Caritas-Centene: Cooperation with evil?

Moral theology is not a subject I wade into all that often, but over the last week, as controversy has raged in the Archdiocese of Boston over a proposed joint venture between the Catholic hospital chain and a non-Catholic insurance provider, I found myself suddenly needing a crash course on things like mediate material cooperation with evil. Anti-abortion activists were insisting that, by participating in a venture that would cover abortion services, Caritas, and by extension the Archdiocese of Boston, would be cooperating with evil. But the archbishop of Boston, Cardinal Sean P. O'Malley, said the deal was no such thing; that so long as Caritas does not provide the abortion services or benefit from them, it's OK.

So what's a religion reporter to do? I decided to consult with the moral theology experts listed by the American Academy of Religion in its database for journalists. I e-mailed most of the list, and about a dozen scholars, as well as a few priests I also contacted, were gutsy and generous enough to share their thoughts on this subject. The result is a story in today's paper. But I also wanted to publish the responses in full -- it's dense reading at times, but for those of you interested in a little theological perspective on the controversy, here you go (click on 'full entry' if you don't see it now):

Rev. James Bretzke, professor of moral theology, Boston College School of Theology and Ministry

"I have been following this (and related cases) in the news so I think I'm familiar with the basic points. Some of the statements attributed to the more extremist 'right-to-life' proponents would NOT be reflective of either the Catholic moral tradition as a whole, or current Magisterial teaching. Let me paste below a section from Pope John Paul II's 1995 Encyclical 'Evangelium vitae' (The Gospel of Life) and then make some comments on it in reference to the current situation. Pope John Paul II writes in Evangelium Vitae, Paragraph 73 the following in regards to civil legislation which may allow for abortion:

'A particular problem of conscience can arise in cases where a legislative vote would be decisive for the passage of a more restrictive law, aimed at limiting the number of authorized abortions, in place of a more permissive law already passed or ready to be voted on. Such cases are not infrequent. It is a fact that while in some parts of the world there continue to be campaigns to introduce laws favouring abortion, often supported by powerful international organizations, in other nations—particularly those which have already experienced the bitter fruits of such permissive legislation—there are growing signs of a rethinking in this matter. In a case like the one just mentioned, when it is not possible to overturn or completely abrogate a pro-abortion law, an elected official, whose absolute personal opposition to procured abortion was well known, could licitly support proposals aimed at limiting the harm done by such a law and at lessening its negative consequences at the level of general opinion and public morality. This does not in fact represent an illicit cooperation with an unjust law, but rather a legitimate and proper attempt to limit its evil aspects.'

Now I believe we have a fairly clear analogous case here in the current brouhaha with the Caritas hospital case. Both Cardinal O'Malley's opposition to abortion and that of Caritas are well-known and well-documented. Thus there is no REASONABLE possibility of scandal, which would mean that someone might be led to believe (mistakenly) that either the Cardinal or Caritas in fact condone abortion.

What the Caritas case involves is not providing abortion services (since they will not do so), but aligning themselves within a health care system that can better serve the needs of their patients. Thus, the intention of their actions, as well as the net effect, will be to better their health care operations, and NOT to increase abortion services.

Those who are 'appalled' by these actions are of course entitled to their opinions, but not their own facts. Neither the Catholic moral tradition, nor the current Magisterium of the Church, has said that we absolutely cannot cooperate (or tolerate) in systems and/or actions that might be considered objectively immoral (such as the war in Iraq, abortion services, economic practices that place an undue and unjust burden on the poor, purchasing a Hummer, etc.). What is forbidden is engaging in these actions with a sinful intent (which is called technically "formal cooperation"), or failing to take adequate precautions to cause real scandal. Scandal is a technical term and does NOT mean "dismay" but rather action that would cause another to seriously mistake our position on a moral issue. If Cardinal O'Malley would have said, 'Hey, this is really no big deal and the hospitals overall are doing good work, so let's not get excited over this issue,' then this might have caused actual scandal. The Cardinal, though, did not say anything of the kind, and his actions both in this matter, and over the long haul are absolutely faultless in this regard.

Regrettably there are still those who believe it is possible to live in a sinless world if we just had strong enough laws and draconian enough sanctions. It does not seem, however, that this was the view of Jesus himself (consider the parable of the wheat and the weeds in Matthew 13:24-30). Certainly the Catholic moral tradition and the Magisterium of the Church have always recognized we live in a flawed world and cannot (and should not at times) take coercive action to try and enforce our understanding of morality. This also was the position of St. Thomas Aquinas in his treatise on 'law' in the Summa Theologiae."

