In a time of cruelty and barbarism, the Catholic Church of the Middle Ages created the modern hospital.

Today, after centuries of tending the sick and the dying, Catholic hospitals are now confronted with new medical technologies that gravely challenge their religious identity.

One-sixth of the nation's hospitals are Catholic, serving Catholic and non-Catholic alike. A significant number of those 616 institutions are university research centers on the vanguard of developing new medical technologies. Yet some of the same advances that help create life also threaten traditional Catholic values.

As Dr. Edmund Pellegrino, head of Georgetown University's Kennedy Institute of Ethics, puts it: "Can a Catholic hospital be faithful to the specific ethics of its healing mission in the face of moral pluralism in a democratic society?"

These questions were brought into sharp focus three months ago by the Vatican's first thorough evaluation of 20th-century medical technologies that generate human life without the sexual act or otherwise violate the Vatican view of God's laws. Artificial insemination from a donor, surrogate motherhood, prenatal diagnosis to eliminate malformed fetuses, in vitro (test tube) fertilization -- all were called "morally illicit."

The document came at a time when Americans of all faiths and no faith had just been troubled by the tug-of-war over a "Baby M" carried by one symbol of the new technology, a surrogate mother.

It also came at a time when many Catholic doctors and hospitals had been edging into new areas or making modest compromises in the light of their de facto situation as healers to non-Catholics as well as Catholics.

The document pleased many Catholics who felt the Vatican had been too timid and slow in trying to stem the tide of test-tube babies and other interventions against what they considered God's will.

It displeased others. Of American in vitro babies, for example, 28 percent were born to Catholic parents, by a recent count.

A 1978 Gallup poll found that 56 percent of American Catholics -- compared with 60 to 75 percent of the public as a whole, by various polls -- supported the procedure.

According to surveys, three or four out of five had long been ignoring the Church's ban on artificial contraception.

To be sure, Catholics are not unique in believing religion must govern some aspects of medicine. Strict Orthodox Jews, some Protestants, the Amish, Christian Scientists and Jehovah's Witnesses all have medical restrictions of one kind or another.

But only Catholic medical institutions serve so much of America, with a Catholic hospital often the only one in town.

To Daniel Maguire, professor of moral theology at Marquette University and one of Catholicism's severest Catholic critics, "the new heavy-handed and ecumenically insensitive {Vatican} document" raises "serious questions about whether Catholics should be in the hospital business at all." ::

On a high bank of the Potomac River, in the heart of Washington, stands one of the nation's leading Catholic medical institutions, Georgetown University Hospital.

The medical care at Georgetown Hospital is considered among the best in Washington. And it is not only care for Catholics. Only a third of the patients are Catholic. Among the medical and nursing staffs, perhaps 40 to 50 percent are Catholic.

Georgetown Hospital today, like the Church as a whole, is a place of questions and tensions. But it is also -- and preeminently -- a place of healing and caring.

Pellegrino says: "To put it as bluntly as I can, our mission is to make your care here as close as we can to the model Christ provided for us. We fail sometimes. But the big difference is: When we fail, we know that we're failing."

Dr. John Stapleton, the hospital's medical director, who is not Catholic, says: "You might notice the religious statues in our lobby or the crucifixes in our rooms. Mass is said twice a day. But apart from that religious content, I don't believe you'd know, on the surface, that this is a religious hospital. The practice of medicine is nonsectarian.

"At the same time, I like working in a place where there is a well-defined set of ethics and human values."

These values also affect other issues in health care today, including the financing of medical care. As Pellegrino says: "Does fiscal survival" -- in this time of severe cost-cutting and competition between hospitals -- "demand too many compromises with the essential spirit of a Christian healing ministry?"

In this area and others, a hospital's tone is often set by its chief executive. Georgetown Hospital's administrator is Charles O'Brien, who worked at major university and county teaching hospitals in the Midwest before coming to Georgetown. He often walks among doctors, nurses and patients to see how things are going. "I think the tone in this hospital is different," he says. "When dealing with life, birth and death, we believe there's a spiritual dimension. We want you to feel that, whether or not you're Catholic. But there is no proselytizing here, no attempt to change anyone's views."

