1. Dan Dwyer, PhD, Senior Vice President Mission Integration Steven Squires, PhD (c), Director Mission and Ethics Trinity Health, Novi, Michigan Catholic Health East Ethics Champions 2010-2011 Wednesday, March 9, 2011 Cooperation as Discernment, Formation, and Development

2. Copyright 2011 Trinity Health - Novi, Michigan 2 Wednesday, March 9, 2011 Objectives 1.Increase awareness of Cooperation: –Description and origins –Typical uses 2.Gain a basic understanding of Cooperation: –Supporting concepts –Taxonomy 3.Appreciate the relevance of using Cooperation: –As a group discernment –With non-traditional issues and settings 4.Application –Case study –Questions

3. Copyright 2011 Trinity Health - Novi, Michigan 3 Wednesday, March 9, 2011 Description of Cooperation  Describes an association with evil.  Is assisting an immoral or unjust act by another.  Use of a matrix or mechanism to assess interactions with others.  The Catechism of the Catholic Church states: “We have a responsibility for the sins committed by others when we cooperate in them… –by participating directly and voluntarily in them; –by ordering, advising, praising, or approving of them; –by not disclosing or not hindering them when we have an obligation to do so; –by protecting evil-doers.”

4. Copyright 2011 Trinity Health - Novi, Michigan 4 Wednesday, March 9, 2011 Origins of Cooperation St. Alphonsus Liguori  Wrote how priests should respond to confessions in the mid- 1700s  People sin in direct and indirect, proximate and remote, intentional and unintentional ways  Wanted decision-makers to use conscience and prudence rather than obedience to rules

5. Copyright 2011 Trinity Health - Novi, Michigan 5 Wednesday, March 9, 2011 History of Cooperation  Cooperation developed into a formalized scheme.  Those who applied moral theology to particular, applied issues, Manualists, began applying the principle of cooperation to health care with the proliferation of technology in the mid-1900s.  The principle is so frequently involved with mergers and acquisitions that it was added to the Ethical and Religious Directives for Catholic Health Care Services (ERDs).  Moralists recognized there are different forms of moral agency.

6. Copyright 2011 Trinity Health - Novi, Michigan 6 Wednesday, March 9, 2011 Framework for Cooperation Who can cooperate? Individuals Organizations (Groups)

7. Copyright 2011 Trinity Health - Novi, Michigan 7 Wednesday, March 9, 2011 Typical Uses of Cooperation Individual  Assisting a morally illicit procedure  Genetic counseling  Using stem cells from aborted fetus research  Prescribing and distributing contraceptives  Voting for health care legislation involving morally grave procedures Organizational  Sponsoring, allowing, or initiating controversial groups or messages  Philanthropic donations  Participation in research, (protocols w/ birth control)  Physician’s practice issues  Mergers, partnerships, and affiliations w/ other- than-Catholic systems

8. Copyright 2011 Trinity Health - Novi, Michigan 8 Wednesday, March 9, 2011 Terms in Cooperation  Agent – the person or organization directly responsible for the evil »Evil act – committed by the agent  Cooperator – the person or organization helping in the commission of sin »Cooperative act – the behavior of the cooperator

9. Copyright 2011 Trinity Health - Novi, Michigan 9 Wednesday, March 9, 2011 Considerations in Cooperation Scandal – It “is an attitude or behavior which leads another to do evil” (#2284). 1 Proportionality – “‘Proportionate reason’ is sufficient reason. The closer mediate material cooperation is to wrongdoing, the weightier or graver must be the reason…to be ‘sufficient’ or proportionate.” 2 Gravity – Evil (sins) are not of the same ilk. Evaluation should account for its significance, severity, and relational impact. 3 Duress – Limiting the liberty to choose some options. 4 1. Catechism of the Catholic Church (CCC). Edited by The Holy See. Second (English) ed. Washington, D.C.: Libreria Editrice Vaticana (U.S. Catholic Conference), 1997. 2. Hamel, R., & M. Panicola. "Cooperating with Philanthropic Organizations." Health Progress 89, 2 (2008): 55. 3. CCC; Ashley, B., deBlois, J., & K. O'Rourke. Health Care Ethics: A Catholic Theological Analysis. Fifth ed. Washington, D.C.: Georgetown University Press, 2006: 51-53. 4. Hamel, R. “Part Six of the Directives.” Health Progress 83, 6 (2002): 37-39, 59.

10. Copyright 2011 Trinity Health - Novi, Michigan 10 Wednesday, March 9, 2011 Considerations in Cooperation Example A Considering a potential merger with a health system that does things the Catholic Church considers evil. Example B Considering secular system affiliation, where all services are separate except for shared purchasing, responsible for surgical supplies on both campuses, which the secular system may use for sterilizations. Using cooperation correctly requires its application to specific acts that lend themselves to little ambiguity.

