In Defense of the Ethical and Religious Directives for Catholic Healthcare

Controversies concerning Catholicism and healthcare have been front page staples over the last few years. Currently, it is the ACLU is suing the United States Conference of Catholic Bishops on behalf of Tamesha Means, who suffered from an acute infection and tragically lost her baby. The lawsuit claims that Ms. Means was denied adequate medical care as a result of the Ethical and Religious Directives for Catholic Healthcare (ERDs), a set of directives promulgated by the Bishops to guide Catholic healthcare. The ACLU accuses the hospital of negligence by failing to offer termination of pregnancy as an option.  While the ERDs do forbid Catholic hospitals from discussing or suggesting abortion or the intentional termination of a pregnancy, this alone does not constitute medical negligence. Instead, this case provides an example for the way in which Catholic moral theology, especially through the principle of double effect, may offer greater public understanding of the guidelines that govern Catholic hospitals.

Ms. Means was 18 weeks pregnant when she suffered from a premature membrane abruption – her water broke. Within 72 hours of abruption, she delivered her baby who died after 2.5 hours.   There is much we do not know that would be needed to determine whether or not Ms. Means has a legitimate claim of negligence with respect to those aspects of her care (and the question of what information she was given regarding her condition). For example, was she given appropriate antibiotics and corticosteroids – which are the basic standard of care in cases of premature rupture of membranes? The answer is unknown as all of this information is protected by HIPAA.

When Ms Means returned to the hospital with a 100.4 fever and acute chorioamniotitis diagnosed, standard medical care involved inducing labor to remove the amniotic fluid.  The claim is that she was not induced or medically treated during the miscarriage because of the ERDs and that when questioned on the failure to induce in 5 cases; the Vice President of Mission Services referred to the ERDs. While each case must be evaluated individually, claiming the ERDs automatically prevent inducing labor is a misreading of the ERDs by failing to apply the principle of double effect.

At the heart of this controversy and lawsuit are the ERDs 45 and 47 which establish the guidelines regarding abortion and maternal fetal conflict. While ERD 45 offers an unequivocal prohibition of all directly intended termination of a pregnancy and all procedures “whose sole immediate effect” is the death of the fetus. It is ERD 47 which applies to this case:

 “47. Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.”

Considerable ink has been spilled as moral theologians, hospital ethicists, and healthcare professionals apply these two directives to complex and heart wrenching cases. Too often, the ERDs are attacked without attention to the entire set of directives for such cases. In this particular medical condition, one does not come to an impasse – early induction of labor even though it is before viability falls under the principle of double effect.

The Principle of Double Effect guides moral decisions where there is both a good effect and an unintended bad effect (this principle is central for both bioethics and just war theory). Healthcare ethicists Benedict Ashley, OP and Kevin O’Rourke, OP lay out four elements to double effect, which I then apply to this case

  1. The directly intended object of the act must not be intrinsically contradictory to the true ultimate goal of human life.  In this case, the goal/intention is to save the woman’s life.
  2. The intention of the agent must be to achieve the beneficial effect and as far as possible to avoid the harmful effects. Here, the intention is to remove infected amniotic fluid; one would save the child’s life if one could. If this rupture occurred post-viability both mother and child would be saved through the induction.
  3. The foreseen beneficial effects must be at least equal to the foreseen harmful effects. The moral value of the mother’s life equals that of the child’s life.
  4. The beneficial effects must follow from the action at least as immediately as do the harmful effects. It is the removal of the amniotic fluid/infection not the child’s death that is the means to save the woman’s life. In fact, the baby lived for 2.5 hours, a factor which supports the approach of the ERDs to consider both mother and baby as patients.

In many Catholic healthcare textbooks, the case of early induction due to serious infection (acute chorioamniotitis) is an example used to teach the principle of double effect in medicine. The ending of the pregnancy is neither intended nor the desired effect when treating a woman 18-23 weeks with acute chorioamniotitis.  The unborn child is not considered the pathogen nor was the child directly acted upon. In fact the child lived for 2.5 hours. The ERDs do not prohibit early induction in these cases of acute chorioamnionitis as it does not constitute a direct abortion.

