For example, how far could doctors go to relieve a dying patient’s pain?

Months before his death in 1958, the pope wrote: “Is the suppression of pain and consciousness by means of narcotics (when it is demanded by a medical indication) permitted, by religion and morality, to the patient and the doctor (even at the approach of death and when one foresees that the administration of narcotics will shorten life)?” His answer was “yes,” if that was what it took to truly relieve suffering.

Pius XII also knew that doctors were pondering ways to apply ancient truths to issues raised by new technologies, said Ian Dowbiggin, author of “Life, Death, God and Medicine: A Concise History of Euthanasia.” The historian from the University of Prince Edward Island spoke to media professionals gathered at this week’s G8 “World Religions Summit” at the University of Winnipeg.

Many of these puzzles remain, which is why ethicists still study another 1957 address by Pius XII to the International Congress of Anesthesiologists, in which he asked when it was necessary to make extraordinary efforts to resuscitate patients.

The pope concluded that if it “appears that the attempt at resuscitation constitutes … such a burden for the family that one cannot in all conscience impose it upon them, they can lawfully insist that the doctor should discontinue these attempts, and the doctor can lawfully comply. There is not involved here a case of direct disposal of the life of the patient, nor of euthanasia in any way: this would never be licit. Even when it causes the arrest of circulation, the interruption of attempts at resuscitation is never more than an indirect cause of the cessation of life.”

Dowbiggin stressed that Pius XII was already engaging complex issues that continue to impact debates — in Canada, the United States and elsewhere — about legalizing physician-assisted suicide. While this decade has seen a “perfect storm” of conflicts about a “right to die,” it is essential that citizens, clergy and public officials study the history of euthanasia before making policy decisions that will touch millions of lives in the future, he said.

“There are deep moral and religious issues at stake in debates about physician-assisted suicide, which is why religious believers have always been involved,” said Dowbiggin. “But what we are hearing today are prominent voices that say that religious people must keep their ideas to themselves, because religion is a private thing — period — and must not affect public life. If that idea is accepted, that’s a major step toward the acceptance of physician-assisted suicide.”

The word “euthanasia” comes from two Greek words that simply mean “good death,” noted the historian. For centuries, Catholics and others have argued that a “good death” is one that is as pain-free and dignified as possible. Thus, religious groups have been at the forefront of efforts to offer in-home hospice care.

However, several trends have aided efforts to legalize physician-assisted suicide, especially scientific advances that have increased the “graying of America,” said Dowbiggin. Thus, people are living longer lives, which also means they are more likely to face lengthy battles with cancer and neurological conditions such as Alzheimer’s and Parkinson’s disease.

Rising health-care costs have also affected “quality of life” debates. After all, as President Barack Obama told the New York Times, the “chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.” The stakes are rising.

Meanwhile, the Hemlock Society has evolved into End of Life Choices, an organization that merged with Compassion in Dying to form Compassion & Choices. Physician-assisted suicide became the “right to die” which has now evolved into calls for a legal “self deliverance” option.

If religious leaders want to keep taking part in these policy discussions, said Dowbiggin, “they must have something positive to say. It is not enough to just keep saying ‘no.’ … They need a vision of what the ‘good death’ looks like. They need to say that this is the goal of all end-of-life care — people making informed moral decisions about hospice and other forms of care that are right for themselves and for their families.”

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In that influential 1960 address, Kennedy boldly proclaimed: “I do not speak for my church on public matters, and the church does not speak for me.

“Whatever issue may come before me as president — on birth control, divorce, censorship, gambling or any other subject — I will make my decision in accordance … with what my conscience tells me to be the national interest, and without regard to outside religious pressures or dictates. And no power or threat of punishment could cause me to decide otherwise.”

And so it came to pass that — politically speaking — JFK begat the Kennedy dynasty, which begat Mario Cuomo, who begat Geraldine Ferraro, who begat Joseph Biden, who begat Rudy Giuliani, who begat John Kerry, who begat Arnold Schwarzenegger, who begat Nancy Pelosi and so forth and so on.

Looking back, it’s clear that Kennedy’s high-risk visit to the Greater Houston Ministerial Association changed Catholic political life. That’s why one of America’s most outspoken Catholic leaders recently seized an opportunity to deliver a very different message to another Protestant audience in Houston.