11. Copyright 2011 Trinity Health - Novi, Michigan 11 Wednesday, March 9, 2011 FORMALMATERIAL EXPLICITIMPLICIT IMMEDIATE MEDIATE Without intent & approval, cooperator acts with wrongdoer in performing a sinful action (e.g., cooperator willingly holds the ladder for a thief trying to enter through an open window) Always Morally Wrong Virtually Always Morally Wrong *Exceptions within tradition for reasons of constraint or duress Morally Allowable w/ Proportionate Reason and Not Cause of Scandal *The more proximate, the greater the proportionate reason required to justify cooperation PROXIMATEREMOTE Help is closely tied to the sin (e.g., cooperator unwittingly sells ladder to thief) Help is not closely tied to the sin (e.g., cooperator makes the ladder) Claiming no intent or approval, cooperator helps wrongdoer by doing something that may not be sinful in itself but can have no more immediate intent — the object of act excludes any other meaning (e.g., cooperator claims not to want the theft to occur but directs the thief to the house & to a ladder for easy entry) Without intent or approval, cooperator helps wrongdoer by an action that is not sinful in itself but is essential or primary to the sinful action (e.g., cooperator objects to the theft but holds the ladder for various reasons) Without intent or approval, cooperator helps wrongdoer by an action that is secondary to the sinful action Slide from Michael Panicola, Corporate VP Mission and Ethics, SSM Health Care Principle of Cooperation

12. Copyright 2011 Trinity Health - Novi, Michigan 12 Wednesday, March 9, 2011 Changing Contexts Individuals Determinations are the purview of ethicist or theologian who decides, often without help, what kind of cooperation an issue is and what options and alternatives exist. Groups Decisions are left to a group of interested individuals who discuss the issue, define the evil or injustice, decide the level of cooperation, and frame options and alternatives.

13. Copyright 2011 Trinity Health - Novi, Michigan 13 Wednesday, March 9, 2011 Changing Issues From the issues mentioned previously to issues that are not moral evils to the Catholic Church per se…  Social injustices  Failure to adhere to mission, core values, or Catholic identity  Controversial decisions or those made without appropriate input  Inappropriate and/or damaging behavior, problem associates (employees)  Associate benefit changes

14. Copyright 2011 Trinity Health - Novi, Michigan 14 Wednesday, March 9, 2011 Advantages of a Group 1.Discernment – Groups have the advantage of being able to frame additional options, alternatives, and risks and benefits. 2.Formation – Use the opportunity for education about the issue and why it is relevant to the organization and Catholic health care, thus indoctrinating participants. 3.Moral Development – We do not advance without challenges to our previous models of thinking, so disagreements in groups serve a purpose for individuals.

15. Copyright 2011 Trinity Health - Novi, Michigan 15 Wednesday, March 9, 2011 Case Study Your organization has been a leader with efforts to enhance diversity programs for associates representing many different racial, ethnic, generational, and religious perspectives. In a Catholic health care ministry, diversity and inclusion programming demonstrates strong commitment to several tenets of Catholic Social Teaching. One group of associates, members of the lesbian, gay, bi-sexual, and transgender (LGBT) community, presents the organization with uniquely challenging decisions. In the Catholic moral tradition, homosexual sexual behavior is considered sinful.

16. Copyright 2011 Trinity Health - Novi, Michigan 16 Wednesday, March 9, 2011 Case Study While recent adjustments in this position require respect and consideration of the individual’s lack of choice of his/her sexual orientation, various teachings and decisions from the hierarchy have continued to emphasize the immoral nature of this sexual conduct. A workgroup forms to address inconsistencies and gaps in benefits wants to consider providing health benefits to committed partners of gay associates who may or may not be considered legally married in various jurisdictions.

17. Copyright 2011 Trinity Health - Novi, Michigan 17 Wednesday, March 9, 2011 Case Study The members of the workgroup are struggling with a desire to maintain strong benefits that represent fairness and consistency across the diverse populations of the organization including members of the LGBT community. But they do not want to promote a position that would place the organization at odds with official Catholic teaching on the matter. There are at least three options: 1.Do not change the current coverage level. 2.Add domestic partner insurance benefits (coverage). 3.Add “plus one” insurance benefits (coverage).

18. Copyright 2011 Trinity Health - Novi, Michigan 18 Wednesday, March 9, 2011 Case Study (In the diocese of San Francisco, CA, the local bishop supported a plan called “Plus One” which did not specifically claim the benefit coverage, required in California, was covering homosexual partners.) Analyses (requires two separate): 1.Domestic partner benefits with The moral evil 2.Plus one benefits with The moral evil

19. Copyright 2011 Trinity Health - Novi, Michigan 19 Wednesday, March 9, 2011 Case Study Questions 1.Is there a moral evil? Regarding domestic partner benefits… 2.Which kind of cooperation is this and why? 3.What would make this a different type of cooperation? For instance, what would mediate material cooperation look like? Regarding plus one benefits… 4.Which kind of cooperation is this and why? 5.What would make this a different type of cooperation? For instance, what would formal cooperation look like?