Lisa Sowle Cahill, professor of theology at Boston College:

"It occurs to me, after having read (reread) the following from the Ethical and Religious Directives for Catholic Health Care Services, 'The possibility of scandal must be considered when applying the principles governing cooperation...The diocesan bishop has final responsibility for assessing and addressing issues of scandal, considering not only the circumstances in his local diocese but also the regional and national implications of his decision,' that it will be an appalling scandal if the Archdiocese of Boston obstructs or refuses to participate in Massachusetts' cutting edge health care reform program.

John Paul II, Benedict XVI, and the Catholic bishops have explicitly and repeatedly identified health care reform as a requirement of social justice and of Catholic social teaching. The bishops have termed reform an 'urgent national priority.' If it is not the priority of the Catholic Church in Boston, its leaders will come across as hypocrites. O'Malley's decision shows moral leadership.

At a time when the Cardinal and Archdiocese are striving to combat the morally unacceptable fact of 47 million uninsured people in this country, it will already be a scandal if the most vocal Catholic response is a debate about 'the principle of cooperation.' Where is the Catholic debate about the best way to ensure health care for all?"

Julia Fleming, associate professor of ethics, Creighton University

"By their nature, decisions about scandal and mediate material cooperation require prudence, as well as sensitivity to the local conditions and particular circumstances surrounding such choices. This is why the Ethical and Religious Directives for Catholic Health Care Services emphasizes the discernment of the local bishop, rather than claiming that a simple rule can resolve all difficulties. The document also observes: 'Scandal can sometimes be avoided by an appropriate explanation of what is in fact being done at the health care facility under Catholic auspices' (No. 71). One should read Cardinal O¹Malley¹s careful statement in that light."

Leslie C. Griffin, professor of legal ethics, University of Houston Law Center

"It is hard for me to see, on the facts given, that there is a problem of cooperation with evil. I don’t see any formal cooperation; Caritas is not engaging in any of the 'intrinsically evil acts' complained of, and it doesn’t share in the intention of providing those evil services. Caritas could easily say here that its moral purpose is to provide health care services, which is a moral good, and it is not formally cooperating in any of the prohibited services. It has set up the program so that it does not provide intrinsically evil services and it is vocal that it will not do so.

Now could this be material cooperation? Again that seems a stretch to me. If joining a joint venture is material cooperation, then just about any participation in the American health care system would be. Insurance companies and the government provide abortion services, does that mean you can have no contact with them? From the facts given, it doesn’t seem that Caritas is keeping abortion providers afloat who would otherwise be out of business. Mere association with abortion providers doesn’t seem contact enough to become material cooperation to me.

There is always the argument about scandal—but this seems to be a created scandal. The church seems quite clear that it is against abortion, etc., and not involved in it. Could anyone doubt that?

If you push the cooperation principle too far you wind up with a sectarian church, which is not at all consistent with the Catholic tradition.

It seems to me the state has more to worry about here than the church!"

Rev. Joseph Hennessey, St. Julia Parish, Weston

"The Cardinal is in a very difficult situation. I know that he is 100% pro Catholic hospital, and 100% pro-life, because they are not just his feelings, they are the teachings of our Church. What some people don't seem to realize is that just by living on the same planet, breathing the same air, living under the same governments, etc., we 'cooperate', we are the 'accessories,' on a very low level, of certain people with whom we completely disagree on several serious moral issues. The key question is not whether to cooperate, but to what degree, at what point does collaboration reach the point of fusion, and then confusion? Without my knowing the exact details of the proposed relationship between Caritas and Centene, it is good that the Cardinal is engaging in wide consultation, especially with trained Catholic moral theologians and canon lawyers."

Rev. Kenneth Himes, chairman of the theology department, Boston College:

"In my comment I do not address the specific details of the debate surrounding the wisdom of the proposed merger between Caritas Christi and the Centene Corporation. Rather, I offer some background on the underlying moral logic that frames the way the question is being addressed by the major voices in the discussion.

For centuries Catholic moral theology focused on preparing priests to serve as good confessors when listening to people manifest their conscience in the sacrament of penance. Consequently, moral theology was a discipline that even in its theoretical speculation remained grounded in practical lived experience. Because life inevitably involves people in situations where despite the best of intentions we find ourselves implicated in evil, Catholic moral theology developed what is called the principle of cooperation. It is a principle that, simply put, asks how we ought to assess our behavior when our actions seem to participate in evildoing, at least to some degree.

