Journal of Religion and Health, Vol. 22, No. 4, Winter 1983

Philosophy in Religious Health Care Facilities R O B E R T J. W I L L I S , Ph.D. Why formulate a philosophy statement? ttow may this statement influence organizational life? Answers to these questions affirm the practical utility of a philosophy within a health care facility. In addressing the first question, consideration is given to the philosophical questions by whom, to whom, and for what purpose is the organization sent. Also considered are its purpose in relating to and mode of relating to its patients. The practical place of a philosophy is illustrated through the difference between for-profit and non-profit corporations. A close analysis of organizational structure, systems, and strategies details this difference.

ABSTRACT:

M o d e r n A m e r i c a s t a n d s as a m o n u m e n t to the practical. Our industrial m i g h t crosses e v e r y ocean, breaches e v e r y continent, influences e v e r y people. Our scientific genius unlocks, explores, and even controls the infinite e x p a n s e s of the v e r y large and the v e r y small. Our r e p r e s e n t a t i v e g o v e r n m e n t offers a compelling and successful vision t h a t has forever c h a n g e d the future possibility of political reality. " Y a n k e e k n o w - h o w , " " t h e P u r i t a n E t h i c , " " b e i n g on time," and " n e v e r w a s t i n g a m i n u t e " have joined h a n d s with " t h e a s s e m b l y line" and " t h e b o t t o m line" in building a t w e n t i e t h - c e n t u r y wonder of the world: the economic and social miracle of these c o r p o r a t e U n i t e d States. In such a n a t i o n w h y w o r r y a b o u t a p h i l o s o p h y ? In the d a y - b y - d a y s t r u g g l e with decisions t h a t echo r o u n d the world with incredible speed, it simply d i s t r a c t s : a relic from a slower-paced, less achieving, locally contained, and only m o d e s t l y influential Medieval society. A m i d the s c r e a m i n g reality of m o d e r n need, do we really have the l u x u r y to philosophize? W h a t practical use could such i m p r a c t i c a l a b s t r a c t i o n s have to professionals actually s t r u g g l i n g with the life and d e a t h issues of individuals, indeed of our planet? If m o d e r n success does not of necessity cancel ancient wisdom, then let us search for its a n s w e r t h r o u g h the s t o r y t e l l i n g ability of its Hasidic m a s t e r s : A woman came to Rabbi Israel, the maggid of Koznitz, and told him, with many tears, that she had been married a dozen years and still had not borne a son. "What are you willing to do about it?" he asked her. She did not know what to say. "IVIy mother," so the maggid told her, "was aging and still had no child. Then she heard that the holy Baal Shem was stopping over in Apt in the course of a journey. She hurried to his inn and begged him to pray she might bear a son. 'What are you willing to do about it?' he asked. 'My husband is a poor bookbinder,' she replied, 'but I do have one thing I shall give the rabbi.' She went home as fast as she could and fetched her good cape, her 'Katinka,' which was carefully stowed away in a chest. But when she returned to the f)O'-'~-4197 s 3 I :IO0-0H 95{)'-'.75

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inn with it, she heard t h a t the Baal Shem had a l r e a d y left for Mezbizh. She imm e d i a t e l y set out after him and since she had no money to ride, she walked from town to town with her ' K a t i n k a ' until she came to Mezbizh. The Baal Shem took the cape and hung it on the wall. ' I t is well,' he said. My m o t h e r walked all the way back, from town to town, until she reached A p t . A y e a r later, I was born." " I too," cried the woman, "will b r i n g you a good cape of mine so t h a t I m a y get a son." " T h a t w o n ' t work," said the Rabbi. "You heard the story. My m o t h e r had no s t o r y to go b y . " ' I n t h e s e h o m e l y w o r d s t h e m a s t e r t e a c h e s : life f l o u r i s h e s w h e n i n n e r inspiration moves one to give up control over one's treasures, when personal c o m m i t m e n t s t r e n g t h e n s o n e t o f a c e w i t h f a i t h t h e d e m a n d s of g r o w t h . I n order to grow, each person, each family, each community, each corporation must b e i n s p i r e d t o w a l k in q u i e t t r u s t i n t o i t s f u t u r e . W h e r e f i n d t h a t ins p i r a t i o n ? - - i n o n e ' s o w n s t o r y , in a v i s i o n t h a t u r g e s a c t i o n a n d b e c o m e s t h e m e a s u r e of m e a n i n g a n d s u c c e s s a n d p e a c e . T h a t v i s i o n a n d i t s s t o r y a r e a p h i l o s o p h y ; n e g l e c t i t a t o n e ' s p e r i l , n o u r i s h i t for r e n e w e d life. S o u n d a d v i c e , p e r h a p s . B u t d o e s a p h i l o s o p h y h a v e no p r a c t i c a l s i d e ? A s i d e from furnishing a distant ideal, can it be integrated into the dominant A m e r i c a n v i s i o n of c o n q u e r i n g t h e p r e s e n t ? Ancient wisdom speaks further: A f t e r the d e a t h of Rabbi Uri, one of his hasidim came to Rabbi B u n a m and wanted to become his disciple. Rabbi B u n a m asked: " W h a t was y o u r t e a c h e r ' s way of inspiring you to serve?" " H i s w a y , " said the hasid, " w a s to p l a n t h a m i l i t y in our hearts. T h a t was why everyone who came to him, whether he was a nobleman or a scholar, had first to fill two large buckets at the well in the m a r k e t place, or to do some other hard and menial labor in the s t r e e t . " Rabbi B u n a m said: " I shall tell you a story. Three men, two of them wise and one foolish, were once p u t in a dungeon black as night, and every d a y food and e a t i n g utensils were lowered down to them. The d a r k n e s s and the misery of i n l p r i s o n m e n t had deprived the fool of his last bit of sense, so t h a t he no longer knew how to use the utensils he could not see. One of his c o m p a n i o n s showed him, b u t the next day he had f o r g o t t e n again, and so his wise companion had to teach him c o n t i n u a l l y . " " B u t the third prisoner sat in silence and did not b o t h e r a b o u t the fool. Once the second prisoner asked him why he never offered to help." " 'Look!' said the other. 'You t a k e infinite trouble and y e t you never reach the goal, because every d a y d e s t r o y s your work. B u t I sit here and try to think out how I can m a n a g e to bore a hole in the wall so t h a t light and sun can enter, and all three of us can see e v e r y t h i n g . ' ' '~ 0nly through sustained and deep reflection may the light of the future be d i s c o v e r e d , m a y f u t i l e r e p e t i t i o n b e b r o k e n , m a y t h e o p p r e s s i v e n e s s of t h e enshackling present be lifted. Action without vision, no matter what its technical e x a c t n e s s a n d e x p e r t c o m p l e t i o n , no m a t t e r w h a t i t s o b e d i e n c e t o t h e m o s t minute detail, leaves the actor a prisoner of a decaying present. Without such r e f l e c t i o n , w i t h o u t s u c h a p h i l o s o p h y , t h e b e s t o n e c a n d o is e x t r a p o l a t e f r o m t h e p r i s o n o f t h e k n o w n m o m e n t t o t h e p r i s o n o f a l i k e f u t u r e m o m e n t , for o n l y