Ms. Means illness, the death of her child, and the trauma she suffered are all great tragedies. There are many important questions to be raised by this case (failure to admit, informed consent, bedside manner, and others which must be examined for negligence) but the ERDs are not to blame. The ERDs are a morally and medically grounded set of directives to guide the important health ministries of Catholic groups (the complexity of their authority has also been addressed by Cathy Kaveny).  Much of the data being cited by the ACLU as evidence, if anything, indicates that while there is widespread knowledge that the Directives exist, familiarity and knowledge of them is ambiguous at best among clinical practitioners.

Failure to give the patient complete information about one’s condition is a serious breach. Failure discuss abortion does not constitute medical negligence and the ERDs do not provide for an easy scapegoat for the ambiguities of this complex case. The ACLU and others are concerned with the growth of Catholic healthcare and in this battle – it is disheartening to see the pain and suffering of a grieving mother being exploited. For those so unhappy with the ERDs and Catholic healthcare, it is worth pointing out that the ire and indignation too often only extends as far as suing Catholic hospitals and not to providing alternative healthcare institutions for under-served populations.

Around the Web

Check out these recent articles from around the web:

Evaluating the status of the Millennium Development Goals by Kevin Clarke, US Catholic: “There will be much more to do after 2015, but for the first time in human history a serious case can be made that extreme poverty and the degradations and suffering which accompany it may be eliminated in our lifetime. And with a prophet like Pope Francis urging us on, much that had seemed implausible suddenly appears joyfully attainable— even inevitable.”

‘Massive evidence’ links Syrian regime to war crimes, U.N. official says by CNN Staff: “A United Nations fact-finding team has found “massive evidence” that the highest levels of the Syrian government are responsible for war crimes in the nation’s long-running civil war, the U.N.’s human rights chief said Monday.”

Mexican bishop takes on cultish cartel in drug war battleground state by Joshua Partlow: “This has been the bloodiest year since 1998 when it comes to drug violence here in the state of Michoacan. For Miguel Patiño Velazquez, a 75-year-old bishop with a white frock and dark circles under his eyes, it is time to speak out.”

How to debate the ‘undebatable’ falsehoods about Social Security by Michael Hiltzik: “But for all their chattering about Social Security’s insolvency, it’s their arguments that were bankrupt.”

9 Reasons ‘Hookup Culture’ Hurts Boys Too by Ryan Sager: “As Wiseman writes, we assume that boys are the perpetrators and beneficiaries of hookup culture — and thus we tend to ignore its effects on them. But those effects, it turns out, can be rather rough.”

Cuts to SNAP devastating to Miss. families by Greg Patin of Catholic Charities: “Recent federal cuts to nutrition support programs such as SNAP, formerly known as food stamps, have worsened the suffering of the hundreds of struggling Mississippi families we help each day. On Nov. 1, the average SNAP benefit fell to just $1.40 per meal, spurring more demand for our services and stretching us to capacity.”

Photos show scale of North Korea’s repressive prison camps by CNN: “North Korea is showing no signs of scaling back its fearsome labor camp system, with torture, starvation, rape and death a fact of life for tens of thousand of inmates, according to human rights group Amnesty International.”

What President Obama Missed in His Inequality Speech by Anna Sutherland: “At the end of his speech yesterday, President Obama mentioned the role of parents, civic organizations, religious leaders, and businesses in rebuilding an economy of open opportunity. Next time, he should also mention marriage.”

Protests Nationwide Seek Living Wage by Kevin Clarke, America: “Today’s fast-food worker, according to a report by the University of Illinois and the University of California, Berkeley, is typically over 20, often raising a child, and just under 70 percent are the primary wage earners in their families. According to the study, 52 percent of full-time fast food workers qualify for federal assistance at a cost to taxpayers of $7 billion a year.”

