Foster McGaw Triennial Conference
Loyola University of Chicago
We meet on an auspicious day to explore more effective ways of preserving, protecting and fostering human life—the 40th anniversary of the end of the war in Europe which claimed millions of lives, both European and American. It was also a war in which, tragically, the word Holocaust will be forever emblazoned in history. We must never forget!
This anniversary is a day not only for remembering victory over the forces of oppression which led to this savage destruction of life but also for recommitting ourselves to preserving and nurturing all human life.
Daily we encounter news headlines which reflect the growing complexity of contemporary life, the rapid development of science and technology, the global competition for limited natural resources, and the violence which is so rampant in parts of our nation and world. The problems of contemporary humanity are enormously complex, increasingly global, and ominously threatening to human life and human society. Each of them has moral and religious dimensions because they all impact human life.
At times we may feel helpless and powerless as we confront these issues. It is crucial that we develop a method of moral analysis which will be comprehensive enough to recognize the linkages among the issues, while respecting the individual nature and uniqueness of each. During the past year and a half, I have addressed this task through the development of a "consistent ethic of life"—popularly referred to as the "seamless garment" approach to the broad spectrum of life issues.
I come before you today as a pastor, not a health care professional or theoretician, not a philosopher, not a politician or a legal expert. As a pastor, I wish to share with you the teaching of the Catholic Church as it pertains to human life issues.
I am very grateful to Father Baumhart for the invitation to address you on "The Consistent Ethic of Life and Health Care Systems." I will first briefly describe the concept of a consistent ethic. Then I will explore the challenge it poses to health care systems both in terms of "classical" medical ethics questions and in regard to "contemporary" social justice issues.
I. The Consistent Ethic of Life
Although the consistent ethic of life needs to be finely tuned and carefully structured on the basis of values, principles, rules and applications to specific cases, this is not my task this afternoon. I will simply highlight some of its basic components so that I can devote adequate attention to its application to health care systems and the issues they face today.
Catholic social teaching is based on two truths about the human person: human life is both sacred and social. Because we esteem human life as sacred, we have a duty to protect and foster it at all stages of development, from conception to death, and in all circumstances. Because we acknowledge that human life is also social, we must develop the kind of societal environment that protects and fosters its development.
Precisely because life is sacred, the taking of even one human life is a momentous event. While the presumption of traditional Catholic teaching has always been against taking human life, it has allowed the taking of human life in particular situations by way of exception—for example, in self-defense and capital punishment. In recent decades, however, the presumptions against taking human life have been strengthened and the exceptions made ever more restrictive.
Fundamental to this shift in emphasis is a more acute perception of the multiple ways in which life is threatened today. Obviously such questions as war, aggression and capital punishment have been with us for centuries; they are not new. What is new is the context in which these ancient questions arise, and the way in which a new context shapes the content of our ethic of life.
One of the major cultural factors affecting human life today is technology. Because of nuclear weapons we now threaten life on a scale previously unimaginable—even after the horrible experience of World War II. Likewise, modern medical technology opens new opportunities for care, but it also poses potential new threats to the sanctity of life. Living, as we do, in an age of careening technological development means we face a qualitatively new range of moral problems.
The protection, defense and nurture of human life involve the whole spectrum of life from conception to death, cutting across such issues as genetics, abortion, capital punishment, modern warfare and the care of the terminally ill. Admittedly these are all distinct problems, enormously complex, and deserving individual treatment. No single answer and no simple response will solve them all. They cannot be collapsed into one problem, but they must be confronted as pieces of a larger pattern. The fact that we face new challenges in each of these areas reveals the need for a consistent ethic of life.
The pre-condition for sustaining a consistent ethic is a "respect life" attitude or atmosphere in society. Where human life is considered "cheap" and easily "wasted," eventually nothing is held as sacred and all lives are in jeopardy. The purpose of proposing a consistent ethic of life is to argue that success on any one of the issues threatening life requires a concern for the broader attitude in society about respect for life. Attitude is the place to root an ethic of life. Change of attitude, in turn, can lead to change of policies and practices in our society.
Besides rooting this ethic in societal attitude, I have demonstrated, in a number of recent addresses, that there is an inner relationship—a linkage— among the several issues at the more specific level of moral principle. It is not my intention to repeat these arguments today.
Nevertheless, I would like to examine briefly the relationship between "right to life" and "quality of life" issues. If one contends, as we do, that the right of every unborn child should be protected by civil law and supported by civil consensus, then our moral, political and economic responsibilities do not stop at the moment of birth! We must defend the right to life of the weakest among us; we must also be supportive of the quality of life of the powerless among us: the old and the young, the hungry and the homeless, the undocumented immigrant and the unemployed worker, the sick, the disabled and the dying. I contend that the viability and credibility of the "seamless garment" principle depends upon the consistency of its application.
Such a quality-of-life posture translates into specific political and economic positions—for example, on tax policy, generation of employment, welfare policy, nutrition and feeding programs and health care. Consistency means we cannot have it both ways: we cannot urge a compassionate society and vigorous public and private policy to protect the rights of the unborn and then argue that compassion and significant public and private programs on behalf of the needy undermine the moral fiber of society or that they are beyond the proper scope of governmental responsibility or that of the private sector. Neither can we do the opposite!