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in a philosophy do the ideal and the possible find the nourishment to overcome the death of each present moment. So may the ancients speak about the practical place of a philosophy, a life story, in our lives. Still, busy modern practitioners rightfully look for current reasons for putting valuable time, energy, and resources into developing a philosophical perspective within their health care facilities. Although open to diverse explorations, the issue may concretely be considered by addressing, in turn, these two questions: 1. Why formulate a philosophical statement? 2. How may such a statement directly influence organizational life?* The purpose of a statement of philosopy A philosophy, to be of practical use to an organization, should address itself to these five questions: 1. 2. 3. 4. 5.

By whom is the organization sent? To whom is the organization sent? To what in these people is the organization sent? For what purpose does the organization address these people? How will the organization in its work relate to these people?

Let us consider each of these questions in turn, and explore the implications each has for the field of health care. B y whom? Every organization is the expression of its founder. That founder--be it an individual, a group, a sector of society, or a society itself--stands forever in the background as a silent observer of and constant check upon the life direction and growth of the organization. In this sense "the founding" of an organization ends with the organization's death. Throughout the organization's life, however, many different "founders" leave their mark on its ever-changing relation to the world it serves. In a complex and long-lived .organization rarely may we speak of "the founder" in other than honorific terms; in reality, such an organization is sent by many founders during its life career. Take a Holy Cross hospital, for example. By whom is that organization sent? By Father Moreau, founder of the Congregation of Holy Cross; or by Mother Angela, founder of these American hospitals; by the whole congregation or by a particular province; by the Catholic Church or a particular diocese; by the people of modern America or by the residents of a particular city or by the people actually served by the hospital? Or by all of the above? Whatever the response, any hospital benefits by clearly recognizing its founders, its ongoing relation to them, and the priority of their influence and authority at any given period of its life. *A brief note: because of the limits of the a u t h o r ' s personal experience, explicit references t h r o u g h o u t will be to Catholic health care facilities. Facilities founded out of P r o t e s t a n t or Jewish t r a d i t i o n s - - w i t h appropriate t r a n s l a t i o n - - a r e e x p r e s s l y m e a n t to be included in the central t h e s e s of this article.

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Where lies the benefit in practice? An example may illustrate. If you are administering a large, inner-city Catholic hospital, and if your hospital admits primarily indigent and poor populations, you undoubtedly will be experiencing continuing pressure in a pluralistic country to give artificial birth control information, to perform sterilizations, to allow medical abortions. Quite obviously, all of these are, in varying degrees, disapproved of by the Catholic Church in its moral teaching and its apostolic hierarchy. But with a contradictory certainty the Catholic people of the United States in their consciences and by their actions do not hold to these moral teachings with the same absoluteness as the official Church. What do you do? Whom do you follow? Your decisions could be more easily made if you understood by whom you are currently being founded and sent, and with what priority. To w h o m ? When one thinks of hospitals and the field of health care, sick people immediately come to mind. Undoubtedly, the sick and disabled have traditionally been the recipients of whatever assistance health professionals could provide, and most would probably agree that they are still being asked to assist them. However, a question arises: Is the health care minister sent only to them? Is he or she restricted to the handling of the ravages of injury and disease and aging upon the human person? Over the past few years, increasingly health care ministers have talked about holistic and preventive medicine, service to the poor and needy, public health education, and even lobbying against unjust social structures that have an adverse effect on the health of a specific people or of the whole world. If health care ministers are only sent to the sick and disabled, then on what basis would a hospital refuse to set aside, at the Pentagon's request, hospital beds to be used in the event of a nuclear war in Europe? Or again, how relate a health care ministry to the divesting of stock supporting apartheid in South Africa, or exercising stockholder pressure against such corporate investment practices? If health ministers are today being sent not only to the sick and disabled, but also to the poor and needy and to the social structures that keep so much of our world in subhuman conditions, then public policy stances would be judged not only reasonable, but required. Indeed, one may wonder if an exclusive ministry to the sick and disabled may not today serve as a cloak of security and inaction in a horribly unhealthy world. Or to put the question sharply: when Israel invaded Lebanon, how many religious hospitals protested? If they did, why did they? If they didn't, why not? Really, it all depends on to whom you are being sent. To what? Quite obviously, health care ministers are called upon to address themselves to the suffering and pain of the sick, to the troubling handicaps of the disabled, to the fears and heartbreak of the dying and bereaved. That has been true traditionally, and few would dispute that it holds true today. Such a stance implies that wherever the human being suffers physical disruption, division, or handicap, there at least primarily if not exclusively does the health care minister turn. Behind this position we may recognize two different but compatible views, one philosophical, the other medical. Philosophically, the human being is considered to be living a kind of Cartesian reality, to be composed of a separable