Does Your New Health Plan Cover Abortion? by Grant Gallicho, Commonweal: “Before the president signed the ACA, he devoted a lot of energy to addressing the concerns of prolife Democrats. Without their votes, the Affordable Care Act might not have passed. Supporters of Obamacare owe them a debt of gratitude. So does Obama. It’s time for the president to settle that debt.”

Marcel as Prophet by Fr. John J. Conley, S.J.: “The author who most impressed the students was Marcel. What struck them were not so much his famous theories of creative fidelity or of the difference between problem and mystery. Rather, it was his prescience as a social critic. In Man Against Mass Society (1955), Marcel took the measure of the culture of death that was incipient in postwar France but has since become part of our daily routine.”

Currency Crisis by Fr. Paul D. McNelis, S.J., America: “Although a breakup of the euro area is not out of the question, the better strategy would be to move forward and maintain the euro with a system of greater fiscal centralization. Clearly the European Central Bank has to harmonize bank accounting and regulatory standards across the system. For the euro to work, national governments will have to yield some—though by no means all—of their fiscal autonomy to a centralized Ministry of Finance in the euro system, much the way state governments have citizens paying direct and indirect taxes to the federal government.”

Hunger in America is a moral crisis that government must help solve by Nancy K. Kaufman and Gradye Parsons: “And it is precisely because the faith community is so involved in alleviating hunger that we support SNAP and other government solutions that reduce need and protect vulnerable people. Indeed, our faith traditions require a commitment, not only to personal charity, but also to systemic and communal justice.”

My shameful military pregnancy by Bethany Saros, Salon: “One of the stigmas attached to a female getting pregnant on a deployment is the assumption that she did it on purpose. It’s whispered about any time the word “pregnancy” comes up right before and during a combat tour. The unspoken code is that a good soldier will have an abortion, continue the mission, and get some sympathy because she chose duty over motherhood. But for the woman who chooses motherhood over duty, well, she must have been trying to get out of deployment.”

Responding to “Feminism at Fifty” by Sidney Callahan: “I think the present feminist movements are more diverse, since religious and ethnic women have taken more of a self-conscious part. There is also more awareness of the economic dimension of women’s need for work. Among educated women there is also a revaluing of marriage and family as important to their fulfillment. Many men are more feminist and cooperative. However, the sexual revolution and so-called hook up culture are bad news for men and women. Yet it is hard to tell the media hype from the real situation. I also think that the feminist pro-life movement has made some progress in the culture in changing women’s ideas about abortion.”

Pro-life, Anti-Maternity Care? I don’t think so

EJ Dionne asks, “If you’re a conservative strongly opposed to abortion, shouldn’t you want to give all the help you can to women who want to bring their children into the world? In particular, wouldn’t you hope they’d get the proper medical attention during and after their pregnancy?”

One would think that the obvious answer to each is “yes” or “of course.” For Christian Democrats, the strongest conservative party in a number of countries, ensuring that pregnant women and their children have access to quality healthcare is a top priority.

For pro-life Democrats here in the US, ensuring that pregnant women receive quality maternity care has been at the center of the movement’s agenda. As a Fellow at Democrats for Life of America, I have seen that pro-life Democrats (1) believe that access to universal healthcare is a fundamental human right; (2) genuinely care about the health and well-being of pregnant women; (3) care as much about preventing miscarriages and driving down the infant mortality rate as protecting unborn children from direct abortions; and (4) are committed to ensuring that pregnant women and their children have access to quality healthcare, as this will alleviate a tremendous concern for many poor and vulnerable women, which is good in and of itself, but also crucial in helping women to choose life.

