C A T H O L I C H E A L T H A U S T R A L I A. matters. S U M M E R healthethics. tackling the.

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1 C A T H O L I C H E A L T H A U S T R A L I A matters issue 60 S U M M E R healthethics tackling the bigquestions

2 from the ceo martin laverty a new law for charities In the Budget, the Commonwealth Government announced its intention to define charity in legislation. The proposal to define charity is part of the Government s broader plan for the not-for-profit sector that involves a review of potential taxation of unrelated business income of charities and the establishment of the charitable regulator by July 1, It might come as a surprise to learn that Australia does not have a legislative definition of charity. This is despite the hundreds of thousands of people who work or volunteer for charities to provide support to disadvantaged or vulnerable people and communities across Australia. Charity is defined at common law; that is, its meaning has been determined by the courts. The Australian common law definition derives most of its meaning from Pemsel s case of 1891, which stated there were four heads of charity: the relief of poverty; the advancement of education; the advancement of religion; and other purposes beneficial to the community not falling under one of these categories. Catholic hospitals and aged care services, together with Catholic schools, social services and other ministries of the Church, are treated as charities under the common law. Being treated as a charity exempts Church ministries from most taxes, allows in many cases for donors to receive a tax deduction for a gift made and entitles many staff to access fringe benefits tax deductions. With charities today able to fulfil their purpose of service to the community, and the common law clear about what is and what isn t charitable, it s reasonable to ask why the effort involved in striking a legislative definition of charity is needed in the first place. With 600,000 charities in Australia, which are as diverse in purpose as they are in size, it will be difficult to reach agreement on a one-size-fits-all outcome that will be able to keep the leaders of all charities happy. It is also a risk that whenever a government legislates in an area it has not previously regulated that unintended detriment follows. Why then is a legislative definition needed? And what might it mean for Catholic hospitals and aged care services? A Federal Treasury consultation paper issued rather late on a Friday evening at the end of October says new charity laws are needed because charities make a very important contribution to Australian society, they receive a range of support from Commonwealth, state, territory and local governments, including tax concessions and grants, and support from the public in terms of donations and volunteering. It is therefore important that there is a clear framework for both the public and regulatory agencies for recognising entities as charitable. A legislative definition was first attempted under the Howard Government in Laws were drafted, but legislation was never put to a vote in the Parliament because of not-for-profit leader dissent. At issue in 2003 was the extent to which a charity should engage in political advocacy. A modified version of those 2003 proposals is now back on the table, with the contentious political advocacy restrictions not part of the new framework. The charity definition consultation paper is not specific about what is proposed, but instead seeks feedback on a proposal that charity be defined as follows: policy & advocacy review of health and medical research in australia 2 aged care reform some ethical considerations 4 doctors trained overseas a dilemma? 8 the sector speaks the organisation of pastoral care in health an australian perspective 10 spiritual renewal program for health care leaders 13 ethics special feature duty of reasonable use of medical treatment 14 umbilical cord blood banks... and the therapeutic potential of stem cells 16 how do we say enough is enough? end-of-life issues in a pastoral context 18 remaining true 20 the teaching of health care ethics 24 do the right thing ethics and the medical course at the university of notre dame 26 Catholic Health Australia

3 to require an entity to be a not-for-profit; for its dominant purpose to be charitable; for it to be of public benefit; for it not to engage in activities that do not further, or are not in aid of, its dominant purpose; that it not have a disqualifying purpose; that it not engage in conduct that constitutes a serious offence; that it not be an individual, partnership, a political party, a superannuation fund or a government body. This initial list of components that might make up a legislative definition should not trigger any serious problems for Catholic hospitals, as this definition mostly mirrors the current common law understanding under which Catholic hospitals and aged care homes derive their charitable status. Importantly, the use of the term public benefit in the consultation paper does not take the same meaning, at this point in time, as public benefit in the United States. The definition process does, however, raise some matters for Catholic organisations to watch. The first question is how the government intends to define public benefit so as not to exclude those charities that charge fees of their clients where it is reasonable to do so. If public benefit was found not to exist where a fee for service exists, private hospitals and aged care services would have some problems to confront. So, too, would Meals on Wheels charities that charge fees, together with disability charities that provide accommodation in return for fees, or children s cancer charities that charge fees for attendance at holiday respite camps. It s not suggested or even likely the Government would want to open up this can of scary worms, but governments in other countries have taken such an approach. Another but more Catholicspecific question arises out of the governance documents under which Catholic hospitals and aged care services are established and currently derive their charitable status. Most constitutions or trust agreements describe Catholic hospitals and aged care services as having a religious purpose, and some (but certainly not all) currently derive charitable status under the advancement of religion heading. As a legislative definition of charity evolves, it may be that Catholic hospitals, aged care services and other Church ministries may be asked by law-makers to elect to describe themselves in a manner that might challenge current canonical practices in order to retain charitable status. This scenario is highly unlikely, and the prospect of this arising will not be known until the legislation is drafted and passes the Parliament, which is still some months off, with much opportunity for Catholic Health Australia (CHA) and others to make a case if need be. It is, however, a matter of some importance for all religious works to watch as the legislative drafting process begins. The Government has invited comment on what should feed into the new laws by mid-december, with legislation to be drafted in early CHA is in the process of considering the risks and opportunities of this area of law reform, and looks to the New Year to see what clarity is given to the Government s longer term plans for Church charities. other news reflections from CHA s scholarship winners 28 calvary ehealth puts group on pathway to the future 30 reflections of a first-year medical student 30 people & places murdoch caregivers provide $23,000 boost for st patrick s 32 director of mission awarded ethics grant 32 patients rate calvary day procedure centre number 1 33 new southern cross care facility opens in NSW CSSA CHA study tour 34 inspirational garden of the senses 35 first round of nurse and midwifery grants awarded 35 comings & goings CHA welcomes three new directors 36 new CEO for st john of god hospital ballarat 36 reflection christmas reflection ins.bk.cvr The views expressed in articles written by external contributors are those of the authors and do not necessarily reflect the views of CHA. Health Matters is published quarterly by Catholic Health Australia Editor Martin Laverty / Copy Editor - Adrienne Day / Design - Iroquois Design National Office, Level 1, Rowland House, 10 Thesiger Court DEAKIN ACT 2600 PO Box 330, Deakin West ACT 2600 P F e secretariat@cha.org.au ABN ISSN

4 policy & advocacy patrick tobin review of health and medical research in australia Many readers of Health Matters will recall the pre-budget rumours earlier this year of a likely $400 million cut to health and medical research over the next four years that would be contained in this year s Commonwealth Budget. Health research comprised 3.6 per cent of total health expenditure in , or $4.2 billion 1. The medical research community supported by the wider health sector reacted strongly against the proposed cuts and mounted a vigorous public campaign in support of continuing Commonwealth Government funding of health and medical research. As it turned out, rather than a cut, the Budget provided a 4.3 per cent increase in funding to the National Health and Medical Research Council (NHMRC). We can only speculate as to whether the rumoured cuts were really intended to occur or were part of the expectations management and kite flying that is becoming an ever bigger part of the Budget processes. As well as announcing an increase in funding, the Budget also contained an announcement by the Government of its intention to undertake a review of health research funding. The terms of reference for the review have been announced and are set out at the conclusion of this article. While we have a culture of high-achieving basic research, as a nation we often struggle to advance discoveries to the point where they are able to be commercialised. There are many complex factors underlying this failure. Some of these factors include the size and nature of our capital markets, limited access to venture capital and a risk-averse investment and management culture. While risk aversion is not totally a bad thing the current state of US and European financial markets is testament to that it also means that we risk letting many otherwise positive opportunities slip through the net. The announcement of the review combined with the recent experience of significant threatened cuts has, however, focussed minds on the range and scope of medical research that is undertaken in Australia and how it is paid for. Readers may note that this article has placed considerable emphasis on the financing aspects of research. This is not entirely unintentional; the terms of reference of the review, its genesis during the period of threatened Budget cuts and comments by ministers at the time of the announcement of the review all focussed on funding. It is clear that the Government would like to see a much greater private-sector contribution to medical and health research funding. In announcing its review, the Government has alluded to changes in the health landscape, including: The changing burden of disease in Australia with the increasing incidence of chronic diseases, including those associated with ageing, and mental illness becoming the leading causes of morbidity and mortality. The sequencing of the human genome and the information and communication technology revolution that have accelerated our acquisition of new knowledge, while also transforming the type of resources and training required to apply these new initiatives in clinical practice. The changing mode of undertaking medical research, with increasing use of larger and multi-disciplinary teams that often work together from multiple locations and countries. The Government has also asked the review to focus on the ever-present issue of how best to translate discoveries from basic research into actual treatment and to ensure that research breakthroughs become clinical practice without undue delay. The issue of translation of research outcomes into actual use is a common theme across many Australian industries and not just in health and medical research. It is clear that the Government would like to see a much greater private-sector contribution to medical and health research funding. Indeed, ministers have noted that Australia lacks the culture of philanthropy that is strongly present in countries such as the United States. While Australia s proportion of philanthropic-sourced funding is relatively small, a number of Catholic hospital groups have world-class research facilities which are significantly funded by philanthropic contributions. It will be important that the review recognises the generosity of existing donors and develops recommendations that will encourage greater contributions from both existing and new donors. At the same time, CHA and its members will be very concerned if the review turns out to be merely a mechanism for spreading the existing pool of private funding more thinly, while Government contributions diminish at the same time. CHA will express these sentiments in its submission to the review and will watch its progress and recommendations with interest. At the end of the day, we all depend on the successful outcomes of health and medical research. Footnote: 1. AIHW Health Expenditure Australia

5 details of the review expert panel members Mr Simon McKeon Professor Henry Brodaty Mr Bill Ferris Professor Ian Frazer Professor Melissa Little Ms Elizabeth Alexander matters for review The review will take into account broader Government policy, including the Government s fiscal strategy, and will focus on optimising Australia s capacity to produce world-class health and medical research to 2020, including reference to the following matters: 1. The need for Australia to build and retain internationally competitive capacity across the research spectrum, from basic discovery research through clinical translation to public health and health services research. 2. Current expenditure on, and support for, health and medical research in Australia by governments at all levels, industry, non-government organisations and philanthropy, including relevant comparisons internationally. 3. Opportunities to improve co-ordination and leverage additional national and international support for Australian health and medical research through private sector support and philanthropy, and opportunities for more efficient use, administration and monitoring of investments and the health and economic returns, including relevant comparisons internationally. 4. The relationship between business and the research sector, including opportunities to improve Australia s capacity to capitalise on its investment in health and medical research through commercialisation and strategies for realising returns on Commonwealth investments in health and medical research where gains result from commercialisation. 5. Likely future developments in health and medical research, both in Australia and internationally. 6. Strategies to attract, develop and retain a skilled research workforce which is capable of meeting future challenges and opportunities. 7. Examine the institutional arrangements and governance of the health and medical research sector, including strategies to enhance community and consumer participation. This will include comparison of the NHMRC to relevant international jurisdictions. 8. Opportunities to improve national and international collaboration between education, research, clinical and other public health related sectors to support the rapid translation of research outcomes into improved health policies and practices. This will include relevant international comparisons. 9. Ways in which the broader health reform process can be leveraged to improve research and translation opportunities in preventative health and in the primary, aged and acute care sectors, including through expanded clinical networks, as well as ways in which research can contribute to the design and optimal implementation of these health reforms. 10. Ways in which health and medical research interacts, and should interact, with other Government health policies and programs, including health technology assessments and the pharmaceutical and medical services assessment processes. 11. Ways in which the Commonwealth s e-health reforms can be leveraged to improve research and translation opportunities, including the availability, linkage and quality of data. 12. The degree of alignment between Australia s health and medical research activities and the determinants of good health, the nation s burden of disease profile and national health priorities, in particular closing the gap between Indigenous and non-indigenous Australians. 13. Opportunities for Australia s health and medical research activities to assist in combating some of the major barriers to improved health globally, especially in the developing world. timeframe The Government anticipates receiving a final report from the panel in late