An active and committed ethics committee helps doctors and families deal with issues of death and dying, and Kennedy Institute ethicists make rounds with the doctors. One committee member is the Rev. Robert Baumiller, the hospital's chief genetics counselor, who holds a doctorate in genetics.

"I saw a 17-year-old girl yesterday whose baby was delivered dead. She was holding her child and grieving. I was able to be with her and talk to her and try to help her," he says. "I think you will find a great understanding of suffering at this hospital. I think you will find a tremendous love for the person." ::

The questions and tensions at Georgetown Hospital have been intensified by the Vatican document, "Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation." At the same time, its prohibitions, the teaching that "the act of conjugal love" is the only approved method of human procreation, the statement that "the vitality and stability of society require that children come into the world within a family and that the family

be firmly based on marriage" -- all were in accord with the views that many doctors and other health workers in Catholic hospitals had already agreed to obey.

Well before the Vatican pronouncement, there had been tugging and pulling between medicine and religion in Catholic hospitals.

Seattle Archbishop Raymond Hunthausen had allowed sterilizations to be performed at Catholic hospitals in his diocese, though only on non-Catholics. He was rebuked by the Church on this and several nonmedical issues, and the Church reiterated its ban on all sterilizations performed solely for contraception.

In New York, a Catholic doctor resigned last year as obstetrics chairman at New York Medical College, a private Westchester County school affiliated with the New York Catholic archdiocese, because he was not allowed to hire a doctor who had written about terminating pregnancy.

Some Catholic hospitals are getting around strictures from the Church by affiliating with non-Catholic hospitals, where procedures such as sterilizations and abortions can be performed.

According to Hospitals, the magazine of the American Hospital Association, "Many Catholic hospitals are finding ways to compete {with other hospitals} without compromising their beliefs."

St. Francis Hospital in Waterloo, Iowa, finding itself under financial pressure, consolidated assets with a community hospital to form a new corporation. Because each institution has its own legal status, maintains the president of St. Francis, one unit of the former community hospital can continue sterilizations without compromising Catholic principles.

"Also," the magazine reported, "some Catholic hospitals that contract {with} HMOs are establishing procedures by

which members who desire abortions can obtain such services." Test-Tube Dilemmas

Georgetown University Hospital, which is part of a Jesuit university, has been in the forefront of institutions seeking to cast traditional Catholic values in the light of new knowledge.

There is now both debate and disagreement there -- though disagreement without disobedience -- with one striking part of the new Vatican document, its prohibition of in vitro fertilization.

In this "test-tube baby" procedure, a husband's sperm is injected into his wife's egg cell outside the womb to create a clump of living, dividing cells, the first cells of a new human being, that are then implanted into the womb of the mother-to-be.

The Vatican calls this procedure, now responsible for more than 2,000 births worldwide, illicit, since human dignity and unity "demand that the procreation of a human person be brought about as the fruit of the conjugal act" between loving spouses.

Yet many Catholic doctors believe this nonsexual means of helping childless married couples have babies is in accord with God's will, since he gave humans the means to devise it, and the good that is done outweighs any possible evil.

Well before the Vatican's statement on in vitro fertilization (IVF), Georgetown University faculty members had started an in vitro program at nearby Columbia Hospital for Women with Georgetown's approval. Had the Georgetown doctors involved not resigned last year for a number of reasons, the university would have found itself sponsoring a forbidden program.

The principal founder of the IVF program was Dr. Richard Falk. Starting in 1983, he reports, "we spent almost a year discussing IVF" with Georgetown ethicists, including Pellegrino and the Rev. Richard McCormick, a leading Catholic ethicist with some views (including those on birth control) contrary to the Vatican's. Then with the Kennedy Institute of Ethics, he is now at Notre Dame University.