The present controversy involving Caritas Christi and its merger with Centene Corporation reminds us of the importance of thinking carefully about levels of cooperation. The tradition points to two important distinctions and three factors to consider.

The first distinction that Catholic moral theology suggests is between formal and material cooperation. Imagine a bystander dragooned into acting as a shield for a bank robber trying to escape the police versus an individual who creates a distraction so that a robber can escape. In the first case, one of material cooperation, the person participates in the theft but as an unwilling individual who does not share the aims of the robber; in the second case, called formal cooperation, the individual is a deliberate player in the overall plan of the robbery and escape.

In other words, material cooperation refers to actions that may entail assistance in evil doing without the agent willing the evil action; formal cooperation signifies acts that are done with the agent’s will directed to the aim of attaining the evil.

Two key elements assist us to make sense of the formal-material distinction. The greater the duress the person is under, the more likely we are discussing material rather than formal cooperation. So putting a gun to a person’s head lessens voluntariness to a greater degree than threatening ridicule. And, secondly, the less serious the harm caused, then the lesser nature of the duress necessary to justify cooperation. Thus, supporting the false statement of a person engaged in perjury requires much greater duress as an excuse than going along with a tall tale or “white lie” by an individual.

A second key distinction for employing the principle of cooperation involves that of proximate or distant cooperation. That is, how closely connected is the action to the commission of evil? For example, working as a sales agent for a liquor company, or serving as a stock clerk in a liquor store, or directly serving a customer who is already apparently under the influence of alcohol, are all actions that may eventuate in some persons becoming inebriated; but there are different levels of involvement in abetting drunkenness.

In making the decision as to what sort of cooperation is permissible, the tradition clearly rules out formal cooperation. But material cooperation is permissible, depending on the nature of the duress, the seriousness of the evil, and the closeness of the cooperation to the causation of the evil. And a final consideration in making a judgment is the good to be obtained by cooperation. In short, is there a proportionate reason present to justify the cooperation in bringing about some evil? Put this way, one can see that good and serious people will disagree on the determination as to whether cooperation is permissible or not in a particular case. That is to be expected since the principle of cooperation is meant to illuminate the decision making process, not mechanically determine it.

Present discussion about the wisdom of Caritas Christi’s merger with the Centene Corporation will likely find intelligent and faithful Catholics on different sides of the issue. The degree of cooperation involved with procedures that are judged unethical, the moral gravity of the procedures (abortion, contraception), the pressures (financial and otherwise) upon Caritas Christi, the goods that are to be attained by a merger – when put together all these aspects leave room for differing assessments. Whatever the outcome of the present situation, it points out the substantial challenges for institutions striving to maintain a Catholic identity while serving a diverse public. The challenges are not unique to Catholic health care facilities but include Catholic educational and social welfare institutions as well."

Aline Kalbian, associate professor of religion, Florida State University:

"The category of cooperation with evil in the Catholic tradition is fairly complicated. It does seem in this case that if Caritas does not participate in or benefit from the services it wouldn't be material cooperation. The question of scandal might be a greater concern here. And scandal is even more difficult to interpret."

David F. Kelly, professor emeritus and founding director of the Health Care Ethics Center, Duquesne University, Pittsburgh, PA

"In my book, 'Contemporary Catholic Health Care Ethics' (Georgetown Univ. Press, 2004, pp. 120-121), I note that the 2001 version of the 'Ethical and Religious Directives for Catholic Health Care Services' claims that the principle of material cooperation cannot be applied to abortion or sterilization or other actions said to be 'intrinsically immoral.' I say that this issue usually arises in the context of mergers of Catholic institutions with other health care facilities. I note that this change from earlier versions (pre 1994) of the 'Directives,' where this restriction (this claim that the principle cannot be applied in these cases) is not present, is questionable, since Catholic moral theology is supposed to be based on reason and not on Vatican decree (the change resulted from a directive from Rome).

In the present instance it seems to me that the 'cooperation' here is clearly 'remote material cooperation,' if indeed it is 'cooperation' at all. (Catholics are not forbidden to pay taxes even if some of the money goes to wars or capital punishment that Church teaching may proscribe, or even if some is used for contraception or abortion.) As I understand this proposal (and I have not had any opportunity to do an in-depth study of it), there is not here any intention of merging Catholic and other facilities, or of abortion being done in any Catholic or partly Catholic (merged) institution.

It is clear to me, at least from what I have read about this proposal, that there should be no objection based on the usual (traditional) interpretation of Catholic moral principles.