The inner relationship among the various life issues is far more intricate than I can sketch here this afternoon. I fully acknowledge this. My intention is merely to bring that basic linkage into focus so I can apply it to the issues facing health care systems today.
II. The Consistent Ethic and "Classical" Medical Ethics Questions
As I noted at the outset, the consistent ethic of life poses a challenge to two kinds of problems. The first are "classical" medical ethics questions which today include revolutionary techniques from genetics to the technologies of prolonging life. How do we define the problems and what does it mean to address them from a Catholic perspective?
The essential question in the technological challenge is this: In an age when we can do almost anything, how do we decide what we should do? The even more demanding question is: In a time when we can do anything technologically, how do we decide morally what we should not do? My basic thesis is this: Technology must not be allowed to hold the health of human beings as a hostage.
In an address in Toronto last September, Pope John Paul II outlined three temptations of pursuing technological development: (1) pursuing development for its own sake, as if it were an autonomous force with built-in imperatives for expansion, instead of seeing it as a resource to be placed at the service of the human family; (2) tying technological development to the logic of profit and constant economic expansion without due regard for the rights of workers or the needs of the poor and helpless; (3) linking technological development to the pursuit or maintenance of power instead of using it as an instrument of freedom.
The response to these temptations, as the Holy Father pointed out, is not to renounce the technological application of scientific discoveries. We need science and technology to help solve the problems of humanity. We also need to subject technological application to moral analysis.
One of the most recent and most critical ethical questions which impacts the quality of human life is that of genetics, genetic counseling and engineering. Perhaps no other discovery in medicine has the potential so radically to change the lives of individuals and, indeed, the human race itself.
As with most scientific achievements in medicine, there are advantages and disadvantages to the utilization of this theoretical knowledge and technological know-how. Many genetic diseases can now be diagnosed early, even in utero, and technology is also moving toward treatment in utero. Proper use of such information can serve to prepare parents for the arrival of a special infant or can allay the fears of the expectant parents if the delivery of a healthy infant can be anticipated. The accumulation of scientific data can lead to a better understanding of the marvels of creation and to the possible manipulation of genes to prevent disease or to effect a cure before the infant sustains a permanent disability.
On the other hand, people also use available diagnostic procedures to secure information for the sex selection of their children. Some may wish to use it to eliminate "undesirables" from society. Many believe that the provision of genetic information contributes to an increase in the number of abortions.
At the other end of life's spectrum is care of the elderly. Our marvelous progress in medical knowledge and technology has made it possible to preserve the lives of newborns who would have died of natural causes not too many years ago; to save the lives of children and adults who would formerly have succumbed to contagious diseases and traumatic injuries; to prolong the lives of the elderly as they experience the debilitating effects of chronic illness and old age. At the same time, some openly advocate euthanasia, implying that we have absolute dominion over life rather than stewardship. This directly attacks the sacredness of each human life.
Other new moral problems have been created by the extension of lives in Intensive Care Units and Intensive Neonatal Units as well as by surgical transplants and implants, artificial insemination and some forms of experimentation. Computers provide rapid, usually accurate, testing and treatment, but they also create problems of experimentation, confidentiality and dehumanization. Intense debate is being waged about the extension of lives solely through extraordinary—mechanical or technological—means.
The consistent ethic of life, by taking into consideration the impact of technology on the full spectrum of life issues, provides additional insight to the new challenges which "classical" medical ethics questions face today. It enables us to define the problems in terms of their impact on human life and to clarify what it means to address them from a Catholic perspective.
III. The Consistent Ethic of Life and "Contemporary" Social Justice Issues
The second challenge which the consistent ethic poses concerns "contemporary" social justice issues related to health care systems. The primary question is: How does the evangelical option for the poor shape health care today?
Some regard the problem as basically financial: How do we effectively allocate limited resources? A serious problem today is the fact that many persons are left without basic health care while large sums of money are invested in the treatment of a few by means of exceptional, expensive measures. While technology has provided the industry with many diagnostic and therapeutic tools, their inaccessibility, cost and sophistication often prevent their wide distribution and use.
Government regulations and restrictions, cut-backs in health programs, the maldistribution of personnel to provide adequate services are but a few of the factors which contribute to the reality that many persons do not and probably will not receive the kind of basic care that nurtures life—unless we change attitudes, policies and programs.
Public health endeavors such as home care, immunization programs, health education and other preventive measures to improve the environment and thus prevent disease, have all served as alternate means of providing care and improving the health of the poor and isolated populations. In the past, if patients from this sector of society needed hospitalization, institutions built with Hill-Burton funds were required to provide a designated amount of "charity care" to those in need.
In some instances, hospitals continue to follow this procedure. However, access to these alternate, less expensive types of health care is becoming more difficult. Cuts in government support for health programs for the poor, for persons receiving Medicare or Medicaid benefits, are making it increasingly more difficult for people who need health care to receive it.
