Dr. Marie R. Hilliard, Senior Fellow at the National Catholic Bioethics Center in Philadelphia, PA, spoke with Msgr. James P. Shea, President of the University of Mary, on a video call on November 23, 2020, to discuss her broad experience in bioethics and of the vocation of nursing, offering insights into difficult ethical questions.
Monsignor James P. Shea (MShea): Dr. Hilliard, could you tell us a little bit about yourself: where you come from, the work you’ve done, and perhaps even why you wanted to become a nurse in the first place?
Dr. Marie T. Hilliard (MH): I decided I wanted to be a nurse when I was five. My mother told me that my dad had suggested it to me then, and I never changed from that desire. So there’s a long history of me wanting to be a nurse, and I don’t think it was a default, either. I considered nursing to be a vocation. I’m not sure how the calling to be a nurse relates to the calling to be a priest, for instance, but I have always thought of nursing as my vocation.
I went to a Children’s Hospital in Boston for my training to become a registered nurse and right away found that you cannot practice as a responsible healthcare professional without realizing that there will be ethical dilemmas you will need to face. I was young, and I was working with very sick children, so I began to see how my fellow nurses – who served as my role models – navigated well some of these tough ethical questions. In fact, later in my professional journey my first publication concerned the ethical dilemma that could arise from do-not-resuscitate orders. I discovered early on that for a nurse, there will always be deep ethical questions that need to be answered.
After working for a while, I went to the Catholic University of America in Washington, DC, to get my degree in nursing. I was still working at the time, and I worked through all of my different degrees – nursing, religious studies, a doctorate in nursing education, and eventually canon law. I found that you cannot be engaged in helping people without seeing that there are unanswered questions that you have to be prepared to answer in the moment. When you work in healthcare you have to be prepared to find answers to difficult ethical questions.
My focus on ethical questions arose from my understanding that nursing is a vocation. If nursing is a vocation, it has to be lived well. I hope I’ve lived it relatively well. My concern today is that people are entering this high-tech profession, which is what healthcare is today, without a grounded understanding that this is not merely a job, but rather is a vocation. That’s why I’m so glad to be part of the bioethics program at the University of Mary.
MShea: And that’s why we’re glad to have you as part of it! One of the factors that has allowed you to be so impactful in the world of bioethics is your broad experience: your academic and professional experience has touched on questions of healthcare and ethics from so many different angles.
MH: I really see the hand of God in it. I ended up in nursing education, tenured at a Catholic college, and found myself educating the next generation. I recognized how much responsibility I had in making sure I imparted everything correctly. My mother, who would review materials with me before I presented them, always said to me, “You’re not teaching content, you’re teaching yourself.” That’s what we do in education – hopefully, we’re presenting a good model. There is something sacred in educating the next generation.
I was tenured, but a job opened up in which I could be the executive officer of the Connecticut Board of Nursing Examiners. I worked for the state for ten years, and I regulated 62,000 nurses and all the schools of nursing. While I was gaining experience in working in the government, I joined the United States Army Reserve – working as a nurse in the military is a vocation in itself! During that time, the Archdiocese of Hartford reached out to the military, saying they had a Peace and Justice Commission and they wanted to make sure it was balanced. I was always committed to my faith, but at the time I didn’t think of myself as wearing it on my sleeve. The military pointed them in my direction, and the Archdiocese appointed me to their Peace and Justice Commission – and lo and behold, my colleagues voted me as chair. So while I was working for the government and serving as a military officer fulltime, I also started getting a taste of working for the Church as a volunteer.
I found that you cannot be engaged in helping people without seeing that there are unanswered questions that you have to be prepared to answer in the moment. When you work in healthcare you have to be prepared to find answers to difficult ethical questions.
That experience made me think that perhaps I would work for the Church someday, as a retiree. I had my doctorate at this point, but I started going to school at night to get a degree in religious studies – and that became important later. The bishops didn’t know I was pursuing that degree. They knew me as a state regulator who knew government, and they knew me as someone who was loyal to what we understand to be the good in terms of Church teaching. They asked me to be the director of the Connecticut Catholic Conference, which was their policy arm in the state, the month after I had finished my religious studies degree. I took that job, even though I was still far from retirement. I really see the hand of God in all that.