6 policy & advocacy aged care reform some ethical considerations The Productivity Commission s report, Caring for Older Australians, identified the strengths and weaknesses of the current aged care system. Its reform proposals represent a watershed for the sector by ending the rationing of most aged care services and giving people an entitlement for care based on assessed needs, choice of provider and choice where to use their entitlement. The reforms would address a number of ethical issues inherent in the current system. They would also pose potential ethical challenges if not implemented carefully. The Commission s proposals include: Individual entitlements for care based on assessed needs, with an emphasis on re-ablement and independence. Individual choice, whether the care entitlement is used at home or an aged care home, and choice of service provider. A national network of Commonwealth-managed Seniors Gateway Centres to replace the existing disparate care assessment and information services. These centres would provide easily understood information; an assessment of care needs and financial capacity to contribute to care costs; an entitlement for approved aged care services; and initial care co-ordination. Modest co-payments by individuals who can afford to contribute to their care costs (with a maximum lifetime limit) and individual responsibility for meeting accommodation and living expenses (with safety nets). Access to a Government-guaranteed line of credit secured against the principal residence (the Home Credit Scheme) that would allow people to meet their aged care expenses without having to sell their home. A protected person, including a spouse, would be able to continue living in the residence while they remained a protected person without having to repay the advance. Choice whether to pay for accommodation by a periodic payment (rent) or a fully refundable accommodation bond. Continued access to the age pension if a person chooses to sell the principal residence by depositing any surplus funds from the sale in a Pensioners Savings Account. Direct access to low-intensity community support services. Freedom to purchase additional services and higher quality accommodation. Under the Commission s proposals, restrictions on the number of residential places and care packages would be phased out, while distinctions between residential low and high care and between ordinary and extra service status would be removed. Safety and quality standards would be retained. An Australian Aged Care Commission (AACC) would be responsible for quality and accreditation, and would transparently recommend to Government efficient prices for care entitlements and accommodation payments for supported residents. The current aged care system is discriminatory in several key ways: The rationing of aged care services means that not all people assessed as being in need of aged care have the same opportunity for timely access to services. Also, the current regulations which limit community aged care to 22 per cent of the aged care places means that people are being denied equal opportunity to receive care in their own home, or the security of knowing that as their care needs change, they will have the option of continuing to receive care in their own home. Contributions individuals make towards their accommodation and care costs are inequitable. Bondpaying low care residents, including those who age in place, and bond-paying extra service residents are paying more for their accommodation and are subsidising the accommodation costs of others. Similarly, income-tested residents contribute more towards their care costs than people with similar care needs living at home with a care package. Because the Government sets the maximum price for high care accommodation regardless of amenity, high care residents (of equal means) pay the same for accommodation regardless of room size, quality of furnishings, aspect and location within the home. This means that someone in a multi-bed ward can be asked to pay the same as someone in a single room with an en suite. Introducing care entitlements based on assessed needs, with choice of service provider and where care is received, would address the above concerns and increase the fairness of the system. The proposal to introduce nationally consistent user contributions for care, whether that care is received at home or in an aged care home, would also introduce more equity into the system, as would the proposal that the same accommodation payment arrangements should apply for all residents. The proposed Seniors Gateway Centres will determine aged care needs using standard assessment tools. However, regardless of how rigorous these tools may be, trained assessors will be undertaking them and therefore a degree of subjectivity will be a remaining element. It will be essential that the proposed new consolidated arrangements are well resourced and performance managed to reduce this subjectivity and to deliver more timely, consistent and fairer assessments than under the current system. 4

7 richard gray & nick mersiades Significant changes to user contributions are proposed. As well as changes to make contributions consistent across care settings, care contributions would be based on an individual s total assets (including the principal residence), rather than income only, as is currently the case. As well, all residents will be expected to pay for their accommodation costs on the same basis rent or bond with safety nets. These changes would introduce new major areas of user pays not hitherto used for contributing to the cost of aged care. Opposition will come from those areas of society that believe government should pay for all aged care regardless of the consequences for taxpayers. It would make a quality aged care system more affordable. It would provide a form of social insurance for care costs that recognises that an individual s need for aged care is unpredictable, whereas accommodation and living expenses are predictable. And, most importantly from an ethical point of view, it would allow greater scope for taxpayer funding to be used to support the most needy. Sensible use of user contributions is also a means of achieving greater fairness across generations, especially as there will be relatively fewer taxpayers to meet the aged care costs of the Baby Boomers. Setting the right balance between individual responsibility and community responsibility will be important... Setting the right balance between individual responsibility and community responsibility will be important for achieving support for the reforms. Reasonable contributions by individuals towards their care costs with a maximum lifetime limit and individual responsibility for accommodation and living expenses with safety nets for those of limited means is sensible policy. However, history on co-contribution and maximum limits tells us that cut-off points can lead to those who fall just over the threshold line being disadvantaged. A sensible use of tapers so that subsidy levels are gradually reduced as wealth increases will be necessary to smooth out the impact and make the system as fair as possible. continued next page 5

8 aged care reform some ethical considerations cont. The current proposal is that the basic standard of accommodation for supported residents be set at an average of 1.5 residents per room. Catholic Health Australia (CHA) will be advocating for the accommodation payment to be based on the regional cost of supply of a single room/ en suite service with agreed basic design features such as room size and quality of fittings and furniture. This approach is based on the assumption that the cost of a single room/en suite configuration, putting aside regional differences, can vary depending on design features and building amenity, while still meeting acceptable standards. Aged care providers will be required to publish the daily rental for their beds and a corresponding fully refundable accommodation bond. Residents will be able to choose to pay either daily rental or a bond. In a competitive market for aged care consumers, this should provide better choice of provider and preferred accommodation. But will it play out that way for all? An aged care system designed to ensure choice of services will have limited applicability for certain groups and communities. This includes rural and remote and Indigenous communities, and people with special needs such as the homeless and people with mental health issues and challenging behaviours. To ensure access to quality services for such groups, the new system will need to include, as is being proposed, special funding arrangements such as block funding, expanded use of the multipurpose service model, capital grants and tendering for services. The financing arrangements for the system will also need to be able to identify and cover any additional costs that may be intrinsic to providing care and support for people with special needs, including people with palliative care needs, people living with dementia and the reforms are an opportunity to place the provision of future aged care services on a more sustainable basis. The AACC will make independent and transparent recommendations to Government on regional accommodation prices for supported residents and the regional price of delivering approved aged care services. We should not expect that the Government will pay the same market-based accommodation payment for supported residents as non-supported residents pay. However, the standard of accommodation that the Government funds for supported residents will have a bearing on the overall level of equity in the system regarding accommodation standards. catering for diversity. The AACC will be required to take these special needs into account, but it will be important for sector advocates to engage with this process to ensure that this happens. A person may be assessed as having the potential to benefit from a re-ablement program to enable them, with the assistance of aids, to perform more activities for themselves and reduce their dependence on taxpayer funded services. While such programs are likely to be free to encourage participation by all, some may decline. They ve done the 6

9 housekeeping, shopping, cooking and cleaning all their lives, now in their twilight years they want it to be done for them and at taxpayers expense. The administration of this policy will call for some sensitivity and judgement, though the situation is not dissimilar to that which can also be faced in the wider subsidised health system. Choice to receive care at home will increase the focus on those that choose to stay at home for longer than their care needs sensibly dictate. The approved provider of the care at home will face duty of care challenges when it is clear that the care they can provide is falling short of what their client needs. Do they decline to continue delivering care? Do they increase their care levels ignoring the added unfunded cost? Any unfortunate care consequences and unnecessary hospitalisations could lead to community and political agitation for more rigid entitlement decisions. Securing tomorrow s skilled workforce is an ongoing concern. The Commission s recommendations would help by requiring the AACC, in making recommendations on care entitlement prices, to take into account the appropriate mix of skills and staffing levels for the delivery of care and the need to pay fair and competitive wages. If the Government doesn t ensure that care staff wages are fair and competitive, it will reinforce the community view that older people are not worthy of the same level and quality of care as applies to those in hospital. Not all of the complex decisions and judgements that the Government and providers will need to make in reforming and rolling out the structural changes will pose ethical or moral challenges. Nearly all of them will, however, have some consequence for the frail aged, their families and the community. If the Government doesn t ensure that care staff wages are fair and competitive, it will reinforce the community view that older people are not worthy of the same level and quality of care as applies to those in hospital. Being able to choose whether to purchase additional services and higher quality accommodation will pose the question as to what services form a part of the Governmentfunded care entitlement, and those that an individual can purchase in addition. The current regulatory arrangements that specify which services are to be delivered as part of a care entitlement will need to be carefully reviewed to give consumers greater certainty. Aged care is a part of the health system. CHA has consistently argued that commodifying health is not in the best interests of the disadvantaged and most vulnerable in our community. But on balance, the reforms are an opportunity to place the provision of future aged care services on a more sustainable basis, including underpinning the viability of services and the affordability of quality aged care. 7

10 policy & advocacy doctors trained overseas a dilemma? Overseas-trained health professionals provide a significant proportion of the Australian health workforce, particularly overseas-trained doctors, and especially in areas where it is difficult to attract Australian-trained professionals, such as rural and remote areas. The establishment of Health Workforce Australia (HWA) and the considerable investment the Australian Government is making in education and training of health professionals will see a decrease in Australia s reliance on overseas trained doctors (OTDs) in the long term. It is, however, likely that OTDs will continue to play an important role in the make-up of Australia s medical workforce for some time. 1 It seems Australia s health care system has been dependent on OTDs for many years. According to Mark Cormack, the chief executive of HWA, Australia is the second least self-sufficient of OECD countries in training health professionals. 2 Almost 40 per cent of the medical workforce in Australia are OTDs and they constitute half of the medical workforce in rural and remote areas. OTDs who have applied to work in Australia have received their training in 120 different countries and specialist qualifications from 91 different countries. 3 In November last year, the Minister for Health and Ageing, Hon. Nicola Roxon, asked the House of Representatives Standing Committee on Health and Ageing to inquire into and report on registration processes and support for OTDs. The inquiry has been extensive and the committee is aiming to write the report over the Christmas period to present early in the New Year. The terms of reference were to: 1) Explore current administrative processes and accountability measures to determine if there are ways OTDs could better understand colleges assessment processes, appeal mechanisms could be clarified, and the community better understand and accept registration decisions. 2) Report on the support programs available through the Commonwealth and state and territory governments, professional organisations and colleges to assist OTDs to meet registration requirements, and provide suggestions for the enhancement and integration of these programs. 3) Suggest ways to remove impediments and promote pathways for OTDs to achieve full Australian qualification, particularly in regional areas, without lowering the necessary standards required by colleges and regulatory bodies. 40 per cent of the medical workforce in Australia are overseas trained doctors. Does focussing on OTDs and other overseas-trained health professionals as a medium-term solution to our health workforce shortage pose ethical dilemmas and global implications? The recruitment of overseastrained health professionals from developing countries can create ethical dilemmas for services and funders in Australia. It has been said that recruiting from overseas, and particularly from developing countries, could have the effect of creating a shortage of health care professionals in these countries, resulting in the compromise of their own health care systems. This type of recruitment is also said to add pressure on their already struggling workforce. For example, we know that the health workforce in many developing countries struggles to cope with major health problems such as malaria, cholera and HIV. Parking to one side the ethical dilemmas involved in recruiting from under-developed countries, Australia, as a country, has since white settlement always had people arriving and settling here to work from all sorts of places and across all sorts of professions. The more interesting question is how we, as a country, treat these overseastrained health professionals once they arrive on our shores. Sometimes the story is not always a happy one. There have been a total of 175 submissions and 22 supplementary submissions received for this inquiry. A review of the submissions received paints a very unhappy picture. It appears that many OTDs who have come to Australia have experienced a less than satisfactory time when it comes to securing permanent residency or admittance to medical colleges. Some of the quotes from the submissions include: You were on your own once you arrived into Australia. No one cared whether you passed examinations or not. The Australian Medical Council has contracted, since 2006, with their agent, The Educational Commission for Foreign Medical Graduates (ECFMG), in the USA, to verify the medical school qualifications of the OTDs. (There is) evidence of delays of up to two years before the Competent Authority Pathway verifies education. The Medical Board completely ignored the fact that I practised in Australia as a GP in an area of need for more than 10 years without problems, ignored the annual reports from my supervisor where I was marked at the expected level in all areas of assessments for all these years. 8