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and distinct body and soul. Medically, the health care professional is required to restore physical health to a physically disrupted body. Where suffering and pain, disability and death alone attract the health professional, there do the Cartesian and medical models join hands and reign. In a recent rewriting of its heath care philosophy, the Sisters of Mercy Health Corporation of Farmington Hills, Michigan, specifically broadened its ministry in these words: " B y health, we understand not simply release from suffering and pain but also the development of human life: within the individual, between individuals, and within social structures. '':~ With this statement the Corporation directs member hospitals to address not only pain and suffering, but also the growth needs of individuals, groups, and even societies. No longer should they wait only for the signs of physical division before acting; by right and by d u t y they should direct their resources toward any area of human individual or social growth and development. Does such a philosophical position make any concrete difference? Here is an example: S M H C is a member of the New York-based Interfaith Center on Corporate Responsibility. As such it supports actions as diverse as 1) seeking to educate prospective tourists about the systematic repression of human rights in Guatamala, 2) gathering information on current infant feeding practices in Mercy hospitals with an eye to understanding the part they may unwittingly be playing in the questionable practice of stressing infant feeding by formula rather than by breast milk, 3) establishing institutional guidelines for socially responsible corporate investments. Only a philosophical perspective that addresses the whole of the human person and the ongoing healthy development of human society would make these and similar actions not just acts of social justice required of all Christians, but integral parts of their health care ministry. For what? If your philosophy of ministry directs you to suffering and pain, disease and disability, it does so in the cause of the cessation of suffering and the eradicating of pain, the curing of disease and the overcoming of disability. It seeks quite simply the return to normal bodily functioning and a sense of physical well-being. In actual practice, however, religious hospitals strive for more than this. Their pastoral ministers look to spiritual and psychological needs, and hope to be instruments of inner solace and peace. Their personnel departments are concerned not only with questions of satisfied employees or social justice, but increasingly with questions like "the formation of a hospital community." Their management teams put money, effort, and personnel resources into programs aimed at continuing education and the overall health of employees and their families. The question remains, however: are these practices espoused because of religious affiliation and sound management, or are they identifiably part of the health care ministry? For a hospital that considers the object of health care to be the growth and development needs of individuals, groups, and society itself, these practices would be intrinsic to the health care ministry. When Mercy hospitals affirm that "we dedicate our efforts to aid all persons in their striving for human wholeness--physically, spiritually, socially, and intellectually, ''4 they say to

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everyone they touch: " W e certainly value your normal bodily functioning and sense of physical well-being, but these grab only part of our attention. Your family life, your life as an employee, your intellectual and psychological growth, your movement toward God, concern us equally, as health care ministers." Why introduce your employees to flex time; why allow personal days and suitable vacations; why stress collegial management and encourage responsible participation in union activity: sound management, or an extension of the health care ministry? Why have a chapel and religious services, why employ pastoral ministers; why involve families of patients and employees in "the building of community": religious dedication, or a further expression of your health care ministry? Depending upon your philosophical position, upon the overall purpose of your health ministry, you will make daily decisions aimed at the return to health, the further development of human life, or both. H o w relate? The history of modern medical care parallels the development of our industrial and technological societies. Scientific discoveries have joined a growing technical genius to our abundant natural resources. The result: miracles! Medical care today serves more people than ever, and the profession daily expands its ability to overcome both the ravages of disease and the crippling effects of trauma. Indeed, even death has increasingly met its match: just look at the infant mortality rates and the longevity rates in this country compared, say, with forty years ago. Few would contest that for the good of the patient medical care today relates to diseased, injured, and deteriorating parts of the human body more efficiently and more effectively than ever in medical history. But is that enough? One thinks of the fabled surgical patient who complains: "The minister prayed for my soul, the nurse worried over my blood pressure, and the doctor put all his attention into removing my gall bladder. Who, indeed, was caring for me?" That complaint seems hardly fair if in losing his gall bladder, his body and perhaps his soul, were saved; that is, if your philosophy of health care directs medical professionals to relate skillfully and appropriately only to the bodily parts demanding medical attention. Complaints similar to this echo like ghostly accusations along hospital corridors: "I was treated like a thing": " N o one really cared about how I felt"; "I was never consulted about anything, nor could I get any straight information about what was happening to me"; "Their schedule and their convenience were clearly more important than me"; "Hospitals may be good places to be sick in, but they are awful places to get well in"~ "I was treated like a child who was expected to do only one thing: obey." Such complainers, at least implicitly, expect that health care professionals should relate not just to their bodily parts b u t to them as persons. Even when the person assumes the role of a more or less helpless patient, the personhood remains and rightfully demands respect. How might a hospital with an articulated philosophy view the antics of the macho physician of hospital folklore? It's morning rounds. Pursued by a gaggle of interns, he bursts into the patient's room. With hardly a nodded hello, he introduces the patient as "an interesting intestinal problem." With a minimal nod to modesty he abruptly exposes the patient's abdomen, probes

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gruffly at it, and proceeds to outline it in clinical detail to his group--interns to him, but strangers to the embarrassed patient. He may, indeed, teach clinical diagnosis brilliantly, but what else is required? If the hospital's philosophy affirmed the dignity and value of the person, if it spoke of dedication to the person and to the person's physical and emotional, spiritual and intellectual growth, then the physician who offends the person offends its ministry. Either this physician, brilliant or not, relates respectfully to this patient, this person, or he has no place in this hospital. As more specialized and more costly equipment--like the CAT Scanner, for example--becomes available in the treatment of disease, decisions must be made, priorities set. If resources go into this equipment, into its relatives and descendants, the number and quality of employees may need to be reduced. The possible result may be less knowledgeable, less capable, less secure people to relate to patients. Personal care gives way to effective care, effective care to efficient care, efficient care to the kind of care an automobile gets on an assembly line. Each part gets tended to, and somehow the thing comes out whole, but nobody--from beginning to end--touches the soul of the automobile, no one ever touches the person.