"Finally," Falk says, "after everyone agreed this was a reasonable academic effort for Georgetown University to participate in, if not at Georgetown Hospital, we went to Father Healy {the Rev. Timothy Healy, the university's president) and presented this to him. I was there. Queenan {Dr. John Queenan, head of obstetrics and gynecology} was there. Father Healy said he would discuss this with the archbishop. I went ahead.

"It was a Georgetown University program at Columbia. It was not in any way underhanded. It was everybody's thinking that it could be moved to Georgetown as it got more acceptable. All the information I got was that the Vatican would approve it."

The first baby was born in October 1985 to a Catholic couple. Nine more have been born since.

In June 1986, Falk resigned from the full-time, paid Georgetown faculty, though he remains an unpaid clinical associate professor. Falk and his associate, Dr. Safa Rifka, moved into private practice and have continued the IVF program at Columbia Hospital. He resigned, he says, "for personal reasons," including a desire to advance himself "and the fact that I was told I was going to have to move my unit to Georgetown Hospital. My question was, what would I do about AID -- artificial insemination from a donor -- and IVF? I was told I would have to give up AID but IVF was no problem, though I was never confident that would be true.

"All this was before the Pope's statement," he points out.

To Queenan, a leading OB-GYN researcher, not having an IVF program is a disappointment. "We're a university. This {IVF} was an advance, something that ought to be done by our department," he says. "After looking at it carefully at all levels -- the ethicists, etc. -- Father Healy approved going ahead with the program at Columbia." This already was where the faculty members had their offices and did all their work, says Queenan. It was "not any dodge."

Queenan is among many Catholic physicians and scientists who are already arguing that the Vatican should reconsider its position on in vitro fertilization. He calls its ruling "an enormous setback" when it comes to helping childless couples.

A Georgetown colleague, Dr. John Proctor Harvey -- professor of medicine and secretary of the bioethics study group of the International Federation of Catholic Universities -- wrote in the Catholic magazine Commonweal this spring: "Catholic physicians like myself will take seriously the authentic magisterial teaching of the 'Instruction' in obedience to Jesus the healer. The plea of this physician is that the theologians will look again" and find that IVF "is now in fact licit," since a couple's mutual love and even suffering is shown there in other ways than sexual union.

Father McCormick believes infertile Catholic couples "will make up their own minds on this question," much as they already make it up when they practice birth control. "Granted, it is not the ideal way to have children, but that does not mean it is morally wrong" when practiced between husband and wife.

"Sexual intercourse," he says, "is not the only loving act."

Dr. Robert White, neurosurgery chief at Cleveland Metropolitan General Hospital and twice a papal knight, is a member of the Vatican's Advisory Commitee for Biotechnology Applied to Man, a group he helped inspire as a subcommittee of the Pontifical Academy of Science. He was among those who helped assure that the Vatican document was correct in its science, whatever the theologians concluded.

A father of 10, he finds the document as a whole heartening in its support of human dignity. But "I argued strongly" for IVF, he reports. "I felt the document should have allowed a couple to use their own tissues, in the classical IVF technique, to try to have a child."

In Europe, opposition has already built up against the Vatican's position. The directors of four European Catholic universities -- two in Belgium, one in France, one in Holland -- have said that they are going ahead with their IVF programs. Alternative Solutions

In a search for alternate yet acceptable techniques to do the same job, Georgetown University is going ahead with a different way of joining sperm and egg for a woman who would be otherwise be infertile. So are Providence Hospital here, St. John's Mercy Hospital in St. Louis and many other Catholic hospitals, says Catholic Health Association Vice President Laurence O'Connell. They are using a method purposely left unmentioned by the Vatican and therefore "licit," O'Connell said, under the document's guidelines.

The technique is called GIFT, for "Gamete Intrafallopian Transfer," a gamete being either a male or female mature reproductive cell -- sperm or egg -- that unites with the other to launch conception.

