NewWorld

Why Should We Care About the Sick?
Our healthcare system is broken. What to do about it? To answer the question, we need to first ask another one: “What kind of society do we want to be?” For Edmund Pellegrino, Chair of the U.S. President’s Council on Bioethics, the answer should be rooted in solidarity with the sick and the notion of charitable justice–justice governed by love
(This article is the first in a Traces series on issues at the center of the American Presidential Campaign)

by Lisa Mahowald

To anybody who is sick or cares for the sick, knows someone who is sick, or simply reads the newspaper, it is obvious that our system of healthcare in the United States is broken; the only controversy is over what to do about it. So Daniel P. Sulmasy, Director of the Bioethics Institute, N.Y. Medical College, introduced the 16th Annual John J. Conley Lecture in Medical Ethics at St. Vincent’s Hospital in New York. The keynote speaker, Edmund D. Pellegrino, Chair of the U.S. President’s Council on Bioethics, entitled his lecture, “Why Should We Care About the Sick? A Discussion on the Foundations for Genuine Health Care Reform.” Peter Steinfels, Co-Director of the Fordham Center on Religion and Culture, participated in the discussion as interlocutor. The audience was filled with doctors and nurses, as well as friends of Crossroads Cultural Center, which co-sponsored the event in collaboration with St. Vincent’s Catholic Medical Center and Medicina e Persona (Medicine and the Person).
Our healthcare system is a web of intricate relationships among healthcare providers, patients, employers, government agencies, and insurance companies. Therefore, any proposal for healthcare reform requires reconciling powerful political interests as well as solving technical public policy problems.

Not only technical problems
Crossroads’ purpose in co-sponsoring this discussion was not to propose or endorse any particular healthcare reform. Rather, their intention, as Catholics and as healthcare professionals, was to point out that healthcare reform cannot be reduced to a set of political and technical problems, if it is to serve real people. Healthcare has to do with human beings, and people cannot be reduced to “problems.” Crossroads hoped to provoke a discussion of criteria to guide our judgment about healthcare reform.
It was somehow fitting that the lecture took place at St. Vincent’s. A hospital founded 150 years ago by the Sisters of Charity of New York to serve the sick poor, St. Vincent’s is now emerging from bankruptcy.
Hospitals are not the only institutions struggling to pay medical bills. According to Dr. Sulmasy, corporate spending on healthcare benefits may be the main reason for layoffs and outsourcing jobs overseas. And even as health insurance premiums rise, 48 million Americans at some point during the year have no health insurance. And that’s not counting the undocumented immigrants who come to hospitals like St. Vincent’s on a regular basis. Meanwhile, doctors and nurses on the front lines don’t like to be told what they can or can’t do for patients, yet they know better than anyone that there is waste in the system.
Indeed, the U.S. healthcare system is charged with failing patients, medical practitioners, and employers.

Our responsibility
Against this background, politicians, professors, and pundits propose fixes that include complete privatization, the use of medical savings accounts, adding new regulations or incentives to the status quo, increasing the federal government’s share in healthcare by broadening Medicare, and scrapping the current system altogether in favor of a national health service, as in Great Britain.
The question Dr. Sulmasy posed to Dr. Pellegrino was: How should we, from a moral point of view, examine healthcare proposals?
The answer, Dr. Pellegrino said, depends on whether we believe we, as a society, have a moral obligation to the sick and disabled among us.
Any of us could be struck down at any moment by catastrophic illness. We can no more decide always to be healthy than we can decide never to die.
Given that reality, Dr. Pellegrino asked, what is our responsibility to those who are sick right now?
To answer that question, he appealed to Aristotle’s theory of distributive justice–allocating scarce resources among the members of society according to each one’s merit, while allowing for epikeia, or equity–making corrections in particular cases, where distributive justice might yield an undesirable result if applied universally. As Dr. Pellegrino applied Aristotle, a just society has a moral obligation to help all individuals to flourish. For a sick person, flourishing requires, at a minimum, receiving medical care. Hence, a good society has a moral obligation to make medical care available to the sick.
But how does a society justly distribute the limited resources of healthcare?
First, Dr. Pellegrino said, medical care cannot be treated as just a commodity, like beer, to be distributed according to supply and demand. Even Adam Smith, he said, deemed some goods too important to be left to the marketplace. As Dr. Sulmasy noted, quoting philosopher Robert Sokolowski: “When I go to the accountant, my taxes are the issue. When I go to the butcher, my stomach is the issue. But when I go to see the doctor, I am the issue.”
Second, while Dr. Pellegrino allowed that rationing medical services will be part of any healthcare system, we must make sure that clinicians do not have to ration care at the bedside of a patient.

A healing relationship
The relationship between a doctor and patient stems from the reality of what it is a healing relationship. In the Hippocratic and Nightingale Oaths, doctors and nurses dedicate themselves to use their competence to serve the patient in front of them. A clinician’s question to a patient, “Can I help you?” implies a promise to act in that patient’s interest.
Dr. Pellegrino wondered aloud how it would sound if the doctor or nurse instead said to the patient, “What can I do for you? But you understand that I will be guided by... my responsibility to preserve the resources of society…”
It is almost unimaginable, but it is happening right now, said Dr. Pellegrino. Doctors and nurses are being forced to serve society’s interests over the interests of the patient. This, for Dr. Pellegrino, is immoral.
Third, Dr. Pellegrino offered several conditions that he believed would have to be satisfied to justify rationing healthcare: (1) a true economic crisis, which he defined as one in which healthcare expenditures prevented Americans from pursuing other necessary goods, such as safety, security, and education; (2) exhaustion of other methods of saving money, such as trimming administrative costs; (3) a fair relationship between the money Americans spend on healthcare for sick people and their discretionary expenditures, such as alcohol and gambling; (4) a mechanism for public participation in the rationing decision; (5) public disclosure of the criteria for rationing; and (6) an equal application of health policy, so that those with greater need would receive greater attention.
Dr. Pellegrino concluded by asking: What kind of society do we want to be? For Catholics, he said, the answer should be rooted in solidarity with the sick and Thomas Aquinas’s notion of charitable justice–justice governed by love.
Professor Steinfels asked Dr. Pellegrino to explain how his criteria took into account the principle of subsidiarity–the idea that matters ought to be handled by the smallest competent authority. Subsidiarity is sometimes cited to support giving small social units, such as families and religious communities, a chance to solve social problems, before proposing a government solution.
Dr. Pellegrino responded that his focus is on a very small social unit: the one-to-one relationship between a doctor and a patient. The quality of this relationship is the final test of the quality of any medical system. None of the other social units can function well, he said, unless the sick ones among them have been helped to flourish.

Guiding criteria
Dr. Sulmasy summarized by identifying a theme that resurfaced throughout the evening: at the center of the practice of medicine is the person, and that person is either sick, a clinician, or a potential patient who has relationships with sick people. Some guiding criteria in judging healthcare reforms gleaned from this lecture might be: when the health industry looks at patients in the same way the automotive industry looks at cars, everyone suffers. A doctor cannot give good medical care if he does not recognize his patient as a person or if he sacrifices his relationship with his patient to rationing concerns. It is impossible to come up with a fair way to pay for healthcare without valuing the human relationships and communities that support the system when governments and corporations fail. Society cannot agree on how to apply new and expensive technologies without facing the ultimate questions: What is a human being? What is the value of health, and is there anything that is more important than health?
No one answered these questions, but a dialogue has been generated among people deeply interested in their resolution.