The place of philosophy in an organization Let us attend now to a second question: namely, how does a philosophy influence the shaping of and ongoing expression of the organizational milieu? We commonly distinguish modern corporations into general categories of profit and non-profit. Given t h a t both charge for services and both may make money, what essentially distinguishes the two? Do stockholders versus no stockholders, a board of trustees versus a board of directors, dispersed profits versus turning profits back into the corporation define the basic difference? Modern society furnishes us a clue in its varying treatment of the two types of corporations. Profit-making organizations pay the full range of taxes that support the various governmental treasuries, which in turn carry out programs for society's benefit. Non-profit organizations avoid this financial debt to society on the presumption t h a t they are already paying it. Their contribution to society does not consist simply in the services they provide {there are, for example, profit-making hospital enterprises furnishing essentially the same services non-profit hospitals do). Rather, they contribute services in support of a vision, as part of a philosophy, as a sharing in a way of living that they and society judge to be of potential benefit to them and others as well. The vision incorporated, lived, shared, forms the essential foundation of nonprofit status, not, as often is supposed, simply the type of services rendered. The corporate world of American business predominantly exists for one thing: profit. Although it may speak of a "philosophy of business," the term is employed analogously. Philosophy here means "our way of doing business"; it does not, as we have been discussing, consider philosophy as "a way of living" which is espoused by the corporation and which it earnestly desires to share with others. Precisely speaking, profit-making corporations have no philosophy if one understands philosophy as a way of life. Instead, such cor-

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porations substitute economic growth, whether as short-range or long-range goals, for a philosophy. This does not deny that other values (such as service to society, contributing to a better world, raising the standard of living, making America strong} may also motivate corporate activity. These, however, are held implicitly, subordinately, and are looked upon as wonderful ideals to be hoped for as long as the b o t t o m line continues to come out black, not red. Where goals substitute for a philosophy, and where goals equal profits, all aspects of the corporate milieu are shaped, altered, or eliminated as they in fact serve or hinder its profit goal. Indeed, corporate life so defined does not exist w i t h i n the corporation; it rather lives in the financial transactions between corporation and consumer. {This truth becomes painfully evident in times of severe recession, like today. The expanding deserts of business deaths, whether they lead to plant closings and employee layoffs or to the declaration of bankruptcy, are directly attributable to the drying up of the financial lifeblood of the seller/buyer exchange.} The corporation exists not in and for itself, not in order to realize some part of an envisioned reality, but rather as a kind of parasite attached to the life of the consumer relationship. In a non-profit organization, on the other hand, its philosophy assumes an essential and central position. Its philosophy is its life. The actual attaining of the organization's goals, the sharing of its vision with others through the services it provides does not, indeed, have any intrinsic relation to the organization's life. J u s t as long as the philosophy motivates those who live it to strive for the growth of the vision, the corporation may live. Only nonacceptance and non-actualization of the philosophy within the corporation will spell necessarily its death. (One has only to think, for example, of currently struggling religious congregations which are experiencing drastically declining membership. Gradually their services will need to be curtailed; eventually they may be little able to share their vision in and through these services. Yet the community will only die at the point when people are no longer willing to strive together to live their vision of life, their philosophy.} Figure #1 may illustrate the central life-giving function of a philosophy by contrasting two corporation structures, one profit-making, the other nonprofit.-' Notice that both share in common six organizational "s's": structure, strategies, systems, skills, staff, and style. They differ in the way these six are ordered, and in how they relate to one another. The profit-making business organizes itself so as to marshal resources for effective transactions with consumers. Three levels of organization order these resources. The most immediate--strategies--governs the way the business meets the consumer. In the event of declining profits, new marketing and sales strategies are usually explored as the first intervention to halt the decline. The next level consists of the business's prime resource for carrying out its strategies: its people. Continuing education, sales and marketing training, development of a particular interpersonal and business style shape these people into effective formulators and presenters of these strategies. Indeed, should strategic changes not prove effective in increasing sales, the staff are either changed, retooled, or trained to relate more effectively both within and without the corporation.

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Figure 1 A Structural Comparison of a Profit-Making and Non-Profit Organization

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The final level defines the boundaries of relationships and sets up the appropriate methods of interaction across these boundaries. A good administrator tampers with these, once established, only for serious reason and when addressing the previous levels has not adequately realized the organization's monetary goals. Radical change here may even touch the identity of the organization. (One may think of the merging of two businesses into one, or the joining of independent corporatons into a corporate system.) As drastic as this may sound, for a profit-making corporation that lives not for itself, whose meaning and purpose lie outside itself, its identity functions more as an identifying label than as a source of life. To lose such a label actually means little as long as this action eventually leads to expanding profits. In contrast, the non-profit corporation organizes itself around its philosophy. This philosophy offers the vision t h a t originally generated the corporation, t h a t continually sustains the corporation and motivates its ongoing activity, t h a t ties all parts of the corporation together, and t h a t ultimately determines how each relates to the corporation itself and to the people it serves. Unlike the profit-making corporation, it fails only to the degree that it ceases to reflect in all its parts and through its external transactions the ongoing striving to realize its philosophy. It has no goal, no bottom line, that must be accomplished in order to stay alive. Rather, it has a vision that must be alive in its members, that must exercise a constant influence on the interactions of those members, and that must be strong and healthy enough to motivate its members to share its life with others. In the remaining portion of this consideration of the influence of a philosophy on a corporation, we will observe individually and in some detail how a philosophy in a non-profit corporation may exercise an ongoing influence on three of the above-mentioned " s ' s " : structure, systems, and strategies. These three are chosen, not to ignore the others, but because modern business treats them as most influenced by profit. They, moreover, with some economy of words may underline how an articulated philosophy may touch all parts of an organization's life. In his recent work on governmental bureaucracy, Dismantling the Pyramid, Paul von Ward briefly, yet clearly, distinguishes structures and systems: "Structure primarily orders human relationships directly for the production of the organization's goods or services. Personnel systems determine the nature of individual ties to the overall entity. '''~ Any modern-day administrator has seen innumerable organizational flow charts in books, company reports, and on one's walls. They seek to fix organizationally and psychologically a place for everyone within the corporate milieu. In doing so, they spell out the "order of human relationships" with a special eye to authority, responsibility, and accountability. Given this division and positioning of power, systems are introduced as channels carrying power throughout the organization. Thus authority acts and is given; responsibility is assigned and taken; accountability is demanded and exercised. To put it simply, structure divides up and arranges power, systems direct the flow of power within and to all parts of the structure. Strategies complement structure and systems. Decisions made to touch a

