ANOTHER IDENTITY CRISIS - Catholic hospitals face hard choices.

Case One. James Michener reports a conversation in Spain some decades ago. He asks about public hospitals and discovers there are none. All hospitals are church-operated. The idea of public hospitals astounds his Spanish friend. "You mean the government taxes you for what the church gives us? Tell me, would sensible men trust politicians to run a hospital? The church you can trust." Of course, in many parts of the United States at that time, Catholic hospitals did serve as the primary health-care providers, offering free or low-cost medical care.

Times change. Catholic hospitals still supply significant services (about 15 percent of all community hospital beds), but at prices as high as-and in settings often indistinguishable from-their public and other private counterparts.

Case Two. In a 1995 statement on the "Rationale of Catholic Health Care," the bishops of New Jersey stress its sacramental character and centrality to the church's mission. They also call attention to "forces which imperil the identity and integrity" of the ministry, including "market forces that gauge the effectiveness of health-care delivery solely in terms of profitability."

Prophetic statements sometimes are ignored. In August 1999, Modern Healthcare, the health-care industry weekly, reported the departure of top executives from Catholic Healthcare West, the fifth largest Catholic hospital system, after an aggressive market-based expansion strategy brought losses of hundreds of millions of dollars.

Case Three. Imagine being admitted to a Catholic hospital for serious surgery; or imagine that you are taking your elderly mother to a Catholic nursing home. What might you see that reassures you, that quickens your spirit in the midst of anxiety? Crucifixes surely; statues of the Virgin or saints quite likely; a chapel. What you will not see are the women religious who formerly dominated the daily life of the institutions they founded and who incarnated its Catholic identity.

Now take away your sense of sight. What will you hear, taste, touch, or smell that identifies this hospital or nursing home as distinctively Catholic? Will the words spoken on admission differ from those in a secular institution? Will the employees handle your mother physically in any different way?

Arguably, the sacramental and incarnational aspects of Catholic life inform Catholicism's distinctive quality. Yet our imagined admission episodes above-and our actual daily experiences in Catholic health-care institutions-may lead us to wonder whether this quality persists in the corridors, patient rooms, admission offices, and surgery suites formerly suffused with Catholicity. We might ask: If the facilities are not clearly sacramental, might it not be time to transfer the resources invested in them to more distinctively Catholic healing missions?

None of this is news to Catholic health-care leaders, to bishops, to well-informed lay persons, or to patients. Catholic identity is as hot a topic in health care as in higher education, the arena where this issue is most prominently addressed in Commonweal and other journals of opinion. The health-care world parallels higher education in its debate over the 1990 apostolic constitution Ex corde ecclesiae, and the nation's bishops have been drawn into hospital identity questions as surely as college campus issues. Bishops in Saint Louis, Chicago, Austin, and other cities have wrestled with plans for mergers and affiliations between Catholic and non-Catholic institutions, and with controversies over contraception and sterilization services in newly created systems.

As with colleges and universities, local bishops seldom own the health- care institutions in their dioceses. Yet they are held accountable by Rome and in the public mind for these institutions' fidelity to the church's moral teachings and for the question of whether the values of the marketplace and the medical profession, rather than Catholic ideals, control the institutions. Just as Catholic colleges and universities opted for lay boards and administrators in the 1960s and 1970s, so, some years later, did the religious orders that had established and maintained Catholic health-care institutions relinquish their control. Just as colleges and universities abandoned doctrinal requirements and hired lay, often non-Catholic, faculty attuned to the principles and incentives of national academic disciplines, so too Catholic hospitals now hire lay and non-Catholic administrators whose professional ethos is the business culture that pervades their profession.

Catholic health-care leaders themselves are attuned to the problems these developments pose. In June 1999, the assembly of the Catholic Health Association (CHA), for example, featured panels on Catholic identity, "sponsor leadership," relationships between bishops and laity, and "sustaining identity in other-than-Catholic partnerships." While the assembly devoted attention to other topics-social justice, meeting the health needs of the poor, and national health-care reform-it is a sign of crisis when identity questions consume so much of an organization's energy.