So why are so many self-identified “pro-life” Republicans in the media and Congress opposing expanded coverage of maternity care and even mocking it? The biggest reason is that a large segment of the pro-life movement is not consistently or wholly pro-life. They are strictly anti-abortion in the sense that they want to prohibit abortion. Surely many think this is the best way to save unborn lives, but this limited approach is grossly inadequate compared to pro-life Democrats’ plan to secure legal protection for unborn lives, while simultaneously working to alleviate the conditions that lead many women (even those who consider themselves pro-life) to procure abortions.

What is behind the adoption of such a limited approach? Is it their conservatism? It is in fact their particular brand of conservatism, one infected by excessive individualism and radical libertarianism. This is clear when we consider the way health insurance works and why some pro-lifers support universal healthcare and others oppose it.

The reason that men need to contribute to the costs of maternity care, even though they will not get pregnant, is because it is so expensive. It is essential to share costs. This is the only way to ensure that all women and their unborn children are covered.

As Michael Hiltzik notes, cross-subsidies are common throughout Obamacare. It is the only way to ensure access to quality, affordable healthcare for the vulnerable, such as those with preexisting conditions who would otherwise struggle to pay for the treatment they need. We help to pay for things we will never need.

Christian Democrats accept this. Authentic compassionate conservatives accept this. Why don’t these Republicans in the media and Congress who consider themselves pro-life?

It is here where the individualism and libertarianism of the movement comes into play. Now we might not expect conservatives to find contemporary liberals’ arguments about enlightened self-interest compelling. Sure, many could hypothetically be persuaded that healthy women and children are good for society and that this will in turn benefit them. Alternatively, one could argue that women should not have to pay more for health insurance, simply because of their sex. One could point out that men play a fairly critical role in the pregnancy process, as both Hiltzik and Dionne do. Yet such arguments about fairness are unlikely to be compelling, as well, as this understanding of fairness is more generally associated with contemporary liberalism.

But what about conservative ideals? Conservatives are supposed to believe in community, in duty, in the common good. Yet these notions are often wholly absent from the rhetoric of right-wing pro-lifers or twisted by their fanatical hatred of government. Some are so anti-government that center-right proposals resemble communism in the alternate reality they have constructed, where they are the heroic defenders of liberty in a nation on the precipice of a descent into tyranny.

I have met extremely thoughtful and compassionate conservative pro-lifers, who have a strong sense of duty and commitment to their understanding of the common good. Unfortunately, pro-life Republicans of this nature are underrepresented in Congress. One is far more likely to find an Ayn Rand-loving man-child with a cultish devotion to the market and an ideology that is fundamentally selfish.

Sure they might praise private charity or philanthropy. Some even spend their time or money on these for non-cynical reasons. But at a fundamental level, they lack a commitment to duty—to protecting the most vulnerable in the most effective and comprehensive way. They lack a real commitment to the common good. Individual rights trump community. Individual rights trump human dignity. Individual rights trump human life.

If the pro-life movement will succeed in its goals, it is essential that these radical individualists move from the core to the periphery of the movement. Only a bipartisan movement of pro-life Democrats and genuine compassionate conservatives can deliver real success. This means the pro-life movement must do more to support pro-life Democrats and to challenge the growing strength of individualism and libertarianism within the Republican Party and the pro-life movement itself. The question is: will the movement figure this out before it’s too late?

Around the Web

Check out these recent articles from around the web:

New Front in the Fight With Infant Mortality By Eduardo Porter: “Pregnant women, across the country and anywhere along the income spectrum, will for the first time have guaranteed access to health insurance offering a minimum standard of care that will help keep their babies alive.”

A Call to Moral Theologians: Biotechnology Needs More Attention by Brian Green, CMT: “Hurlbut’s overarching point of was the importance of moral reflection on our growing biotechnological power. Calling cloning and stem cells issues that have the genuine power to change the course of civilization, Hurlbut emphasized the importance of engaging these issues in the right way, because once a path is chosen we may effectively become locked in to the moral outcomes.”

High-School Sports Aren’t Killing Academics by Daniel H. Bowen and Collin Hitt: “Despite negative stereotypes about sports culture and Ripley’s presumption that academics and athletics are at odds with one another, we believe that the greater body of evidence shows that school-sponsored sports programs appear to benefit students. Successes on the playing field can carry over to the classroom and vice versa.”

