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Development of Church Teaching on Prolonging Life
Kevin D. O'Rourke, O.P., J.C.D.
The Catholic Health Association of the United States, St. Louis, MO
The issue of when to prolong and when to allow to die is debated acridly in our courts, hospitals, and homes. A study of the history and theology of the Catholic teaching on this issue may help to develop a consensus among those who accept the teaching of the Church, as well as among those who primarily follow the ethical norms of our pluralistic society.
The Purpose of Human Life
God gave us the gift of human life to show forth his goodness and love (Gn 1). We, in turn, show our love for God by respecting and fostering that gift of human life. Although we are called to life beyond human life, we do not disdain the gift of human life or reject it to hasten our advance toward eternal life (Lk 8:11).
As Jesus taught, love for God leads us not only to love ourselves, but to love others as well (Mt 22:37). One way to show our love for God, for ourselves, and for others is to prolong human life. Thus it is not an act of responsible human love to willfully and directly end one's own life or the life of another. Suicide and euthanasia have always been denounced by Christians because these acts are considered to be a serious violation of love for God.
Although human life is a great good upon which many other goods depend, sacred Scripture indicates it is not the ultimate good. 1 At times, the choice of another good may justify the indirect surrender of human life. In these circumstances, one does not choose death, but allows death to ensue because another greater good is chosen directly. Jesus on the cross, for example, chose to do the Father's will and freely gave his human life for the salvation of the world. Martyrs surrender their lives rather than deny God in their hour of crisis. Thus Christians have always maintained that life could be surrendered indirectly, if continuing to live would impede the response of love to God.
Human life, then, is a relative good in regard to the absolute precept of Jesus: "Love God, and love your neighbor as yourself." Although prolonging life is usually a value because living humanly draws us closer to God, on some occasions prolonging life becomes an impediment or obstacle to returning God's love.
Teaching of Theologians
From the earliest centuries of the Church, when discussing acts that are opposed to care for life as an act of love for God, theologians focused on murder, suicide, and euthanasia, which by act or omission were intended to cause death directly.
But as the possibility of prolonging life through medicine or surgery increased, theologians started questioning how much effort one should expend to stay alive. Would it be a sin to reject efforts to prolong life if those efforts involved grave suffering, prohibitive expenses, or other serious burdens? Are there situations when choosing to avoid pain, suffering, or economic burden would bring about death only indirectly? In the sixteenth century, theologians began to discuss the questions: When would it not be suicide to allow oneself to die? When would it not be euthanasia to allow another to die?
The first explicit discussion of these questions is by Francisco di Vittoria, a Spanish Dominican theologian whose Relectiones Theologicae were originally published in 1557, 10 years after his death. In this work, Vittoria considered the moral obligation to use food to prolong life. He declared:
Notice that Vittoria does not say a person in good health may starve himself because he is tired of living. Nor does he allow much leeway if the means (food) are effective ("a certain hope of life") and do not involve a grave burden. But he suggests that if a person is so sick and depressed that eating may become a grave burden, that person does not sin by not eating. Clearly, Vittoria recognizes psychic as well as physiological illness, and his notion of grave burden involves more than physical pain.
Vittoria also discusses the morality of using artificial means, namely drugs, to prolong life: "If one has moral certitude that drugs would heal and prolong life, then one should take the drugs himself or give them to a sick neighbor. If he does not, he would not be excused from mortal sin. But because a cure can seldom be certain, one need not utilize drugs even though very ill."
In considering the lawfulness of abstaining from specific foods, even if death would result, Vittoria maintained:
To modern minds, Vittoria may seem liberal in the freedom he allows to refuse certain types of food even if death will ensue more quickly. But he wrote in a time when many would do penance by avoiding certain "more delicate" foods that might have been more healthful. For example, members of some religious orders would never eat meat. Moreover, the underlying reason for allowing people to abstain from healthful foods or to refrain from moving to a more healthful place was the choice of one good (e.g., penance or family stability) that rendered the other good onerous (e.g., eating meat or moving to the mountains). This "choice of goods" theory is basic to the Catholic tradition on prolonging life.