Kennedy’s speech was “sincere, compelling, articulate — and wrong,” claimed Denver Archbishop Charles Chaput, at a Houston Baptist University forum on faith and public life. “His Houston remarks profoundly undermined the place not just of Catholics, but of all religious believers, in America’s public life and political conversation. Today, half a century later, we’re paying for the damage.”

The key, argued the archbishop, is that Kennedy did more than endorse the separation of church and state. He did more than plead for religious tolerance in the public square, after generations of tensions between Catholics and Protestants.

Ultimately, that Kennedy did was pledge to separate his faith from his personal conscience, thus building a high wall down the center of his own heart, mind and soul. How is it possible for Christians to do this, Chaput asked, when dealing with profoundly moral issues such as health care, immigration, abortion, poverty, education, religious liberty, family life, sexual identity and matters of war and peace?

“Real Christian faith is always personal,” he said, “but it’s never private.”

Political and religious leaders have been debating the meaning of Kennedy’s words ever since he spoke them. This was especially true during the 2008 presidential race when critics dissected the beliefs of several candidates who openly discussed their religious beliefs — such as Mitt Romney, Mike Huckabee, Sarah Palin and, of course, the future president, Barack Obama.

During a Fordham University forum on “The Kennedy Moment,” political theorist William Galston of the Brookings Institution said that the key to the 1960 address was the candidate’s bold insistence that his private spiritual views should not even be discussed because they “do not influence his views on public matters.”

Kennedy also endorsed a “separation between democracy and God,” noted Galston, former senior domestic policy adviser for President Bill Clinton. In fact, he used the word “God” only once, in a reference to the presidential oath of office.

This speech “could have been given by a nonbeliever. Indeed — deep breath — I rather suspect it was,” said Galston. “At the very least, there is no indication that JFK regarded the church as having any rightful authority over his public conduct.”

For Chaput, it’s impossible to concede that the teachings of the Catholic faith should have nothing to do with the public lives, vocations and actions of individuals who continue to call themselves faithful Catholics.

Nevertheless, 50 years after Kennedy’s speech in Houston “we have more Catholics in national public office than ever before. But I wonder if we’ve ever had fewer of them who can coherently explain how their faith informs their work or who even feel obligated to try,” said the archbishop.

“At least one of the reasons for it is this: Too many Catholics confuse their personal opinions with a real Christian conscience. Too many live their faith as if it were a private idiosyncrasy, the kind that they’ll never allow to become a public nuisance. And too many just don’t really believe. Maybe it’s different in Protestant circles. But I hope you’ll forgive me if I say, ‘I doubt it.’ “

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Nevertheless, it still makes news when believers vow to act on this conviction.

“Through the centuries, Christianity has taught that civil disobedience is not only permitted, but sometimes required,” proclaimed a coalition of Catholic, Orthodox and evangelical Protestants on Nov. 20, in their 4,700-word “Manhattan Declaration.”

“There is no more eloquent defense of the rights and duties of religious conscience than the one offered by Martin Luther King, Jr., in his Letter from a Birmingham Jail. … King’s willingness to go to jail, rather than comply with legal injustice, was exemplary and inspiring.”

Thus, the declaration’s authors vowed to reject “any edict that purports to compel our institutions” to compromise on centuries of doctrine about marriage, human sexuality and the sanctity of human life. The text was written by evangelical activist Charles Colson, church historian Timothy George of the evangelical Beeson Divinity School and the Catholic scholar Robert George of Princeton University.

The Los Angeles Times offered an especially brutal evaluation of the text, claiming that it offered a “specious invocation of King” and that its logic was ultimately “irresponsible and dangerous.”

But the editorial board reserved its strongest words for the Catholics bishops who signed, asking if they considered “how their endorsement of lawbreaking in a higher cause might embolden the antiabortion terrorists they claim to condemn? Did they stop to think that, by reserving the right to resist laws they don’t like, they forfeit the authority to intervene in the enactment of those laws, as they have done in the congressional debate over healthcare reform?”

So far, 19 Catholic bishops and archbishops have signed, including New York Archbishop Timothy Dolan, Cardinal Justin Rigali of Philadelphia, Archbishop Donald Wuerl of Washington, D.C., and the Catholic shepherds in Detroit, Denver, Minneapolis-St. Paul, Phoenix and Pittsburgh, among other cities.