Unfortunately, some would change these principles and these interpretations to require a more restrictive conclusion than Catholic tradition proposes. This change seems to me to be applied almost only in the area of abortion, which I think to be disingenuous. Even with this exaggerated restriction, however, I cannot see how Catholic health care services are supposed to distance themselves entirely from the society in which they exist and which they serve. Presumably they will not support current American law concerning abortion, but surely they need not for that reason refuse to accept Medicare or Medicaid payments for their patients who have entirely different kinds of procedures, even though these sources of funding may also pay for abortions or sterilizations done in other institutions. They refuse to do abortions but they can still 'cooperate' in a system that permits them as long as they distance themselves from the procedures they claim to be wrong.

Perhaps you would like a quick "primer" on the principle of cooperation?

Assuming an action is morally wrong, the principle asks the question of whether or not one may participate in the act, or in its context, without actually performing the action itself. May I fix train tracks even though I know some of the trains carry innocent prisoners to be executed? May I purchase a house located on land that was, 250 years ago, owned by Native Americans from which the land was stolen? May I clean a hospital's operating rooms even though I know abortions are sometimes performed there? May I lay out the instruments?

The principle distinguishes "formal" from "material" cooperation. Formal cooperation means that I support the wrong action and intend my participation to further it. I would love to kill the innocent prisoners myself, but all I can do is fix the tracks. I hate "Indians," and would be
pleased to steal their land if I could. I would kill all the fetuses I could find, but I am not able to do that, so I clean the OR or lay out the instruments. Formal cooperation is rightly considered the same as performing the act itself.

Material cooperation presupposes that the 'cooperator' rejects the morally wrong act (or does not consider it wrong, which is another matter that I will leave alone here). I have fixed tracks for decades, and most of the trains don't carry innocent prisoners. It's been 250 years since the Sioux were here, and maybe they stole it from people before them. I am a cleaning lady, and my job is to clean hospitals, not to support abortions. I lay out instruments for all kinds of surgeries.

To be acceptable, material cooperation has to be "remote," not "proximate." Sometimes the terms "mediate" and "immediate" are used for "remote" and "proximate," and (unfortunately) sometimes these terms (mediate and immediate) seem to mean the same as "material" and "formal." Clearly the track fixer and the house buyer and the cleaning lady are "remote" from the actual murder, theft, or abortion. The closer you get, the greyer it becomes. If I fix tracks inside the extermination camp, and those are the only tracks I fix, or if I am a real estate agent for a company that consistently defrauds people of their land, or if I work in an abortion
clinic, then I ought to get another job.

(All of this assumes, of course, that the action in question is indeed wrong, or is at least thought to be wrong by the actor or by the institution. I have used examples here of actions that Catholic teaching considers wrong: killing innocent prisoners, stealing land, direct abortions).

The bottom line is this. If I have understood the proposal correctly, it is at best a case of very remote material cooperation. It seems to me to be the kind of case where, were it some other issue than abortion, no-one would worry about it."

Dennis McCann, professor of Bible and religion, Agnes Scott College

"There are two issues, as I see it. One, people need to be reminded that a joint venture is not a merger. Caritas is not being taken over by Centene. Thus it is reasonable to assume that Caritas can and will maintain the integrity of its own (Catholic identity) corporate culture, even as it enters into this joint venture.

Two, there may be too much ambiguity about 'scandal.' By leaving it as open-ended as the archdiocesan statements are, they are inviting activists to create an uproar that would qualify as a 'scandal.' Oh boy!

My personal opinion is that if Caritas gives antiabortion activists veto power over its strategic planning, there will be no end to the demands that could seriously hamper not only the viability of Caritas but the cause of social justice, which is also a strong imperative in Catholic Social Teaching.

One person's 'scandal' is another person's opportunity for politicization and carrying on the culture wars. So it goes.

I don't think there is any confusion here in principle, The danger of 'material cooperation' can be minimized, I think, by establishing specific benchmarks that need to be observed in the joint venture. I think Caritas and the archdiocese already are clear that abortions and other medical services in serious violation of standard Catholic moral theology in this area (BTW: The Church already officially recognizes the principle of the twofold effect and allows the termination of pregnancies in at least two situations: cancerous uterus and pregnancy in the fallopian tubes. What this means is that the Church's official position, even on abortion in not absolute, which may also shed some light on the meaning of 'intrinsically evil.' But more on that in a moment.) will not be performed in the Caritas facilities. This clearly signals Caritas' intent not to materially cooperate. How much further should they go? It is already assumed that Caritas policy (as well as its venture partner, as well as the government) will not force medical practitioners to violate their consciences. If this is not already clear, it should be. But beyond that, perhaps Caritas should make it clear that its 'family planning' counseling services will not do abortion referrals to its partners who play by a different set of moral rules. That should be sufficient, as far as I can tell. If Caritas is clear about what it can and cannot provide in the joint venture, then there should not be any ethical problem with the venture, which as I already noted, is NOT a merger.

