Charles W. Rawlings
Director - Resources for the Civic Conversation
National Council of the Churches of Christ in the U.S.A.
Introduction:
Building an Ethic for the Common Good
Presented at
Envisioning Ethical Atlernatives in Health Care
9 December 1996
At a time when some religious groups have made absolute claims about politics and religion, it may be worth remembering that the commonweal, the public good, is understood by a very large and diverse body of believers to be the fundamental measure of faithfulness. Moreover, part of this shared perspective is the conviction that determining the public good is a matter of democratic practice, not dogmatism.
In an era of privatization it also is important to remember that the ancient scriptures of Jews, Christians and Muslims echo with concerns about equity—a word with a double meaning describing both a just and equitable distribution of resources, but also connoting ownership. The ancient Levitical teaching (Chapter 25) is that ownership is not in perpetuity—we must not wrong one another through ownership.
Most of us who participated in this conference are insured for health care, but if 40 million of our neighbors are not—which is the case today—one unavoidable purpose of any discussion of ethical alternatives in health care must be to find ways to correct this inequitable relationship. As you turn the pages you will see that outstanding voices speak to us with great clarity about the need for universal access for all:
The distinguished ethicist Laurie Zoloth-Dorfman calls universal access a first premise, that places justice in the center of the national debate,
"Let the United States join the rest of the human race," says the President-elect of the American Public Health Association, Dr. Quentin Young, "and recognize that health care is a right."
Democratic practice means the civic willingness to engage these and other complex health care system issues, weighing the alternatives and making decisions under conditions that are never ideal. These extraordinary presentations illuminate the complexity of these issues and offer reasoned critical analysis and constructive suggestions. They are part of a renewed civic conversation across society about the urgency of health care issues today.
Our purpose in publishing this discussion is to provide a resource for the millions of people who serve with dedication and commitment in our health care system—and other millions in our society who share a commitment to the civic task of solving urgent health care issues.
The reader will see just how urgent these issues are. Community Service Society President, David Jones, reports that "only 27 full-time physicians are available to provide care for the 1.7 million New Yorkers in nine of our poorest neighborhood," and he reminds us how that overloads emergency room care, drives up costs and moves us closer to the catastrophe of public health epidemics.
James Tallon, President of the United Hospital Fund, describes how the new "purchaser’s revolution" has turned the health system on its head so that a sick person poses a threat because he/she "generates costs to the system." He contrasts this with the familiar provider-driven system that understood patients as a source of revenues. He asks a practical question:
Is there a uniquely American way of mixing and matching the elements of the system so that we can evolve from where we’ve been over the last 30 years on into a satisfactory future?
Not without some hard work other conference participants tell us. The distinguished Scholar-In-Residence at St. Barnabas Hospital, Elena Padilla, reminds us that "health care is not a morally neutral enterprise."
Given the nature of health care products, the relationship between health care and society, and the collective manner in which health care is financed, there are no true markets in health care delivery, but pseudomarkets or market clones, that mimic the market as they are aided and supplemented by government action
The ironic possibilities with subsidized "pseudomarkets" can be seen as the new for-profit managed care systems draw on Medicaid and Medicare funds to provide services and togenerate private share-holder profits. Does this kind of ownership do harm to others? An answer may lie in the pointed comment made by Dr. Allan Rosenfield , Dean of the Columbia University School of Public Health:
Public health covers a population based perspective. For a managed care company it's their own population…not a geographic population, nor an ethnic population. Rather, It's their covered lives.
Our conference participants speak about an ethical mandate to cover everyone, not just those with money in their pockets. .If the ethical and theological task is "to speak truth to power," as Professor Zoloth-Dorfman says, then we must listen to these voices as they tell us about an enormous amount of decision-making by private interests about public goods in the field of health care. "Here is a $1 trillion plus industry," says Professor Padilla, "that centers on diagnosing, treating, rehabilitating and restoring people to health being turned around as if it were a toy."
Part of the democratic practice at this conference was that half of the time was spent by participants working together in small groups. Their voices are also presented here and they are very powerful and prophetic in a marvelous non-sectarian way. The participant voices address the issue of our vision for health care for all in the future. They ask: what should be the chemistry of healthy communities? They articulate grass roots strategies and share ideas that make civil society real: empowerment, stewardship, universality, equitability, primary care development, prevention, mutual education.
"There is a power shift going on here, a scramble to fill a power void," notes conferee Professor Jo Formicola of Seton Hall University, a catholic lay leader, "We need to find a way to have health care based on justice not profit, to provide a salvific response to transform society, to bring transcendent values to the market place."
In the trillion dollar reorganization of health care now shifting under our feet an old question in American life arises anew: How can the market place embody both the results of its bargaining and deal-making processes and the justice of our values? In a post modern and post ideological time the search for ethical alternatives illustrated in these papers opens up fresh possibilities for us to re-think how we might build a society that enables us to live in equity with one another.