International Catholic University
The distribution of health care in a just manner is a vexing problem in the contemporary developed world. It seems so overwhelming as to be refractory of solution. In the contemporary developing world, the virtual non-existence of health care, which dooms all but the powerful to debilitating disease and early death, is tragic. Attempting to tackle the problem is much like an American President's attempting to solve the problems in the Middle East. The challenges in the distribution of health care are economic, political, and ethical, and just plain human. The just plain human challenge is simply the matter that the goods that can be delivered by the health-care profession are finite and the human need and demand for the goods of health care seem infinite.
When to these challenges is added the commitment to Christian practice, it seems that the complexity is compounded. In describing the ideal of health care informed by the values of the Catholic tradition the Religious and Ethical Directives for Catholic Health Care Institutions has recourse to the understanding of the banquet of the parables of Jesus found in the Gospel of Luke at 14:13. The theme is extending hospitality not as a medium of exchange -- you invite your friends and your family and important people to the banquet and they are understood to have a duty to reciprocate -- but rather of extending hospitality as a way of rendering care for the vulnerable. Jesus instructed the disciples with these words: "When you hold a banquet, invite the poor, the cripple, the lame, the blind" (Luke 14:13). The Directives, in quoting the words of Jesus, stop there in mid-sentence. It is instructive to complete the sentence. The text reads, "When you give a banquet, invite the poor, the cripple, the lame, the blind; and you will be blessed, because they are not able to pay you back." The text concludes with the promise that "God will repay you on the day the good people rise from the dead." The claim that Catholic health care is a response to the challenge of Jesus means that Catholic health-care institutions are not primarily economic entities, although a sound economic base is required for their continuous operation. They are institutions that, first and foremost, are called to extend hospitality -- as medical care -- to the vulnerable. Hence Catholic health care has a particular identity and an additional set of challenges that derive from its special mission and identity.
What I would like to do in this lecture is (1) to examine some of the challenges to health care; (2) to suggest that a reformation in the way we think about (a) who we are and (b) what we need and (c) how best to put into place arrangements that serve our needs might guide the direction of solutions to the health-care Gordian Knot, (3) to offer some suggestions in regard to health care as a political enterprise, a way that a democratic polity puts into place the structures that serve its needs, and (4) to offer some suggestions in regard to health care as a Catholic enterprise, a way that a people with a particular set of values fashions the structures that witness those values.
Among the economic pressures are: the rising costs of health care coupled with the ever increasing demand and ever increasing cost of the delivery of high-tech medicine, the steadily increasing percentage of GNP -- from 4% in 1940 to over 16% in 2000 -- that is consumed by health care costs, the steadily increasing cost of insurance, insufficient levels of reimbursement from government and other third-party providers, the reluctance of patients who now perceive themselves as "fully covered" to pay out of pocket for health care, an increasing number of uninsured -- now numbering about 14% with approximately 7% of those opting out of health-care insurance -- with the consequence of their limited access to health care, and the demand for ever higher, occasionally obscene, levels of compensation by physicians, especially physician employees.
Added to the economic pressures intrinsic to the practice of medicine is the pressure spawned by the litigious culture within which medicine is practiced. This litigious culture, whatever its origin, has generated numerous lawsuits, some justified and some not, against physicians. Of course, those that are justified, ought to result in appropriate and sufficient awards for damages to the injured party, and, if the harm was the result of medical malfeasance, ought to result in appropriate oversight and penalty of the physician, including the penalty of loss of the privilege of practice. Some of the lawsuits, however, have resulted in outrageous financial awards, well beyond reasonable compensation for the economic losses caused by the injury or harm suffered. When to this compensation for economic loss is added outrageous awards for pain and suffering, the disproportion of the financial award redounds through the system, across the professions, and into society. The frequency of lawsuits has resulted in the loss of physician time from practice, the increase in medical tests and procedures ordered for patients to protect physicians and hospitals and an increase in costs for the patients, the increase in malpractice insurance, the decrease in the number of physicians willing to engage in certain specialties or to practice in certain geographical regions, and the rise of a new generation of obscenely wealthy trial lawyers who receive 25% - 30% cut of the jury awards . . . and the downward spiral continues.
