clinics and medical practices in Eugene, access to abortions becomes more limited. [New Speaker] It would be $22 for an annual exam, and that includes the breast, pelvic and PAP exam, and the lab fees for that. [Fogarty] At this Eugene office of Planned Parenthood, a group of women meets to discuss their concerns about Sacred Heart. They call their group Choice, which stands for Citizens for Healthcare Options, Insuring Choice for Everyone. This group was formed to oppose Sacred Heart's expansion plans. State Representative Kitty Piercy doesn't attack the Catholic Church itself, but rather its role in Lane County.

[Piercy] I'm certainly willing for them to have their point of view when it is constrained to their hospital. But it changes dramatically when you're talking about what's going to be available in our whole community. And then it becomes an important discussion - that the community really be aware of what's happening to them. [Fogarty] Attorney Laura Parish attempted to voice that concern as a member of Sacred Heart's governing board. She resigned last year out of frustration over the hospital's policy barring doctors from performing abortions, or any other procedure objectionable to the church on Sacred Heart's time or property. [Parish] If they have enough doctors who are Sacred Heart employees, who are subject to the 'not on their property, not on our time' rule, then the number of physicians available who can provide that service and who are willing, to should diminish considerably. And, there aren't that many right now. [Fogarty] As Catholic healthcare companies grow, many conservative church officials have discouraged integration with non-Catholic organizations. But in Eugene, in order for Sacred Heart to expand, it can only merge with secular care providers.

[Dr. Kincade] We've got a nice, quiet day here. [Fogarty] Dr. Rick Kincade works in the Urgent Care Center. It's part of the Eugene Clinic, a multi-specialty group practice of about 75 doctors. Earlier this year, the Catholic HMO Peace Health took over the Eugene Clinic. The urgent care center treats minor medical emergencies. More serious problems, Kincade says, are sent to Sacred Heart's emergency room. [Dr. Kincade] Because of just the volume constraints and the fact that you don't have an in-house facility here, it's part of the way of triaging acutely ill patients into a facility where they can go directly to ICUs or directly to surgery, if need be. Everybody here is either walks in, carried in, hauled in on a stretcher. [Fogarty] Since the acquisition of the Eugene Clinic, Kincade has been subject to the Catholic HMO's policies. He says while the number of doctors performing abortions may have decreased, women still have access to the service at McKenzie-Willamette Hospital in Springfield. Or at the remaining non-Catholic private practices

in the area. [Dr. Kincade] It's the same thing that one hospital may do open heart surgery and another may not. And, that may be hospital policy - may be what they have available. And, physicians are used to practicing in that way, where they can do one thing in one place, and another in another. [Fogarty] Kincade doesn't mind that Peace Health is a Catholic institution - religious issues rarely arise in his work. Instead, Kincade worries about any healthcare institution that is so large. [Dr. Kincade] A lot of health care contracts are made with employers that don't allow for much flexibility. And, I think there are some disadvantages there. And, I think obviously the whole idea of monopoly in large systems is certainly there. And, you know, once you have a monopoly, you can pretty much play the game that you want. I think that there are real concerns in that fashion with very large organizations. [Fogarty] Catholic hospitals provide 16 percent of healthcare nationally, making the Catholic Church the largest single healthcare provider in the country.

Although Sacred Heart doesn't have a monopoly on healthcare in Eugene, it has become big enough to be considered a community organization, rather than a private one. That's the view of Courtney Campbell, a philosophy professor and medical ethicist at Oregon State University. Campbell says, as Sacred Heart integrates with other health care providers in Lane County, at some point it crosses the line between private moral values and public good. [Campbell] Insofar as that line is crossed, and it's a very fuzzy line to be sure, but insofar as that private-public line, its boundary is crossed, then it seems to me that the HMO, the institution, its private religious concerns, if you will, have got to in some sense be reconciled with, or in some cases perhaps compromised, for the greater public good that they're trying to serve. [Fogarty] In Oregon, a new private-public line has been drawn on the issue of assisted suicide. A majority of Lane County voters, 57 percent,

approved of the practice when ballot Measure 16 passed. But the Catholic Church opposes assisted suicide - a stand reaffirmed by Pope John Paul II, since the election. As more doctors and medical services in Eugene come under the purview of the church, its policies would prevent doctors, and hospital time or property, from filling out a lethal prescription if assisted suicide becomes legal in Oregon. For OPB, I'm Colin Fogarty. [New Interviewer] We asked OSU philosophy professor, Courtney Campbell, to speak with us further about the issues raised in the story you just heard. Campbell says, the area where private morality overlaps with public good poses difficult questions that must be answered by individuals, and by society as a whole. [Campbell] Sometimes what's in the best interests of society may well conflict rather dramatically with what may be in the best interests of a person's view of the good life, or religious traditions on view of the good life.

