Catholic health care must remain Catholic, even in instances of collaborations or mergers with non-Catholic institutions, say new directives from the U.S. bishops.

The sixth edition of the Ethical and Religious Directives for Catholic Health Care Services was “overwhelmingly accepted” by the United States Conference of Catholic Bishops (USCCB) at their spring meeting in Fort Lauderdale, said Bishop Robert McManus of Worcester, who chairs the USCCB’s subcommittee on health care, which was responsible for compiling the new directives.

Overall, the directives deal with a myriad of issues, including health care at the beginning and end of life, as well as pastoral and spiritual responsibilities of Catholic health care institutions to their patients.

The new edition includes multiple updates to the sixth section of the directives, which deal with collaborative arrangements with other health care organizations and providers, whether those are Catholic or secular.

The new and updated directives are a result of four years of study and consultation with the Vatican and with the National Catholic Bioethics Center, McManus told CNA.

They clarify, among other things, that Catholic health care institutions must maintain their Catholic identity and provide care consistent with Church teaching even in instances when they collaborate or merge with other healthcare institutions.

“The rule of thumb is a Catholic hospital in partnership with a non-Catholic hospital cannot formally cooperate with doing evil,” Bishop McManus said. Formal “cooperation (with evil) is always eliminated, it cannot be done.”

The directives state that formal cooperation with evil happens “not only when the cooperator shares the intention of the wrongdoer, but also when the cooperator directly participates in the immoral act….(and) may take various forms, such as authorizing wrongdoing, approving it, prescribing it, actively defending it, or giving specific direction about carrying it out. Formal cooperation, in whatever form, is always morally wrong.”

Material cooperation, on the other hand, occurs when “the one cooperating neither shares the wrongdoer’s intention in performing the immoral act nor cooperates by directly participating in the act as a means to some other end, but rather contributes to the immoral activity in a way that is causally related but not essential to the immoral act itself. While some instances of material cooperation are morally wrong, others are morally justified,” the directives state.

Material cooperation is never justified in actions that are “intrinsically immoral, such as abortion, euthanasia, assisted suicide, and direct sterilization,” the directives state. Other situations of material cooperation may be more morally complex.

According to the bishops: “Reliable theological experts should be consulted in interpreting and applying the principles governing cooperation.”

Another important consideration in situations of collaborations and mergers is the principle of scandal, McManus said.

“Theological scandal, strictly speaking, means that I cannot do or say something that might cause someone else to enter into sin,” he said.

“So even if there is cooperation that has been justified by (as) material cooperation, if that might cause scandal, even after attempts to explain why a Catholic and non-Catholic institution are partnering, if there is the reality of scandal, that has to be avoided,” he said.

The directives also clarify the role of a bishop in overseeing collaborations of Catholic and non-Catholic institutions.

Joe Zalot, a staff ethicist with the National Catholic Bioethics Center, told CNA that these directives are necessary because health care collaborations are increasingly common, and can create complex situations when determining who has authority over these entities.

“Basically what’s happened is that many of the Catholic hospitals, historically they were founded and run by religious orders, particularly women’s religious orders, and as those orders are literally and figuratively dying out, there were not enough sisters to administer them,” Zalot said.

As a result, some Catholic health care institutions are now overseen by what are called juridic persons in canon law, which are legal entities recognized by the Vatican. Because these juridic persons exist within a diocese, or in some cases multiple dioceses, the local bishop or bishops share responsibility in ensuring the Catholic identity of these entities, Zalot said.

“What these directives are doing is recognizing that fact and trying to define the role of the bishop in terms of Catholic health care entities in his diocese. Essentially the bishop has oversight of what happens in his diocese,” Zalot said.

“What the bishops are saying is not new. What they’re doing is clarifying the role of the bishop in terms of Catholic entities in (their) dioceses,” he added.

Zalot said that for the most part, these directives usually do not pose problems for Catholic institutions that seek collaboration with non-Catholic ones.

“What (the bishops) are concerned with is ensuring the identity of the Catholic institution remains, even within these mergers. And actually it does happen, we see it, there’s hospitals that have been merged into or bought by a secular institution. But one of the elements of the contract or the purchase agreement is that these institutions remain Catholic,” he said.

“And as far as I know, most secular institutions don’t have a problem with that,” he added. The directives just help to ensure that “what is happening in a Catholic healthcare institution actually is Catholic, and you’re providing care consistent with the teachings of the Church.”

While discussing the revision of the directives at the general assembly in Fort Lauderdale, Archbishop William Lori of Baltimore noted that three of the five Catholic hospitals in Baltimore are already in collaborative arrangements, and that the new revision “doesn't answer every question, but it does offer helpful guidance.”

Cardinal Donald Wuerl of Washington said the revision “walks a very clear path through many complex issues,” preserving the theological principle of the autonomy of individual dioceses in pastoral ministry. It “makes clear there should be collaboration between dioceses, without taking away the autonomy of the individual bishop.”

The USCCB voted to approve the revised Ethical and Religious Directives June 14, by a vote of 183 to 2, with 2 abstentions.