Several norms set out by Vittoria are operative in Catholic teaching today:
Ordinary and Extraordinary Means
The writing of Vittoria had great influence on many theologians who lived after him. 4 However, those theologians perfected Vittoria's thoughts by considering other cases in the light of contemporary medicine. For example, the introduction of anesthesia in the nineteenth century caused theologians to reconsider pain as a reason for refusing surgery. However, they were not called on to solve cases resulting from sophisticated methods of prolonging life. They did not discuss, for example, the obligation to prolong the life of a person in a coma because no effective means existed to do so. Therefore the distinctions of the past must often be made more exact.
The most important distinction in need of clarification is the one between the terms "ordinary" and "extraordinary" means to prolong life. These terms were gradually introduced in Catholic teaching over the centuries, although they were used with different meanings. 5 This led to confusion, which was noted in the document Declaration on Euthanasia published by the Vatican in 1980. 6 The confusion arises from the fact that originally the term "ordinary" was used in a generic sense to denote "common" means to prolong life, that is, means readily at hand and available to all. The term "extraordinary" originally referred to means that were either expensive, difficult to obtain, or inconvenient to arrange for the average person.
Over the years, the terms also were used in a specific ethical sense to signify whether a particular means to prolong life was morally obligatory (ordinary) or morally optional (extraordinary), for a particular person. Used in the generic sense, the terms signified whether the medicine or procedure in question was readily available for the average person. Used in the specific sense, the terms denoted whether the means to prolong life would be effective and without grave burden for a particular person.
In theological writings, the terms "ordinary means" and "extraordinary means" were often used interchangeably. A medicine or surgical procedure could be designated as ordinary in a generic sense but as extraordinary when applied to a particular patient. The noted medical moral theologian Rev. Gerald Kelly, SJ, used the terms in this sense as late as 1950 when discussing the use of artificial hydration and nutrition. 7 After declaring that intravenous feeding is an "ordinary means" to prolong life, he stated that it could be considered extraordinary for a particular patient if he or she is not profiting spiritually from it.
Consideration of Circumstances
Pope Pius XII solved the ambiguous use of the terms ordinary and extraordinary when he stated that the determination of ordinary and extraordinary means requires a consideration of the "circumstances of persons, places, times and cultures." 8 In using these terms, then, one should specify whether one is offering a general description of availability or a specific ethical judgment based on effectiveness or grave burden for a particular patient. Simply because a procedure is available does not imply that one has a moral obligation to use it. Respirators and blood transfusions are readily available in all acute care hospitals, but the hospitalized person has a choice about using them; this choice would require the patient to ask, Are these means effective? Would their use involve a grave burden?
A more modern complication concerning the terms ordinary and extraordinary means arises from the use of the terms in a medical context. In this context, the terms are used to distinguish medical therapy which is standard and accepted from medical therapy which is innovative or experimental. Thus antibiotics are ordinary therapy for pneumonia. But the artificial heart is extraordinary therapy for degenerative heart disease. When used in this sense, therapy which is extraordinary may become ordinary. Hence, the use of the terms ordinary and extraordinary means to prolong life always require further specification. The terms signify specific moral judgments only when considering the effectiveness or burden of a particular therapy for a particular person.
Why did the theologians who developed this teaching in regard to allowing to die fail to distinguish clearly between the generic (availability) and specific (moral obligation) use of these terms? Perhaps they presumed that most of the means to prolong life that were effective and readily available did not involve a grave burden for the person in question. As medical practice and technology became more advanced, however, many available and effective means to prolong life would result in a grave burden. For example, after the introduction of ether, amputations could be performed without severe pain, but a person might determine that living without two legs would be a grave burden and choose to live as long as possible without the amputation.
In summary, the theologians who wrote from the sixteenth to the nineteenth centuries considered morally obligatory (ordinary in the ethical sense) those means to prolong life which for a particular person would be effective in prolonging human life for a significant time and would not involve a grave inconvenience. They considered optional those means which for a particular person would be doubtfully effective for prolonging life or which would not prolong life for a significant length of time or would be judged too burdensome.
To understand the teaching of the theologians and later statements of the Magisterium in regard to prolonging life and allowing to die, certain assumptions of the theologians' writings must be considered.
The theologians always assumed that suicide and euthanasia were moral evils. Both involve a direct intention of death and action (or inaction) from which death results directly. Clearly, the theologians did not conceive that they were fostering a direct choice of death when they stated that life need not be prolonged if the means are ineffective or involve a grave burden. Rather, they sought to allow the choice of a moral good for the person that may also lead indirectly to death.