At mid-week, the project (ManhattanDeclaration.org) had attracted about 230,000 endorsements, including those of famous evangelicals such as Focus on the Family founder James Dobson, National Association of Evangelicals President Leith Anderson, Evangelicals for Social Action Director Ron Sider and Bishop Henry Jackson, Jr., a Pentecostal leader in the Washington, D.C., area. Orthodox leaders who have signed include Metropolitan Jonah Paffhausen of the Orthodox Church in America and Wichita (Kan.) Bishop Basil Essey of the Antiochian Orthodox Christian Archdiocese.

Responding to claims that the declaration is merely a partisan attack on President Barack Obama, Colson noted that it states that in the Roe v. Wade era, “elected officials and appointees of both major political parties have been complicit in giving legal sanction to the ‘Culture of Death.’ ”

On sexuality, the document stresses that some people are “disposed towards homosexual and polyamorous conduct and relationships, just as there are those who are disposed towards other forms of immoral conduct. … We, no less than they, are sinners who have fallen short of God’s intention for our lives. We, no less than they, are in constant need of God’s patience, love and forgiveness.”

While nothing in the Manhattan Declaration is truly new, arguments about its call for civil disobedience will help draw sharper lines between traditional believers and the powers that be in an increasingly diverse and secular America, said Dr. H. Tristram Engelhardt, Jr., senior editor of the Christian Bioethics journal at Oxford University. He is professor emeritus at the Baylor College of Medicine and a philosophy professor at Rice University.

“This document is the product of a political coalition, but it’s not political in the same sense that the tax code is political,” said Engelhardt, who is advising several Eastern Orthodox leaders who are studying the text. “This is political in the sense that these Christians are working together on certain issues that have moral and public implications.”

The reality is that its authors believe there are “certain God-ordained truths” that continue to have authority and weight in American life, he said. The big question: Are they right or wrong?

“You could make a case,” concluded Engelhardt, “that anyone who recites the Nicene Creed, or anyone who believes that God has established any requirements for how we are supposed to live our lives can now be called a Fundamentalist in the context of this secular culture. … That is what this debate is actually about.”

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This has been a consistent pattern in recent surveys and it can be seen in most pews, from conservative evangelicals to liberal mainline Protestants, said Greg Smith, senior researcher at the Pew Forum on Religion and Public Life. This pattern is especially clear among American Catholics.

“The people who attend worship services more often are going to be opposed to abortion and those who rarely or never attend are going to support legalized abortion,” he said. “You go once a week? It’s going to be about two-thirds against. Rarely if ever? It’s about two-thirds in favor. …

“That division is still there. But the big news is that both of these groups have been moving in the same direction for the past year or so. We’re seeing support for abortion rights weakening across the board.”

A new Pew Forum survey found that the percentage of Americans saying they believe abortion should be “legal in all/most cases” fell from 54 to 47 percent during a single year. Meanwhile, the percentage of people who said they believe abortion should be “illegal in all/most cases” rose from 40 to 44 percent. The “undecided” camp grew from 6 to 9 percent of those polled.

“The nation remains pretty evenly divided,” said Smith. “However, what we can see is that support for legalized abortion is weakening in many groups and it’s stalled in others. … How much people practice their faith is a crucial factor in this.”

Support for abortion rights remains high among American Jews, but the latest Pew survey showed a drop from 86 percent in favor a year ago to 76 percent now. Support among Americans with no religious affiliation at all fell from 71 percent in favor of legalized abortion to 68 percent.

One of the most dramatic shifts came among members of white mainline Protestants — liberal churches that have consistently supported abortion rights. The numbers were especially dramatic when church attendance was factored into the equation, noted Smith.

Support for abortion rights among mainliners who attended church once a week fell from 54 to 42 percent, while support among those who said they attended less often than that fell from 68 to 60 percent.

To no one’s surprise, opposition to abortion rights among evangelical Protestants remains high, but the numbers have risen even higher in the past year. Church attendance is a major factor, with 79 percent of white evangelicals who worship once a week saying abortion should be “illegal in all/most cases.” A year ago, 73 percent took that stance. Among white evangelicals who go to church less often, opposition to abortion rose a dramatic 12 percent — from 47 to 58 percent.

The contrast between regular and occasional worshippers was also dramatic among white Catholics. Opposition to abortion rights rose from 57 to 67 percent among Catholics who reported going to Mass once a week. Among those who said they attended Mass less often, support for legalized abortion declined slightly during the past year, from 65 to 62 percent.