11 liz callaghan Being a single parent, I could not afford the financial luxury to challenge the Medical Board in court and obeying the immigration law I permanently left the country on 26th of September I m a single parent, my 14-year-old son was born in South Africa, but he grew up in Australia. He was only three years old when we first arrived in I would like to mention that for my attendance of these post-graduate courses I paid as an international student besides the fact that I was in the country for already seven years and I paid taxes. I have been working in Australia for 11 years. I have two children born in Australia. I have no status in the country. I have no Medicare access. Since my wife is a NZ citizen and qualifies for Medicare benefits, I have to pay Medicare levy and surcharge without having access to Medicare benefits. Since I don t have access to Medicare I pay private health cover as a visitor... after 11 years in the country. If a doctor fails the RACGP (Royal Australian College of General Practice) exam, he is referred to the (preemployment) clinical interview and if he fails, the registration is cancelled. When doctor s registration is cancelled he must leave the country in 30 days because visa 457 is activity specific (medical) and location specific. If you cannot work as a doctor, you cannot stay in the area you live and the only option is to leave. The Visa 457 bounds also the whole family. This is because the visa is issued for maximum four years. Every time when you renew your visa you need to pass medical requirements. If you or one of the family members fails the health requirements, this family member cannot stay in the country. The main issue is the residential uncertainty of the doctor and his/her family. Takes 6 years to train a doctor, another 3-4 to specialise. If after working in Australia for over 10 years the system is not sure if the doctor is competent to practise, I don t think that the problem is in the doctor. or OTDs) are medical refugees and as such should be grateful for any Australian hospitality. Further, that all IMGs have substandard medical training. I believe that my, and many other IMGs experiences, show the present registration system to be deeply flawed, often inappropriate, almost always unfair and prejudicial. My employment contracts have always been financially inferior to my Australian-trained colleagues. To put it bluntly I call it doctors with borders or being an open doctors prison in outback Australia. Many submissions recount how OTDs have had to undertake the exams with a number of major stresses including having a visa that expired only weeks after the exam, having a family in limbo not knowing whether or not they would be moving to Australia and, in addition, receiving conflicting advice from various medical colleges as to whether or not he/she could apply for reassessment at the same time as applying to sit the exam. The AMA submission to the inquiry states: Given the nature of rural practice with its emphasis on resourceful individualism, generalist medical skills, isolation, lack of supervision and small communities, there could not have been a worse place to send IMGs. Similar anecdotal stories about visa delays and registrations issues are heard from our CHA member directors of nursing as well, in relation to nursing and allied health international recruitment. Perhaps we would do well to reflect on how our own institutions treat our overseas-trained health professionals, and ask whether we are providing clear lines of communication, support and advocacy for these professionals when it is needed. Footnotes: 1. Carver P, Self Sufficiency and International Medical Graduates - Australia National Health Workforce Taskforce, Melbourne, Marg Overs, tweeted 28th October,2011, 10.30am. 3. Geffen L, editor. Assuring medical standards: the Australian Medical Council Canberra, ACT: Australian Medical Council, 2010 Reference: Across the entire registration spectrum there are systems that at first glance appear sensible, logical, necessary and reasonable. These systems also appear to be fair, unbiased and equally accessible to all applicants. They are anything but. Certain individuals would have the Australian public believe that all IMGs (International Medical Graduates 9

12 the sector speaks the organisation of pastoral care in health an australian perspective On November 23, in the San Pio X Hall at the Vatican, a meeting of bishops who oversee pastoral care within health services drawn from around the world was convened by the Pontifical Council for Health Care Workers. The Pontifical Council asked Bishop Patrick Power, the Auxiliary Bishop of Canberra-Goulburn and the Chairman of the Australian Catholic Bishops Conference s Commission for Health and Community Services, to address the meeting on the topic of the Organisation of pastoral care in health in the Church from an Australian perspective. Below is a copy of the speech Bishop Power gave to this conference in Rome. A Samaritan came near the man who had been mugged, and when he saw him, he was moved with pity. As ministries of the Catholic Church spread across Australia, our work is inspired by the God who in Jesus went out to strangers to heal and to make our world just. Like the Good Samaritan, we in Catholic health and aged care in Australia are committed to walk with those in need, regardless of their beliefs, rich and poor alike. In this way, we remain true to the call of the Gospel. I am very humbled to have received this invitation to be with you during this conference, and I express my thanks to the president and the members of the Pontifical Council for being able to share these few days with you. The words I opened with, that reflect on the Samaritan and the importance of the parable to the Church s health ministry, are not my words. They are instead the words of the shared purpose statement under development by the hospitals, medical research centres, aged care homes and home visiting services that are operated by our wonderful Catholic lay people and religious in Australia. It is really on behalf of these talented lay people and religious that I am here today. We are blessed that Catholic hospitals and aged care services in Australia are strong. There are 75 hospitals and 550 aged care services. The Church operates 10 per cent of the nation s hospitals and aged care services. These services are growing. A decade ago there were 55 hospitals. Two thousand extra aged care beds have been added to Catholic services in the last three years. Forty thousand staff work in these services, almost all of them lay people. Our hospitals and aged care services in Australia are organised by nature of their history. Nearly all services were started by religious congregations over past decades in response to community need. As the numbers of religious started to decline, a number of partnerships were formed between different religious congregations to ensure ministries were able to continue. In more recent times, lay people have started exercising managerial and governance roles once performed by religious. In all, there are 76 different canonical bodies that today oversee health and aged care services. Very few of these are bishops. In fact, there is only one bishop in Australia, the Bishop of Lismore, who has responsibility for a Catholic hospital. Unlike the case of Catholic schools, most bishops in Australia readily acknowledge that it is the religious and lay people who have given the gift of Catholic health care to the Church in Australia, and that it is these religious and lay people who deserve the support to carry these ministries through into the future. We the bishops of Australia have three separate means of relating to these wonderful Catholic ministries in health care. 1 0

13 bishop patrick power auxiliary bishop of canberra goulburn The first is through the Australian Catholic Bishops Conference. I chair the Bishops Commission for Health and Community Services, and we meet with the leaders of health and community services as needed. The relationship this commission has with Catholic hospitals and aged care services is very good, and we are grateful that whereas the hospitals and aged care services are mostly canonically independent of the bishops conference, we nonetheless have a sound working relationship built on the principles of mutual respect. The second is through Catholic Health Australia, the association of Catholic hospitals and aged care services. The association is very strong, reflecting the collegiality with which the different hospitals and aged care services work together in fulfilling the health ministry of Jesus. Catholic Health Australia is a key adviser to the bishops on health policy. Catholic Health Australia is a strong voice for Catholic teaching in the political and media landscape of Australia, and not only focuses on health and aged care policy but is also a champion of the social determinants of health. It is the social determinants, known as early childhood experiences, schooling, access to food and housing, and employment security, that the World Health Organisation says determine how long a person will live and how healthy they will be. Catholic Health Australia is driving governments to focus on the social determinants of health, and the Church, through its social services and schools, is well qualified to be making this case on behalf of the poorest and neediest within the Australian community. The third is through our diocesan connections. Each of the hospitals and aged care services within a bishop s diocese is constantly seeking bishops involvement in the health ministry of the Church. We bishops are blessed to have excellent working relationships with those who exercise the mission of the Church in health care in Australia. Through these three channels of engagement between bishops, hospitals and aged care services, we have put in place several formal mechanisms. The first is the Code of Ethical Standards of Catholic Health and Aged Care Services. I have several copies with me for anyone who might be interested. It is a practical guide for staff in Catholic hospitals and aged care services on how to live the mission of Christ through informed understanding of Church teaching of health ethics. It was authored by both the bishops and Catholic Health Australia, and is used even beyond the walls of Catholic hospitals. It is a document that draws from the teachings of this Pontifical Council s Charter for Health Care Workers. The second mechanism is near to completion. The bishops and Catholic Health Australia have authored the Guide for Understanding the Governance of Catholic Health and Aged Care Services. It came about in recognition of the reality that lay people are today exercising the governance responsibilities once carried out by religious, and that bishops themselves have very rarely, if ever, exercised such responsibility. The guide expresses agreement of Catholic Health Australia and the bishops on how Catholic governance can best be practised in recognition of civil law, canon law and theological requirements. The guide also describes certain requirements of Catholic formation, and the need for this formation to be ongoing and more engaging over the course of a person s maturity in faith. It is my hope that back in Australia where the bishops are this week meeting as a conference that they will ratify the final draft of this guide which is the product of 18 months of work by bishops and Catholic health administrators. 1 1

14 the organisation of pastoral care in health an australian perspective cont. We bishops are very proud of our Catholic hospitals. They are some of the best and most trusted hospitals in Australia. At a time when many Australians are suspicious or cynical about organised religion, they trust the place of Catholic hospitals within the community. The face of Jesus is presented with compassion and expertise to the Australian community through our excellent Catholic hospitals. Governments across Australia have a high regard for Catholic hospitals and aged care services. Unlike the situation in some other countries, our state governments actively fund 21 Catholic public hospitals to provide services to any person in need. Our 550 Catholic aged care services all receive some type of federal government funding. Government health funding is in fact very good in Australia, as universal access to health care is provided through a taxpayer-funded system called Medicare. Medicare enables any Australian to see a doctor, be treated in hospital or receive pharmaceutical treatment for free if they are not themselves able to afford the cost of their healthcare. That does not mean that governments always take the same view as the Church when it comes to certain ethical positions. Abortion is legally accessible in Australia. Euthanasia is not legal, but there are many in the community including some parliamentarians who are campaigning to have it legalised. The bishops and Catholic Health Australia are working to ensure that the movement in favour of euthanasia does not see it legalised in the years ahead. This will continue to be a very difficult task. Governments do, however, respect the ability of Catholic hospitals to operate in accordance with Catholic ethical teaching. No Catholic hospital does or is required to provide abortion services, or to provide contraceptive advice or assisted fertility services. Governments respect Catholic ethical teaching within Catholic hospitals and aged care services, allowing them to operate in compliance with the Code of Ethical Standards of Catholic Health and Aged Care. Catholic hospitals in Australia face many of the same problems as the wider Church in western nations. Church attendance is declining in Australia, as is the number of practising Catholics. The number of people willing to take on a life-long commitment in the priesthood or religious life is similarly falling. This is placing pressure on Catholic hospitals and aged care services as to how they are able to administer the sacraments to hospital patients or aged care home residents. Lay people are undertaking bachelor degree qualifications in theology to serve as mission leaders and pastoral caregivers. Committed Catholics are working in large lay pastoral care teams to tend to the spiritual needs of the sick. Clergy continue to have a presence, but this presence is declining. As well, some of our brother priests find the pace of modern-day hospitals a very real challenge. Just as many Australian parishes do not have priests, some hospitals and aged care services have difficulty in having clergy available on all occasions when they are needed. In some circumstances, particularly in country areas where clergy are most stretched, access to the sacraments is sometimes limited. There are no easy solutions to this problem under current circumstances where committed Catholic lay people are available but not empowered to celebrate those sacraments reserved to the ordained clergy. Whilst our Catholic health services in Australia are vibrant today, the challenge for us bishops is to keep pace with the changes which are continually occurring. We need, in partnership with all involved in Catholic health care, to read the signs of the times. Technology is moving fast, new ethical challenges arise with almost every new treatment, and with declining numbers of Catholics in the Australian community there are less Catholic lay staff, religious and priests available to work in Catholic organisations. We must support those willing to work in the service of the Church, and find pathways to sound ethical decisions. The future for the Church in health care is strong, if we put faith in our lay leaders and continue to assist them in their formation and understanding of Catholic identity and support them in their work for God and his people. Those of us involved in Catholic health care in Australia take heart from Pope Benedict s words to this Council last November: To bend down like the Good Samaritan to the wounded man, abandoned by the side of the road, is to perform that greater justice that Jesus asked of his disciples and actuated in his life. We in Australia commit ourselves wholeheartedly to continuing our ministry in that spirit. 1 2