Why Russia Is Growing More Xenophobic by Ilan Berman: “More and more, Russians from across the political spectrum are identifying with (and organizing around) a national identity tinged with racism.”

Lead Still Major Problem Worldwide by Kevin Clarke, America: “Even though lead poisoning is entirely preventable, lead exposure causes 143,000 deaths and 600,000 new cases of children with intellectual disabilities every year, according to the World Health Organization (WHO).”

Vatican Insider Interview with Bishop Robert W. McElroy: “The statements, the actions and the gestures of Pope Francis have illuminated the scandal of global poverty not with harshness, but with a gentleness of truth that stirs the conscience to recognize realities that one already knows, but prefers not to recognize.”

Don’t abandon the women of Afghanistan By Paula J. Dobriansky and Melanne S. Verveer: “The international community must work to ensure that women’s gains in recent years are protected and that Afghan women continue to make political and economic progress. Any future support for the country’s government must be explicitly tied to continued defense of equal rights and continued progress of female citizens.”

Remembering Genocide in Kigali by Kerry Weber: “Perhaps one of the most notable characteristics of the Kigali Memorial Centre is its simplicity: a small fountain; a stone courtyard; some gardens, with water fixtures flowing through them. And the long, brown slabs of brick marking the graves of 250,000 of the men, women and children who died in the 1994 genocide in Rwanda.”

Vatican’s media adviser offers ‘Top 10′ ways to understand Pope Francis by Carol Glatz, CNS: “No matter how some media may want to spin it, Pope Francis won’t fit into the political categories of left or right, and he will challenge everyone with the truth of the Gospel, said the Vatican’s media adviser.”

When We Don’t Feel Like Loving Our ‘Loved Ones’ by Michael Wear: “In some areas of Christian culture, our vision of loving the stranger is expanding while our vision of loving those closest to us is restricting.”

Assad’s War of Starvation by John Kerry: “The world already knows that Bashar al-Assad has used chemical weapons, indiscriminate bombing, arbitrary detentions, rape, and torture against his own citizens. What is far less well known, and equally intolerable, is the systematic denial of medical assistance, food supplies, and other humanitarian aid to huge portions of the population. This denial of the most basic human rights must end before the war’s death toll — now surpassing 100,000 — reaches even more catastrophic levels.”

A Preferential Option against the Poor

The Republican Party’s slide to the right reached an embarrassing point this week. On Thursday, House Republicans attacked food security by voting to pass deep cuts ($40 billion) in the Supplemental Nutrition Assistance Program (SNAP).  Yesterday they voted to gut the Affordable Care Act, a policy that would leave millions without health insurance and result in tens of thousands of deaths.

Jonathan Chait accurately describes the current agenda of Congressional Republicans: “to repeal Obamacare without a replacement, maintain short-term austerity, weaken labor laws, loosen financial regulation, and defend every tax deduction enjoyed by the affluent.” This is basically the inverse of Catholic social teaching, a preferential option against the poor. To be fair, it’s an assault on millions of middle-class Americans as well.

How did Congressional Republicans end up here? What happened to the belief that those who work hard and fulfill their responsibilities should be able to provide for their families? Do Republicans really believe that those who are incapable of working should not receive any assistance from the government?

Why are Congressional Republicans so extreme and plutocratic? The single most important reason is the corrosive impact that money has in our electoral system. Fundraising has become the primary job of members of Congress, and the economically powerful subvert democracy and the common good for personal benefit. It is possible that Republicans will halt this march to the right in order to win national elections or for some other reason, but until real campaign reform passes and is upheld by the Supreme Court, wealthy interests in both parties will successfully promote agendas that contradict the common good. Only then will we have a chance to end the Second Gilded Age.