These numbers are logical because Catholics who are active in the church are exposed more often to sermons, prayers and ministries that incarnate church teachings on the sanctity of human life, said Deirdre McQuade of the pro-life office at the U.S. Conference of Catholic Bishops.

“Those who are less invested in the sacraments — attending church, receiving the Eucharist and going to confession — may have less access to the truth about life, and fewer resources to believe and accept it,” she said.

In the end, stressed Smith, this survey underlines two realities. First, there is little evidence that America’s debates about abortion are fading. Second, it’s clear that religious faith and practice remains one of the most crucial dividing lines on this issue.

“It’s important to realize that millions of Americans see themselves as caught in the middle” on abortion issues, he said. “Take those mainline Protestants, for example. Even though it seems that their support for legalized abortion is weakening, they probably see themselves as moving from one position in the middle to another position in the middle. They may be changing what they believe, but not very much.”

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The Congregation for the Doctrine of the Faith sent the guidelines to the leader of the Archdiocese of Washington, D.C. However, Cardinal Theodore McCarrick chose not to share the letter with America’s bishops, which kept its blunt contents secret — until a leak in Italy.

“The Church teaches that abortion or euthanasia is a grave sin,” warned the letter, adding that there is a “grave and clear obligation to oppose” civil laws and judicial decisions that “authorize or promote” these acts. At the same time, it explained that there “may be a legitimate diversity of opinion even among Catholics about waging war and applying the death penalty, but not … with regard to abortion and euthanasia.”

On the central issue, the guidelines said when a person’s “formal cooperation becomes manifest (understood, in the case of a Catholic politician, as his consistently campaigning and voting for permissive abortion and euthanasia laws), his Pastor should meet with him, instructing him about the Church’s teaching, informing him that he is not to present himself for Holy Communion until he brings to an end the objective situation of sin and warning him that he will otherwise be denied the Eucharist.”

Months later, the letter’s author — Cardinal Joseph Ratzinger — became Pope Benedict XVI. There is no evidence his views have changed.

However, the status of politicians who clash with Rome remains controversial, especially when Catholics occupy strategic positions on the U.S. Supreme Court, in the president’s cabinet and on Capital Hill.

Tensions from the Ratzinger letter were also felt during the public events marking the passing of Sen. Edward Kennedy, one of the most symbolic and influential Catholics in American political history.

Catholics on both sides of the aisle dissected the rites, seeking signs of favor or disfavor. The outspoken Cardinal Sean O’Malley of Boston presided in the funeral Mass, but played a small role. Was that important? Where were the region’s other bishops? Were television crews told to avoid camera angles that would reveal who received Communion?

But the most symbolic moment occurred during the graveside service in Arlington National Cemetery. That’s when the now retired Cardinal McCarrick — a close friend of Kennedy — read the dying senator’s private appeal for a final papal blessing.

“I know that I have been an imperfect human being, but with the help of my faith, I have tried to right my path,” wrote Kennedy. “I want you to know, Your Holiness, that in my nearly 50 years of elective office, I have done my best to champion the rights of the poor and open doors of economic opportunity. I’ve worked to welcome the immigrant, fight discrimination and expand access to health care and education. I have opposed the death penalty and fought to end war. …

“I have always tried to be a faithful Catholic, Your Holiness, and though I have fallen short through human failings, I have never failed to believe and respect the fundamental teachings.”

McCarrick read excerpts from a Vatican reply, keeping some parts private. The final lines, written by a papal aide, were simple: “Commending you and the members of your family to the loving intercession of the Blessed Virgin Mary, the Holy Father cordially imparts his Apostolic Blessing as a pledge of wisdom, comfort and strength in the Lord.”

Kennedy’s letter raised a familiar and haunting question: Are the Catholic doctrines on the sanctity of every human life, from conception to natural death, part of the church’s “fundamental teachings” or not?

While praising the senator’s career, McCarrick added what was almost certainly a gentle reference to his clashes with the church on abortion, gay rights and other doctrinal issues. The bottom line: Kennedy maintained a 100 percent pro-abortion-rights voting record, according to NARAL Pro-Choice America.