15 the sector speaks spiritual renewal program for health care leaders Earlier this year, I was fortunate to be a participant in the US Catholic Health Association Ecclesiology and Spiritual Renewal Program for Healthcare Leaders. I found it a wonderful experience in gaining a deeper understanding of the call to the health care ministry vocation and a fascinating insight into the spirit, structure and function of the Catholic Church in Rome and how health care fits into their worldview. I had expectations that the program would be a high-quality leadership formation experience that would enable me to identify new perspectives on my work. I can certainly say that my expectations were exceeded. Fortunately for us, we commenced the program by attending the beatification of Pope John Paul II and with the other 1 million people in attendance, it was a very inspiring beginning. The program offers tutorials and presentations for half of each day and then an outing or meeting with relevant individuals, sacred sites or institutions. On the first day, we were offered great insight into the workings of the Holy See and spent some time exploring the Vatican Museum, Sistine Chapel and St Paul Outside the Walls. This particular day provided valuable insight into how the Holy See views Catholic health care in a global context and the importance that Catholic health care has in the life of the community. The next day involved a visit to Assisi undertaking discussions around the lives and spirituality of St Francis and St Clare and of course attending a Eucharist in the basilica in Assisi. While obviously quite inspiring, presentations from the team leaders provided much formation around spiritual maturity and the importance of Catholic imagination. It is evident in a formation context that lay leaders need to aspire to move beyond an elementary understanding of the Catholic faith. That evening we had a presentation from John Allen, author of All the Vatican s Men. His talk certainly reinforced the idea that any Catholic health care leader needs to move beyond simply having excellent technical skills into a better understanding of the faith and pillars that underpin the health care ministry. If you have not read John Allen s book, it is a good read. On the last day of the course, we attended Mass at Santa Susanna and debated expressions of spirituality that have shaped the Catholic healing ministry on an institutional, professional and individual level. I very much enjoyed the conversations with other US Catholic health care leaders and we all agreed that exercising leadership, while incredibly meaningful and satisfying, is very challenging during this time of rapid change. Overall, the program was reinforcing around the importance of leadership in the health ministry as well as providing a window into the structure and function of the Vatican. Importantly, this formation experience gave me an opportunity to revisit the core of Catholic tradition and identity, and is an exemplar of the importance of ongoing formation for leaders in the ministry. For more information on the Ecclesiology and Spiritual Renewal Program for Healthcare Leaders, visit the US Catholic Health Association website: Day three involved a papal general audience in St Peter s Square and in the evening we met with Sant Egidio Community representatives, which provided a valuable and powerful opportunity to discuss what it means to serve the poor as well as debate the notion of radical Christianity and formation of the heart. The following day was a day of meetings with members of the Congregation for Institutes of the Consecrated Life and Societies of Apostolic Life, the Pontifical Council for Health and the Congregation for the Doctrine of the Faith. These provided a deeper understanding and insights into the processes of the various dicasteries and much reinforcement that health is one of the major outreach institutions of the Catholic Church. steven rubic, CEO st vincent s & mater health sydney 1 3

16 ethics special feature duty of reasonable use of medical treatment Catholic Health Australia invited a number of ethicists, and those involved in teaching ethics, to contribute to this issue of Health Matters. The views expressed in these articles are those of the author. The duty of care is not absolute when it comes to demanding specific treatments to cure diseases or to prolong human life. The medical profession and the State are not bound to go to unreasonable lengths to provide every possible treatment regardless of cost, so long as basic comfort and care are always provided. The availability of resources, personnel and finances of the family, hospital and government budgets must be considered along with the prospects for a patient s recovery when determining if there is a duty to provide any specific medical treatment. The drawing of the line between where treatment should be given and where it need not be given is one of the most perplexing moral dilemmas that doctors and competent patients have to face. More than 50 years ago, Pope Pius XII taught that:... normally one is held to use only ordinary means according to circumstances of persons, places, times and culture that is to say, means that do not involve any grave burden for oneself or another. A more strict obligation would be too burdensome for most men and would render the attainment of the higher, more important goods too difficult. Life, health and all temporal activities are in fact sub-ordinated to spiritual ends. 1 Often it is difficult to apply moral principles in individual cases. The Catholic Church s Declaration on Euthanasia (1980) offers the following wise guidelines: If there are no other sufficient remedies, it is permitted, with the patient s consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity. It is also permitted with the patient s consent, to interrupt these means, where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient s family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques. It is also permissible to make do with the normal means that medicine can offer. Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community. When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help a person in danger. Consultation among colleagues may facilitate the task of assessing the balance of likely benefits for a patient resulting from surgery against the burden of deterioration 1 4

17 rev norman m ford don bosco youth centre & hostel of health or increased suffering for the rest of one s life if no treatment is given. The probability of a successful outcome resulting in an improved condition would need to be sufficiently high to justify surgery where the risk to the life of the patient is substantial. A doctor may accept a colleague s alternative medical opinion but not if the advice is believed to be medically unsound. deciding that continuing medical treatment, as distinct from palliative care, is unwarranted or too burdensome and may be discontinued. In other words, informed and competent patients do have a right to draw the line in a morally responsible way between warranted and unwarranted, that is, extraordinary, medical treatment. Doctors should respect this eminently human and personal decision. The drawing of the line between where treatment should be given and where it need not be given is one of the most perplexing moral dilemmas Family members may be at their wit s end, hoping that doctors may propose a satisfactory remedy, afraid or unable to suggest much themselves. Doctors may need to reassure them that no intervention is in the best interests of the patient. It is frequently a matter of listening to the family s unexpressed heartfelt cry rather than merely hearing the words they utter. Under no circumstances should doctors act against their conscientious professional judgement by initiating treatment that is not in the best interests of the patient. The community should allow doctors all the necessary freedom to follow their own professional judgement. Medicine is not an exact science and errors may be made in good faith without any suggestion of incompetence or the need of actions for wrongful death. Pope John Paul II wrote that when death is clearly imminent and inevitable, one can in conscience refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted 2. Pope Benedict XVI has said much the same: To eliminate death or to postpone it more or less indefinitely would place the earth and humanity in an impossible situation, and even for the individual would bring no benefit 3. These quotes of two popes may well have a message for us not to seek to prolong life beyond reasonable bounds for patients afflicted by a terminal illness or condition. Catholic teaching morally requires people to have recourse to ordinary means to preserve life. It does recognise competent patients moral right to follow their conscience when Footnotes 1. Pope Pius XII, Address to the International Congress of Anaesthesiologists, Acta Apostolica Sedis, 49 (1957)1030; The Prolongation of Life, The Pope Speaks ( ) Encyclical Letter, The Gospel of Life, 1995, n Encyclical Letter, On Christian Hope, 2007, n

18 ethics special feature umbilical cord blood banks... and the therapeutic potential of stem cells We in Australia are used to being blood donors and indeed, in times of emergency, we are used to being blood recipients. Our blood service is a remarkable, if unremarked, expression of human solidarity. The same, too, can be said of the recent development in Australia of public umbilical cord blood banks. Until recently, umbilical cord blood was discarded as medical waste. Now it is considered to be a valuable medical resource from which can be extracted stem cells stem cells that may be useful in the treatment of a range of serious conditions. At the moment, these stem cells are used by haematologists as an alternative to bone marrow transplantation. In the future, they may well be used in the treatment of a wide range of conditions. These cells are classified as adult stem cells so named to distinguish them from embryonic stem cells. They are obtained from the umbilical cord in a process which is painless for mother and child and which poses no risks to either of them. Much is still to be discovered about the potency of various kinds of stem cells. It used to be thought that adult stem cells were limited in their ability to differentiate that they could only differentiate into the tissue of their origin. Now there is evidence to suggest that they can differentiate to become other cell types as well. Indeed, in 2006, scientists discovered that some pluripotent stem cells could be artificially derived from non-pluripotent stem cells by forcing an expression of specific genes. The development of induced pluripotent stem cells (IPS) is welcome for both ethical and scientific reasons. It seems likely that it will provide pluripotent stem cells, the sourcing of which does not involve the destruction of an embryo. Around the world, research on the therapeutic potential of stem cells is regulated by law. The key difference is between jurisdictions which prohibit research involving the destruction of the human embryo and jurisdictions which do not. Until 2002, Australian law prohibited such research; One by-product of the debate is the widespread misconception that the Catholic Church opposes stem cell research. A stem cell is a cell which has the ability to differentiate into specialised cell types. There are two main sources of stem cells: Embryonic stem cells are formed during an early phase of the development of the embryo; adult stem cells are found in many tissues in the human body, brain, bone marrow, skin, muscle, blood, blood vessels, liver etc. Adult stem cells remain in a quiescent or non-dividing state for years until they are activated by disease or tissue injury. Embryonic stem cells are extracted from the four- to fiveday-old embryo in a process that destroys the embryo itself. Adult stem cells are extracted from human tissue in a harmless way. Once extracted, scientists place the cells in a controlled culture that prevents them from further specialising or differentiating but allows them to divide and replicate. Once they have been allowed to divide and propagate in a controlled culture, a line of healthy, dividing and undifferentiated cells is called a stem-cell line. Stem cells can be categorised by their potential to differentiate into other types of cells. Embryonic stem cells are totipotent, meaning that they can become every type of cell in the body. Other stem cells are pluripotent, meaning they can differentiate into almost all cells types; multipotent, meaning they can differentiate into a closely related family of cells; oligopotent, meaning they can differentiate into a few different types of cells; or unipotent, meaning they can produce only the cells of their own type. now it merely regulates it. As a matter of interest, a few weeks ago the European Court of Justice ruled that research involving the destruction of human embryos could not be patented. Responses to the decision of the European Court show that the debate about what the law should say about research that destroys human embryos was and continues to be complex. One dimension of it concerned a debate about means and ends. Proponents of legalisation emphasised the desirability of the end that is to say, their position focussed on the development of therapies that would likely result from research which involves the destruction of human embryos. Opponents of legalisation emphasised the moral status of the means, with their position focussed on an ethical evaluation of the means used in pursuit of a therapeutic goal, in particular that the means should not include the destruction of human embryos. Proponents generally thought that there was nothing wrong with destroying human embryos in and of itself (so they rejected the claim that they were inattentive to the ethical status of means they said that they just had a different view of those means). Opponents often thought that the likely therapeutic benefits of research involving the destruction of human embryos were being shamelessly 1 6

19 dr bernadette tobin plunkett centre for ethics hyped. Certainly in the last 10 years there have been some wonderful discoveries about the therapeutic potential of adult stem cells indeed, it seems increasingly likely that the human body contains the ingredients of its own regeneration. We shall certainly need wisdom, as well as scientific expertise, in harnessing that potential! One by-product of the debate is the widespread misconception that the Catholic Church opposes stem cell research. For nearly 10 years, the Catholic Archdiocese of Sydney has awarded a significant grant, on a competitive basis, to stem cell researchers from around Australia for research which meets the highest standards of scientific excellence, from which therapeutic applications are likely to arise, which is innovative in that it displays novelty in its experimental approach, which is undertaken by researchers with a track record of success in undertaking similar or related research and who have obtained matching funds from another source and for whom receipt of the grant will be significant for the undertaking of the research. Of course, it goes without saying that the research must comply with the standards set out in the Code of Ethical Standard for Catholic Health and Aged Care Services in Australia. Over the years, the researchers who have won this grant are conducting research on stem cells found in the blood, the teeth, the skin and the connective tissue. To return, then, to the topic of umbilical cord blood banking. The stem cells found in umbilical cord blood can be used in either autologous or allogeneic transplants. In an autologous transplant, the person s own stem cells are transplanted back into his or her body. In an allogeneic transplant, stem cells are collected from a donor and transplanted into another person. Allogeneic transplants are possible only where the donor and the recipient have matching tissue types. At the moment, only about a third of patients who need an allogeneic transplant find a suitable donor within their family. Most therefore have to rely on either adult volunteer donors who are registered with a bone marrow donor registry or on umbilical cord blood that has been donated to a public bank. Nowadays, however, parents in affluent countries like Australia are being urged to store their child s umbilical cord blood in a private bank. These private banks are commercial concerns not surprisingly they talk up the likely need the child will ever have for his or her own cord blood. And of course the more that cord blood is stored in private banks, the less it is available for people who actually need it. Though there is nothing inherently wrong with setting up or using such banks, I think that their existence undermines the availability, for those who need it, of a resource for treating serious illness. If so, then those responsible for governing Catholic health care institutions have a reason, derived from solidarity with the sick, not to give institutional support to arrangements that undermine equity of access to needed treatment. 1 7