In GIFT, the wife first donates an egg cell, which is taken from her by instrument, just as in IVF. The husband and wife then have intercourse, the required act of love, with the husband wearing a special condom with a pinhole -- the pinhole to allow a bit of semen to escape, thus avoiding the onus of contraception and making this a "natural" act. They promptly take the sperm to the hospital, where it is joined with the wife's egg cell -- not in a test tube, but inside the wife's fallopian tube, which leads to the womb.

"With GIFT," says Dr. Michael DiMattina, the program's director, "fertilization takes place in the woman's body, rather than in a test tube or laboratory flask."

And doctors overcome the problem of a blocked fallopian tube by inserting the egg and sperm beyond the blockage so they can pass to the womb.

Georgetown now has three pregnancies from this method, one of them in its 20th week.

Yet not all Catholics are pleased with some of these ways of getting around forbidden practices. To McCormick, the use of the pinhole condom -- sometimes called a "Catholic condom" -- is "demeaning."

"To me," he says, "it's frightening that we must come down to that type of casuistry."

Queenan simply says: "Science is going to advance. One responsibility of people in universities is to find ways of helping the infertile."

Georgetown has gained a reputation as an OB-GYN center skilled at many techniques, including managing the most complicated, high-risk pregnancies, one of Queenan's specialties. Twenty area hospitals now send it their highest-risk mothers for monitoring and delivery.

Since a giant share of Vatican rulings affect obstetrics and gynecology, however, Queenan may have Georgetown's toughest job.

When a Georgetown doctor wants to help a married woman conceive by artificial insemination -- and she must be married -- he must tell her husband how to collect his semen as part of sexual intercourse, using the special condom.

If a woman wants a contraceptive, there must, by the rules, be some other "licit" medical reason for its use, such as regulation of the menstrual cycle.

If a woman wants to have her tubes tied to be sterilized, Queenan can advise her on the pros and cons, "but I tell her, 'I can't do it.' " Still, he says, "a lot of patients go elsewhere to do it, then come back."

There are also many patients on "natural family planning," Queenan says. This is no longer the unreliable "rhythm" or calendar method, but now more sophisticated ways to help women monitor their fertile and infertile periods. He has a $15 million federal grant to try to perfect natural planning, and believes that "within three or four years we will probably" see great advances in this method.

At the recent American College of Obstetrics and Gynecology meeting, Queenan points out, "there were some 800 papers, and only one on natural regulation of fertility."

He believes, however, that there will be "more of a dialogue now" because he and others are pushing for it. Genetic Defects and Abortion

The Rev. Robert Baumiller, a genetics counselor, offers information and guidance to couples deciding whether or not to have a child or, after prenatal testing, facing the possibility or certainty of a retarded or deformed baby.

This is a hard task in any hospital. It may be doubly hard at a Catholic hospital, where, if a couple decides to have an abortion, it is anathema to the Church.

Baumiller himself -- a priest, a believer in the sanctity of all life and at the same time a counselor with a duty to the parents -- must remain neutral. He often wears ordinary clothes, not priestly garb, during his counseling. "To some people," he explains, "it's off-putting" -- they may think he will present the Church's point of view.

That he does not do. "Our responsibility," he says, "is to make sure the couple knows the risks and what choices are available -- to empower them to make a decision."

The matter of "choices" means, of course, that the counselor must make sure the couple knows all the alternatives, including abortion. "I may not agree with that," he says. "But I have a professional responsibility to inform. We do not engender virtue by keeping people ignorant. No one in this hospital would force their opinions on other people. We respect the autonomy of the individual."

In one sense, he adds, "we have to be the fairest of counselors. If I counsel someone according to my own bias or belief, I have no redress against persons in the next medical school who move people toward a different end."

Many couples, Catholic and non-Catholic, will decide to carry a baby to full term despite a defect. And many, Catholic and non-Catholic, will not. What if a couple does want an abortion?

"We would not terminate the pregnancy here. But we would not abandon the parents. We would give them all the information we could, and give them loving care and support whatever their decision."