For example, a person who would refuse an amputation without anesthesia because it would be too painful would be choosing to avoid excruciating suffering, even though the choice might hasten death. To say that Catholic teaching does not allow actions that indirectly bring about death or that may hasten death is erroneous.
The theologians of the past were applying the principle of double effect to the question of prolonging life. This principle is used extensively in Catholic theology but is not derived from faith. 9 Rather, the principle of double effect is derived from human experience and deals with undesirable effects of human choices; effects that may be foreseen as results of a choice but are not directly intended. If one fails to understand the principle of double effect, one will not be able to understand the difference between the acts of suicide or euthanasia and the act of allowing to die. It seems the dissenting judges in the Brophy case did not understand this principle--hence their impassioned statements concerning the majority opinion.10 The majority opinion in the Brophy case acknowledged this principle implicitly when it stated that Brophy's proxy could choose a good--cessation of a degrading form of existence--even though death would result indirectly.1l As Rev. Thomas O'Donnell, SJ, indicates, when artificial nutrition and hydration are withdrawn from a permanently comatose patient with an irreversible disease, the withdrawal of medical care is not the cause of death. "The cause of death is the irreversible disease, which has caused both the terminal coma and the inability to eat and drink.... Thus, rather than causing death, their withdrawal accurately could be viewed as letting inchoative death occur."12 It seems that the courts faced with decisions concerning the maintenance or withdrawal of life support would do better to use the principle of double effect than to use ambiguous language such as "right to privacy," "right to die," or "death with dignity."
Decisions of Conscience
The theologians developing the Catholic tradition in regard to prolonging life did not seek to remove decisions of conscience from ailing individuals. Thus they did not compile a list of "objective means" that were too painful, expensive, difficult, or embarrassing for everyone. Neither did they seek to determine what would constitute "a significant length of time" to prolong life. Rather, they determined some generic reasons that would justify the choice of a good that indirectly led to death and called upon people to make the required specific applications. As befits sound theology they set boundaries and allowed people freedom to make decisions within those boundaries.
The theologians sought merely to outline general actions that people in normal circumstances would avoid or perform to prolong life. But in regard to specific actions that might or might not be judged ineffective or too burdensome, they called on individuals to decide for themselves. Even eating food, as Vittoria pointed out, could be a "certain torture" for some depressed persons, and thus it would not be a morally obligatory means of prolonging life for the person in question. If, in some circumstances, eating food is a morally optional means to prolong life, how much more so might be contemporary means to prolong life--ventilators, antibiotics, blood transfusions, and artificial nutrition and hydration--be judged optional if a sick person determines that the use of such procedures would be doubtfully effective or involve a grave burden?
Role of the Proxy
The Church's traditional teaching. then, calls on the individual to decide what is ineffective, what constitutes "a significant time," and what is too burdensome. The theologians presumed that if one is unable to decide for oneself, a relative or friend should decide. This is called "proxy consent" or "substitute judgment." Persons close to the one needing help are presumed to be moral agents for the incompetent person because they love the patient and will determine what is of benefit to the patient. If this presumption is proven false, others, even the courts, should make the ethical decisions for incompetent patients.
The Church's teaching does not impose on the proxy (or the courts) the incompetent person's wishes as the absolute norm for decision making. Pope Pius XII stated: "The rights and duties of the family depend upon the presumed will of the unconscious patient if he is of age and sui juris [having full legal right or capacity]. Where proper and independent duty of the family is concerned, they usually are bound only to use ordinary means."13
Thus the proxy should determine what is best for the patient, using the known wishes of the patient as a guide, but also considering the present circumstances. An incompetent person may have made known that a particular course of action be followed, but circumstances may have so changed that the proxy believes the incompetent patient would judge differently were he or she able to do so. For example, a person may have declared that given a certain physiological condition or disease, that all life support should be removed. But the proxy might determine to continue therapy in order to have the family gather before death, to alleviate pain, or to restore consciousness for spiritual purposes. The proxy should never carry out unethical actions, for example, acts constituting euthanasia, even if this is a known wish of the incompetent person. If the patient's wishes are not known, the proxy should consider what would be reasonable care for this patient. When determining "reasonableness," the proxy may ask, How will the decision for care affect other members of the family? The Church's teaching on proxy consent differs from the statements (although not always the practice) of some courts and certainly differs from the thought of many contemporary ethicists who use the person's autonomy as the absolute criterion for proxy decision making. Some contemporary ethicists would approve abetting suicide or mercy killing if it were clear this is "what the patient desired."
