We cooperate with others in the world in order to achieve or preserve important goods, or in order to diminish or avoid worse evils or harms. According to Catholic moral teaching, it is for these basic reasons that we may legitimately cooperate in a limited way with others who do what we would consider to be wrong, depending on the type of cooperation. If this were not the case, great good that should be done would be neglected, and greater harms that should be avoided would continue. In this context, cooperation in moral wrong can be defined as “any physical or moral assistance knowingly given by an organization to the commission of a morally objectionable act principally performed by another (the principal agent).” The cooperator may or may not be morally culpable or blameworthy, depending on the type of cooperation.
To intend the wrongdoing of others is called formal cooperation. As applied to Catholic health care organizations, formal cooperation in evil occurs when the organization freely and directly participates in the objectionable action of another agent and/or shares in the object of that agent’s intention, either for its own sake or as a means to some other goal. Implicit formal cooperation occurs when the organization denies intending the wrongdoing of the principal agent, but participates in the action directly and in such a way that it could not be done without this participation. Catholic organizations are not permitted to engage in either implicit formal or formal cooperation in evil.
Formal cooperation is to be distinguished from material cooperation, principally in the matter of intention. As applied to Catholic health care, material cooperation occurs when the Catholic organization does not intend the immoral object of the principal agent’s act, yet is involved in circumstances that materially contribute to the immoral action in some causal way. Whether material cooperation would be permissible depends on further distinctions, following below.
Immediate material cooperation occurs when the organization provides for, contributes to or participates in specific circumstances that are essential to, or are an essential condition for, the principal agent to carry out a specific objectionable action. Directive n. 70 of the Ethical and Religious Directives specifically forbids Catholic health care organizations from engaging in immediate material cooperation in acts judged by the Church to be intrinsically immoral, “such as abortion, euthanasia, assisted suicide and direct sterilization.” These actions are considered “intrinsically immoral” inasmuch as they are evaluated to be essentially not good for the human person, regardless of circumstances or personal intentions. But under Church teaching, their gravity is not considered equal—e.g., direct killing of innocent human life is worse or more grave than direct sterilization, even though Church teaching evaluates both as intrinsically immoral. This matter of gravity is important for determining whether there is a proportionate enough reason to justify mediate material cooperation under the circumstances.
Mediate material cooperation occurs when the Catholic organization provides for, contributes to or participates in circumstances that are not essential to a principal agent’s specific wrongful action. Proximate mediate material cooperation makes a causal contribution to the principal agent’s act, which is directly ordered to the act. An example would be leasing space to an independent, self-insured family practice group, which in the course of practice writes some contraceptive prescriptions, but where the Catholic lessor neither condones such activity nor contributes anything essential to a contraceptive act itself. Remote mediate material cooperation makes a causal contribution to the principal agent’s act, which is indirectly ordered to the act. An example would be a Catholic hospital informally affiliating with a family practice group for some medical education and for preferred partner status. Some physicians in the group engage in some contraceptive practices in their own facility or at other facilities. The Catholic party does not contribute anything essential to that activity, but the physician practice indirectly benefits from the affiliation through increased patient volume, which in turn indirectly contributes to the writing of more contraceptive prescriptions.
Whether a particular form of mediate material cooperation can be properly characterized as “proximate” or “remote” is not always self-evident, and often depends on one’s understanding of the facts, or from which perspective one is examining the case. This is why ethical decisions on these matters ought not to be made in a vacuum or in isolation from multiple perspectives. Either form of mediate material cooperation may be permissible for the Catholic organization under certain conditions:
- when there is a proportionately serious reason for the cooperation (increasing access to morally appropriate services for the poor and underserved, decreasing infant mortality, stewardship of limited resources, and securing Catholic health care presence in the community, are just a few examples of serious reasons why an organization might want to consider cooperating with another provider, and which may very well justify the cooperation);
- the moral distance of the cooperator must be proportionate to the gravity of the wrongdoing (for example, mediate material cooperation in contraceptive counseling would not require as great a moral or causal distance as mediate material cooperation in direct sterilizations);
- proximate mediate material cooperation requires a more serious reason for cooperation than remote mediate material cooperation (i.e., a causal contribution that is directly ordered to an objectionable act requires greater justification than a causal contribution that is indirectly ordered to an objectionable act); and
- the danger of scandal must be sufficiently avoided. According to the Ethical and Religious Directives, n. 71: “The possibility of scandal must be considered when applying the principles governing cooperation. Cooperation, which in all other respects is morally licit, may need to be refused because of the scandal that might be caused. Scandal can sometimes be avoided by an appropriate explanation of what is in fact being done at the health care facility under Catholic auspices. The diocesan bishop has final responsibility for assessing and addressing issues of scandal, considering not only the circumstances in his local diocese but also the regional and national implications of his decision.”