Five years into that job, maybe less, I was sitting in the gallery at the Capitol in Hartford, and around midnight heard an amendment called on a bill. The language of that bill was a smokescreen, but it would have taken away the seal of the confessional. I sent a note down to a legislator I knew would be appalled by that, and he said, “Marie, I’m going to ask if this amendment is about the seal of the confessional on the floor, but I’m sure it will be a ‘no.’” Sure enough, the answer given on the floor was a ‘yes’, the amendment was about the seal of the confessional. The amendment passed overwhelmingly in the House, with a veto-proof majority, so I had to work to get it stopped in the Senate. I remember getting home at 5:00am and faxing all the pastors, “Father, this time we really have to pay attention here. This affects you!”
This experience was important because it helped me to realize that I really understood the Church, but more preparation would be appropriate. I approached the bishops and told them I was interested in studying canon law in the summer program at Catholic U. This, again, is where I see the hand of God in my life: I was told that even though I had these degrees in nursing, I would need a degree in religious studies if I were to enter the canon law program. And that’s when I was able to say, “Here, I have one!” So they sent me.
Several years later, after my mom died, as my brothers and I had been committed to her care, a position opened up at the National Catholic Bioethics Center, and I was able to re-locate to Philadelphia to become their director of public policy. I had degrees and experience in nursing with a doctoral dissertation on ethics, I had been chair of the ethics committee for my state’s nursing association, I had worked in government and the military, and I was now a canon lawyer: it all came together perfectly, and I did not plan any of it!
MShea: Thank you for that background, because it really shows God at work in your life. It is also important because I wanted to talk to you about public policy and its impact on practicing ethically, on respecting the rights of conscience and the natural moral law in the delivery of healthcare.
MH: Public policy is everything in terms of how we live in society, so it really has a tremendous impact on healthcare. That means we have to stay on top of these questions and policy proposals.
As a young nurse at a secular children’s hospital in Boston in which there can be a diversity of opinion, I started recognizing that inevitably in the delivery of health care one will encounter some of these dilemmas. It was a wonderful nursing school, and my values were respected. There was no one telling me to leave my religion in the locker room, but that is the sort of thing young nurses are encountering now. Just recently six professional associations published a statement negative to religious accommodations concerning transgender procedures and abortion, claiming that such rights of healthcare professionals are interfering with patients’ access to care. Nothing could be further from the truth: conscientious health care dictates that a woman suffering from complications of an abortion would never be denied compassionate care. That same compassionate care would be provided to those suffering from gender identity dysphoria, without cooperating in mutilating procedures. Furthermore, conscience objections are not solely based on religious adherence. The premise appears to be that persons of faith discriminate against patient autonomy, as if healthcare professionals are meant simply to be automatons. That’s why we run into this mindset and these lawsuits that look at healthcare professionals and say, “If you don’t do what I want, you’re a bad person.” Unfortunately, that mindset is creeping into public policy.
A number of things have been done recently to try to strengthen religious liberty, such as the Conscience Rule, which was meant to protect providers and individuals from having to provide or refer for services like abortion and assisted suicide against their conscience objections. It was immediately enjoined, however, meaning it cannot be implemented. It is a wonderful rule, protective of me and your nursing students, and now it has been enjoined.
Public policy is everything in terms of how we live in society, so it really has a tremendous impact on healthcare.
Another issue that has already been enjoined is a legal definition of ‘sex.’ In the Affordable Care Act, there are terms that have to be fleshed out, and the Trump administration had defined ‘sex’ to be consistent with legislative history, as something determined by the genes and chromosomes with which one was born. So that’s another legal safeguard for many Catholic healthcare providers and practitioners concerning a number of important ethical questions today, and that also has been enjoined. Obviously as Catholics we respect the dignity of all human persons, regardless of sexual orientation or gender identity, but that doesn’t mean we should be forced to cooperate in procedures that go against our conscience objections. An example of this is playing out in California now, where a Catholic hospital transferred – not referred, which one cannot do for an immoral procedure, but transferred – a patient who wanted a hysterectomy as part of a transgender surgery. The hospital was not discriminating against the individual in question – they were not refusing to care for the patient simply because the individual sought to transition from identifying as a woman to identifying as a man. Rather, the hospital refused to remove a healthy uterus – to mutilate a healthy function – in principle. A lower court has said that the hospital can be sued for this.
This all goes back to what I had said earlier: as Catholic healthcare professionals who are serving real people, we have to be prepared to answer some tough questions, which also means that we have to stay on top of public policy proposals. Our students in the bioethics program at the University of Mary have diverse backgrounds: there are obviously nurses and physicians, but there are also priests and lawyers and teachers. That is so important, because we really need to stay on top of these questions in a variety of fields, especially public policy.