The Spiritual Goal of Life
Gary M. Atkinson, Ph.D., points out that Vittoria and the other theologians were influenced by St. Thomas Aquinas, who explained that the moral measure of all human activity is whether it leads to God, the final end.14 Thus, when the theologians described something as "too difficult," they implied that it would make loving God too difficult. The theologians did not emphasize this norm for judging what makes a means of prolonging life "too difficult." But Pope Pius XII, in 1957, clarified the tradition by explicitly presenting the spiritual goal of life as the norm for judging whether a grave burden is present. He declared:
Hence any medical therapy that would make the attainment of the spiritual goal of life less secure or seriously difficult could be judged a grave burden and could be considered an optional or extraordinary means to prolong life.
Emphasizing the spiritual goal of human life specifies more clearly the terms "ordinary" and "extraordinary," a specification that was not required when life support systems were not as advanced as they are today. Contemporary life support systems may prolong a state of existence which not only involves grave burdens for the patient, but also preclude spiritual activity on the part of the patient. Thus a more adequate and contemporary explanation of "ordinary" means to prolong life would be: those means which are obligatory because they enable a person to strive for the spiritual purpose of life without grave burden. "Extraordinary" means would seem to be: those means which are optional because they are ineffective or a grave burden in helping a person strive for the spiritual purpose of life. One cannot judge what is effective or a grave burden without considering the physiological condition, as well as the social and spiritual circumstances of the patient.
If it is reasonably certain that only physiological function can be prolonged in a comatose person, and that the human organ (the cerebral cortex), which is necessary for human spiritual activity, is unable to function, is there a moral obligation to prolong life? To pursue the spiritual purpose of life, one needs a minimal degree of cognitive-affective function. Therefore, if this function in an adult cannot be restored or if an infant will never develop this function, and if a fatal disease is present, it seems the adult or infant may be allowed to die because medical therapy is ineffective. Prolonging life simply because physiological function can be prolonged long after cognitive-affective function ceases irreparably is not a sufficient reason to continue therapy. Declaring medical therapy to be ineffective when spiritual function cannot be restored seems to be the ethical responsibility of physicians.16
People may define the spiritual goal of life in different ways. The phrase "loving God and neighbor" seems to express the Catholic tradition. Others would define the spiritual purpose of life as serving God and neighbor, leading a good life, enjoying life, relating to others, or contributing to society. No matter how the spiritual purpose of life is defined, some degree of cognitive-affective function is required to strive for it. If cognitive-affective function is irreparably lost, mere physiological function need not be prolonged because such therapy is ineffective to achieve the spiritual purpose of life.
Maintaining that the life of a fatally ill person need not be prolonged does not imply that the person should be neglected. Every dying person should be given spiritual and physical care. A person whose spiritual function is irreparably lost is still a human being. We have a moral obligation to keep such patients comfortable. In regard to patients who may experience pain, the teaching of the Church, (once again utilizing the principle of double effect) is quite clear. After declaring that physical suffering is unavoidable and that some Christians may choose to join their suffering with the sufferings of Christ, the Church states:
The obligation to keep patients comfortable leads some to demand artificial hydration and nutrition for all patients in order to avoid physical suffering, even for those persons who are in an irreversible coma.18 But is there any medical indication that persons in this condition feel physical pain? The neurological experts consulted in the Brophy case did not think so.19 Moreover, in hospices and infirmaries of religious sisters, the latter institutions being the embodiment of compassionate care for the dying, artificial hydration and nutrition are seldom used once a dying patient lapses into a coma. In sum, evidence seems to be lacking that removing or withholding tube feeding from individuals in a deep coma or a persistent vegetative state results in great pain for the patient.
Burden to Others
Another latent issue in the traditional teaching of the theologians is the burden that care givers, usually the family, might experience if a person's life is prolonged. If all circumstances must be considered, then the patient must ask, What will a decision to prolong my life mean to the people who must care for me? Would the burden be in accord with "the common sense of the Christian community" if the family would have to give the patient nursing care 24 hours a day and devote all its savings and income to that care?