All Catholic Bishops Must Act on Medicaid Expansion

Bishop Paul Swain of the Diocese of Sioux Falls, SD is out of step with the official stated position of the U.S. Conference of Catholic Bishops, which affirms that “health care is a basic right flowing from the sanctity and dignity of human life.”  In the battle over Medicaid expansion, Bishop Swain chooses to remain steadfastly on the sidelines.

The bishop’s silence betrays the pressing need to act on behalf of the “least among us”—those who will suffer without the promise of accessible and affordable health care.

Where a leadership void exists, millennial Catholics should fill it.

Our faith is grounded in a man who went about healing those with no food, no shelter, and no hope for being healed elsewhere.  Our generation is primed for civic-mindedness and social activism.  We must demand a level of public engagement from the Sioux Falls Diocese and others across the country on crucial life issues like basic healthcare for all, especially the poor.

I am calling on Catholics in South Dakota to make their voices heard, but I also urge fellow millennials to bring focused energy to bear where their dioceses are unresponsive to the cries of the very ones whom Jesus came to help.

Here is the immediate background:  A ruling by the U.S. Supreme Court in June 2012 leaves the choice of expansion of the federal-state Medicaid program under the Affordable Care Act up to each individual state.  So far, about half of the states have announced their intention of participating in expansion, while 19 states have either declared they will not participate or are leaning toward not participating.  Four states are currently pursuing alternative models.  States can choose to opt in or out of Medicaid expansion at any point. Though the federal government covers 100% of the expanded Medicaid benefits from 2014-2016, this gradually drops to 90% in subsequent years.  The smaller administrative costs for expanding Medicaid will be shared equally between federal and state governments.

In late 2012, South Dakota Gov. Dennis Daugaard announced his intention to reject federal funding to increase health coverage for low-income citizens in his own state.  Expansion of the Medicaid program in South Dakota would result in health coverage for as many as 48,000 low-income citizens.  A push for expansion during the 2013 state legislative session was unsuccessful and the issue was not put to a vote.

When questioned by local reporters and Catholic social justice advocates, Bishop Swain has so far refused to endorse the expansion of Medicaid in South Dakota.  And while each bishop and his diocese are free to operate with relative autonomy, Bishop Swain is decidedly at variance with the U.S. Conference of Catholic Bishops, who wrote in a 2009 letter to the U.S. Senate:

The bishops support the expansion of Medicaid eligibility for people living at 133 percent or lower of the federal poverty level. The bill does not burden states with excessive Medicaid matching rates. The affordability credits will help lower-income families purchase insurance coverage through the Health Insurance Exchange.

Furthermore, dozens of Catholic bishops across the country have themselves publicly and vigorously supported Medicaid expansion.  Bishop Swain’s abdication of moral leadership is unacceptable for such a visible Church figure, especially on this urgent life issue.

The U.S. Bishops produced a guide outlining Catholic political responsibility entitled Forming Consciences for Faithful Citizenship: A Call to Political Responsibility from the Catholic Bishops of the United States.  The bishops write, “Some question whether it is appropriate for the Church to play a role in political life. However, the obligation to teach about moral values that should shape our lives, including our public lives, is central to the mission given to the Church by Jesus Christ.”

This is why, for instance, in April 2012, the Bishops strongly condemned the U.S. House budget crafted by Rep. Paul Ryan (R-WI), writing a formal letter to lawmakers urging them to “resist for moral and human reasons unacceptable cuts to hunger and nutrition programs.”  They continued in the letter, “As pastors and teachers, we remind Congress that these are economic, political and moral choices with human consequences.”

And on the issue of care for the poor and the sick, the bishops are unambiguous, calling for “greater assistance for those who are sick and dying, through health care for all…the USCCB supports measures to strengthen Medicare and Medicaid.” Indeed, every Catholic bishop in the states of Texas, Ohio, Florida, Illinois, Arizona and New Mexico, among others, has publicly urged their governors to embrace Medicaid expansion.