Among the political pressures, political as broadly construed, are the competing claims of the efficiency and appropriateness of the federal government as the sole provider of health care as opposed to the similar claims of the free market to provide health care through a variety of mechanisms that range from fee-for-service to for-profit managed care systems.
Among the ethical problems are the just and appropriate use and distribution of medical technological advances, what counts as disease to be ameliorated by medicine, the withdrawal and withholding of treatment that is no longer beneficial, the continuation of treatment that is beneficial, and rationing -- precipitated by infinite need in the presence of finite resources -- of potentially beneficial services.
To try to put some order into this complex problem, let me begin by addressing the issue on the level of the individual in society, then move to the professions, and then, finally to a consideration of the problem of system. But before going forward two observations need to be made. The first is that we live our lives as individuals in society. The second is that health care is a scarce resource. The first requires us to regard the good of others as well as our own good. The appropriate operative ethical principle is not "who dies with the most toys wins . . . or who dies having consumed the most resources wins." The operative ethical principle is "love your neighbor as yourself." The second observation requires us to understand that health care is a scarce resource and obliges us to use, wisely and appropriately, this scarce resource. These observations apply across the board, that is, for the individual, for the profession, and for the polity.
The problem of health care as a problem for individual human beings is first a conceptual problem -- the problem of understanding the essential nature of health care. Very often the attempt to approach the issue is to locate it in the disjunction which is offered in the following: health care is either a right or a commodity. At the extreme, the rights-holder claims health care as a positive right -- a welfare right -- to be provided by . . . well . . . by someone. The commodity claimant considers health care as a bit of merchandise, another thing to be purchased by those consumers who have sufficient funds. This proposed disjunction is a false dilemma. Neither understanding, taken on its own, is correct; however each has some truth in its claim. So perhaps what is called for is an Aufhebung, a higher insight that embraces the truth of each and leaves behind as false the absolute claims of both. It has been suggested that health care be considered a good, a basic good such as food, clothing, and shelter. Basic goods are the necessary conditions for human flourishing. So if health care is a basic good, then it occupies a position similar to other basic goods. But the basic goods are produced by society for the good of society. In this highly individualized environment, human beings often forget the social nature of the production of the basic goods and they often forget the givenness of the materials that are present in the world to make possible the production of the basic goods. These materials include the raw materials of the earth and the intellectual material of human intelligence that guides the enterprise that fashions the raw materials into goods. Human beings who are capable participants in the society are responsible to take reasonable means to provide these goods for themselves and for their families. If for some compelling reason, however, there are some people, who because of infirmity, or immaturity, are unable to provide this good for themselves and their families, then the basic good needs to be provided for them. If health care is appropriately considered as a basic good, then the same principles that are operative in supplying other basic goods should be operative in the distribution of health care. Everyone should have this good -- at a basic level. Once this basic level is provided, then the scarce resource should be made available for purchase. The liberty to purchase should be accompanied by a sensitivity toward those less endowed.
A second problem for the individual human being in regard to health care as a basic good is the understanding of its scarce nature. One of the ways that human beings understand scarcity of goods is in their real payment for these goods. However, now much of health care is compensated for by third party payments, private insurance -- most often paid for by employers as a benefit and later mandated by the government for businesses of a certain size -- and by the government in the Medicare and Medicaid programs. This is a relatively new phenomenon; it came into existence after World War II. Now on its face, that seems like a good . . . and it is a good, but it is not an unproblematic good. The delivery of this new good forgot to take into account human nature. The third-party payment system insulated the individual from the cost, therefore the basic good ceased to be understood as a scarce resource. Economists, observing this new arrangement, report that the use of medical resources by patients varies dramatically with the existence of third-party payments. Their conclusion, easily understood when human nature is taken into account, is that the larger the share paid directly by the patient the smaller the growth in expenditures in medical products and services. Conversely, the smaller the share paid directly by the patient the larger the growth in expenditures in medical services and products.