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particular person or group inside or outside the organization bring systems from potential to action and infuse life into otherwise static structures. A homely analogy may add clarity. Kindly look at your hand. Notice its structure: attached to a wrist joint, it features predominantly a solid, yet mobile, structure Ithe palm) and an extremely flexible group of long, slender structures (the fingers) with a somewhat heavier, shorter, and less flexible structure opposite to them {the thumb}. This structure by itself is static. {Note that a dead man, simply by being dead, does not suddenly lose this structure!) Now, if you will, swivel your hand at the wrist, and bring your thumb and fingers together as if you were turning a screwdriver. You have just activated the static structure of your hand by using one of its various systems--in this instance a "turning system." You might have employed any one of a number of such systems (like bringing your thumb and spread-out fingers together without turning your wrist, as if you were kneading a rubber ball). You did not, however, because you have decided that the best available strategy for getting promoted lies in approaching your boss; you have just knocked on her door; having heard a welcoming "hello and enter," you now must turn the doorknob in order to carry out your strategy. (Just grasping the knob and kneading it like the aforementioned ball will not further this strategy.} Strategy, therefore, determines the choice of an appropriate system and activates its potential. And structure comes alive through the implementation of a specific strategy. Given this understaning, let us consider each of these in turn. Structure. Directly or indirectly many current hospital philosophies state, " I n our works we affirm the dignity and value of each person." How might that statement be structurally implemented? A person's dignity and value are actively affirmed in a work situation when-talents and abilities are recognized; jobs performed match them; organizational structures support and facilitate their optimum application; their ongoing growth and development lead to new jobs and a shifting of organizational structures to fit new levels of work capability. In general, talents and abilities may be attributed to four distinct groups of workers: 1. Technicians: those trained in procedures. 2. Specialists: those capable of setting up procedures and training others in them. 3. Craftsmen and professionals: those whose activities flow from a unique capability and result in personal expression. 4. Creative originators: those whose inspiration discovers or invents new activities and procedures. Does it really matter much to the employee whether he or she is considered

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to be in one group or another? Consider four common areas of organizational activity: setting of work norms, supervisory control, project planning, and performance evaluation. In complex organizations like hospitals each takes on a decidedly different look depending on the work category. Administrators commonly set specific parameters on work hours, break time, job productivity for their technicians. Nurses' aides, for example, shall clean a certain number of rooms between 8:00 A.M. and 10:00 A.M. Period! Specialists, like personnel in the x-ray department, also have administrative directives structuring their work; these, however, usually are based on optimum utilization of the equipment and the necessary response to patient need. But what administrator would dare to dictate the number of surgeries or the number of minutes per surgery to a medical craftsman? Or who could place reasonable work prescriptions around the thinking, research, and experimentation of pioneers like those who gave Dr. Barney Clark an artificial heart? For medical professionals and creators work norms can only come from the similar activity and received j u d g m e n t s of their peers. Depending upon one's group placement, supervision is radically different. Individual technicians can expect close and constant supervision by administration, with direct feedback on the quantity and quality of one's work. Specialists are ordinarily relieved of this ongoing administrative attention, but they will be told how their work measures up against resource utilization potential and hospital needs. The medical and nonmedical professionals are expected to be able to show a sometimes questioning administration how they have used hospital resources and helped to meet patient needs, but otherwise their supervision amounts to little more than a negative check against unprofessional behavior. Medical researchers usually gain little supervisory attention other than a general expectation that their activity somehow fits within the overall purpose of the institution. What shall be done and how shall it be done? Technicians are told specifically. Specialists receive specific goals that they may meet their own way. Professionals are urged to meet general goals of quality care, and medicine's creators are expected to "contribute to the growth of the field." Work autonomy--from "having a job" to "doing a good j o b " to "professing one's discipline"--comes with the work category. Finally, each group of workers is evaluated by very different standards. Technicians are expected to be responsible and efficient in getting the job done, and economical in their use of resources. Specialists must get the agreedupon tasks done expeditiously and well. Medical professionals will be measured by the standards of their profession and must be models of professional integrity. Medical researchers and creators are to contribute to the field by expanding and deepening the work of their predecessors through their independent and original efforts. Does it matter in which category a hospital places this or that person? Emphatically, yes! Quite clearly, an organization that philosophically affirms "the dignity and value of each person" acts ethically and congruently by placing each employee in the correct work category, by offering employees experience and training

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opportunities that may further work autonomy, by positioning administrators and supervisors appropriately for the given group. Not to do so stunts human growth, dries up motivation, and risks rising levels of employee frustration and anger. Hospital managers may note these and similar questions about philosophy and structure: 1. W h a t career advancement opportunities do you provide for housekeeping and dietary personnel, your technicians? 2. To what extent does administration allow department heads procedural freedom without direct administrative supervision? 3. Who evaluates your R.N.'s? Are they evaluated as professionals, based on peer group rating? 4. Do creative originators--in medical science, health care practice, applied administrative theory--have any place or freedom to create in your hospital? These and like questions could help a hospital to understand the shaping power of philosophy upon organizational structures. They could also stimulate a "philosophy audit" to determine the actual continuity between organizational philosophy and organizational structures. Systems. In its philosophical statement the Mercy Health Center of Dubuque, Iowa, speaks favorably of "participative management," which includes "colle~ality, subsidiarity, and accountability." In effect, it directs its administration to work through these systems to form a working community of management and staff. How, specifically, do these systems bring about such a community and lead to participative management? Upon entering a group, an individual immediately seeks to ascertain the appropriate rules of social interaction that define the kind and degree of intimacy allowed by the group. "Are we all business here? . . . . Must I make an appointment to speak with my supervisor? .... Are personal concerns legitimate topics of conversation?" The initial discomfort we all experience when first meeting " t h e g a n g " may be attributed to the need to answer this most pressing of questions: " H o w close may we be here?" Unanswered, this discomfort soon changes to fear as the spectres of negative judgment, disapproval, and rejection darken one's interactions. At this juncture, either the individual resolves the growing fear by physically or psychologically leaving the situation, or the individual makes use of communications systems already in place. Such systems may be as implicit and informal as the opportunity to see how others act or as explicit and formal as a written code of behavior. They serve the primary and essential function of introducing the newcomer into the group. Without these appropriate systems the group will itself soon shatter as its members search out other sources of interpersonal acceptance--in safety. Should the newcomer stay with the group--the intimacy question handled to an acceptable extent--a second question soon urges an answer. To join a group