Today we seem to have three tiers of care: standard care for the insured, partial care for Medicaid patients, and emergency care only for the 35 million Americans who are uninsured. Do we nurture and protect life when there appears to be an unjust distribution of the goods entrusted to our stewardship? How can Catholic hospitals continue both to survive and to implement a preferential option for the poor?
This is not merely a theological or pastoral issue. Access to standard health care is largely nonexistent for about half of the poor and very limited for the other half who are eligible for Medicaid or Medicare. The United States has the worst record on health care of any nation in the North Atlantic community and even worse than some under-developed nations.
Judith Feder and Jack Hadley, currently co-directors of the Center for Health Policy Studies at Georgetown University, have conducted research on uncompensated hospital care. Some of their findings are particularly disturbing. They concluded, for example, that non-profit hospitals—including Catholic facilities—do very little more for the poor than for-profit hospitals (which is very little, indeed). Free care provided by private, nonprofit hospitals averaged only 3.85% of all charges (gross revenues) in 1982. I am aware that some dispute the accuracy of these findings in regard to Catholic hospitals, but I have not yet seen data which shows that, overall, these institutions provide substantially more free care than their counterparts.
I must also affirm, of course, that there are some inner city and other Catholic hospitals which do a great deal for the poor. Nonetheless, as the research seems to indicate, hospitals average less than 5% of patient charges for uncompensated care. Much of this is for deliveries to women who appear in heavy labor at our emergency rooms and the subsequent neonatal intensive care for their infants born with severe problems because of the lack of care given their mothers during pregnancy.
Our national resources are limited, but they are not scarce. As a nation we spend more per capita and a higher share of our Gross Domestic Product (GDP) on health than any other country in the world—nearly twice as much as Great Britain, for example. Yet our system still excludes at least half the poor. In 1982 the U.S. share of GDP devoted to health care was 10.6% against 5.9% within the United Kingdom, which has universal access to health care and a lower infant mortality rate than the U.S.
The basic problem of health care in the U.S. is managerial: the effective allocation and control of resources. The key is the underlying philosophy and sense of mission which motivates and informs managerial decisions.
As a nation, we spend enormous amounts of money to prolong the lives of newborns and the dying while millions of people don't see a doctor until they are too ill to benefit from medical care. We allow the poor to die in our hospitals, but we don't provide for their treatment in the early stages of illness—much less make preventive care available to them.
These facts are disturbing to anyone who espouses the sacredness and value of human life. The fundamental human right is to life—from the moment of conception until death. It is the source of all other rights, including the right to health care. The consistent ethic of life poses a series of questions to Catholic health care facilities. Let me enumerate just a few.
- Should a Catholic hospital transfer an indigent patient to another institution unless superior care is available there?
- Should a Catholic nursing home require large cash deposits from applicants?
- Should a Catholic nursing home transfer a patient to a state institution when his or her insurance runs out?
- Should a Catholic hospital give staff privileges to a physician who won't accept Medicaid or uninsured patients?
If Catholic hospitals and other institutions take the consistent ethic seriously, then a number of responses follow. All Catholic hospitals will have outpatient programs to serve the needs of the poor. Catholic hospitals and other Church institutions will document the need for comprehensive pre-natal programs and lead legislative efforts to get them enacted by state and national government. Catholic medical schools will teach students that medical ethics includes care for the poor—not merely an occasional charity case, but a commitment to see that adequate care is available.
If they take the consistent ethic seriously, Catholic institutions will lead efforts for adequate Medicaid coverage and reimbursement policies. They will lobby for preventive health programs for the poor. They will pay their staffs a just wage. Their staffs will receive training and formation to see God "hiding in the poor" and treat them with dignity.
I trust that each of you has an opinion about the importance or viability of responses to these challenges. My point in raising them is not to suggest simplistic answers to complex and difficult questions. I am a realist, and I know the difficulties faced by our Catholic institutions. Nonetheless, I do suggest that these questions arise out of a consistent ethic of life and present serious challenges to health care in this nation—and specifically to Catholic health care systems.
Medical ethics must include not only the "classical" questions but also contemporary social justice issues which affect health care. In a 1983 address to the World Medical Association, Pope John Paul II pointed out that developing an effective medical ethics—including the social justice dimension—fundamentally depends on the concept one forms of medicine. It is a matter of learning definitely whether medicine truly is in service of the human person, his dignity, what he has of the unique and transcendent in him, or whether medicine is considered first of all as the agent of the collectivity, at the service of the interests of the healthy and well-off, to whom care for the sick is subordinated.
He went on to remind his listeners that the Hippocratic oath defines medical morality in terms of respect and protection of the human person.
The consistent ethic of life is primarily a theological concept, derived from biblical and ecclesial tradition about the sacredness of human life, about our responsibilities to protect, defend, nurture and enhance God's gift of life. It provides a framework for moral analysis of the diverse impact of cultural factors—such as technology and contemporary distribution of resources—upon human life, both individual and collective.
The context in which we face new health care agendas generated both by technology and by poverty is that the Catholic health care system today confronts issues both of survival and of purpose. How shall we survive? For what purpose? The consistent ethic of life enables us to answer these questions by its comprehensiveness and the credibility which derives from its consistent application to the full spectrum of life issues.