A third problem for the individual, even the individual who recognizes the scarceness of the resources, is the best way to use the resources. A reasonably healthy life style contributes to the lessening of the need for the scarce resource. But inevitably, the day arrives when there is need . . . and what, then do we require as medical intervention? The response most often heard is "do everything." What does "do everything" mean? It ought to at least mean that the medical interventions be appropriate, that is, that the resources used in medical treatment prove a commensurate benefit to the person. This seems the appropriate place to recall and apply the distinction between ordinary and extraordinary means in the pursuit of health care and to insert a reminder that only ordinary means are morally obliging.
A fourth problem for the individual human being is the reminder that the power of health care is to provide a limited means to care for a limited life. We are finite beings and the material bodies of our finite sojourn are corruptible. That our lives are lived in such circumstances is gift and limit. Stanley Hauerwas in his works, especially Practicing Patience, suggests that the practice of Christian patience has a great deal to offer to the community in its concern for health care. He says,
To be patient when we are sick requires first that we learn how to practice patience when we are not sick. God has given us ample resources for recovering the practice of patience. First and foremost, we have been given our bodies which will not let us do whatever we think we should be able to do. We are our bodies and, as such, we are creatures destined to die. The trick is to learn the great good things my body makes possible without hating my body, if for no other reason than the death of my body is also my death. To practice the patience of the body is to be put on the way to holiness as we learn that we are not our own creations (Hauerwas, 26-27).
The patient acceptance of the limits of health care and the patient acceptance of the limits of life, prevent our looking to health care for a salvation that it cannot deliver.
A fifth problem for the individual is the understanding of the appropriate restriction of the scarce resource of medicine to medical need. Medical resources have as their primary application to cure illness, to assuage suffering, and to provide compensation for disability. The use of these scarce resources ought not to be requested by patients, until such time as medical resources are available in sufficient quantity to respond to real need of the community. This requires individuals to be sensitive to the needs of others -- to be aware of the requirements of solidarity. An appropriate remedy here might be for the individual, who has the desire and the wherewithal to purchase medical resources that become available, once the basic needs of all have been met, to donate an amount of money equal to the cost of the procedure to a relevant charity.
To address the problem of the distribution of health care at the level of the medical profession requires that the observations previously indicated -- we are all members of a society and medicine is a scarce resource -- be recalled and it be remembered that the physician as individual encounters all the same problems as other individuals. The physician as professional assumes greater obligation for proper distribution. A consideration of the nature of the profession provides the grounding of the obligations of the profession and sheds some light on how the profession can contribute to the amelioration of the distribution problem. Membership in a profession is a privileged position whose purpose is to serve the public good. This commitment to serve the public good is paramount, even though the practice of the profession provides the livelihood for the professional. The privilege of membership in a profession confers status to those so admitted and confers obligations upon the professional. The profession of medicine, however, is not the private property of the physician. The physician receives knowledge and power from institutions that the society has put into place to allow the physician entry into the profession. While physicians work very hard for their education, and physicians pay a great deal of money -- which represents only part of the cost -- for that education, and physicians have the right to expect a fine level of compensation, they ought not to consider their profession their private property. The institutions -- the medical schools, the colleges and universities of which they are sons and daughters, the scientists -- both the famous and those who labored in relative obscurity -- who came before them, the teachers -- who invested so much in them, the country that sustained peace and offered them the liberty that permitted their course of study -- were not created by them. All of these were put into place by society that some might have the privilege of becoming physicians in order to serve the needs of society. Physicians, by accepting the opportunity to become physicians, enter implicitly into a social contract between themselves and society for the purpose of caring for the sick and disabled members of society. At this difficult time in medicine, (I refrain from using the word crisis; that word should be reserved for the distribution of the good of medicine in developing countries) physicians ought to remember this social contract, reflect on its meaning, explicitly affirm it by their actions. Having accepted these particular goods of this society, physicians now have certain obligations, certain duties toward it and its members -- to use the skills that they have learned and the competencies they have mastered for the good of their patients and for the good of their society.