20 ethics special feature how do we say enough is enough? end-of-life issues in a pastoral context The following is an abridged version of a talk given to the annual Catholic and Anglican Clergy day, Brisbane, One of the reasons I chose this topic is because it is one of the ones about which I am most frequently consulted. The second reason was because I have found that we have lost the language with which to talk about such matters. By we I mean Christians who think in terms of a tradition that holds that every human life is sacred. Because we have lost our language, we tend to adopt the language being forged by the secular society, and that language will often lead us to places we would rather not go. We begin with a general ethical principle regarding respect for human life. In the context of health care, we can express that principle as follows: If a person is ill, he or she is obliged to seek help to maximise their chances of recovery and to minimise the effects of chronic disability or handicap. If illness is lifethreatening, a person should seek to avert the threat. The negative norm is: You should not directly attack the good of life there is no such thing as a life unworthy of life. The positive duty rules out one kind of bad practice, which is referred to as under-treatment. Under-treatment can be defined as the failure to take appropriate measures to treat symptoms or the condition itself, when those measures could bring real relief and are not considered too burdensome or intrusive. The language that is often used here to justify lack of treatment is that of futility. Medical personnel, family or even the patients themselves might say that treatment is futile because they are going to die anyway or because they will not be restored to the level of functioning that they consider desirable. We need to be very careful of the use of the language of futility here. Often what is meant is that the person s life is judged to be futile. It is a judgement about the meaning of someone s existence. But we cannot judge the meaning of someone s life. We cannot judge someone s life to be futile. However, there is a correct usage of the word futile, and that is when it is properly applied to the proposed treatment. A treatment is futile when the treatment does not achieve its purpose. So if the treatment is aimed at cure, when cure is no longer possible, then that is futile treatment. I have stated our positive duty and that it rules out undertreatment. But like all positive duties it has limits. A failure to respect those limits can lead to over-treatment. Over-treatment can be defined as continual use or commencement of procedures aimed at cure where that is no longer possible, or use of burdensome and intrusive procedures which are of no real benefit. So how do we walk the line between under-treatment and over-treatment? Many will talk about the quality of life of the patient, or their own quality of life, and make a judgement on what they consider an acceptable quality of 1 8

21 dr ray campbell queensland bioethics centre life. However, the corollary of that is that there is such a thing as a life no longer worthwhile. Others will simply talk of autonomy and say that it is up to the patient to decide, and if they are not competent, then someone who can speak for the patient might decide. However, they offer no real criteria for making these judgements. In our tradition we used to speak of ordinary and extraordinary means. Those terms used to be fairly common currency. They appeared in medical dictionaries as well as ethical textbooks. However, today you will find that fewer and fewer people in the medical profession are familiar with those terms. Last year I did a series of seminars in various Catholic health and aged care facilities. I asked how many were familiar with those terms at every seminar. About four out of every 100 people were familiar with the terms. That came as a bit of surprise to me. It did not worry me too much because I do not use that terminology either, but it did make me think about what was the language they were using to discuss these matters. Most of them had taken on board the language of quality of life. I am going to suggest an alternative. And then there are those who cannot afford drugs that would sustain their lives. For oneself or others, but does not mean that others can relieve themselves of the burden of care. In light of the patient s condition. The patient s condition is relevant. This is not a judgement on the quality of life, but an assessment of the consequences of treatment for someone in this condition. These are the kinds of things that need to be considered in deciding what is best for this patient. In talking with patients, families and carers, you could ask them to consider or to ask the doctors: How will the person handle the treatment? Will it cause him or her pain and discomfort? How much benefit will it give? It has been my experience that people relatives and patients themselves find the language of the benefit and burden of the treatment helpful in making such decisions regarding treatment in these end-of-life circumstances. First of all, it removes them from making some kind of judgement on So how do we walk the line between under-treatment and over-treatment? I said that there are limits to our positive duty. The limits can be expressed as follows: There is no obligation to have a treatment which has little or no chance of succeeding, that is, no futile treatment; and there is no obligation, other things being equal, to undergo treatment that imposes excessive hardship or is overly burdensome. If we look back at the usage of ordinary and extraordinary we discover that ordinary meant obligatory and extraordinary meant optional. But what made something extraordinary treatment? Its burdensomeness. So today we talk about the benefit and the burden of the treatment proposed. The burden may be: physical, which refers to pain and discomfort. Before anaesthesia, many treatments we consider normal today would have been considered physically too burdensome. Psychological, including cultural and personal sensibilities. This might refer to the stress of being away from one s family and familiar surroundings, or it might be cultural taboo regarding a man being examined by a woman doctor. Moral. The classic case here is the Jehovah s Witness refusing a blood transfusion. Economic. We might tend to think that this is rarely the case here in Australia, but it is very prevalent. People are dying waiting to see specialists in our public hospital system because they cannot afford to see them privately. the value of life of the person that they love. They are able to focus on the treatment and assess its value. It also gives them a language which they can use in talking to the medical personnel. Medical personnel are able to give a reasonably objective answer to questions such as: How will that treatment help or benefit my mother or father? What kind of burden or suffering will it inflict upon them? This kind of language is helpful for the competent patient when you are talking directly to the patient, and for the relatives who might have to make a decision for a non-competent patient. One of the most difficult cases is that involving a young person. Parents find it very difficult to let go and say enough is enough. I was involved in a case where there was conflict in the family. One parent was ready to let their young child go; the other wanted the doctors to continue treatment. When we spoke to that parent, not simply in terms of the prognosis, but in terms of the suffering that the treatment itself was inflicting upon the child, then that parent was able to let go. The parent realised that the treatment itself was causing suffering, and not treating was not killing their baby, but allowing the child to die. Finally, this way of thinking and talking is helpful if someone is considering completing an advance health care directive and is the language used in the documents regarding advance health care planning on the CHA website. 1 9

22 ethics special feature remaining true This is an abridged version of a talk given on September 1 at the Catholic Health Australia national conference at the National Convention Centre in Canberra. Let me begin with a story or, more accurately, a conversation. I don t understand you, said the businessman to the nurse. The businessman was a patient in a Catholic hospital. Perhaps it was your hospital, or a hospital in your town, because this is a true story. The nurse who tells it describes herself as an ordinary nurse in an ordinary Catholic hospital. The businessman continued: The people I move with, we all try to make as much money as we can. Some of us sometimes cut corners, because we want as much money as possible with as little effort. Beyond that, people like me live large we practise what is sometimes called conspicuous consumption. But I don t understand you, the businessman repeated. I ve noted the hours you work, the shifts, and how hard and demanding your work can be. I ve noticed that you try very hard to care for everyone. And I know more or less what you d be paid, and I know that you could make much more money with much less effort doing any number of other jobs. I don t understand you at all, the businessman said yet again. Then he added as his eyes suddenly filled with tears, But I m very glad that there are people like you in this world. origins are in two sources: the Judaeo-Christian ethic and Greco-Roman philosophy. These are sometimes called faith and reason. Traditional morality developed enormously during the high middle ages, the historical period between the 11th and 15th centuries. Since then, it has continued to develop, with Catholic social teaching contributing to this process. All around the world, there are many people who have found their moral code and their motivation for living through traditional morality. What are some of its themes? Firstly, traditional morality accepts that life and even survival are sometimes precarious, and therefore that we must continue to work to preserve and build up both individual life and the common life of society. Secondly, traditional morality is based on a common understanding of what it is to be human. It is this common understanding of what it is to be human that informs traditional morality in its understanding of what truly promotes human flourishing. Thirdly, traditional morality holds that human beings find their fulfilment above all through service. We are happiest and most fulfilled not when we are overly focussed on ourselves and our rights and our needs and our wants, but rather when we give ourselves away in service. Finally, traditional morality is concerned about three things. It is concerned about the common good of society. It is also concerned about the good of families, for it recognises families as the building blocks of society. And it is also concerned about the good of individual persons. As a group, we Boomers are the Enlightenment vision carried to its extreme. In my opinion, one of the most important clashes that is happening in today s world is the clash between traditional morality and a new morality that has emerged over the last few centuries. This clash is happening all over the world, and it happened in a simple way in this conversation. In this article, I will first describe both traditional morality and this new morality. As I do so, you will probably notice that the nurse in the story is an exemplar of traditional morality, while this businessman is an exemplar of the new morality. I will then explore the clash between these two worldviews. This reflection should highlight just how important it is that we remain true the theme of this conference. traditional morality In many ways, the history of western civilisation is a history of the ongoing development of traditional morality. Its Indeed, the challenge for traditional morality is to hold these three concerns in the right balance and not to be so concerned about one area that it neglects the others. Within this creative tension, though, its focus above all is on the common good the good of society, the good of all. 1 This concern for the common good is the most distinctive feature of traditional morality. Indeed, traditional morality often asks us to make some individual sacrifices for the good of all. Note that the nurse from my story is an exemplar of this worldview. More than that, note the profound connections between traditional morality and the distinctive ethos of health care. To commit oneself to give care and to be a healer as a nurse, as a doctor, or in any other role within health care is to recognise that we find our own fulfilment through service. It is to commit oneself to the common good through a mission of care and healing. 2 0

23 fr kevin mcgovern caroline chisholm centre for health ethics It involves a profound recognition of how precarious and fragile life really is. And it is to accept some measure of self-sacrifice, in many different forms, as the price one pays for one s commitment to healing and to the common good. There are indeed profound links between traditional morality and the distinctive ethos of health care. Over the centuries it was within the culture or worldview of traditional morality that the distinctive ethos of health care has been formed. the new morality In historical terms, the new morality really is new it dates back only to the 17th or 18th century. Specifically, it dates back to the so-called Enlightenment, which saw itself as a new beginning within western civilisation. The Enlightenment assumed that we have no common understanding of right or wrong, or even of what it is to be human. There is only my view and your view and everyone else s views, and the Enlightenment assumed that we have no way of deciding which views are more accurate or more true. 2 For this reason, the only vision that the Enlightenment offered is that, as much as possible, each of us should be free to follow our own path and pursue our own goals and live our own way. Its emphasis is therefore on autonomy and free choice. Thus, the Enlightenment assumes that human beings find their fulfilment above all not through service but through freedom and through free choice. This concern for individual freedom is the most distinctive feature of the new morality. A third factor in the development of the new morality is secularisation or, to give it another name, the eclipse of the sense of God. In its Pastoral Constitution on the Church in the Modern World, the Second Vatican Council warned of the significance of this. Once God is forgotten, the council wrote, the human person becomes unintelligible. 5 Once we lose sight of the Creator, we no longer see ourselves as the Creator s creation, and we gradually lose sight of who we truly are. Further, as we lose sight of the spiritual side of life, we focus only on the material side. We become materialistic, and we start to think that the purpose of life is nothing more than consumption. Finally, note that the businessman from my story is an exemplar of the new morality. I should stress that I am referring only to this particular businessman. Obviously, not every businessman is like this. Thus, we can summarise themes of the new morality. It is focussed only on the individual and on personal autonomy. It believes that human beings find their greatest fulfilment through consumption and through getting what we want. It is therefore materialistic and consumerist. The Enlightenment vision has also continued to develop through history. Enter the Baby Boomers: those of us born between 1946 and Yes, we re talkin bout my generation. 4 As a group, we Boomers are the Enlightenment vision carried to its extreme. We are the me generation. We Boomers place an extreme emphasis on individualism and on personal autonomy. Our twin cries are I gotta be me! and I gotta get my way! We Boomers therefore rail and fight against anything that would restrict our free choice. We are the generation which effectively decriminalised abortion in many jurisdictions around the world. We are the generation which is currently most passionately involved in the battle to legalise euthanasia. 2 1