Catholic health-care institutions have ridden out many storms over the last century and a half, and have proved unusually resilient. The reputation, medical quality, and financial picture of most remain solid. Yet there is pervasive anxiety in the hearts and minds of Catholic health-care leaders: They worry whether elegant principles can survive the heat of operating rooms, admitting offices, and nurses' stations; whether increasingly lay and non-Catholic executives and boards can adequately replace the women religious whose orders founded their organizations; whether institutions that serve largely non-Catholic patient populations and that increasingly rely on precarious Medicare and Medicaid funding can remain committed to a unique Catholic mission.

efenders of Catholic health care argue that Catholic hospitals are a vital part of the medical system, providing the highest quality of care to patients, funding substantial charity care for the uninsured, and furnishing advocacy leadership for universal health-care coverage. Further, Catholic institutions keep vital principles before the public- the protection of life, commitment to social justice and the common good, service to the poor-principles all too likely to be lost in society's contradictory double quest for medical miracles and cost containment.

Moreover, real change is taking place in Catholic institutions. One example is Campaign 2000, the CHA's commitment to place health-care reform at the top of the agenda for the 2000 elections and to develop a national consensus during the next three years on accessible and affordable health care for all Americans. Catholic health-care institutions now have alliances with housing, youth and family, education, and anticrime initiatives, often in association with Catholic Charities agencies or with other Catholic and non-Catholic community organizations. They cooperate in campaigns against assisted-suicide initiatives, and they commit themselves to measurable goals for indigent care and assistance to local communities.

Yet these initiatives have their limits. First, the institutions undertaking them harbor all of the internal tensions in the church itself: divisions between liberal and conservative Catholics, the phenomenon of "cafeteria Catholicism," and the assumed irrelevance of the church's moral teachings to many self-identified Catholics. Additional internal tensions stem from friction over Catholic labor teachings and the response of Catholic institutions to labor organizing (see sidebar).

Second, the more committed Catholic health care is to delivering high- quality, advanced medical care, the more it must wrestle with medicine's technological ambitions-the illusion of life without suffering, the denial of death, the pipe dream of pharmacological or surgical solutions to aging, and the consequent spiraling rise in health-care costs. Modern medicine worships at the altar of research, development, and the market; Catholicism worships elsewhere.

Theologian Edward Schillebeeckx contended that the church is the "earthly representation of the sign of salvation in heaven." With Vatican II, the church rediscovered its own sacramentality: As Christ is the sacrament of God, so the church is the sacrament of Christ. Catholics, therefore, are a sacramental people and the Eucharist is the center of Catholic life. Signs and symbols-tangible, visible, and audible-tell Catholics who they are and identify the church to non- Catholics.

Principles like justice, freedom, respect for life, human dignity, and the common good are vital to Catholic faith. Nevertheless, they are both too abstract and too generic to form a distinctive Catholic identity, whether in health care, education, or parish life. They must "find flesh," become incarnate, in words, gestures, and ambiance. A case in point: Because breakfast is often the only meal cancer patients enjoy, Calvary Hospital in the Bronx, New York, goes to great lengths to insure that patients do so. Each floor of the hospice has its own kitchen, where breakfast is prepared. Residents can smell the aromas of sizzling bacon and fresh-brewed coffee from down the hall before they ever see their meal. This sensitivity to patients' needs expresses something distinctive, admirable, and generous about the Catholic way of doing things. Unless such a sense is palpable and routinely noticeable in Catholic health-care institutions, the institutions fail the "identity challenge" of what makes them distinctly Catholic, even when they meet their medical and economic challenges successfully.

iven these challenges, what should those charged with maintaining and broadening Catholic health care in the new century do to ensure its Catholic quality and character? Here is a brief set of recommendations.

* First, internal reform of the Catholic hospital should move it away from strict adherence to the culture of medical technology. This is not to deny that millions of persons benefit from the advances of medical science. But medicine itself, as the Institute of Medicine reported last year, can be pathological as well as curative. Thus, Catholic hospitals in particular should practice a studious skepticism about technological "progress" in contemporary medicine, and should make it clear that they exist to care for the whole person, not to propagate the latest "medical breakthrough."

In the last decade, birth care in hospitals has become more family- centered and less "medical." Catholic hospitals should devote substantial resources to developing similar types of care that underscore the Catholic understanding of life and death, not only for patients but for their families. For example, in the future hospitals should restructure intensive-care units to allow families more access to their loved ones. Stories about Catholic facilities indistinguishable from their secular counterparts, though, are all too common. With trends that include shorter hospital stays and the fragmentation of care between ever more specialized personnel, the task of incarnating Christ's healing becomes more urgent.