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means a willingness to strive for group goals and meet group needs. One does so, however, only if one's own needs and goals may here find some satisfaction and accomplishment. Although the work place is not specifically the appropriate arena for personal development, it must afford such, to some minimally acceptable degree. Personally unsatisfied workers experience growing anxiety as their personal needs and goals go unmet. This anxiety soon drains away motivation. It leaves workers passive and indifferent to the group task, distracted by their own inner turmoil, and thrashing about inappropriately for personal assistance. In effect, their actions proclaim: " I f you deny the validity of meeting my needs and goals, I will deny the validity of meeting yours." Collegial systems offer a positive alternative to these personal denial responses. They legitimate personal perceptions, validate personal priorities, afford each the chance to strive for a personally acceptable work world. In the give-and-take of collegial discussion many personal needs are quieted: the need to be heard, to be accepted and valued, to be treated as an equal; the need to exercise one's abilities in a public forum, and to see them positively productive: the need to grow intellectually and emotionally through open and intense human interaction. Through such group action, moreover, goals of individual and professional advancement are offered, situations calling forth personal and intellectual expression stretch and deepen one's sense of oneself. Collegial management is often pressed for in the name of effective communication, or of getting the best information through the interaction and growth of diverse viewpoints, or of getting workers more readily to buy into the group's decisions. Rightly so, but let us not overlook its deepest meaning: the setting up of an environment where group m e m b e r s - - b y expressing themselves appropriately, capably, and effectively--may contribute to the group's growth and development while realizing the same in oneself. Here the "dignity and value of all persons" is seen in action. Such personal expression, however, must issue in group and individual behavior. H u m a n beings need not only to share but to influence, to see others acting differently in response to their talents and abilities. The strength of this need propels people first into discussion and persuasion, then demands and manipulation, finally into the ranges of physical and psychological violence. Or tension will be relieved by forming subgroups in which to be influential. Coalitions, alliances, cliques, and gangs inevitably issue from group situations denying influence to individuals. A case in point: modern workers' unions publicly may be espoused as a means of wresting j u s t concessions from management; personally they represent the individual's driving need to influence his or her world, to have a part in shaping it. John Paul II's recent encyclical "On H u m a n Work" proclaims anew the social right of workers to unionize, ~as does the U.S. Bishops' "Pastoral Letter on Health and Health Care. ''~ Both echo the call of John Paul II to honor effectively "the desire of employees to be treated as responsible men and women, able to participate in the decisions which affect their life and their future." "~ Hospital administrators today often argue quite reasonably against

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allowing unions into their hospitals. If the hospital's philosophy includes being sent by the Catholic Church, then there seems little room, however, to argue against systems of subsidiarity, systems that vest "decision-making authority and responsibility as close as possible to the point in the organization where the impact of the decision will be felt and at the point where persons are most competent to make the decisions." *~ Such systems give employees mechanisms in the work place to influence and shape their work world. Whether unions present the most appropriate forum for such influence in a given hospital may be arguable; that some such forum is humanly and philosophically called for is not. Finally, we face the question of identity: "Who am I to be here?" The most ultimate, most important question, unanswered it raises terrible frustration. And just as the adolescent identity crisis spawns outrages of fighting, resistance to authority, and various a t t e m p t s to gain control in the adult world, so employees unable to fit in with the organization, unable to identify the group's activity as their own, will be constant sources of disruption and irritation. Institutional coups d'dtat, palace rebellion, movements to remove authoritarian department heads or supervisors often have their source in this identity frustration. Accountability systems give a functional alternative to such social disruption. Through them appropriate responsibility is given and responsible behavior expected and evaluated. They demand also the assessment of individual talents, the matching of these to the needs and goals of the group, the availability of necessary resources, and the psychological space and trust needed for responsibility truly to be exercised. This also includes the reasonable possibility of failure, of not having the job done perfectly. It also, happily, opens up the opportunity for personal growth and an enhanced dedication to the life and goals of the organization. Strategies. Managers are forever planning. Profit and non-profit cotpotations alike expect them to search out promising paths into the future and to shepherd their movement from present reality to the ongoing realization of future possibilities. Since planning takes up so much of corporate time and managerial resources, it seems an ideal candidate to consider as a strategy in relation to philosophy. It also may demonstrate the deep practical chasm separating corporations without a philosophy {ordinarily profit-making) from those striving to live out a specific one {ordinarily non-profit). In profit-making corporations the long-range goal is economic. Increased sales, sound investments in human and non-human resources, expanding markets, and diversification of products--the stuff of future planning--aim solely at eventual profit for stockholders and ongoing fiscal health for the corporation. Among long-range goals it exercises a determined and determining priority. Sound planning in this context depends essentially on three analyses: of present forces influencing consumer activity; of identical social and psychological, technological and political trends