If there is confusion, it may be regarding what it means or doesn't mean to be 'intrinsically evil.' This is a technical term, and it surely means more than, 'very bad,' 'seriously disapproved,' 'must be resisted as a matter of conscience.' Up until recently, I thought the consensus among Catholic ethicists was to move away from the use of this terminology, since it tended to be inapplicable or arbitrarily applied to one area of life (issues stemming from human sexuality) but not others (say, issues regarding nuclear warfare and/or the torture of terrorist suspects). If you can't get the Magisterium to be consistent about this, then maybe the term should be dropped. Alternatively, if abortion is intrinsically evil, then how could nuclear warfare and torture not be?

But as we saw in the recent Presidential campaign, there were those anti-abortion militants who wanted to make sure that abortion was a UNIQUE moral issue, transcending all other considerations stemming from Catholic moral and social teaching. Well, OK, that's their opinion. But I don't believe that the consensus among Catholics qualified to have a say on this (professional theologians and ethicists) will support them. Maybe I don't count and maybe I shouldn't. But I certainly would not support them. Absolutizing abortion creates more problems than it solves. Etc.

Intrinsically evil may be an oxymoron. Taking a life under any circumstances is a very serious matter. But even the Church has recognized that there are times when it is morally responsible to do so. Hence it is OK to serve in the armed forces and police, to perform capital punishment, terminate pregnancies in some (very narrow) circumstances. But note, if taking a life is ever justified morally, then it means that taking a life is NOT intrinsically evil. Under some circumstances, it may be done responsibly, regretfully, mournfully. Indeed, as is clear from St. Augustine on down, not to take a life (as in using lethal violence to stop even greater violence) may itself be more irresponsible than taking it.

But 'intrinsically evil' has been politicized and at least some of the US bishops are apparently incompetent enough, or cowardly enough to endorse such politicization (shifting from moral reflection to ideological combat) when it favors their political allies. The only confusion is what is being deliberately sown in order to carry on the culture wars, that cannot be fought or won on any other basis that half-truths, downright lies, and massive self-deception.

Anyway, I go on too much. It is not surprising to me that the antiabortion absolutists will jump on this merger in order to create the impression that it is scandalous (to whom? anyone but themselves? and what are their motives?). I just hope and pray that the Cardinal will continue to keep a steady hand in all this, and not allow himself to become captive to a group who seem hellbent on turning the church into a ever diminishing sect. So it goes."

Rev. David O'Leary, university chaplain and professor of religion, Tufts University

"Formal and material co-operation are very high moral theology terms. The Ethical & Religious directives for Catholic health care institutions are very difficult for the everyday person to understand. Be assured that Saint Elizabeth hospital, or any Catholic hospital will not be performing any abortions. But there will have to be clear lines of demarcation concerning the medical practices or places that will help out with problem pregnancies. One can not put up a sign in a hospital hallway, saying the Catholic hospital ends here. I strongly believe that Cardinal O'Malley is assessing and addressing the situation correctly. The Catholic Church will always strive to project a moral vision and provide a structure of moral reasoning that will help illuminate a direction for personal conscience, professional ethics and public policy on all questionings threatening human life."

Todd Salzman, associate professor of ethics and theology department chairman, Creighton University:

"'The Principle Governing Cooperation' is one of the most complex Catholic moral principles to interpret and apply. While it was included in the appendix of the 1994 revision of the Ethical and Religious Directives for Catholic Health Services (ERDs), it was removed as an appendix in the 2001 edition in part, one may assume, because it is so difficult to apply. So, it is not surprising that there is a debate over whether or not the proposed joint insurance venture between Caritas Christi Health Care and Centene Corporation constitutes cooperation in evil due to the financial support of abortions through health care insurance by Centene.

