The Catholic faith teaches that we must be in the world, though not of the world. In a world of limitation, where sin and evil are inevitable, this can become very complicated. On the one hand, we must not do evil that good may come from it (Romans 3:8) yet, on the other hand, the good that we should do is often connected to some evil. After a long controversy in the 17th century between Catholic moralists who took a more rigorist approach to the application of the moral law and those who took a more lax approach, St. Alphonsus Liguori (d. 1787) made the Principles of Cooperation acceptable by introducing the distinction between formal cooperation and material cooperation, and by a further consideration of scandal. The principles begin with the presumption that subjectively good intentions, good consequences, or other circumstances cannot transform an objectively immoral act (i.e., an intrinsic evil) into a morally licit act.
Until recently, most healthcare providers in the United States enjoyed a relative degree of independence from one another. Today this is increasingly more difficult, if not impossible. Contemporary clinical medicine has reduced the need for the present number of hospital beds—reimbursement structures have changed, more procedures are now handled on an out-patient basis, and more complicated procedures require shorter hospital stays. In the healthcare "market," competition is often a cost-driving, not a cost-containing force. These and other factors mean that many "stand-alone" institutions are unsustainable economically. Under these circumstances, many Catholic healthcare organizations will have to partner with non-Catholic providers in order to continue with their mission of healing, especially for the poor and vulnerable. The principles of cooperation are useful and necessary tools for evaluating the ethical dimensions of these partnerships, and for structuring them in a way that is morally appropriate and sustainable. In determining the potential of partnerships, in particular where the identity of the Catholic partner could be impacted, the Ethical and Religious Directives calls for proper authorization by diocesan bishops or their delegates (see Part Six).