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that give promise of shaping the world of tomorrow; of consumer needs in that world and the economic forces that will influence both corporation and client. These analyses move by extrapolation from today's facts, both present realities and real trends, to the projection of a most likely world. Known certainties should generate likely probabilities, not just possibilities and clearly not uncertainties, as the basis for intelligent planning. An excellent example of such planning in the health care field may be found in a 1980 report of the Trend Analysis Program of the American Council of Life Insurance. As the program's name indicates, the analysis of trends forms the basis of three different scenarios of the future shape of health care--in 2030 A.D., to be exact. Out of a " v a s t continuum of possible futures" three images are presented as most probable, at least in some of their parts: 1. "Routine utilization of high technology medical care"; 2. "Individual responsibility for personal health and well-being"; 3. "Governmental responsibility for all health problems." v., In the conclusion of this report, the authors present management with two pages of provocative questions that may specifically direct their decision making in light of these probable health care futures. 13 Note, however, that these questions respond to probable futures; they do not seek to shape any one future according to a particular vision or philosophy. Here lies the primary difference between the planning just described and planning flowing from a philosophy and striving for its ongoing realization. In this regard, it is enlightening to note one of the Trend Analysis Program's basic assumptions: " . . . the future is not beyond our control; what we do today will affect the future; we are not at the mercy of totally unpredictable or preordained decisions. ''H Given that assumption, one might expect recommendations, suggestions, questions that could lead to decisions taken in order to shape a specific future. Such expectations are unmet. Future planning from a philosophical perspective seeks, not to respond to a given future but, rather, to create a future one wishes to give. As the philosophy of the Mercy Hospital in Johnstown, Pennsylvania, well says: " . . . the human person [is] . . . . Always in process, ever discerning . . . . From resources deep within, the person says yes to life and reaches to re-create." ~ This philosophical position would appear to require future planning to be a creative functioning, to be a bringing into existence out of the m y s t e r y of human life a healthy, wholesome, caring world. How might one structure such a creative planning process? How might it differ from non-philosophical planning? As an example, let us here note in most summary fashion the "prospective planning" of Gaston Berger, a French philosopher. ~" It is offered as a likely method for shaping the future through planning in light of one's philosophy. In concept Berger's strategy is simple yet revolutionary. Consider briefly his five steps:

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Step Two:

Step Three:

Step Four:

Step Five:

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Analysis of present reality. The organization takes note of its present reality, and of the forces both within and without the organization that influence its ongoing functioning. This differs from the aforementioned planning as not initially analyzing these forces nor seeking to discover in and through them future trends. Philosophical formulation. Reflecting on its life and vision, the organization articulates its philosophy as the basis for future planning. Imaging the future. Looking toward the future, using all of its creative resources, the organization generates its image of the desirable future. From the " v a s t continuum of possible futures" it selects that future most congruent with the vision of life it espouses and seeks. Confrontation. From the vantage point of that desirable future the organization now analyzes its present reality. It particularly asks: What obstacles can we identify in ourselves to the eventual realization of our desired future? What potentials do we possess that could be released and channeled into creating that future? Shaping the future. Program goals are set: goals of overcoming specific obstacles, releasing specific potential, channeling specific energies into shaping the desired future.

Future planning with a philosophical base such as Berger's is eschewed by some as not being hardheaded and concrete enough, as smacking of wishful thinking. On the contrary, such planning accepts as legitimate and useful data obtained through employing the full range of human powers: intellectual and volitional, visual and emotional, intuitional and communal. Planning done only on the basis of intellectual analysis may, ironically, be accused of not being sufficiently intelligent, as it neither brings the variety of human abilities to bear on the planning task nor does it weigh all of the data available.

Conclusion

At this article's beginning, in answer to the question, " W h y a philosophy?" we heard a hasidic master tell of the importance of having one's own story. To end where we began, let us address that question again, but this time by reflecting briefly on our present times. Three sets of pressures today urge religious health professionals to take a strong philosophical orientation in health care: pressures on religious health care ministry, on the field of health care itself, pressures on and across our troubled planet. Pressures on religious health care ministry. No one need remind religious that "things ain't like they use to be in the good ole days!" Where once their hospitals carried special meaning because of the compassionate presence and

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spiritual strength of their sister nurses and administrators, often nowadays the declining number of sisters means decreased presence to and diminished influence upon their patients. And should sisters unexpectedly drop in on a patient, they do so without a traditionally comfortable uniformity of presentation, unity of purpose, and uniqueness of vision. Perhaps such diversity always existed, but, if so, it was more hidden, and to many, disturbed less. No matter how one assesses those days compared to the present, that perception of community oneness did generate a sense of security to patients grappling with physical and sometimes spiritual uncertainties. The combined pressures of economics and tax requirements have, moreover, forced most health care ministries away from the direct ownership of religious congregations into the trusteeship of public bodies. This has signaled a diminished opportunity to shape the directions of institutions through sister trustees and to oversee their implementation through managerial decisions. In addition, as congregations search out the limits, meaning, and responsibilities of sponsorship instead of ownership, still possible authoritative religious presence often appears diffused and relatively ineffectual. When religious health systems and hospitals have an articulated philosophy of health care, and when that philosophy's required implementation in daily operations comes under priority scrutiny from the congregation, a united presence is more directly felt. The thrust here, indeed, has been that an articulated philosophy could be the central practical reality in the institution--furnishing motivation, giving direction, and demanding ultimate authority. P r e s s u r e s o n h e a l t h care. Like it or not, the field has become part of corporate America. As scientific discoveries inevitably lead to technological advances that demand more space, more specialists, more money, the neighborhood hospital gradually disappears, to become first a business, then an institution, and finally a complex corporation. Now many even take the next step into more massive and further removed multi-hospital systems. The result is a public image much like that of any for-profit corporation, health costs climbing precipitously so as to take nearly one out of every ten consumer dollars, services increasingly being provided on a "cash on the barrelhead" basis. As if complexity and financial pressures alone could not sufficiently cool the healing relationship, the genius of pragmatic America has joined in to take more and more human relating out of health care. Realizing that "to divide is to conquer" here also, the field cuts doctor and patient alike into finer and finer objects for study and training, concern and treatment. We are regularly confronted today with material working of "eye, ear, nose, and throat upon pneumonia," "heart and circulation upon angina," and other such relational obscenities. The logic of these nonhuman health care relationships carries us to the brink of absurdity when medical science keeps the heart beating and lungs pumping and blood circulating long past the death of the brain and the presumed demise of the patient. Here even after the storied "doctor-patient relationship" has vanished, health care goes blithely on. How bring healing's core back to itself? How restore "whole" and "holy" and "help" to health care? To look for corporations to dissolve, for technology