“They called him, ‘The Lion of the Senate,’ and indeed that is what he was,” said the former shepherd of the Washington archdiocese. “His roar, and his zeal for what he believed, made a difference in our nation’s life. Sometimes, of course, we who were his friends and had affection for him would get mad at him when he roared at what we believed was the wrong side of an issue.”

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That’s when critics spotted an odd detail in this guide for end-of-life medical decisions. It urged aging veterans to seek expert advice from one group — Compassion & Choices. It helps to know that this organization was created in 2005 through the merger of two groups, Compassion in Dying and End-of-Life Choices and that, until 2003, End-of-Life Choices was known as the Hemlock Society.

The Bush White House pulled that edition of “Your Life, Your Choices,” but a revised version — minus the plug for Compassion & Choices — has been restored to the VA.gov website. Conservative critics remain worried.

“Obviously, the Catholic church and our bishops have been strong advocates of health-care reform, especially when it comes to making the system more accessible for the poor and needy. That’s a no-brainer,” said John Haas, president of the National Catholic Bioethics Center and a member of U.S. Conference of Catholic Bishops task force on health care.

“But this VA issue shows why we just don’t trust the government when it comes to helping people make all the moral and religious decisions that come at the end of life. … The Hemlock Society? Catholics would rather do our own counseling, thank you very much.”

It’s easy for outsiders to get lost in the details of the sprawling packages of legislation now being debated on Capitol Hill. However, Haas stressed that critical questions remain unanswered about how efforts to reform America’s health-care system will affect hot-button issues such as abortion, stem-cell research and health-care rationing for the elderly and chronically ill.

Thus, a letter from the U.S. bishops to Congress and the White House pledged support for accessible, affordable, universal health-care reform that truly “protects and respects the life and dignity of all people from conception until natural death.”

In the headlines, it is easy for these concerns to be crunched into shouted questions in health-care forums about taxpayer-funded abortions and fears that government “death panels” will micromanage critical decisions in nursing homes.

But calmer, quieter voices inside the Washington Beltway still want to know more about the proposed Center for Health Outcomes Research and Evaluation, which legislation sponsored by the late Sen. Edward Kennedy claims would “collect, conduct, support and synthesize research comparing health outcomes, effectiveness and appropriateness of health care services and procedures.”

While striving to avoid risky specifics, President Barack Obama has said it will be impossible to expand health-care services without tough-minded reforms that cut costs. This is especially true when discussing care for the elderly.

“That’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here,” said Obama, in a much-quoted New York Times interview.

“I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. … That’s part of why you have to have some independent group that can give you guidance.”

The president recently went further, according to Twitter postings from a conference call with 1,000 rabbis. Obama reached out to these religious leaders, stressing, “We are God’s partners in matters of life and death.”

No one doubts that millions of Americans want help while making decisions about end-of-life medical issues, stressed Haas. The question is whether most would prefer to face these ultimate issues with help from government experts or from their own pastors, rabbis, priests, hospice workers and other religious counselors.

“The Catholic Church has a highly developed body of teachings and traditions to help guide people through these kinds of decisions,” said Haas. “We believe that hospice care is normal and good. We believe that it’s right to die a good death, with an emphasis on the relief of pain and suffering. …

“But let’s be clear. We think the government has an agenda on these kinds of issues and it’s not the church’s agenda. When it comes to dying, controlling costs is not our primary goal.”

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Nevertheless, a full-page advertisement in the New York Times during the 1992 Democratic National Convention raised eyebrows because a few prominent Democrats endorsed “A New American Compact: Caring about Women, Caring for the Unborn.”

One name in particular jumped out in this list — Kennedy.

“The advocates of abortion on demand falsely assume two things: that women must suffer if the lives of unborn children are legally protected; and that women can only attain equality by having the legal option of destroying their innocent offspring in the womb,” proclaimed ad’s lengthy and detailed text.

“We propose a new understanding, one that does not pit mother against child. To establish justice and to promote the general welfare, America does not need the abortion license. What America needs are policies that responsibly protect and advance the interest of mothers AND their children, both before AND after birth.”

Near the end, the statement added: “We can choose to reaffirm our respect for human life. We can choose to extend once again the mantle of protection to all members of the human family, including the unborn.”

It really wasn’t a surprise that Eunice Kennedy Shriver — who died on Aug. 11, after a series of strokes — was among those who signed the document, along with her husband Sargent Shriver, the 1972 Democratic nominee for vice president.