Such problems are encountered often by families with severely debilitated newborn infants. Should the life of every newborn infant be prolonged, simply because it can be, regardless of the burdens this would cause the family?20 About 20 years ago Baby David was born in Houston with severe immune deficiency (SCID). His life was prolonged by placing him in a germ-free plastic bubble for 13 years.21 Ultimately, he said it was too difficult to live in that manner and he asked that the bubble be removed. He died shortly thereafter. The lives of other infants born with SCID could be prolonged in the same manner, but is this humane treatment? This significant question is not, Is it possible to prolong life? but rather, Is there an ethical obligation to prolong life?
Confirming the Traditional Teaching,
In 1980 the Church magisterium spoke again on the matter of prolonging life.22 The document did not change the traditional teaching in any way, but sought to clarify it by stating:
Although the terms "proportionate" and "disproportionate," as well as the terms "burden" and "benefit," have replaced "ordinary" and "extraordinary" to a great extent, these more contemporary forms are not without potential ambiguity. Before determining whether particular substance (whether natural or artificial) or medical therapy is proportionate or disproportionate, we must first determine the condition of the patient and whether the act or medical therapy in question is effective in prolonging life for a significant time or whether it involves a grave burden for a particular person. If these basic moral specifications are not discerned, then a consequentialist's interpretation could result from use of the new terms.
Norms Governing the Decision
In summary, then, these are the important norms in regard to prolonging life gathered from the theologians and the magisterium:
Public Policy and Ethics
Although the ethics of personal decision making that will ensure the fulfillment of our response to God's love is a serious concern of the Church, the Church is also concerned with public policy in regard to prolonging life. Laws and court decisions are an important adjunct to personal decision making because they serve as an educational as well as a coercive factor in the lives of individuals.
When offering prudential advice to the courts and legislatures in regard to public policy, however, the statement of Church agencies should be in accord with the traditional teaching of the Church. A good example of accurate advice was offered by the National Conference of Catholic Bishops Committee for Pro-Life Activities. In commenting on the statement on Uniform Rights of the Terminally Ill Act proposed by the Commission on Uniform State Laws, the bishops cautioned against promoting euthanasia and requested that legislation establish a strong presumption in favor of using artificial nutrition and hydration. But the statement also allowed for withdrawal of life support that is ineffective or a grave burden and agreed that "laws dealing with medical treatment may have to take account of exceptional circumstances when even means for providing nourishment may become too ineffective or burdensome to be obligatory."23
Contrasted with the Pro-Life Committee's statement is the statement of the New Jersey State Catholic Conference in regard to the Jobes case. Nancy Ellen Jobes, 31 years old, was severely brain damaged and her existence was maintained by means of artificial nutrition and hydration in a nursing home. Her spouse asked the court for permission to withdraw all life support systems. After maintaining that Nancy Jobes "is not dying," the amicus curiae brief of the New Jersey Catholic Conference stated: "The conference maintains that nutrition and hydration, being basic to human life, are aspects of normal care, which are not excessively burdensome, and should always be provided to a patient."24 In June 1987, the New Jersey Supreme Court granted permission for the withdrawal of all life support systems from Mrs. Jobes stating that the right of a patient to refuse life-sustaining medical treatment may be exercised by the patient's family or close friend. Thus the court held that in certain circumstances withdrawal of nutrition and hydration is neither euthanasia nor suicide.
Although the intent of the New Jersey Catholic Conference to avoid "a slippery slope" in matters of allowing to die is laudable, accurate ethical distinction must be used or the Church teaching in the matter, which has been respected and followed by many in our pluralistic society, will lose credibility.
Understanding and following the Church teaching in regard to life support will not make the decision to withhold or withdraw medical therapy an easy one. Such decisions will always be accompanied by anxiety and sorrow. Decisions of proper ethical care will continue to bother and befuddle healthcare professionals, patients, and their families. Indeed, the degree of anxiety and sorrow accompanying these decisions may be a good measure of one's humanity. However, the Church teaching will enable people to make just and compassionate decisions that express effectively their love for God. The papal magisterium in the latest statement in this regard sums up the issue well: "Life is a gift of God, and on the other hand death is unavoidable ... Death marks the end of our earthly existing but at the same time it opens the door to immortal life. Therefore, all must prepare themselves for the event in the light of human values, and Christians even more so in the light of faith."25
1. Patrick Senay, "Biblical Teaching on Life and Death," in Donald McCarthy and Albert Moraczewski, eds., Moral Responsibility in Prolonging Life Decisions, Pope John Center, St. Louis, 1981.
