AMA Journal of Ethics^®

Roman Catholic health care facilities follow a set of guidelines that are compiled in a publication entitled The Ethical and Religious Directives for Catholic Health Care Services. Developed in 1949 by what was then known as the Catholic Hospital Association, these directives were published by the United States Conference of Catholic Bishops in 1971 and most recently updated in 2001. Whereas the early versions of the directives almost exclusively concerned specific procedures that were either allowed or not allowed in Catholic hospitals, especially those procedures that occur at the beginning or at the end of life, the 1994 and 2001 versions begin with a section entitled, "The social responsibility of Catholic health care" [1].

Each of the six sections of the ERD, as the document is known, begins with an introductory narrative. As part of the introduction to the chapter on social responsibility, the bishops state:

…the biblical mandate to care for the poor requires us to express this in concrete action at all levels of Catholic health care. This mandate prompts us to work to ensure that our country's health care delivery system provides adequate health care for the poor. In Catholic institutions, particular attention should be given to the health care needs of the poor, the uninsured and the underinsured [2].

Preferential Option for the Poor

The bishops speak of the care for the poor—or the preferential option for the poor—as a biblical mandate. The gospel narratives often link this option to the early proclamation of Jesus in the synagogue where, quoting Isaiah, he notes that his mission is to "bring glad tidings to the poor, proclaim liberty to captives, recovery of sight to the blind, to let the oppressed go free, and to proclaim a year acceptable to the Lord" (Luke 18-19). Other pertinent texts refer either to the beatitudes, which declared the poor to be blessed (Matthew 5:3-12; Luke 6:20-23), or to Matthew's account of the last judgment scene, in which the poor are seen to represent Christ (Matthew 25:31-46).

The language of preferential option for the poor in the body of the ERD, however, is of more recent origin, coming from the Latin American Bishops' Conferences that met in Medellin, Colombia, in 1968 and in Puebla, Mexico, in 1979. The Medellin Conference called upon the Catholic Church in Latin America to become a church of the poor: "to be the evangelizer of the poor and one with them, a witness to the value of the riches of the Kingdom, and the humble servant of all our people" [3]. During the Puebla Conference, the term "preferential option for the poor" was coined. In their description of the term, the bishops stated that "this option does not imply exclusion of anyone, but it does imply a preference for the poor and a drawing closer to them" [4].

In 1986, the United States Catholic bishops continued discussion of this theme. They explained, "As followers of Christ, we are challenged to make a fundamental 'option for the poor'—to speak for the voiceless, to defend the defenseless, to assess lifestyles, policies and social institutions in terms of their impact on the poor" [5]. A year later, Pope John Paul II also addressed this theme in an encyclical:

The preferential option or love of preference for the poor…is an option, a special form of primacy in the exercise of Christian charity, to which the whole tradition of the Church bears witness. It affects the life of each Christian inasmuch as he or she seeks to imitate the life of Christ, but it applies equally to our social responsibilities and hence to our manner of living, and to the logical decisions to be made concerning our ownership and the use of goods [6].

Health Care and the Option for the Poor

To understand how the Catholic preferential option for the poor affects health care, one must explore the nature of health care itself. According to Catholic social teaching, health care is not a commodity best regulated by a free market economy. Rather it is a social good that is considered to be a basic right. If health care is a basic right, then the fact that tens of millions in this country and billions around the world lack access to it must be viewed as a grave injustice. The Catholic social tradition stresses that the antidote to this injustice is solidarity and dedication to the common good.

This notion of a preferential option for the poor involves a self-conscious move from a passive understanding that the work of Christians is to provide charity to the poor to an active position that demands justice for the poor. The latter stance raises questions regarding the causes of injustice, which are often linked to what Pope John Paul II called the social structures of sin. The preferential option demands solidarity with the poor, defined not as some "feeling of vague compassion" but "a firm and persevering determination to commit oneself to the common good" [7]. What do such responsibilities encompass? The Jesuit theologian Thomas Massaro puts it succinctly, "The entire tradition of Catholic social teaching…can be interpreted as a unified effort on the part of church leaders to encourage a more humane society where the most vulnerable members are better protected from harm" [8].

Cardinal Joseph Bernardin, the late archbishop of Chicago, was a prelate who took the preferential option for the poor seriously. His book, Consistent Ethic of Life was an attempt, as he repeated in many of his talks dedicated to this topic, "to defend the right to life of the weakest among us and to be visible in the support of the quality of life of the powerless among us" [9]. In a 1986 address at the Catholic Medical Center in Jamaica, New York, he articulated the contours of the sorts of challenges that must be faced by those in health care who take seriously the mandate of a preferential option for the poor. As one reads his words, one could simply substitute "preferential option for the poor" for "consistent ethic":

If Catholic hospitals and other institutions take the consistent ethic seriously, then a number of responses follow. All Catholic hospitals will have outpatient programs to serve the needs of the poor. Catholic hospitals and other Church institutions will document the need for comprehensive prenatal programs and lead legislative efforts to get them enacted by state and national government. Catholic medical schools will teach students that medical ethics includes care for the poor—not merely an occasional charity case, but a commitment to see that adequate care is available. If they take the consistent ethic seriously, Catholic institutions will lead efforts for adequate Medicaid coverage and reimbursement policies. They will lobby for preventive health programs for the poor [10].

Cardinal Bernardin continued:

My point in raising these issues is not to suggest simplistic answers to complex and difficult questions. I am a realist, and I know the difficulties faced by our Catholic institutions. Nonetheless, the consistent ethic does raise these questions which present serious challenges to health care in this nation—and specifically to Catholic health care systems [10].

At the present time, the preferential option for the poor in health care is more of an ideal than reality. It calls for what Catholics describe as a conversion of heart. Yet, it also offers hope to more than just the poor. Thomas Massaro suggests:

To adopt the principles of Catholic social thought is to agree that we all need to work hard so that full participation is extended to all, without favoritism or discrimination. We all have something to contribute to the common good, and all may benefit from the gifts we bring to the common table of human community and solidarity [11].