Public policy should be reflective of the will of the people. We are about to see this question play out around the Hyde Amendment, which protects us from having to cooperate with abortion through tax dollars. I don’t believe forcing people to pay for someone else’s abortion is the will of the people, but some in Congress and the incoming administration have signaled that they are in favor of repealing it. So we will see where that goes, and as I have said, that is the sort of thing all of us – not just those in healthcare – have to stay on top of.
MShea: We’ve touched on the topic of bioethics a few times, so I wonder if we could get more deeply into it for a moment. Bioethics engages actively with all kinds of currents of technology, applying timeless principles to things that are emergent. I’ve heard you talk about various principles that we bring to bear in Catholic healthcare. What are some of the basic bedrock principles that you have found to be important in your practice and teaching of bioethics that we will still be able to bring to bear ten, fifteen, fifty years from now, no matter what emerging technologies arise?
MH: I’ve always put it this way: “We won’t kill you, even if you ask us to. We won’t kill your unborn child, even if you ask us to. We won’t mutilate you or destroy normal, healthy functions, even if you ask us to.”
The number one principle behind all this is human dignity, and from that we get the right to life. We are all made in God’s image: we’re not mere animals, even in terms of reproduction.
What makes us different in many ways from the secular mindset is the natural moral law. It is interesting that Aquinas built so much of his understanding of ethics on Aristotle, who obviously pre-dated Christianity. That’s what St. Paul is getting at when he says certain things are written on the heart of man. I found this to be true when I was fighting against public funding for embryonic stem cell research in Connecticut. People who often didn’t understand my position until I really explained it to them tended to have this reaction that I call the “ick” factor. There are some things that are just so basic to the human person that the natural response is to have this “ick” factor response when one recognizes them being violated.
Aquinas concluded that the ultimate end or goal of human life is happiness with God. He was building off Aristotle, who had recognized that the human person pursues ends perceived as goods in the pursuit of the ultimate end, happiness. Aquinas built off the thought of someone who obviously was not Christian – Aristotle – and basically set our framework for bioethics today. That means that for us to recognize and apply the natural moral law and uphold human dignity, we can look to that ultimate end of the human person and make sure that nowhere along the long road of human life and healthcare are we violating it.
In the secular mindset, on the other hand, there are four legs, if you will, or principles: autonomy, beneficence, non-malfeasance, and justice. From Hippocrates until the twentieth century, we operated on the prima facia principle that healthcare is “to do no harm.” But now we live in this utilitarian, supposedly-altruistic society that says that whatever gets us to the end we want as quickly as possible is acceptable. The secular world is saying, “We might have to do harm to do good,” or “If that patient wants it, do it.” It rests on this idea of “if we can, we should.” So Hippocrates has been thrown out by many, and Catholic healthcare is standing up against these first principles of our utilitarian society.
We won’t kill you, even if you ask us to. We won’t kill your unborn child, even if you ask us to. We won’t mutilate you or destroy normal, healthy functions, even if you ask us to.
Students preparing for service in healthcare need to recognize that autonomy does not trump all else. We need to get back to “do no harm” and “do good,” back to justice for all people, justice to the unborn. Catholic healthcare embodies the four principles I mentioned – respect for autonomy, beneficence, non-malfeasance, and justice – but it does so within the framework of natural law and the ultimate good. We keep in view that happiness ultimately means being united to God and that each person has been made in God’s image.
This takes us back, again, to questions of public policy. These secular principles aren’t just playing out in the minds of individual healthcare workers, but are playing out in the townhouse, the statehouse, Congress, and the United Nations. It’s important for students to be able to recognize that the same principles that guide someone at the bedside are also present in public policy initiatives.
MShea: I’m very attentive to the grounding of the things you were saying just now, which come from a strong philosophical foundation, but you said something interesting at the beginning of your response I want to turn back to: the “ick” factor. Even people without education in the Catholic view of the world and bioethics can have this strong response to so many violations of the natural moral law. I see in the “ick” factor a kind of popular application of the natural moral law. While it is a strong response, there are methods and ways of overcoming it with ideology that work their way in and capture the imagination, such that some things that would have horrified our grandparents are widely accepted today. Can you speak about how that is accomplished so effectively?
MH: It’s all about language. Change terminology to make the unacceptable acceptable. We see this in how we talk about conception, for instance. We don’t talk about the human embryo anymore, but instead we say “it is a fertilized egg.” The embryo is neither just a fertilized egg nor an “it.” The embryo is a human being with his or her complete genetic code already in place. The implication that he or she is anything less than a human being is scientifically false. I think it all started with contraception, which changed the meaning of human sexuality to be all about me, which then turned the result of that sacred act into a product and a burden. And now the burden – that little embryo – can be destroyed, or even worse, researched on, because it’s not a “he” or a “she” but rather is a commodity. So much of this mindset is wrapped in the language of “pro-choice,” so again, it’s about language. Using language to make the unacceptable acceptable has eroded our understanding of what is written on the human heart.