I think Cardinal O'Malley's statement is correct in that such an arrangement between the two would not constitute formal or immediate material cooperation. ('Caritas Christi Health Care has assured me that it will not be engaged in any procedures nor draw any benefits from any relationship which violate the Church's moral teaching as found in the Ethical and Religious Directives. Caritas Christi has been consistently faithful to these standards in the past and will continue to do so in the future.') Given the complex economic and legal relationships between government, health insurance companies, and health care providers, there is necessarily cooperation at a number of different levels, however, this is not necessarily moral cooperation that would violate the ERDs.

As I understand it, the point of this particular arrangement from the perspective of Caritas is to cooperate in providing access to quality health care for the poor and uninsured or underinsured. Catholic social teaching is very clear that access to health care should be a basic human right. The concern of scandal is an important aspect of the principle of cooperation. The Universal Catechism defines scandal as 'an attitude or behavior which leads another to do evil.' In this case, the fear of scandal by so-called 'pro-life' groups is that Caritas' participation in this arrangement would seem to implicate it in somehow supporting the practice and/or funding of abortion. Cardinal O'Malley's statement should dispel this concern, and with it, any fear of scandal.

What could also cause scandal, however, is that Caritas would reject cooperating with Centene in a program that would provide health care for the most needy and vulnerable in society. The scandal here would be that it is perceived as acceptable to neglect the basic needs of the poor and socio-economically vulnerable. It seems to me that this type of scandal is a greater, though less recognized scandal, in this discussion. Universal access to health care is very much a 'pro-life' issue."

William Schweiker, professor of theological ethics and director of the Martin Marty Center, The University of Chicago Divinity School

"It seems to me that the Cardinal is trying to make a careful and discriminating judgment in order to advance two concerns basic in Catholic social thought: an affirmation of the dignity of human life and the need to serve the poor. The connection to the Centene Corporation is to help the outreach of the Church’s medical ministry, but this comes with the insistence that Catholics respect the dignity of human life.

The Cardinal’s point, and this might be missed by some of the anti-abortionists, is that he does not want the two concerns to clash in such a way that the outreach to the poor is sacrificed. At issue, at a deeper level, is the concern for moral purity, if I can put it like that. The anti-abortionists want to have a simple and direct principle to protect the Catholic stance; the Cardinal, in the long tradition of Catholic moral casuistry, is trying to enact the fullness of the Catholic moral vision without qualifying its distinctiveness. He seems to have done so, in my judgment.

There are three ideas to get straight in order to assess this issue.

First, by 'intrinsically immoral (or evil) acts' are meant those actions that can never under any circumstances be justified or licit. Christians have always held that there are some such actions—like murder or idolatry. There are actions that per se cannot be intended or done without immorality.

Now, second, by “cooperation” is meant the conditions under which Catholics and Catholic institutions can work with others realizing that there will not be complete agreement, say on details or principles.

Third, the crucial terms in the directives about health care are “Catholic health care organizations are not permitted to engage in immediate material cooperation in actions that are intrinsically immoral . . .” In the terminology of Catholic moral theology what this means is that an organization or an individual cannot be engaged in cooperation that immediately brings about an evil act or end. This is important since one does not know what unintended or long term effects could be—so one might engage in an act that is good and yet later have ill effect at later other time and thus unintentionally. “Materially” cooperates is to be involved in the actual action. This is important since one might not know all the procedures going on in an institution while agreeing with its basic principles and yet not knowingly or intentionally engage in some wrongful act.

The point is that one cannot do the wrongly act oneself. These distinctions (immediately; materially) are meant to sort out the ways in which one is or is not held morally responsible for an action the consequences of which we cannot fully know—given the limitations of human knowledge and the complexity of medical procedure.

It seems to me that the anti-abortionists might not be seeing that Catholic teaching has always affirmed its core principles but also provided ways for to think about tough cases. Taken to its extreme the anti-abortionist argument should require Catholics to denounce any and all association with any organization that does not agree with all of its principles. But in that case, some of the other values and purposes of the Church would be sacrificed. It is that problem that the Cardinal seems to be addressing by drawing on these distinctions."

Thomas A. Shannon, professor emeritus of religion and social ethics, Worcester Polytechnic Institute:

"I would think that if the agreement is that Caritas neither benefits from nor provides nor refers people to abortion services then they are not cooperating in evil. It is also important to remember that there are also critical justice issues involved, particularly with respect to providing insurance to people who are low income or are marginalized from the mainstream in a variety of ways. This kind of relationship seems to clearly separate Caritas from Centene and thus ensure that Caritas in not involved in providing abortion services but also affirms the needs of justice to provide health care to the poor. I think there is a point at which the issue of justice needs to move more to the forefront of the argument. I think the Cardinal's statement summarizes the argument nicely."