24 ethics special feature remaining true cont. the clash of worldviews To consider the clash between these worldviews, we turn to John Paul II s encyclical Evangelium Vitae. The late pope said that at this time we are facing an enormous and dramatic clash between good and evil, between death and life, the culture of death and the culture of life. 6 Thus, John Paul alerts us that the new morality is also the culture of death. He notes that it arises from a notion of freedom which exalts the isolated individual in an absolute way, and gives no place to solidarity, to openness to others and service to them. 7 This helps us to understand the significance of what is happening. Remaining true is not just a nice idea or a clever catchphrase. Instead, it is remaining true to traditional morality, which fosters and protects civilisation itself. It is also remaining true to the traditional morality that underpins the distinctive ethos of health care as a healing profession. In this clash of worldviews, then, both the distinctive ethos of health care as a healing profession and even civilisation itself are at stake. In our institutions and throughout society, one of the most important clashes that is happening in today s world is the clash between traditional morality and a new morality... This intense individualism, this extreme autonomy and this excessive freedom ultimately undermine the common good. Indeed, John Paul also calls it a war of the powerful against the weak, 8 for this new morality turns those who are powerful away from the weak, and the weak, who need help, are abandoned and harmed. All things considered, then, the new morality is really an anti-civilisation a worldview that actually undermines civilisation and the common good. It is a pseudo-morality or even an anti-morality. we fight to preserve the essence of civilisation. It is hard to conceive of anything more important. If we lose sight of traditional morality and the common good, do we stand at the beginning of a new Dark Ages? So there is a clash going on. It is the clash between traditional morality and a new morality. It is the clash between religious faith and secularisation, between concern for the common good and a selfish individualism. It is the clash between civilisation and an anti-civilisation, between the culture of life and a culture of death. Please remain true and stand with us on the side of the culture of life. Footnotes: 1. The Compendium of the Social Doctrine of the Church defines the common good as the sum total of social conditions which allow people, either as groups or as individuals, to reach their fulfillment more fully and more easily. (#164) More simply, it also describes it as the good of all people and of the whole person. (#165) In traditional morality and also in the Catholic vision of life, all members of society (#167) and in particular the government (#168) must contribute to building up the common good. 2. This exclusive focus on subjective standards and the attendant refusal to recognise objective standards of right and wrong is called moral relativism. It is a deep-seated feature of contemporary culture which threatens the capacity of many individuals to truly tell right from wrong, and also endangers the authentic progress of society. 3. The different cohorts or generations are the Silent Generation ( ), the Baby Boomers ( ), Generation X ( ), Generation Y ( ), and Generation Z (2002+). My friends who belong to Gen X or Gen Y sometimes protest to me that their generations can be just as self-centred as my own. While this may well be true, I remind them that my generation thought of it first. 4. The Who, My Generation, My Generation (UK: Brunswick Records, 1965). The song is an anthem of adolescent and Boomer rebellion. 5. Vatican Council II, Gaudium et Spes (Pastoral Constitution on the Church in the Modern World), #36. In #22, the Council also notes that Christ fully reveals humanity to itself. 6. John Paul II, Evangelium Vitae (The Gospel of Life), # Ibid, # Ibid, #

25 Determining the Future: A Fair Go & Health for All Edited by Martin Laverty and Liz Callaghan $29.95 This book brings together a unique collection of essays on the social determinants of health from some of Australia s leading health and social policy experts medical professionals, academics, opinion leaders, thinkers and writers. Contained within its pages are diverse and confronting policy and practical proposals that invite all Australian governments to broaden their health policy parameters to include a new focus on the social determinants of health. This is a must read for politicians, policy-makers and those working or studying in health, social services, education, housing, political science and social justice. To order: Contact the CHA office, t Order online from CHA website Order from the publisher, Contributors: Professor Frank Brennan SJ AO, Martin Laverty, Fran Baum, Dr Matt Fisher, Colin Wood, Hon Michael Board JP, Salli Hickford, Taanya Widdicombe, Professor Laurie Brown, Dr Binod Nepal, Dr Tom Calma, Mick Gooda, Dr David Cooper, Mike Daube, Dr John Falzon, Dr Rhonda Galbally AO, Dr Steve Hambleton, Ben Harris-Roxas, Michelle Maxwell, Mark Thornell, Sharon Peters, Patrick Harris, Patrick McGorry, Dr Jenny May, Colleen Koh, Professor Leonie Segal, James Doidge, Dr Jackie Amos, Peter Sainsbury, Dr Elizabeth Harris, Marilyn Wise, Melissa Sweet, Helen Wiseman, Gloria Larman, Dr Tim Woodruff, Rachel Yates, Leanne Wells, Scott Brown, David Butt, Liz Callaghan. 2 3

26 ethics special feature the teaching of health care ethics Earlier this year, a former student ed me about an ethical dilemma that was occurring in her workplace. She was employed in ICU at a well known international tertiary hospital. The case involved a 35-week pregnant woman involved in a high-speed motor vehicle accident. The woman was diagnosed as brain dead. Her unborn child had also suffered severe hypoxia so it was determined that even though technically alive, it was a non-viable foetus. The question of organ donation was presented to the woman s husband but also for that of the unborn child for foetal tissue sampling. It was with regards to this latter scenario that my past student contacted me for some ethical guidance. Throughout our correspondence she constantly stated: I m so glad we studied ethics Jo I reckon I would have walked away from nursing by now because of issues like this one! Another time she also indicated that even though she still did not know the answers, at least she could understand all sides of the ethical debate, know the processes for the deliberation at an institutional, legal and social level, but more importantly be in a position to be the best possible patient advocate given the complexity of the clinical scenario. The Australian Catholic University has a long tradition in the education of health care professionals in the area of ethics. The university s mission statement provides reasoning for the inclusion of such education in these courses. This statement presents the commitment that the University explicitly engages the social, ethical and religious dimensions of the questions it faces in teaching and research, and service. This mission statement has its foundations in the Catholic Church s intellectual tradition, social justice teachings and respect and defence of the inherent and inviolable dignity of every human person. point of view on life issues? That would be contrary to the purpose of providing such education and is definitely not what the understanding of academic inquiry and education at a tertiary level is all about. Yes, students are presented with the Church s teachings in the area of health care ethics, with a particular focus on the writings of Pope John Paul II and his seminal bioethics encyclical Evangelium Vitae The Gospel of Life. However, they are also presented with all points of view on these contentious ethical and social issues, from Singer to Greer and Fisher to Kant. It is important that through their own intellectual engagement with the course content, students will come to a further understanding of ethical reasoning beyond the strongly relativist views presented at clinical and academic level and in contemporary Australian health care ethical discourse. These students will then become effective patient advocates in situations of moral uncertainty, to protect vulnerable members in society and advance the professionalism of their study specialisation. Despite the International Council of Nurses development and adoption of a professional code of ethics for nurses in 1953, health care ethics has traditionally been the domain of the medical profession. It is of interest to note that when there are calls for social, media or professional commentary on an ethical dilemma in the provision of health care, such as abortion or euthanasia, nurses are rarely asked to voice their reasoned argument despite being the largest health care profession in Australia. Traditionally there has been a dismissive approach to the role of nurses in health care ethical deliberation, in that others such as doctors, philosophers and theologians know best and for nurses just to continue care, not These students will become effective patient advocates in situations of moral uncertainty The Melbourne campus has provided an undergraduate health care ethics unit for more than 20 years. For the last two years, there has been the implementation of a master s unit in health care ethics education and more recently the development of a professional development education unit for Australian nurses and midwives. This unit is currently being developed with the support of the Mary Philippa Brazill Foundation and will be implemented in early One of the common questions that I get asked about the health care ethics units is Are you just getting the Church s contribute to these discussions. This paternalistic attitude towards nurses has been challenged in recent decades through the increasing number of nurse ethicists employed in academia and health care settings at a national and international level. Nursing is a moral undertaking. As prominent Australian nurse ethicist Megan-Jane Johnstone states: It is because of the potential to cause morally significant harm to others not to mention the breach of trust that could occur as a consequence of such harm being caused that nurse practice warrants attention from an ethical view. 2 4

27 joanne grainger australian catholic university Despite this need for registered nurses to be engaged in policy and clinical decision-making regarding health care ethics, it is often our own profession that does not provide effective leadership in these areas. One example is the Victorian Abortion Law Reform Act (2008) and the stated provisions that have negatively impacted Victorian registered nurses. During the Victorian Law Reform Commission s 2008 public consultation into the potential social, legal and ethical impact of decriminalisation of abortion in this state, over 500 submissions were received from various Victorian and national representative groups. From these submissions, the Victorian Abortion Law Reform Bill was drafted and then subsequently adopted in parliament. Out of these 500 or so submissions, not one was from a professional nursing or midwifery body to present a reasoned position on the impact of such law changes to Victorian registered nurses. This lack of representation of nurses to the VLRC allowed the complete negation of Victorian registered nurses right to full conscientious objection to their direct participation in any treatment or procedure that procures an abortion. the day-to-day clinical management of vulnerable patients in our health care system. Without such engagement, the resulting outcome may be the negation of the notion of registered nurses as moral agents in the provision of care, essentially risking the professional status of nursing in the health care team. It is hoped that several past, current and future students will become the future leaders in this complex area of health care. In this sense, ACU is contributing to the development of the professional standing of many health care disciplines through ethics education. Reference: Johnstone, M-J. (2009). Bioethics: A nursing perspective. Sydney: Elsevier Another area where the nursing profession has not had adequate and balanced representation is in the current debate about the adoption of a studied neutrality position in end-of-life care, in particular with regards to an action of assisted suicide or euthanasia. What these issues present is that there needs to be more health care ethics education at an undergraduate and postgraduate level for all professional groups involved in 2 5

28 ethics special feature do the right thing ethics and the medical course at the university of notre dame Imagine this. You are a doctor, and you admit an elderly lady, Betty, to hospital. Betty requires treatment for her diabetes a serious and ongoing health problem and one that she has suffered from for some time. She needs to spend several weeks in hospital. Because she lives alone, Betty arranges for her daughter, Karen, who has been caring for her for some time, to have access to her bank accounts so that bills and other household expenses can be dealt with while she s in hospital. Under your care, the treatment goes well and Betty is able to return home. But just before she is discharged, it becomes clear that Karen has drained her mother s savings in going on a well-earned holiday, rather than spending the money on maintaining the house. Distraught, Betty asks you, Doctor, what should I do? Can you help me? we must also equip them with a capacity for ethical reasoning that is invaluable to a strong foundation of effective medicine and compassionate care. They must also recognise that their patients are people whose well-being is impacted by their physical, mental, social and spiritual needs. The first step in ensuring that our graduates are both excellent and ethical doctors is to select students who understand that a career in medicine means that they will constantly engage with ethical questions. Additionally, we hope our students will show capacity for empathy and compassion, and will particularly value Notre Dame s knowledge and teaching in ethics in addition to what they will learn through an excellent medical curriculum. Notre Dame delivers our medical training in the context of Catholic faith and values. While we welcome students and teachers our job [is] to help them learn how to learn across their lifetimes. Should you call the police or social services? Advise Betty that the most important thing is to rebuild her relationship with her child? Contact Karen? Here at the University of Notre Dame School of Medicine in Sydney, we know that most of the time there are no simple answers to ethical problems. And doctors are presented with ethical dilemmas every day of their professional lives. Just as we train our medical students in the knowledge and technical skills they need to be safe and competent doctors, of all faiths, the mission of our organisation is distinctively Catholic with the utmost respect for life from conception, a deep concern for the physical, emotional and spiritual needs of the individual and a passion for social justice and global health. This is apparent to students from their first days at the university. One of the practical ways in which our mission is expressed is through the core curriculum that all students at the university are required to complete as part of their degree 2 6

29 dr christine bennett university of notre dame course. Entitled the LOGOS program, the core curriculum has been recently updated to offer more choice and relevance to the needs and preferences of students. There are four compulsory modules in the program: Think an introduction to the foundations of philosophy and, in particular, the skills of critical thinking and informal logic. Choose an introduction to the key concepts and theories in western moral philosophy as well as skills in practical reasoning and decision-making. Live an introduction to some key concepts in theology. Learn a final module that provides students with an opportunity to learn about what the Catholic Church believes about some key issues, including a number of controversial topics. The LOGOS program is not about teaching students the right answers to the challenges they will encounter, but rather it equips them with the tools to think and act ethically. This is not always easy. Learning to be a doctor is enormously challenging intellectually, emotionally and through the heavy study load. Students respond to these challenges in different ways. As part of their course, students compile a portfolio of reflections and insights they have gained from encounters with patients and the lessons they learn. We also ask students to keep a journal of their thoughts and feelings as they progress through the course. These private reflections are a useful way of working through the emotional and sometimes spiritual challenges that are an essential part of learning to be a humane and compassionate doctor. Why is all this important? Isn t it enough that we aim to educate our students toward high ethical standards and then trust them to do the right thing? The answer to this challenge is found in medicine itself. Our medical students are at the start of their careers. Some will be practising medicine for the next 40 or even 50 years. Students graduating now will be treating patients in And just at the medical practice of 1971 was transformed by 2011, so too will things be different by Advances in medical knowledge throw up new ethical challenges that require a response from individuals and the profession. Stem-cell research is one such example. This simply was not something that a doctor trained 40 years ago would have needed to think about. Now it is but one topic at the forefront of debates in medical ethics. Medicine is a career that challenges us to be lifelong learners. As our graduates move through their careers, they will face dilemmas that we have not even thought of yet. That is why as Dean of Medicine I see it as our job to help them learn how to learn across their lifetimes. We believe our school s mission, underpinned by the core curriculum, will contribute to the excellence of care and the high standard of ethical behaviour that we want from the next generation of Australian doctors. Christine Bennett with students on Birthing Kit Assembly Day, a social justice initiative to provide sterile birthing kits to women in the developing world. (Photo by Gerard Williams, The University of Notre Dame Australia) 2 7