In a letter to Gov. Rick Perry, for instance, the Texas bishops write:

Failing to care for the poor and vulnerable unnecessarily increases sickness, premature death, and needless suffering.  It would result in the unnecessary, untimely deaths of an estimated 8,400 low-income Texans every year.

The reality of health care funding is that when people are uninsured and cannot pay their bills, we all pay the price in higher private insurance premiums, overwhelming pressures on the local hospital districts and county government, and hikes in local taxes to cover the cost of uncompensated care.

We need to draw back for the benefit of Texans the tax dollars that Texans send to Washington.  Otherwise, other states will use our nation’s tax dollars to expand their Medicaid programs, while we continue to pay higher local taxes and insurance premiums to provide for uncompensated care.

The USCCB stresses in Forming Consciences, “In the Catholic Tradition, responsible citizenship is a virtue, and participation in political life is a moral obligation.” The Catechism of the Catholic Church itself makes clear, “It is necessary that all participate, each according to his position and role, in promoting the common good.”  Since all Catholic bishops trace their origins to the apostles of Christ, bishops have a special role and responsibility in promoting the common good: to teach and to lead on critical moral issues in dire need of action.  Access to affordable health care is one of those urgent issues.

In Forming Consciences, the Bishops quote Pope Benedict XVI in Deus Caritas Est:

The Church cannot and must not take upon herself the political battle to bring about the most just society possible.  She cannot and must not replace the State.  Yet at the same time she cannot and must not remain on the sidelines in the fight for justice.

When criticized for remaining neutral on Medicaid expansion, Bishop Swain offered flimsy and inconsistent excuses.  The bishop has asserted, for example, that it is not his role to be involved in the political process.  Swain, who prior to converting to Catholicism served as Legal Counsel and Director of Policy for Governor Lee Sherman Dreyfus (R-WI), said on a Sioux Falls radio program in February, 2013:

Part of it is a difference of opinion in what the role of the Church is, of a bishop is.  And part of it is based on my past experience as a lawyer and working in government and having an understanding of the legislative process.  The teaching of the Church is that affordable health care ought to be provided for all.  And how that’s done is a challenge that people of goodwill can disagree on.  Medicaid is a fine way to do it.  But the details of it are beyond my personal understanding.  And so I’ll defer to those who are experts in the field, and particularly to our elected officials to figure out how to do it.

Speaking on special interests in the political process, he acknowledged that the Church has a role to play, but said, “We’re not a political part of that power in that sense.  So the Church sets principles based on the teachings of Christ.”

But the U.S. Bishops make clear in Forming Consciences that this is not enough.  They write:

…the failure to respond to those who are suffering from hunger or a lack of health care, or an unjust immigration policy are all serious moral issues that challenge our consciences and require us to act.  These are not optional concerns which can be dismissed.

Moreover, Bishop Swain’s claims of political abstinence are inconsistent with his own past behavior.  In 2006, he told cheering congregants that he would proudly vote for an abortion ban on that year’s ballot, along with a constitutional amendment banning same-sex marriage.  “…We must take stands on issues in the public sphere,” he told the gathered crowd, “when they touch the core of what we know by reason to be true and affect the salvation of souls.”

Leading up to the following election in 2008, Bishop Swain penned a public letter on that year’s abortion ballot issue—Initiated Measure 11—and distributed it to all the parishes within the diocese.  He wrote, “It is not for me to make judgments about political realities.  We must, however, respond to what is before us.”  And in a comment that seems uncannily analogous to his admittedly ambivalent views on recent health care legislation and regulations, Bishop Swain offered, “Sometimes morally flawed laws already exist.  In this situation, the process of framing legislation to protect life is subject to prudential judgment and ‘the art of the possible.'”

As for the salvation of souls, scripture tells the story of the Last Judgment (Mt 25:31-46), reminding us that we will be judged by our response to the “least among us.”  The Catechism of the Catholic Church teaches, “Those who are oppressed by poverty are the object of a preferential love on the part of the Church…”

So how does Bishop Swain explain his refusal to take a position on expanding Medicaid—a crucial life issue—when he has taken such firm stances on other political issues?