2. "Relectio IX; de Temperentia," Relectiones Theologicia, 1587: cf. Relecciones Teologicas, edition critica, Madrid: Imprenta La Rafa, 1933-35, Vol. III. The Relectio was a lecture that Vittoria, the preeminent theologian at the University of Salmanca, Spain, would give at the beginning of the school year. These lectures always treated a difficult, contemporary ethical issue. For example, he considered the rights of the natives in the New World, the rights of the Spanish to convert the natives, the norms for international law, and other timely topics. Hence, we may presume that in his time the question of prolonging life was as disputed as it is in our time.
3. "Relectio IX; de Temperentia."
4. Daniel Cronin, The Moral Law in Regard to Ordinary and Extraordinary Means of Conserving Life, Gregorian, Rome, 1958.
5. The use of the terms increased in the seventeenth centuly. D. Banez (1604) speaks about extraordinary means being optional. By the time of Cardinal de Lugo (1660), the terms "ordinary" and "extraordinary" are firmly in place.
6. Congregation for the Doctrine of the Faith, "Declaration on Euthanasia," (June 26, 1980) Origins vol.10, n. 10 (August 14, 1980) p. 154-7.
7. Gerald Kelly, "The Duty to Preserve Life," Theological Studies, June 1950, p.218.
8. Pope Pius XII, "Prolongation of Life," The Pope Speaks, vol.4, 1958, p.343; Congregation for the Doctrine of Faith.
9. Joseph Mangan, "An Historical Analysis of the Principle of Double Effect," Theological Studies, vol. 10, 1949, pp.40-61; John Connery, "Catholic Ethics: Has the Norm for Rule Making Changed?" Theological Studies, June 1981, p.232.
10. Leslie Rothenberg, "The Dissenting Opinions: Biting the Hand That Won't Feed," Health Progress, December 1986, p.38.
11. Patricia Brophy vs. New England Sinai Hospital, Inc. (Mass. Sup. Jud. Ct. Sept. 11, 1986). "In certain thankfully rare circumstances the burden of maintaining the corporeal existence degrades the very humanity it was meant to serve. The law recognizes the individual's right to preserve his humanity, even if to preserve his humanity means to allow the natural processes of a disease or affliction to bring about death with dignity."
12. Thomas O'Donnell, SJ, "Comment," Medical Moral Newsletter, February 1987, p.7.
13. Pope Pius XII.
14. Gary M. Atkinson, "Theological History of Catholic Teaching on Prolonging Life," in Donald McCarthy and Albert Moraczewski, eds., Moral Responsibility in Prolonging Life Decision, Pope John Center, St. Louis, 1981.
15. Pope Pius XII.
16. E. Pellegrino and D. Thomasma, For the Patient's Good, Oxford Press, New York, 1988, p.73.
17. Congregation for the Doctrine of the Faith.
18. New Jersey Catholic Conference Brief, "Providing Food and Fluids to Severely Brain Damaged Patients," Origins, January 22, 1987, p.582.
19. See Footnote: "Testimony of American Society of Neuro-Surgeons," p.l2.
20. While the most recent regulations from the federal government concerning cure for debilitated infants may allow, through a generous interpretation, consideration of the burden to the parents, the first two sets of norms (which were later declared unconstitutional by federal courts) did not allow for consideration of this burden. Clearly, the interpretation of "grave burden" on the part of parents had led to the violation of rights on the part of some debilitated infants such as Baby Doe in Indiana, but rights are not protected and equitably decisions are not fostered by means of unethical laws and/or regulations. See Federal Register, May 18, 1987; Jan. 12, 1984; April 15, 1985.
21. "David the 'Bubble Boy' and the Boundaries of the Human," Journal of the Arnerican Medical Association, Jan. 4, 1985, pp.74-76.
22. Congregation for the Doctrine of the Faith.
23. "Statement on Uniform Rights of the Terminally Ill Act," Origins, June 26, 1986, p.222.
24. New Jersey Catholic Conference Brief.
25. Congregation for the Doctrine of the Faith. The Catholic Health Association of the United Stales is the national organization of Catholic hospitals and long term care facilities, their sponsoring organizations and systems, and other health and related agencies and services operated as Catholic. It is an ecclesial community participating in the mission of the Catholic Church through its members' ministry of healing. CHA witnesses this ministry by providing leadership both within the Church and within the broader society and through its programs of education, facilitation, and advocacy. This document represents one more service of The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-0889, 314427-2500