30 other news reflections from CHA s scholarship winners Earlier this year, Catholic Health Australia announced Kris Botha, executive director of human resources at Cabrini Health, and Kim White, workforce and quality manager at St John of God Health Care Warrnambool, as the recipients of the 2011 CHA scholarships for the Graduate Certificate in Leadership and Catholic Culture. Following are reflections from both Kris and Kim on their first year of study. kris botha, cabrini health The experience of the first year in the Graduate Certificate in Leadership and Catholic Culture has been enriching and rewarding. My first reflection was the range of experienced and talented people who come together to make up the leadership teams of our Catholic health and aged care facilities. This is an opportunity to share and reflect with people from mission, finance, executive teams, human resources, medical administration, governing boards and management of aged care groups a diverse group that shares one thing in common: we are all leaders in Catholic care. We are here because we are invested personally and professionally in this service and vocation of sharing in Jesus healing ministry at some level. Our first unit, Catholic Ethos and Care of the Human Person, provided the opportunity to reflect, and to develop the skill of recording this reflection in a formal sense. This has been an enriching experience which is invaluable in day-to-day consideration of issues in the workplace, but also in the broader context of thinking beyond health care to our other work in social services and reflecting on why this is an imperative for us, in reaching out beyond our walls, and to encourage and provide opportunities for reflection for others. A major focus for me from a mission and people perspective was around Catholic health leadership and formation in the years to come. The presentations raised issues of recruitment to our teams into the future that have a significant impact on our services. On reflecting, this is not only about leadership, but about all levels of staff and their commitment to Catholic health and what underpins it as an increasing number of people come to work with us who will not have the background in Catholic health that many of us do, or understand its significance. For many, the Church s healing mission may be words without much meaning, and our recruitment processes and future formation are matters for serious consideration and planning in preserving Catholic identity and its integrity in the care we provide, and a solid alignment with the mission and values of our organisations. This unit s presentations and opportunities to share with colleagues provided an invitation to constantly reconnect with the values of my own organisation and to remember that indeed all our missions are rooted in the Gospel values, varying according to the charism of our founders. It is that spirit of service of our founders that inspires us. There was an invitation to tell stories and share rituals, to remind us of where we come from, our Catholic tradition, the theology of Catholic health, and how stories ground us and remind us of the journey, and enable us to be leaders who carry forward what makes what we do important and be able to instil that in our future workforce. Our second unit presented a great background and clear, easy-to-understand description of ethics in a faithbased context and highlighted reference points that provide clarity in the deliberations around ethical issues that confront us in Catholic health. This unit has provided a greater confidence to discuss and debate contemporary problems and ethical dilemmas and contribute in a more meaningful way, and to contemplate both local matters and those of public policy with a new depth and discernment, in keeping with our Catholic tradition. There is new insight to value what makes the appreciable difference in care in a Catholic facility, and a new understanding of the Code of Ethical Standards of Catholic Health Australia that describes as complex the ministry of care to the sick, frail and dying and care for the whole person beyond the limits of science and standards of ethical health care. I appreciate and value the opportunity provided by Catholic Health Australia to undertake this Australian Catholic University program and their ongoing contribution to the development of Catholic leadership, and my own organisation, Cabrini Health, for its great support and encouragement. 2 8

31 kim white, st john of god health care Having now completed the first two units of the ACU Graduate Certificate in Leadership and Catholic Culture, I believe it has provided me with a deeper understanding of the theological basis of our mission and Catholic traditions at St John of God Health Care. My previous studies have been focussed around nursing and business skill development and have been very practical in their delivery and learnings. This course has had a significant focus on reflection and particularly reflection on self, which has been enhanced not only by the thinking, but also the scribing of thoughts and reflection into a reflective journal. This exercise has not only allowed for learning, but allows and promotes reflection for action in your everyday practice. The theological basis of the course and the discussions held with colleagues, and the emphasis on reflection has allowed for a greater depth of reflection and understanding of not only my own practice within St John of God Health Care, but also that of the practices of the organisation as a whole. The understanding gained during the course has given me the confidence to influence and discuss not only ethical or moral issues, but also to provide leadership that is reflective of Catholic culture. This new understanding of Catholic tradition has also allowed me to participate at a greater level and depth in our divisional management committee Reflection for Action sessions. In a practical sense, my gained knowledge, understanding and confidence has increased my ability to support the Catholic identity of the hospital. This includes being proud of our Catholic tradition and promoting this identity and tradition. As the workforce manager at St John of God Warrnambool, this is enabled by ensuring our Catholic values and history are clearly articulated in all parts of workforce management including positions vacant advertisements, both internally and externally, and caregivers position descriptions and making sure that those we employ have values that align to those of our organisation, not just a technical skill set. The opportunity to complete tasks and network with other senior leaders across Catholic organisations has been another great aspect of the course. The sharing of these experiences and the discussions around issues has been not only enjoyable but invaluable in providing further learning opportunities, as we learn from one another s experiences. I am looking forward to the further two units in 2012 and thus the completion of my Graduation Certificate in Leadership and Catholic Culture and thank CHA for the opportunity to do so by the awarding of the scholarship. The second unit of the graduate certificate has provided me with knowledge and understanding to work through and discuss with colleagues ethical or moral issues that may arise in our hospitals from time to time. The theological and practical base of this unit broadened my understanding of ethics from a Catholic tradition perspective, which then has provided me with a greater depth of the principles to apply ethical theories within the Catholic tradition. 2 9

32 other news calvary ehealth puts group on pathway to the future The Australian Government s $466.7 million investment in a national personally controlled electronic health record system has given Calvary Health Care ACT a head start to the future. It s an exciting opportunity for us to be involved in a major new national health care initiative that really will revolutionise and transform patient care at all levels, said Walter Kmet, national director of public hospitals for The Little Company of Mary Health Care group. Calvary ehealth is one of nine systems Australia-wide reflections of a first-year medical student Rose McFee is about to complete her first year of bachelor of medicine/ bachelor of surgery at The University of Notre Dame in Sydney. Rose reflects on her journey to becoming a medical student, her choice of university and her plans for the future. Why medicine? My journey to becoming a medical student began almost 10 years ago. I didn t always know I wanted to pursue a career in medicine. I didn t even think about studying medicine after high school the impressive UAI marks needed to secure a place made undergraduate medicine seem impossible. My real passion was basketball. So, instead of going to uni here in Australia like most of my friends, I went to the other side of the world to Pennsylvania in the United States on a basketball scholarship. I had a fantastic experience studying a bachelor of arts, playing college basketball and experiencing the American culture. Studying an arts degree was the perfect choice for me because, like so many high-school leavers, I wasn t sure what I wanted to do after school. I developed a real interest in biology, particularly human biology and anatomy and the sporting injuries sustained by myself and my teammates over the years! When I returned home after completing my degree in the US, I worked for a while with the NSW Deaf Society and then enrolled in a bachelor of health science at The University of Sydney. I became increasingly aware of Australia s health care system, health policy and the social determinants of health. What really struck a chord with me was the health inequity that exists for Indigenous people and those from rural backgrounds. I could see this was an area where I could make a difference. A volunteer placement to the Northern Territory affirmed my desire to study medicine. I loved the Northern Territory. There I saw a very different side to health care compared to a typical doctor s surgery in Sydney. The high prevalence of diabetes, renal failure involving the need for dialysis, high rates of smoking and 3 0

33 which are being developed in advance of the national rollout. Our specialisation in aged and palliative care, and chronic disease, is the cohort group for Calvary ehealth and this will provide unique insights as we begin to link hospitals, clinics, specialists and general practices across the ACT and southern NSW. The region to be covered by Calvary ehealth is one of the largest of all nine winning tenders stretching south from Ulladulla to Mallacoota on the NSW/Victorian border then west towards the River Murray sweeping up through Deniliquin, as far north as Lake Cargelligo then Broken Hill. alcohol consumption, and the incredible challenge faced by many in terms of access to health care services were just some of the differences that stood out to me. This was a gift for me to learn more about Indigenous culture. It was clear to me that outback Australia is a place in desperate need of good doctors to provide quality medical treatment. These experiences motivated me to apply for graduate entry medicine at The University of Notre Dame. I was over the moon when I received my letter of acceptance late last year. Why Notre Dame? Like most medical degrees these days, The University of Notre Dame offers a graduate-entry course. Most of the teaching is conducted in small problem-based learning (PBL) groups. A graduate course really appealed to me. My fellow students come from diverse backgrounds, which really adds benefit to our learning because everyone has a different perspective and can contribute something fresh to group discussions. My PBL group this year has a nurse, an engineer, a lifeguard, a public health worker, and a student with a PhD in heart failure! Notre Dame is a Catholic university, which was another factor that appealed to me. The university values the importance of social justice and social inclusion. In addition to being taught the necessary clinical skills, we are also encouraged to be mindful of the context in which we practise those skills. There is a strong emphasis on pastoral care and the course includes three compulsory core curriculum subjects of ethics, philosophy and theology. I think the inclusion of these subjects demonstrates the value Notre Dame places on forming doctors with the ability to think about ethical issues. Doctors encounter ethical issues on a daily basis, so it s important for new doctors to be trained to appreciate diversity and prepared to tackle difficult ethical and moral decisions that arise in health care. What comes next? As I write this article, I have just completed my clinical exam at the end of my first year. I am so amazed at how much I have learned about medicine and I m only at the start of the journey! I have had some great opportunities this year including trips to Lithgow and Dubbo with the Notre Dame rural health club, attending Cancer Australia s recent Pink Ribbon breakfast, spending time shadowing a GP in Paddington and meeting several inspiring doctors at various Notre Dame events. I am constantly amazed at how many different career paths there are to follow with a medical degree. I haven t yet made up my mind which path is for me. My ideas are endless: working with people who experience disadvantage such as the homeless and refugees, emergency medicine, general practice, cardiology, or obstetrics and gynaecology. One thing is for certain. I would definitely like to pursue a career in rural health, and get back to the Northern Territory some time in the near future. There is a need for good doctors in rural and remote parts of Australia and I d love to do it! 3 1

34 people & places murdoch caregivers provide $23,000 boost for st patrick s Caregivers, hospital auxiliary, patients, visitors and doctors all contributed to the successful St John of God Hospital Murdoch Charity of the Year fundraising program that raised nearly $23,000 for St Patrick s Community Support Centre. At a celebration morning tea, St Patrick s thanked St John of God Hospital Murdoch caregivers for their generosity with a performance by the centre s community choir, the Starlight Hotel Choir, featuring members who will directly benefit from the fundraising program. Murdoch director of mission Colin Keogh said the centre was already a focus of social outreach and advocacy activities at the hospital and was a natural fit for the organisation. St Patrick s Community Support Centre in Fremantle provides accommodation and support to homeless men. There has been a strong relationship with St Patrick s since 2006 and, as recipient of our Charity of the Year, we were able to increase that support. St Patrick s Community Support Centre chief operating officer Michael Piu and St John of God Hospital Murdoch director of mission Colin Keogh with members of the Starlight Hotel Choir. director of mission awarded ethics grant Belinda Clarke, director of mission with Calvary Health Care Tasmania, has been awarded a 2011 Mary Philippa Brazill Foundation Grant to support her attendance at the first International Association for Education in Ethics Conference at Duquesne University in the United States. The conference will host international experts from around the globe presenting on a wide variety of topics in the area of ethics, including religious ethics, medical ethics, bioethics and nursing ethics. Ms Clarke said being awarded the grant was an honour which would allow her to enhance her knowledge and understanding of ethics education, in particular in the areas of religious ethics, medical ethics and bioethics. After I attend the conference, I will create an ethics interest group for Calvary Health Care Tasmania, she said. My hope is to inform and enable people to become better equipped in ethical decision-making in the area of health care ethics, and, in particular, Catholic ethical decision-making. Dr Bernadette Tobin, Mary Philippa Brazill Foundation Trustee, presenting Belinda Clarke, right, with the grant. 3 2