And, those lines do get to be very blurry when either the public sector, or the public morality, imposes a kind of view of rightness or goodness on private understandings. Or, private individuals or private groups tried to impose their sense of what's good on the larger public. And, that's where we have some very deep conflicts. [Interviewer] You yeah, that's I guess, where we turn to Measure 16. And look at this in a case - in one hand here, you have a majority of people in Oregon and even in one area in Lane County voting for the measure. But the major health care provider in that area, Lane County, is an arm of the Catholic Church, which is doctrinally opposed to assisted suicide. Is it possible to reconcile those two positions? [Campbell] I think it's - on that particular issue, the divisions are so deep, that it's going to be very hard for an employee for example, of Sacred Heart, of

Sacred Heart healthcare system, to reconcile on one hand their personal and say religious-based moral positions with perhaps their understanding of what the public might want or at least the majority of the public might want. And in Lane County, I think that the best that one can do is to utilize the conscience clause of Measure 16, which allows for them to say no to, you know, a prospective patient. And then, the patient has to take the initiative to seek out another healthcare provider. [Interviewer] Some people suggest that you look back at the history of the Catholic Church at one point, monks were doing, were in the firefighting business, But, as that became professionalized, they withdrew from that. Now, they suggest that since healthcare has become so professionalized and such a large industry, maybe it would be time for the church to step back from that. Leaving aside the practical considerations, which admittedly are considerable, is that

does that make some sort of sense that maybe having a religious organization involved in such a large corporate industry at this point - maybe those two things don't mesh as well as they used to? [Campbell] Well, I think you put your finger on a very good point. As the healthcare system becomes more and more of an industry, and the concern is to cater primarily to the interest in this, and provide services for consumers - no longer patients, but people that are defined as consumers of healthcare goods. Then, the tension and the possibility of conflicts between an industry- based ethic, which is concerned mainly with efficiency and mainly with utilization reviews and profits and so forth, there's going to be a great deal of prospective conflict between that and a kind of healthcare that, if you will, harkens back to traditional kinds of values in which the neighbor was to be served

in his or her totality, as an object of love. I don't think that that ultimately means that this professionalization and industrialization of the healthcare system will mean that Roman Catholicism will ultimately sort of pull back, or pull away from, healthcare and leave it completely to the secular world to provide health care. I think that they have the Roman Catholic system believes it has a great deal of stake as part of its witness to the world about what the Christian gospel is supposed to be about, and what the Christian message is supposed to be about, is precisely to take care of the neighbor in his or her not only spiritual needs, but temporal needs. And, those are best met in certain ways through the provision of healthcare. [Interviewer] Well, assisted suicide is, in many ways, just the latest example of a fundamentally moral issue being almost forcibly molded to public policy debate.

And we've had this in the case of the abortion debate, even civil rights to a certain extent. Are there any lessons to be learned from the experience with these other issues as to how individuals and the public at large sort of think through them and try to arrive at some sort of decision on their conduct and how they're going to continue to handle this in the public policy arena? [Campbell] These traditions, these religious traditions, be they Catholic or other traditions, particularly Jewish, do have a long history of, I think, moral wisdom that needs to be respected rather than rejected or marginalized in our public debates. Indeed, even to the making of public policy, I don't think and it would be constitutionally inappropriate for a religious viewpoint to be the the source of a public policy position, whether it's Measure 16, whether it's of various kinds of measures on homosexuality or the like.

But it is important for those views to be considered in the process of public policy formation, because after all, religious communities are a public themselves. They're a smaller public, small "p", if you will, as opposed to a big "P", but they are part of the larger public, and they have not only duties and responsibilities and loyalties to their own religious convictions and traditions, but they also have loyalties as and responsibilities as citizens in a democratic society. And one of those responsibilities is to participate in the formation of good public policy that makes sense for all of society. And sometimes they won't win or their positions won't win out, but at least they need to be listened to and heard. I think that's what we mean in a society by tolerance and respect for different views, rather than just simply rejecting them because they quote-unquote are religiously based. [Interviewer] So a question that you come back to, I guess, in considering this whole issue,

is who decides what the public good is? And, this is, again it seems, to me is sort of at the heart of this question. [Campbell] I think what we need to try and avoid is, making the procedural question, who decides what is in the best interest of the public? The primary question, what we need the discussion about, is what are the values that say all Oregonians can agree on as a matter of public policy, that should shape our decisions about something like termination of treatment at the end of life. Or, reproductive choices and the like. Can we identify some not only procedural values, but also substantive values such as mercy, such as dignity, such as patient choice. Such as of concerns about not harming

other individuals and the like, such as respect for the sanctity of life, such as concerns for the interests of third parties. If we can identify some of those values, and I guess it's, I am somewhat optimistic about this because of my educational setting and background. But, I think those values - those sort of common values can come out through a process of discussion. Then I think the process question, "Who decides?", will rightfully take its place as a secondary question or a subsidiary question. [Interviewer] So maybe at least having Measure 16 on the table is a start... [Campbell] I think it's an excellent start towards trying to think about what kinds of values and what kinds of decisions people from all walks of life and from all backgrounds - whether they're caregivers, whether they're patients, whether

they're representatives of institutions, whether they're insurance providers and the like, whether they're family members...what kinds of values are trying to be met and trying to be expressed by the dying patient, who say opts for physician-assisted suicide as opposed, to say, hospice care. Or, as opposed to other advance directives or something like that? What's really behind that kind of request? And certainly within the state of Oregon, that has been interpreted as, if you will, a wake up call to medicine to do a lot more with respect to control of pain, control of symptoms, and new emphasis on palliative care. And what came out of that this last legislative session, was a new bill with respect to pain dosages that medical care providers could offer. So I tend to think, that again, with Measure 16 being a good example, there's been a public policy

change, or at least a medical policy change, because of the impact of Measure 16 and how various kinds of medical caregivers have responded to it. I know that hospices have rethought some of their thinking, in terms of care-giving, because of what they may or may not have to do with Measure 16, were to be litigated at some level and approved. I know the institutional ethics committees, hospital ethics committees at various hospitals around the state, have also gone through that process of really, really thinking "what is it that we stand for as a hospice?" Or, "what is it that we stand for as a hospital?" Or, "what is it that we stand for as a profession?" [Interviewer] Courtney Campbell is a professor of philosophy at Oregon State University. He spoke with me this week from our studios at KOAC, in Corvallis.