Yes, she was the sister of President John F. Kennedy, Sen. Robert Kennedy, and Sen. Edward Kennedy and part of a family dynasty that changed how Americans view progressive politics and Catholicism.

But Eunice Shriver also attended convent schools, considered becoming a nun and remained a daily-Mass Catholic throughout her life, while teaching the Rosary prayers to her five children and 19 grandchildren. She was a public supporter of Democrats for Life, Feminists for Life and the Susan B. Anthony List, which supports pro-life women who seek public office.

“She was pious, I think, a very, very pious woman,” said Robert F. Kennedy Jr., stating the obvious during a six-hour public wake and Mass for his aunt at Our Lady of Victory Church on Cape Cod.

An official tribute went further while connecting her faith with the issue that dominated her public life.

“Inspired by her love of God, her devotion to her family, and her relentless belief in the dignity and worth of every human life, she worked without ceasing,” said the family’s public statement. “She was a living prayer. … She set out to change the world and to change us, and she did that and more. She founded the movement that became Special Olympics, the largest movement for acceptance and inclusion for people with intellectual disabilities in the history of the world. Her work transformed the lives of hundreds of millions of people across the globe, and they in turn are her living legacy.”

The mainstream obituaries and media tributes that followed her death also connected Shriver’s work with the poignant life of her older sister Rosemary Kennedy, who was mentally disabled. In a historic 1962 article for the Saturday Evening Post, Eunice yanked one of Camelot’s most tragic secrets into the open — under the stark headline, “Hope for Retarded Children.” In the decades that followed, she worked tirelessly to pull Rosemary into the family circle.

Nevertheless, elite journalists failed to connect the dots between Shriver’s fierce activism on behalf of children facing disabilities and her commitment to defending the lives of the unborn, including babies with Down syndrome and other genetic flaws.

For Eunice Kennedy Shriver, the sanctity of life was a Catholic issue, a political issue and an intensely personal issue.

“She was preeminently pro-life, against abortion and there to protect and underscore the dignity of every person. This, of course, manifested itself in her love for children with disabilities,” noted Cardinal Sean P. O’Malley of Boston, in a reflection posted online.

“While Eunice’s works were remarkable, I don’t want to lose sight of the fact that her Catholic faith and education was a very important part of what motivated her and helped her to interpret reality. … It was certainly the soil out of which grew her passion and dedication to the less fortunate and those who are challenged by disabilities and mental retardation.”

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Consider, for example, this reference to health care in its chapter on the biblical instruction, “You shall love your neighbor as yourself.”

“Life and physical health are precious gifts entrusted to us by God,” notes the catechism. “Concern for the health of its citizens requires that society help in the attainment of living-conditions that allow them to grow and reach maturity: food and clothing, housing, health care, basic education, employment and social assistance.”

The implication is that governments — as a matter of social justice — should help citizens obtain basic health care, according to a letter sent to Congress and the White House by the Domestic Justice and Human Development Committee of the U.S. Conference of Catholic Bishops.

Health care is a human right, not a privilege, argued Bishop William F. Murphy.

“All people need and should have access to comprehensive, quality health care that they can afford, and it should not depend on their stage of life, where or whether they or their parents work, how much they earn, where they live, or where they were born,” wrote Murphy.

But there’s a problem. The letter stresses that the church will support accessible, affordable, universal health-care reform if it “protects and respects the life and dignity of all people from conception until natural death.”

Try telling that to Health and Human Services Secretary Kathleen Sibelius, Speaker of the House Nancy Pelosi, surgeon general nominee Regina Benjamin, Vice President Joe Biden and other Catholics who play strategic roles in Washington, D.C., right now — while rejecting Catholic teachings on many critical health-care issues.

That’s the political reality that the bishops are facing, said Leonard J. Nelson III, a health-care law specialist at the Cumberland School of Law at Samford University.

For the bishops, Catholic teachings on the sanctity of human life are crystal clear, from birth to death, from abortion to euthanasia. Yet the bishops also support health-care for all — rich and poor. It’s getting harder and harder to keep these issues woven together.

“The bishops have been talking about social justice and health care for years and years and now the political climate has changed around them,” said Nelson, author of the new book, “Diagnosis Critical: The Urgent Threats Confronting Catholic Health Care.”

“The politicians who are in command are ready to pass some kind of health-care reform and they have all kinds of reasons to include abortion in that package. … That’s the fix that the bishops are in.”

