I have the pleasure of responding to Cory D. Mitchell and M. Therese Lysaught’s fascinating, thoroughly argued discussion of how Catholic health care fails to fulfill its own mission to improve health, via the “appropriation” of the structural sin of residential segregation. The argument makes extensive use of Cathleen Kaveny’s category, “appropriation of evil,” but push the concept beyond individual agents to structures by highlighting the ways that Catholic health care benefits from what they name as the “intrinsic evil” of residential segregation. Their argument has wider implications, not just for health care, but for how we understand our participation, cooperation, and appropriation of moral evil across a range of structural sins. For my response, I want to focus on two elements: first, wrestling more deeply with the implications of intention in the category of “appropriation,” and second, how a finer-grained attention to the workforce in health care might reveal additional forms and means of resistance to structural sin.

Per Mitchell and Lysaught, Kaveny’s category of appropriation parallels the classic category of cooperation in Catholic moral thought, but inverts the elements. Where cooperation attends to how auxiliary agents are incorporated into future acts of sin, appropriation concerns the incorporation of past or concurrent acts of sin into a primary agent’s work: e.g., the use of data derived from Nazi experiments (51-52). Also like cooperation, an agent’s intention matters: for both formal cooperation and appropriation, the agent needs to be intending the moral wrong that occurs (52). Without that kind of intention (or what Kaveny calls “ratification” with respect to past events) one is still at the risk of material appropriation, which (like material cooperation) may or may not be licit (53). So, in the case where a scientist wants to use information garnered from Nazi experiments, but also condemns those experiments as a violation of human rights, she is not formally appropriating the moral evil of that work. However, she may still be at risk of material appropriation if she is not appropriating the morally compromised work for a sufficient, substantial good. Moreover, even if that good is substantial, the appropriation of moral evil can still act reflexively on the agent, impacting her moral character (54).

What is interesting here is that Mitchell and Lysaught accept Kaveny’s assertion that intention requires both assent to a particular end as well as control over achieving that end (53). While appropriation does not have to be fully intended to still affect one’s moral character, intention – particularly control – does seem to dictate some of the ways that appropriation of residential segregation shapes Catholic health care’s corporate character. Some of the concrete effects of appropriation they name are: the closing of hospitals in low-income communities while building new ones in affluent areas; staffing that fails to represent the demographics of the people being served; the view that “charitable work” is sufficient to counteract residential segregation; passive acceptance of residential segregation as a problem too large for Catholic health care systems to address; promotion of “white saviorhood;” and confirmation bias about communities that suffer from health disparities (59-60). 

Yet it seems to me that in scaling the category of appropriation up from persons to institutions, Mitchell and Lysaught may be rendering the intention of healthcare systems  – their “assent and control” – somewhat monolithically. They do assert that addressing this problem “requires sound multilevel organizational discernment in order to navigate the minefield of structural sin,” but their complaint seems to be primarily leveled at high-level administrators and CEOs. I suspect this is because major decisions, such as the building and closure of hospitals, happen in places  like corporate headquarters. 

But many of the other elements listed seem to involve more localized levels of healthcare, such as staffing. Here I’m thinking particularly of Mitchell and Lysaught’s point that healthcare remains a career that can lift people into the middle class (57), which is why it would behoove Catholic healthcare systems to hire from the communities they serve. I absolutely agree with the major claim here, but I think it needs more parsing out. There are large swathes of the healthcare industry where the majority of people hired are women of color, generally with limited education and from economically fragile backgrounds: namely, those involved with direct care work, such as CNAs, medical assistants, direct support professionals, and home health workers, as well as those in a category called “non-nurturant” care work who do the logistical and administration support for the prior positions (think: receptionists, janitorial staff, etc). Yet these positions are not paid the wages necessary for class mobility: hourly pay ranges from $10-$17/hr, in most cases falling below a living wage for the location where they work.

In many ways, attention to this group of workers within the healthcare industry heightens the moral claims of Mitchell and Lysaught’s work: not only do health care systems profit from the health disparities caused by residential segregation, they are also able to hire underpaid workers from those areas to maintain a bottom line (and pass the proverbial buck on why those wages are so low, since care work wages are often determined by Medicaid/Medicare reimbursements). But I would also suggest that the stratification of health care workers within a system might also reveal differences in how the appropriation of evil works to malform the moral character of Catholic healthcare systems. 

For example: a woman of color working as a CNA might well fall into a sense of being too small to really address a problem as large as residential segregation – but that is hardly an inaccurate perception (this may be the lack of control that belies intention). Yet, it also seems unlikely to me that the same CNA would participate in the charitable work of her employer with a white savior complex (implying a lack of consent). In fact, in my own fieldwork with a disability services provider, I found that frontline healthcare workers were often very able and willing to articulate criticisms of how they felt taken advantage of by employers (e.g., the low wages for the intensity of care work).  So, even if we allow that the unintended institutional appropriation of residential segregation affects moral character, I think it is difficult to predict the shape this takes, and that moral appropriation at an institutional level might still be resisted on a personal level. 

Which brings me to a larger point with respect to shifting the category of appropriation from persons to institutions: since no institution is a monolith, there are almost always sites of resistance to sin and injustice even when it seems like the structures as a whole are participating in it. The constructive suggestions that Mitchell and Lysaught offer center on the role of “community change programs,” citing the example of organizing volunteers to walk children to school (61). Here, too, the decision-makers that Mitchell and Lysaught are addressing seem to be higher-level administrators, who they call on to partner with external (to the health care system) organizations and community leaders. Those are great suggestions, but I do wonder whether the implicit power dynamics in these suggestions risk a kind of “top-down” solution that could perpetuate the very problems of white saviorhood caused by appropriation to begin with. 

Part of the solution should include the people already working in healthcare systems who are or have been affected by the injustice of residential segregation. So, in addition to Mitchell and Lysaught’s ideas, I would also suggest that there needs to be internal work and reflexivity on behalf of these institutions, that starts with the most disadvantaged workers. Unions and labor organizing – something many Catholic institutions resist, in health care and otherwise – can address pay and benefit disparities. Organizing can also help workers feel agency in the face of larger forces that seem generally disempowering – labor unions might themselves be a necessary component of public health

I think Mitchell and Lysaught make a really important contribution here, especially by resisting the urge to reduce structural sin to the clear intentions of a few select actors. Nonetheless, I think the solutions also cannot rely on a few actors with power and control in an institution, but needs to look to the margins, first.