We see changes in language having impacts in other areas, as well. It’s now considered discriminatory to say you won’t participate in sexual transition procedures that mutilate healthy organ systems. There are now legal cases surfacing where young people who were encouraged to undergo such procedures are saying, “You didn’t help me understand what I was experiencing at the time, and you did me harm.” Finally a district court has said that it is against the First Amendment to ban counseling therapy for people who have gender identity issues or same-sex attraction, because in doing so you are cheating a child or parents who might have wanted some help.
I’m not saying that people don’t suffer from gender identity issues, they do. But so much of the discussion around that topic has been shrouded by changes in language. I think a lot of this has been furthered along in our public schools, where secular values increasingly prevail.
MShea: That makes me think back to your earlier example about the bill in the statehouse in Connecticut that would have impacted the seal of the confessional, and how it slipped by so many people unnoticed. As Catholics in the public sphere, we have to be aware of language and we have to be sensitive to tactical shifts, even small and incremental ones. We also have to be conversant in the nomenclature of our age so that we can navigate it deftly.
MH: We have to be good advocates, because so many people don’t really understand these issues. The thought is often that if someone wants something, healthcare professionals must provide it and government must acquiesce, or else we’re being unkind or discriminatory. In many of these cases, government acquiescence actually turns into the government creating a new standard everyone must abide by.
It’s often a slippery slope. When I think back to when I was in nursing school, nobody ever taught me how to assist in the killing of a baby. Now, to leave that out of healthcare training is seen as cheating the future physician or nurse out of important knowledge. It’s a slippery slope that led us to where we are, and perhaps we failed to see the signs of the times along the way.
There are some things that are just so basic to the human person that the natural response is to have this “ick” factor response when one recognizes them being violated.
MShea: It’s so important that we recognize the signs of the times. When you talk about language, I think about Justice Anthony Kennedy’s soaring rhetoric in Planned Parenthood v. Casey, and so few people are able to see beyond the rhetoric into the real sinister meaning of establishing one’s personal autonomy as absolute.
MH: There are great misunderstandings of what is meant by ‘freedom’ in our society. A lot of that confusion comes up around misunderstandings of the First Amendment. The Establishment Clause – that there will be no state religion – is often used against us based on a misunderstanding. Whenever people heard that I was moving from working in the government to working for the Church as a registered lobbyist, I would be asked, “Isn’t it a violation of the separation of church and state to bring those views into the state Capitol?” That’s obviously based on a misunderstanding of the separation of church and state. The views of the Church are really the views in the best interest of the human person in society.
The same thing happens with the Free Exercise Clause in the First Amendment, which has also been turned against us. We have to be diligent to make sure that people are not successful in silencing us. We’re seeing some of these questions arise with COVID today – for a long period of time we didn’t have Mass, and we’re running into the question of how far this could go. We’re having cases of Catholics not receiving the sacraments in the hospital because they won’t let priests in. The Free Exercise Clause is so important for us to be able to bring our views into the public square, into public policy.
It’s not uncommon to see Catholic politicians hiding behind these misunderstandings, saying “Don’t worry, I don’t listen to Rome, Rome isn’t going to tell me what to do.” Well, as Catholics we believe that Rome – the Vatican, the tradition – has the best interests of the human person in mind. If we create a situation in which the only people who are able to follow the law in healthcare practice or to make the law are people who are willing to kill another human being – much less pre-born persons – we are in trouble. Such persons will never truly be your advocate as a patient and will never truly be your advocate in society. And the mindset underlying all this is a real distortion of the First Amendment.
MShea: We’ve talked about the place of the Catholic healthcare in the United States today - perhaps you could speak to the legacy of Catholic healthcare in this country and the role it has played in the history of healthcare in the United States?