Meanwhile, he said, leaders of Catholic hospitals and health-care systems will almost certainly face challenges in the near future.

For starters, they could be pressured to join networks and cooperatives that have no reason to follow the bioethical guidelines detailed in the “Ethical and Religious Directives for Catholic Health Care Services” adopted by the U.S. Catholic bishops. It will be hard for Catholic leaders to cooperate with government approved health-care programs and receive government funds while declining to offer services such as contraception, sterilizations and referrals for abortions.

Catholic leaders also know that another life-and-death issue looms in the background. As President Barack Obama noted in a recent New York Times interview, it’s impossible to cut or control costs without government efforts to shape health care in the final years of life.

“That’s where I think you just get into some very difficult moral issues,” said Obama. “But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.”

The Catholic bishops, noted Nelson, have not addressed these end-of-life scenarios — yet. Will government agencies or advisory boards be given the power to decide whether patients facing Alzheimer’s or Parkinson’s disease receive expensive medications? Who will decide whether elderly patients have a high enough “quality of life” to continue receiving medical care?

“Productive people in the middle years of life are always going to get the health care they need,” said Nelson. “The big threats to the sanctity of life come at the very beginning and at the end. If you’re going to defend the church’s teachings on health care, you have to focus on those threats. The bishops have to find a way to do that.”

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“If anyone has an urge to kill someone at an abortion clinic, they should shoot me,” said the late Cardinal John O’Connor, preaching to his New York City flock in 1994. “It’s madness. It discredits the right-to-life movement. Murder is murder. It’s madness. You cannot prevent killing by killing.”

The cardinal’s famous soundbite was part of a larger debate during the mid-1990s, as pro-life leaders articulated precise reasons why frustrated activists on the fringe of their movement should reject violence. This debate remains tragically relevant, after the killing of late-term abortionist George Tiller while he was serving as an usher at Reformation Evangelical Lutheran Church in Wichita, Kan.

The alleged gunman Scott Roeder has expressed sympathies for the views of activists who — as in this “Defensive Action Statement” at ArmyofGod.com — argue that this kind of violence is morally justified.

“We … declare the justice of taking all godly action necessary, including the use of force, to defend innocent human life (born and unborn). We proclaim that whatever force is legitimate to defend the life of a born child is legitimate to defend the life of an unborn child.”

This is precisely the argument that O’Connor and others fervently opposed 15 years ago. Quoting the Catholic Catechism, Pope John Paul II, Gandhi and other sources, he attacked the ancient consequentialist argument that good ends justify any means.

“Where does this spiral end? How is it limited? Surely, we are all as tired of abortion as we are tired of murder. But we must fight murder without conforming to it or condoning it,” wrote the cardinal, as part of “Killing Abortionists: A Symposium” in the journal First Things.

“Let us attend to God’s revelation: ‘Do not be conquered by evil, but conquer evil with good’ (Romans 12: 21). … No Christian, however well-intentioned, has the moral right to declare himself the sole detective, district attorney, judge, jury and supreme court in our democratic society and on his own authority set aside the natural law and the Ten Commandments, allegedly to advance the fifth of those Ten Commandments.”

While frustrated by new political defeats, mainstream abortion opponents have continued to embrace this viewpoint. The list of organizations strongly condemning Tiller’s death includes the National Right to Life Committee, U.S. Conference of Catholic Bishops, Americans United for Life, Focus on the Family, Concerned Women for America, Care Net, the Susan B. Anthony List, Priests for Life and many others.

“Murdering someone is a grotesque and bizarre way to emphasize one’s commitment to the sanctity of human life,” noted Richard Land, president of the Southern Baptist Ethics & Religious Liberty Commission. “People who truly believe in the sanctity of human life believe in the sanctity of the lives of abortion providers as well as the unborn babies who are aborted.”

Land noted that another important document emerged from the 1994 debates, produced by a circle of Southern Baptist theologians. A major theme in this “Nashville Declaration of Conscience” is that Americans continue to have many legitimate ways to challenge their government’s abortion laws, short of violent revolution.

Ultimately, this document concluded, it is the “people of the United States, acting through legitimate governmental institutions, who are responsible and ultimately accountable for immoral laws permitting and protecting the taking of unborn human lives. … Legalized abortion on demand is the single gravest failure of American democracy in our generation. But we recognize it as a failure of a legitimate democracy rather than as the imposition or decree of an illegitimate regime.”