A second problem for physicians lies in the success of medicine. The advancement of medical science -- technologies, medicines, antibiotics, etc. combined with the advance in medical skill as well as the advance in pain relief medication have opened the door for the safe use of the art of medicine beyond serving the sick. These tools can be used to satisfy human desires whether the desire be to be more beautiful, to look younger, to be taller. How ought the profession respond to these desires and where ought the line be drawn? There has been in the past fifty years a proliferation of the non-medical use of medicine. Plastic surgery is just one example; elective abortion is another. On the horizon is the request by patients for the amputation of healthy limbs. If the request is given a name such as body dysmorphic disorder and it is included as a disease in the DSM -- the Diagnostic and Statistical Manual of the American Medical Association -- ought physicians apply their sophisticated surgical expertise to satisfy the desire? Now just as individuals ought not to use medicine for non-medical needs until the basic health care needs of all members of society are met, so too physicians ought to reserve the use of their skills to medical need. If the basic needs of all in the community are met, then physicians should enjoy the opportunity to satisfy appropriate human desires. An appropriate remedy here might be for the physician who has the expertise, desire, and the time to render such non-medical service, to donate an equal service to a less fortunate person.
A third problem for physicians is maintaining their own competence and the competence of the profession. Each physician is required to be competent in the discipline and to maintain the standards of the profession. The maintenance of the standards of the profession requires physicians to oversee their colleagues in the profession. Attention to these related obligations should decrease the level of harm, whether the harm be culpable or not, to patients with a subsequent decrease in the malpractice suits.
Of course all the obligations developed here for the medical profession apply, mutatis mutandis, to the legal profession.
With all these considerations in place, the next consideration is the role of a democratic polity in putting into place the necessary structures to serve the health care needs of the citizens. How will that polity make possible a system of health care that serves human need, that respects human dignity and recognizes human limits, that is competent and efficient, that rewards the sacrifices of those who will provide the service, and will continue the marvelous advances of medicine? Now while I do not want to play American President in the Middle East, I do want to offer some suggestions. Neither a free-market approach nor a welfare-rights approach is adequate. The free-market approach forgets the needy; the welfare-rights approach is unmindful of the limits of human nature and the limits of the resources of medicine. Here are a few suggestions. The first is that when health care is understood as a basic good, then it follows that the primary obligation falls upon individuals to provide it for themselves and their families. With the satisfaction of this obligation comes the right to make choices. However, choice is always limited and, here, should be limited by real medical need. Second, if the individual cannot provide the basic good of health care, then the polity is obliged to provide a basic health care package. The basic package will have to be limited. The determination of the contents of that basic package is to be a task undertaken by public participation of all the stakeholders. Third, medicine is a scarce resource. The scarceness of the resource will be ameliorated if individuals use only what they need and if physicians restrict their practices to real medical need. Fourth, because of the economic stratification of society, stratified both because of levels of income and because of levels of medical need, there need be in place assisted opportunities to purchase a variety of plans. This last provides incentives to move beyond the basic package. Fifth, the intersection of medicine and law at the point of patient harm should be settled not in the courtroom, but before panels with the expertise and practical wisdom to render fair judgments and the power to enforce those judgments. Finally, the Catholic Health Care System has a particular witness role to play in the contemporary world. If for economic reasons and practical reasons, it chooses or must withdraw from its extensive involvement in medicine, then Catholic Health Care Institutions should provide services where those services will have the greatest impact for the values it holds and the values it would witness. The locus of Catholic Health Care may shift to issues at the beginning of life -- the care of pregnant women and their children -- and issues at the end of life -- the care of the dying. And in their refusal to kill they may initiate the transformation of the culture death -- a culture that embraces killing as a solution to problems -- into a new culture of life. That there are few Catholic Health Care Institutions and that their range of service would be rather limited should not appear to be overwhelming obstacles in a tradition that once numbered twelve and the twelve had very limited resources.