MH: Whenever I teach on that subject I say, “The history of nursing and healthcare is the history of the Catholic Church.” It goes back as far as Phoebe in the New Testament. St. Benedict arranged for the basic delivery of healthcare in the early sixth century. The first organized system of healthcare delivery was established by the Order of Malta during the Crusades. For many centuries, the monastery was the local hospital, so when monasteries were confiscated after the Reformation, many places were left without systems of healthcare. The Church has been on the forefront of providing healthcare through history. That’s what Florence Nightingale understood. It’s interesting to look at whom she took with her when she went to Crimea: Anglican and Catholic nuns. The system of nursing she developed is really why you go to a hospital today. I might be a bit biased here, but the reason you go to a hospital is for a nurse – you can go to a surgery center, or you can go to a lab, or you can go to a pharmacy to get your immunizations, but you find nursing in a hospital. So when healthcare systems came to the United States – it was actually before Florence – those systems were basically replicating Catholic hospitals. The first hospital west of the Mississippi was founded by St. Elizabeth Anne Seton in 1830 in St. Louis.
Catholic healthcare went where the needs were, going into immigrant populations and the inner cities to start hospitals and schools of nursing, because that’s what the Church does. Basically, the history of healthcare in this country, and really around the world, is the history of the Catholic Church.
Using language to make the unacceptable acceptable has eroded our understanding of what is written on the human heart.
That history explains why one out of every seven patients in the United States is cared for in a Catholic facility today. It used to be one out of five, but that number has changed because it is really expensive to deliver healthcare, so a number of hospitals have been merged or sold. But it is revealing that in many of those cases, where a Catholic hospital or clinic is merged or sold to a non-Catholic entity, it continues to adhere to the Ethical and Religious Directives for Catholic Healthcare Services. These institutions are willing to do that because people in the community understand the good care – the holistic care – that is given in a Catholic hospital, so they don’t want that identity lost. Our office at the National Catholic Bioethics Center has helped many institutions to navigate contracts on those questions, because it is really prevalent.
The history of Catholic healthcare is synonymous with the history of healthcare. I always say, “We don’t look for baptismal certificates in the emergency room.” We might look for an insurance card, but we don’t look for a baptismal certificate! We went to where the poor and the vulnerable were, and we still do.
MShea: With all these insights into what those preparing for healthcare professions are facing today – and also your edifying remarks about the central role of the Church throughout the history of healthcare – I was wondering if you could talk for a moment about what it’s like to have a life in healthcare and why it’s such a noble profession. What would you say to those who feel called to the health sciences as a profession, whether in bioethics or in a clinical setting? I think it’s so important they see that they can really make a difference if they engage these bioethical questions as cheerful warriors.
MH: We certainly have to accept that call as cheerful warriors, or else we will give in and just follow the crowd. That would leave us in a very sorry state. I think it is important for our students – for all students preparing for service in healthcare – to realize that they are actually teaching people along the way when they are prepared to think about these difficult ethical questions. I have three nieces who are currently studying to be nurses, and one of them recently articulated that the reason she is studying everything so intensely is because she knows that someday patients will rely on her to have that information. That’s a wonderful insight. This is important work we’re doing.
As I’ve said, I consider nursing to be a vocation, and those moments where you know you made a difference are just incredible. I know many nurses who actually offer to pray with patients and be a presence for them. Anyone who has been in a hospital knows that a caring nurse makes all the difference. So those moments make it all worthwhile.
One of my nieces who is a nursing student told me how she is being approached in the residence hall on campus by other students asking about different symptoms and so on. For the rest of your life, it doesn’t end. That five-year-old who knew she wanted to be a nurse and took it very seriously is being replicated, and that’s what we need to hold onto: this isn’t just a job, it’s a calling. The law is just the lowest common denominator: if you want to be a presence for good, you have to go beyond and raise difficult questions and step up to be an advocate. We need nurses who are willing to saying, “I’m not going to contribute to or cooperate with that” when they encounter something damaging to the human person. This doesn’t mean we are breaking the law or forcing anything on patients that they don’t want, but it does mean that we might have to transfer a patient for something we won’t cooperate with. If we only have nurses who follow the status quo and go along with anything that’s asked of them, we will be in a very sad state.
Don’t be afraid to go into healthcare. We have people calling the National Catholic Bioethics Center all the time saying, “I’m afraid that I won’t be able to live out my vocation in healthcare today because of the secularization of it all.” We need you there! We need Catholic healthcare professionals who understand the true definition of the good. If you need advice, the National Catholic Bioethics Center has a free 24/7 hotline that provides bioethics advice – not medical advice, but bioethics advice. There are programs training more and more bioethicists, such as the National Catholic Bioethics Center’s certification program, and our own University of Mary graduate degree in Bioethics. There are legal groups like the Alliance Defending Freedom that provide pro bono services when healthcare professionals have their rights violated. The Catholic Medical Association has a bootcamp for medical students and residents to prepare them to serve and respond to difficult situations and questions. Please go into the profession and let us help you navigate the questions you will encounter. We need you! You’re not alone.