* Second, technological progress carries unintended consequences. Seat belts, air bags, and level-one trauma centers have all saved lives. Still, they have left many people chronically disabled and their families ill-equipped to cope, financially, psychologically, and spiritually. As Catholic hospitals have established or affiliated with rehabilitation centers, it is not at all clear that they have successfully integrated pastoral care or sacramental environments as part of their therapy regimes.

Similarly, surgical and pharmacological progress has preserved not only severely damaged infants but also thousands of disabled and demented elderly persons. The traditional (though only decades-old) nursing home has become the residence for many, a place nonetheless shunned (even when well-run) by many potential residents. In past centuries, Catholics were organizationally inventive enough to create religious communities like the Little Sisters of the Poor or the Hawthorne Dominicans that met new needs. Is it too much, too idealistic, to expect similar creativity today? It may be a stretch to expect creation of new religious institutes dedicated to a sacramental presence in rehabilitation, care for the mentally and physically disabled, and care for the elderly. Yet other forms of institutional creativity are both required and more realistic.

For example, Medicare and Medicaid reimburse only for home-care visits that deliver a medical service-yet often the patient's real need is for conversation, help with housework, or support for family caregivers. These services are sacramental in character, not strictly medical. Because they cannot be reimbursed, the agencies are reluctant to have nurses and aides provide them. Suppose, however, that a Catholic home- care agency were always to send a team on its visits, where one person is the medical caregiver and the others are volunteers recruited from local parishes. Suppose Catholic hospitals, nursing homes, and other institutions were to unite to ensure the financing and training necessary so that every parish could establish a parish nurse program? Parish nurses already work with health-care institutions, parish staffs, and parishioners, not only to meet physical health needs but to integrate spiritual, emotional, and sacramental healing. This model could be expanded.

* Third, the new American culture paradoxically blends a "winner-take- all" economy, the Reagan-Clinton model of what John Paul II calls "superdevelopment," with pockets of intense poverty. Each produces new casualties, who find themselves (voluntarily or not) in medical or quasimedical settings-addiction treatment centers, mental-health facilities, shelters for victims of family abuse, and counseling programs. Clearly, the church must challenge the economic conditions that help produce such injuries, while simultaneously creating health- care institutions that recognize the spiritual dimension of these ills and the sacramental dimension of genuine healing of mind and spirit. The working poor and recent immigrants go without health insurance and are denied basic human rights to health care. Specialized clinics, operated by the church in locales where such devastation occurs, would appropriate institutional responses to new challenges. Washington, D.C.'s Christ House, Columbia Road Health Services, and Jubilee Housing, all inspired by the nondenominational Church of The Saviour, might serve as models.

* Fourth, given these developments, the hospital is no longer the central location of sacramentally oriented Catholic health care. But, the Catholic hospital is not an anachronism. It still provides critical and necessary medical care. In addition, Catholic hospitals are often the best sources of the financial capital and medical legitimacy required by new institutional forms.

Nevertheless, as indicated above, it may be time for the church to move more rapidly toward new types of institutions. If a hospital is Catholic only in name, residual history, or refusal to perform certain procedures, it may be time to sell it to the highest bidder and put the resources to better use elsewhere, meeting new needs with an institutional identity that is distinctively Catholic. If a Catholic nursing home, for example, is not actively seeking partnerships with local parishes to foster the development of new structures of sacramental care, it needs to rethink its reason for existence as a Catholic institution.

None of these recommendations should be interpreted as a call for Catholics to abandon hospitals or public-policy advocacy. On the contrary, Catholic health-care institutions and Catholic leadership in public policy are central in addressing social and policy needs. Yet, even if universal health insurance were enacted, Catholic institutions would have to serve millions of persons who would still fall between the cracks. And Catholic health care would still face a crisis of identity. The nation and the church will be ill served if Catholic hospitals and clinics survive merely as Catholic shells surrounding essentially secular medical institutions.

Sacraments are meeting places where we limited human beings taste unlimited love. They are signs of hope and sustenance, catalysts for growth and resolve. If Catholic health care has any purpose in the new millennium, it will be as the bearer of such a sacramental identity, of such a hope.

Clarke E. Cochran is a professor of political science at Texas Tech University in Lubbock, and a deacon of the Diocese of Lubbock.