One approach was to claim that there was no bill to review.  He said in the February radio interview, “This particular issue there’s actually no bill written, and the lawyer in me and the old government official in me says I wanna read something before I endorse it.”

This is a red herring. With the exception of the four states seeking waivers to expand Medicaid using federal funds as premium assistance to purchase coverage for newly eligible beneficiaries, each state must simply decide—Yes or No—whether to opt in for Medicaid expansion under federal law.  The mechanism for how this is done is spelled out in great detail in the Affordable Care Act, which is easily available to the public via the internet as a downloadable PDF.  Bishop Swain should know this.

Next, the bishop alleges that health care policy may be used to restrict “freedom of conscience.” This issue, which numerous Catholics dispute now that various exemptions have been granted, is distracting him from the central issue at hand. First, adequate life-saving health care for thousands of low-income South Dakotans should not be held at the mercy of a culture war battle over contraceptives.    Second, let’s remember that broader access to health care reduces abortions, a clear concern of the bishop and all faithful Catholics.  Countless studies, such as this one from the Brookings Institution, make clear that expansion in states’ Medicaid programs will reduce rates of abortion, teen pregnancy, and out-of-wedlock childbearing. Whether one is focused on the primary task at hand of ensuring universal health coverage or the most important social issue, minimizing the number of abortions, the need to support Medicaid expansion is clear.

Every year, an estimated 26,000 to 45,000 Americans die because they lack health insurance. Surely, Bishop Swain’s commitment to life extends to caring for those whom Jesus loved most—the poor and the sick.

I understand Bishop Swain is a religious leader. One could argue that expanding Medicaid is merely a political issue. It is a political issue, but for Catholics, providing care to those in desperate need is fundamental to our faith.  This is not a time for our religious leaders to guard their political capital; it is a time to stand firmly on the right side of a moral issue.  A life issue.

While the Church labors to hold on to the devotion of members of all ages in America, it finds itself in an urgent struggle for relevance in the lives of an entire generation in particular. Such rigidity and aloofness on the pressing social justice issues of our time is a recipe for losing the millennial Generation.

The election of Pope Francis and his immediate change in tone and priorities for the Church are encouraging signs.  Francis has signaled a shift in focus toward social justice, a greater role for Catholic women, and even encouraged young Catholics to make a “mess” in their dioceses in the name of shaking up the old guard and spreading their faith.  Meanwhile, he has conspicuously chosen to deemphasize hardline rhetoric on Church doctrine related to social issues.  These are long strides in the right direction, but will enough American bishops and other clergy get the message?  That will depend, in large part, on how young Catholics respond.

We came of age in this new millennium.  We are the change we were waiting for.  And all around us we see what change looks like. We are defined by our diversity and tolerance, not by the moralistic culture wars that have characterized American politics for the past three decades.  We are focused and determined to lead America into a new civic era of pragmatic problem-solving.

That is why we call Bishop Swain and other Church leaders, silent in the face of losing crucial Medicaid funding, to expand their understanding of preserving life, to see that rejecting these funds amounts to a rejection of real life-and-death assistance for those who need it most.

Please join me in my insistence that Bishop Swain and other reluctant advocates add their voices to the dozens of Catholic bishops who do urge their state leaders to support Medicaid expansion.

Join me also in my hope that our Catholic clergy lead their flocks by embodying the social gospel that lies at the very heart of the life and ministry of Jesus Christ, who did not just talk about compassion, but showed it; did not just teach us about love, but was it; and did not just preach about taking care of the least among us, but did it.  Will we as Catholics follow in the footsteps of Christ our Lord through our actions?

Ryan Casey is a 2010 graduate of the Georgetown Public Policy Institute at Georgetown University.  He lives in Sioux Falls, SD.  You can follow him on Twitter @RyanCaseySD.