35 patients rate calvary day procedure centre number 1 The Calvary Day Procedure Centre Wagga Wagga has been ranked number one among 206 hospitals surveyed across Australia by Press Ganey Associates, a national comparative benchmark organisation for health care. Press Ganey advised that the key to Calvary s very positive outcome included nursing care and the efficiency of the admissions process, hospital chief executive Joanne Williams said. The patients surveyed rated Calvary s nursing staff highly for their concern for patient s comfort past surgery and their instructions regarding home care and were extremely happy with the anaesthetists and surgeons explanation prior to surgery. This result is a credit to all associated with the centre particularly our staff, doctors and volunteers, Mrs Williams said. new southern cross care facility opens in NSW November 5 marked the official opening of Southern Cross Care s newest residential aged care facility the St Lawrence Apartments in Harden, NSW. The new facility will provide a home to 45 residents who will each enjoy single rooms with en suite and tea-making facilities. The facility includes spacious dining, lounge and activity areas, several quiet sitting rooms as well as a prayer room/chapel. The official opening was presided over by John Killick, a long-serving board and committee member, while Archbishop Mark Coleridge, Rev. Beth Dimmick, Pastor Rhana Wright, Fr Frank Keogh and Fr Kevin Barry-Cotter led the ecumenical blessing service. Paul McMahon, the CEO of Southern Cross Care, said that the aspirations and needs of residents are the absolute focus of Southern Cross Care. Older people are the most valuable and valued members of our community they deserve only the best. We are very proud of what has been achieved. The project, costing about $9 million, was fully funded by Southern Cross Care. Archbishop Mark Coleridge blesses the new facility. 33

36 people & places 2011 CSSA CHA study tour The 2011 Catholic Social Services Australia (CSSA) and Catholic Health Australia (CHA) Study Tour, which concluded in late October, was a unique opportunity to reflect on the theory and practice of Catholic mission and identity as expressed though pastoral and social service. The enrichment experience was shared by 16 senior representatives from a variety of Catholic social service, health and aged care organisations around the country. The five weeks of the formal program included a stimulating variety of learning experiences. The tour commenced in Rome, where formal meetings were held with related Vatican social service and health agencies. Visits to key sites of religious and historical significance deepened the group s appreciation of the heritage and tradition of the Catholic Church. Accommodation at the newly opened Domus Australia was a real highlight. The theoretical component was complemented by visits to a range of service agencies and hospitals in and around Belgium, as well as a stimulating meeting in the Netherlands Parliament with a Dutch theologian newly elected to the upper house. Reflective practice was fostered through a twice-weekly group learning process that assisted the integration of new insights through sharing of intellectual and personal responses. The result was an unforgettable sabbatical that stretched the group s appreciation of Catholic identity while reaffirming the ground of Catholic tradition which unites our various services. A memorable corollary was the camaraderie and friendship which united the group, sustained spirits and ensured not all the highlights were academic. Formal study at the University of Leuven in Belgium provided an outstanding, specially designed lecture program on topics ranging through Catholic social ethics, spirituality of leadership, lay spirituality, environmental ethics, inter-religious dialogue and a framework for analysing approaches to Catholic identity. The 2011 Study Group with newly elected member of the Netherlands parliament, Ruard Ganzevoort, at The Hague. 3 4

37 inspirational garden of the senses An innovation by the Day Centre at Calvary Health Care Bethlehem will see palliative care patients and those with a range of progressive neurological diseases helping to create a sensory garden full of colour, fragrance and texture. The garden has been conceived to stimulate patients whose senses have been diminished as a result of their medical condition and, importantly, to also engage and offer respite. Palliative care patients with cancer may experience a loss of taste and smell because of chemotherapy or radiation therapy. To accommodate this, the new garden will include aromatic plantings of thyme, rosemary, oregano, marjoram and gardenias. Patients with progressive neurological diseases often experience a range of sensory loss, most commonly the sense of touch. Their sense of touch will be catered to by plants with different textures such as lamb s ears, mountain blue grass or English lavender. The garden is a work in progress. It will continue to be planted and tended by patients over time and visitors and patients will be able to take cuttings from the plants and re-pot them to take home. first round of nurse and midwifery grants awarded The first 10 recipients of the Australian Catholic University-Catholic Health Australia Nurse and Midwifery Unit Manager Professional Development Grant Program were announced in November by ACU dean of health sciences Professor Michelle Campbell and CHA chief executive Martin Laverty. The grants offer incentives for nurse and midwifery unit managers to spend time in like facilities within the Catholic hospital and aged care network, gaining insights into how other units are run. The announcement of the first 10 professional development grants of $2500 each follows the publication of last year s CHA Nursing and Midwifery Project report that recommended professional development options for senior nurses and midwives. The first grant recipients will undergo their professional development programs in the coming months, with a further 10 grants to be awarded in March ACU-CHA Nurse and Midwifery Grant Program First round recipients Helen McAllister, from St John of God Murdoch, who will visit the Mater Mothers Private Hospital, Brisbane. Dana Gray, from Calvary Health Care Tasmania, St Johns, who will visit St John of God Health Care Nepean Rehabilitation service. Wendy Chamberlain, from Calvary Health Care Tasmania, Lenah Valley, who will visit St Vincent s Private, Darlinghurst day surgical unit. Judelle McFarland, from St Vincent s Private Melbourne, who will visit St John of God Health Care Subiaco. Penny Spencer, from St John of God Bendigo, who will visit Cabrini and Epworth coronary care units. Shirley Lechmere, from St John of God Bendigo, who will visit Calvary North Adelaide maternity unit. Maryanne Attard, from Calvary Central Districts Hospital, who will visit a CHA member day surgery unit. Elizabeth Thomas, from the Mater Hospital Mackay, will network with other CHA member palliative care services to benchmark. Grace Loh, from the Mercy Hospital Mt Lawley, will use funds to support her course in health management and public health. Emma Daly, from Cabrini Health, will use funds to attend the Advanced European Course: Suffering Death and Palliative Care, in the Netherlands, in February

38 comings & goings CHA welcomes three new directors The CHA Stewardship Board has welcomed Professor John McAuliffe, Dr Tracey Batten and Ms Valerie Lyons to the Board following the retirement at the August AGM of three long serving members. Professor John McAuliffe Professor John McAuliffe, the chair of Mater Health Services Brisbane, joins the Stewardship Board as the nominee of the Institute of the Sisters of Mercy. Prof McAuliffe is chairman of the Brisbane Housing Company, president of Multicap, and a current divisional councillor of the Institute in Queensland. He is a past president of the Australian Property Institute and was a regional manager of the Commonwealth Department of Administrative Services. Dr Tracey Batten, the group CEO of St Vincent s Health Australia, joins the Stewardship Board as the new chair of the CHA Health Policy Committee. Dr Batten has previously been the CEO of Eastern Health in Melbourne, the CEO of Dental Health Services Victoria, and prior to that held various medical appointments at St Vincent s Melbourne, Western Hospital, Geelong Hospital and the Aberdeen Royal Infirmary in Scotland. Dr Tracey Batten Ms Valerie Lyons, the CEO of Villa Maria in Melbourne, joins the Board as the new chair of the CHA Aged Care Policy Committee. Ms Lyons was previously the CEO of Southern Cross Care Victoria, and worked in accounting practice in her early working life. Ms Lyons is a member of the board of Aged and Community Services Australia, and is the board chair of Aged and Community Care Victoria. She is also a board member of Community Care Australia and National Disability Services Victoria. The Board would like to acknowledge and thank our retiring members, Sr Therese Carroll (previous chair), Sr Berneice Loch and Sr Helen Monkivitch for their service, commitment and invaluable contributions over many years. Valerie Lyons new CEO for st john of god hospital ballarat St John of God Health Care has announced the appointment of Michael Krieg as the new chief executive officer for St John of God Hospital Ballarat. Mr Krieg s experience in the health sector offers a broad range of for-profit, Catholic and regional sector experience. He has fulfilled the role of CEO at both public and private hospitals in regional settings in Victoria and Tasmania. His most recent position was CEO of Calvary Health Care Tasmania overseeing the operation of four hospitals totalling over 400 beds in both Hobart and Launceston. Mr Krieg replaces John Fogarty who, after eight and a half great years with the St John of God Health Care Group, is leaving to take up an appointment as executive director hospitals, aged care and community services with the Melbourne based Mercy Health. Mr Fogarty s career with St John of God started in 2003 as the first member of the group s Melbourne office. His early roles included assisting with the integration of Berwick Hospital and the acquisition and integration of Nepean Hospital. Following his active engagement in the planning of the Ballarat Hospital redevelopment, he was appointed the hospital s CEO from May (L-R) Outgoing hospital CEO John Fogarty with his wife Gabrielle and Dr Michael Stanford (St John of God Health Care Group CEO). 3 6

39 christmas reflection susan sullivan As this edition of Health Matters lands on desks across the country, the sights and sounds of Christmas preparation will be present everywhere. While the anticipation of parties and holidays and sharing of gifts creates a special kind of atmosphere (alongside the weariness that often constitutes the underside!), it is easy to defer awakening the spiritual dimension of the season until the opportunity has all but disappeared. Too often, Christmas is distilled into a message about celebrating the birthday of Jesus. Perhaps this results from the child-centred focus that often prevails at Christmas. Yet it is much more about an awareness of the future than the celebration of a past event. Much can be said about the mystery of God entering into the finitude of the human condition in the person of Jesus. Most significant for our ministries of service to those who are sick, suffering and dying is the promise of a new way of being and relating which we experience tangibly through all that Jesus was, all he said and all he did. Christians have a short cut for expressing the richness of this new way of being and relating: the Kingdom of God, which might be named the Reign of God as we strive to transcend exclusive language, or perhaps even better for its relational connection, the KIN-dom of God. At the heart of our faith is the embrace of this mystery of the Kin-dom of God, which Jesus birth among us signals. So much of Jesus healing and teaching was about making visible the Kin-dom. The journey through Advent the anticipation of the coming of Jesus reflects our daily and lifelong anticipation of the better way promised by and through Jesus; the way which leads to fulfilment and wholeness, to connectedness and human flourishing. And herein lies the paradox. Jesus is born. The Kin-dom is here! Yet we are acutely aware that the world is not yet as it could or should be. The Kin-dom is not yet fully realised; it s here, but it s not yet complete. So we find ourselves still waiting, still longing, for that reality we ve been promised through the coming of Jesus, what we know in our hearts is possible, yet is often experienced in moments that can fade all too quickly. We glimpse something wonderful and sustaining in a moment of connection with a colleague, in the satisfaction of providing caring support for a patient, in the hopefulness of a quiet exchange with an elderly resident. Then we are caught again in the busyness and demands of our roles. So as we wait (busily!) for the celebration of Christmas, it s worth reflecting on how we might live today so that the future possibility of wholeness breaks through into the present. What are the ways open to us each day to make the Kin-dom more visible, more real, to those we live with and work with and serve? In striving to live the way of Jesus, we not only make that way present in the here and now, we actually keep the promise of a better way alive, we build hope that it is possible even when the evidence seems slim. For what do you dream for your family? For your workplace? For your patients, residents, clients? Let an Advent longing fill our hearts and motivate our actions in the here and now. We may not be able to realise our dream fully, but we can bring it a little closer to reality through faithfully attending to the opportunities small and large for making a personal, relational, compassionate connection with others and through working to bring this same way alive in the vision and plans of our organisations. Together we can inspire others to share the challenge of living a new reality. And we can keep hope alive that we are always on the way towards fully realising the Kin-dom.

40 Catholic Health Australia would like to wish all of our members, their staff, patients, residents and clients a very happy and holy Christmas and a joyous and peace-filled new year has been a busy and exciting year for CHA and for all of us involved in health and aged care. We look forward to working on behalf of our members in 2012 as Australia continues down the path of health and aged care reform.