Abortion continues to stretch the “American body politic near the breaking point” because the issue pivots on fundamental moral questions, noted ethicist David Gushee of Mercer University, who drafted the Nashville document early in his academic career. In terms of history, only debates over slavery cut this deep.

But it’s wrong to blame abortionists, politicians, talk-radio hosts or any other single group of people for this conflict, he said. All Americans need to look in a mirror.

“In a vast, diverse, squabbling, pluralistic democracy, even on matters of the gravest and most heartfelt significance we face sometimes irreconcilable differences,” said Gushee. “If that democracy is to survive, we must learn to deal with them without killing each other.”

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Pope Gregory XVI proclaimed that “no one in the future dare to vex anyone, despoil him of his possessions, reduce to servitude, or lend aid and favor to those who give themselves up to these practices, or exercise that inhuman traffic by which the Blacks, as if they were not men but rather animals, having been brought into servitude, in no matter what way, are, without any distinction, in contempt of the rights of justice and humanity, bought, sold and devoted sometimes to the hardest labor.”

Nevertheless, the first bishop of Charleston, S.C., attempted to soften the blow. Quoting scripture and Catholic doctrine, Bishop John England wrote a series of letters arguing that the pope didn’t mean to attack those — including Catholics — who already owned slaves.

“Bishop England was not a bad man. He was not personally in favor of slavery, nor was he a racist,” noted Father John Raphael of New Orleans, at a rally organized as an alternative to the University of Notre Dame’s graduation rites.

“In fact, Bishop England exercised a cherished and personal ministry to black Catholics,” he added. “But in the face of strong, anti-Catholic sentiment and prejudice, he simply wanted to show his fellow antebellum Southerners that Catholics could be just as American as everybody else and that tolerance of their cherished institution — slavery — was not in any way opposed by the Catholic church.”

It was wrong for Catholics of that era to seek any compromise on slavery, stressed Raphael, who serves as principal of St. Augustine High School, one of Louisiana’s most prominent African-American institutions. It is just as wrong, today, for Catholic leaders to compromise on abortion. At least the slaves were allowed to live, to be baptized and to receive the sacraments, he said.

The symbolism was obvious, since the priest is a prominent African-American graduate of Notre Dame.

The symbolism was more than obvious, since he was speaking at a rally protesting Notre Dame’s decision to grant President Barack Obama an honorary doctor of laws degree, clashing with a U.S. Catholic bishops policy that states: “Catholic institutions should not honor those who act in defiance of our fundamental moral principles. They should not be given awards, honors or platforms which would suggest support for their actions.”

The Mass and rally on Notre Dame’s south quad followed hours of prayers in the university’s Alumni Hall and famous Marian grotto. These solemn, peaceful events received little media attention, even though they drew several hundred or several thousand participants, depending on who did the counting, as well as 25 Notre Dame faculty members, 26 graduating seniors and Bishop John D’Arcy of the Catholic Diocese of Ft. Wayne-South Bend. A louder standoff between police and 100 off-campus activists — led by anti-abortion leader Randall Terry — received most of the news coverage.

During the actual commencement address, a few protesters yelled, “Stop killing our children.” Most of the graduates booed the protesters, then chanted, “Yes we can,” Obama’s campaign slogan, and “We are ND” as they were removed.

Notre Dame President John Jenkins stressed that Obama accepted Notre Dame’s invitation knowing that “we are fully supportive of church teaching on the sanctity of human life and we oppose his policies on abortion and embryonic stem cell research.”

“President Obama is not someone who stops talking to those who differ with him,” stressed Father Jenkins. Then he added, “Mr. President, this is a principle we share.”

Meanwhile, many of the speakers at the “Notre Dame Rally for Life” openly criticized Obama’s policies, but consistently focused their harshest words on the actions of the current Notre Dame administration.

“Faith without works is dead, words without actions are meaningless,” said Father Raphael. “If, as we have been told, a dialogue is actually taking place … between the presidents of Notre Dame and the United States, between the university and the nation, then, for the university at least, that dialogue must be shaped by truth and charity, and protecting the sanctity of all human life, as the church understands life, must be its goal. …

Actively building a culture of life at Notre Dame must become central to the university’s witness and mission to the nation and to the world.”

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