The question of abortion arises, of course, after the pregnant woman has had a test -- amniocentesis or ultrasound or some other -- that may reveal a problem. The Vatican in March said a woman who seeks such a test with the intention of aborting a malformed fetus would be committing a "gravely illicit act."

How, then, can a Catholic hospital give such tests conscientiously when it may be abetting sin?

For one thing, Biemiller says, testing induces more couples to have babies than to refrain, since many have unwarranted fears and counseling and testing reassure them. But more important, he repeats, "it is our responsibility to inform and inform fully."

Arthur Caplan of the Hastings Center, which studies bioethics, calls that "moral fudging," since "for most congenital disease and abnormalities, the only option is termination of the pregnancy."

But Baumiller agonizes for the aborted child and parents alike.

"It goes against everyone's grain to terminate a pregnancy," he says. "The grief and problems that result from that choice are great. There is no choice for these parents that will make everything right.

"Very few of us find ourselves in that situation. I can tell you what I hope I would do, what I ought to do. But none of us can say what we would do." Future Doctors

Georgetown Hospital trains OB-GYN residents -- future practitioners, Catholic and non-Catholic. There are things they can't do at Georgetown, such as abortions and sterilizations. They get part of their training at other hospitals.

Until five years ago some of them did abortions and sterilizations at those hospitals on their own time, not as part of the Georgetown curriculum. No longer, at least with Georgetown's knowledge. The practice was stopped because some Georgetown alumni complained that church rules were being flouted.

Georgetown doctors maintain that the residents' training doesn't suffer. Much of the same knowledge needed to perform forbidden techniques is gained in "licit" procedures, they say, and it is still possible for residents to "observe" these procedures elsewhere or pick them up later on their own. But "we must teach about all these things," Queenan says, "because our residents have to take national board exams, which include all these subjects."

A sister Catholic institution, Baltimore's St. Agnes Hospital, also trains OB-GYN residents. Last year, the national accrediting council tried to withdraw its approval of St. Agnes, saying the hospital not only had no birth control clinic but was not seeing that its residents got adequate training elsewhere.

An aggrieved St. Agnes is suing the board and recently won a temporary injunction against it. But the future of its training program is still up in the air.

To many physicians, it is essential that Catholic teaching hospitals stay at the forefront of medical advances. Queenan is a national accrediting board examiner. He was also, during his pre-Georgetown years, a medical consultant to Planned Parenthood associations in New York and Louisville. He is also associate editor of Dialogues in Oral Contraception.

"If you don't have Catholics represented in some of these things," he says, "you don't have any opportunity to see what's going on and have any effect.

"Somehow or other we must be part of the real world." 'Conscientious Reflection'

Chicago Cardinal Joseph Bernardin, a supporter of the Vatican document, surprised many non-Catholics, when he said last month that couples who have been unable to have children "must make their own decisions" after "prayer and conscientious reflection" on this "teaching" -- that is, on the Vatican document.

Does that mean a Catholic who chooses in vitro fertilization, or some other techniques called "illicit," has not sinned?

Different Catholic theologians give somewhat different answers. "Some," says one, "are stricter literalists than others."

"It was not in the infallible classification," Pellegrino points out. "I can't really disagree with any part of it. Do I feel bound by it? Personally, yes . . . No Catholic would depart from it without questions in his mind . . . {But} I do not judge the morality of others who make a different decision."

And clearly, some may.

To Cardinal Bernardin, "matters as complex as this require continuing study and dialogue." The document itself calls for a dialogue not only within the Church but among opinion makers, politicians, scientists and doctors -- while, somewhat paradoxically, calling on governments to enact laws enforcing the document's strictures.

Sin or not, then?

"If you think something is not wrong, you don't have to confess anything," says Dr. Harvey. "Your guide to moral behavior is your conscience. Our church says you should use magisterial teaching," like the Vatican document, "to form your conscience."

Father Daniel Gatti, Georgetown Hospital's chief chaplain, agrees. "We still have to follow our consciences," he says. "This is the basic teaching of the Church."