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to retreat, for specialties to vanish is to play games with oneself and one's patients. The only serious direction lies in a vision of human dignity and value that one demands to be present in every action, situation, and relationship in the hospital. P r e s s u r e s on a n d a c r o s s o u r p l a n e t . We live in perilous times, yet ones filled with opportunity. The very darkness allows hope for saving light. Our terribly unhealthy world will either die horribly or, out of its terror, find new life. Mankind's past and future decisions are placing weighty demands upon the life of our earth. These decisions and their predicted results may be divided into three general areas: 1. On the side of global catastrophe, decisions made or not made will make an already sick planet sicker, even to the extinction of planetary life. We face the terrifying possibility of nuclear annihilation. We are confronted by the spectre of a regressed human condition brought about by the irresistible spread of poverty, disease, and technological devastation wedded to over-population. Should neither of these horrors become reality, we still could simply wither away like a deformed branch on the evolutionary tree as we stubbornly court a dying status quo. 2. Decisions made in the hope of furthering human culture may be made under the aegis of control. Through authority exercised in culture's name various worlds may be shaped: --one of racial or national orthodoxy, as attempted by Germany in Europe, by Russia in Eastern Europe, by the United States in Southeast Asia and Latin America; --one of behavioral conformity, as is championed by academics like Skinner, or law-and-order types like Philadelphia's ex-mayor/cop Rizzo, as is foreshadowed in the fantasy worlds of W a l d e n Two, j; 1984, 1.~and B r a v e N e w World. 1~,~

3. Human culture may also be furthered by turning inward toward meaning and self-control, motivation and hope. In an era of the human spirit, human life would seek its own future, would produce beings either more individually ~ndependent and capable or more interpersonally enlivening. Or perhaps, true respect for our planet and all forms of life might release forces previously suspected only by mystics and prophets, by people like de Chardin who envisioned the development of a new, healthier, happier kind of human being in a new humanity. Today, our world is divided. Internationally, we court global catastrophe in the name of orthodoxy. Nationally, we play papa, policeman, and scientist in the name of control. Individually, we seek human growth and development; but when the chips are down, we turn quickly to the forces of orthodoxy and control. How does a health care ministry touch these dark times?--primarily through a vision of what human life is, the direction it is seeking, the assistance it requires; secondarily through a deep realization of one's past traditions and desired futures, one's energies and motivations, one's concerns and

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abilities. Articulated in a philosophy of health care, this could direct one's ministry into a variety of actions: lobbying for nuclear disarmament and refusing to cooperate with a government preparing for nuclear destruction; sending nurses and doctors to Vietnam and Cambodia, E1 Salvador or Lebanon, in support of human life and decency, no matter the warnings of political orthodoxy: resisting managerial and medical paternalism exercised in the guise of order and efficiency, by including employees and patients in the deliberations and decisions that directly affect their lives: emphasizing the centrality of the healing relationship in face of scientific, technological, and logical pressures to dehumanize both health provider and patientz offering those who enter our doors a community of love, a religion of contemplative awareness, and an opportunity to grow in a "divine milieu"; striving for the sake of human dignity not only to cure or repair or preserve, but even more to empower persons with the forces of life. Challenging, yes, but what a wonderful and worthy human challenge it is.

References 1. Buber, M., Tales of tile ftasidim: The Early Masters. New York, Schocken Books, 1947: p. 286. 2. - - , Tales of the ttasidim: The Late Masters. New York, Schocken Books, 1948. p. 247. 3. Sisters of Mercy Health Corporation. A Procedural Handbook to Assist in: Understanding, Developink5 and Implementing a Philosophy. Farmington Hills, Michigan, April, 1982. 4. Ibid., p. i. 5. Athos, A.G., and Pascale, R.T.. The Art of Japanese Management New York, Simon and Schuster, 1981; p. 202. B. Von Ward, P., Dismantline the Pyramid. Washington, D.C., Delphi Press, 1981; p. 188. 7. Delbecq, A.L., et aL, Matrix Organization: A ('onceptual Guide to Organizational Development. Madison, Wisconsin, G r a d u a t e School of Business, Bureau of Business Research and Service, 1969, pp. 3-14. 8. J o h n Paul II, "Laborem Exercens," papal encyclical "On H u m a n Work." Rome, 1981. paragraph #20. 9. United States Catholic Conference, " P a s t o r a l Letter on Health and Health Care." Washington, D.C., November, 1981, paragraph #B4. 10. J o h n Paul lI, address at Montery, Mexico, J a n u a r y 31, 1979. 11. Mercy Health Center, " I n t e r p r e t a t i o n of Philosophy S t a t e m e n t . " Dubuque, Iowa, 1982, p. 2. 12. Trend Analysis Program, American Council of Life Insurance, " H e a l t h Care: Three Reports from 2030 A.D." TapReport, #19, Spring, 1980, p. 1. 13. Ibid.. 19-20. 14. Ibid., p. 1. 15. Mercy Hospital, "Philosophy S t a t e m e n t , " Johnstown, Pennsylvania, 1980. 16. Berger, G., The Phenomenology of Time and Perspeeti~'e. Centre d ' E t u d e s Prospectives, Presses Universitaire de France, 1963. 17. Skinner, B.F., Walden Two. New York, Macmillan Company, 1948. 18. Orwell, G., 1,984. New York, Harcourt, Brace and Company, 1949. 19. Huxley, A., Bra,,e New World. New York, Doubleday, Doran and Company, 1932.