Kelly Stuart, MD, MPH, MTS
Medical Director, Clinical Ethics
Bon Secours Virginia HealthSource Inc.
[email protected]

The same night he got up and took his two wives, his two maids, and his eleven children, and crossed the ford of the Jabbok. ²³ He took them and sent them across the stream, and likewise everything that he had. ²⁴ Jacob was left alone; and a man wrestled with him until daybreak. ²⁵ When the man saw that he did not prevail against Jacob, he struck him on the hip socket; and Jacob's hip was put out of joint as he wrestled with him. ²⁶ Then he said, "Let me go, for the day is breaking." But Jacob said, "I will not let you go, unless you bless me." ²⁷ So he said to him, "What is your name?" And he said, "Jacob." ²⁸ Then the man said, "You shall no longer be called Jacob, but Israel, for you have striven with God and with humans, and have prevailed." ²⁹ Then Jacob asked him, "Please tell me your name." But he said, "Why is it that you ask my name?" And there he blessed him. ³⁰ So Jacob called the place Peniel, saying, "For I have seen God face to face, and yet my life is preserved." (Genesis 32:22-30 NRS)

I have a confession to make. When the Affordable Care Act first passed and was signed into law, I cried. I felt sick. Yes, I am an absolute believer that all of humanity should care for each other, and all people deserve medical care, regardless of ability to pay. Yes, I believe we, physicians, should share our gifts and our wealth with those in need. Yet I found myself in crisis over the health care reform bill. Many say that the frustration physicians feel about the bill stems from being left out of the debate, and this is true for a good number of physicians. I believe there is more to it than that. I did not know it at the time, but I was mourning our profession's inability to recognize and participate in the full blessing. There has been so much talk about the rights that individuals have to medical care that there has been little or no regard for the blessings that all of humanity has to gain from caring for each other. Sure, it is obvious to most people that healthy societies have the best chance at flourishing, but it is not as obvious to many people that how we get there matters.

The United States government is concerned with addressing the health needs of its citizens, and thus it has determined that physicians are just going to get on board with reform or be left out entirely. Indeed, health care reform already failed in the nineties, and the legislative majority and executive branch were not going to take the chance that any opposition would prevent the current reform. While essentially leaving dissenting physicians out of the debate violates the leadership concept of subsidiarity, it may be understandable for a government looking to meet the health needs of a population groaning under the weight of widening disparity.

Still, there is more at stake than medical needs and services. There is opportunity here for real benefit beyond physical wellness. Willingly caring for all humanity holds the potential for profound reciprocal blessing for physicians and patients; our government simply is not equipped to concern itself with that aspect of reform.

Fortunately, Catholic health care has the means and the perspective to do better by its providers. We can take this opportunity to embrace physicians' struggles and encourage their volitional participation in service to humanity — the blessing of right relationship, friendship, love.

There is a lot of discussion today about health care as a basic human right. Catholic health care organizations have always tended to the needs of the poor and disenfranchised of the world who are unable to represent their own needs, and this caring for humanity stands grounded in sound biblical and theological foundations. So when did the notion of health care as a basic human right enter into the modern conversation for Catholic health care? In 1963 Pope John XXIII issued the encyclical Pacem in Terris. In it, he beautifully presents the cosmic truth that in order for humanity to thrive in creation, we must tend to one another's needs by acknowledging and respecting certain rights. Included in these rights is medical care — particularly, "the right to be looked after in the event of ill health" and "disability stemming from [a person's] work" (11).¹ This encyclical had significant meaning at a time in which the world populations were just beginning to make progress in the struggle against social injustice in the face of seemingly endless world resources and abundance. The sixties brought the face of global crimes against humanity and the American civil rights movement into the forefront. For this and other reasons, rights language emerged as relevant and helpful. Drew Christiansen notes, "In the 1960s most educated Catholics and even more non-Catholics assumed that natural law was consistent with the language of duties but not with the language of rights. So the encyclical's recourse to rights language itself constituted an intellectual challenge. For some it seemed a capitulation to the Enlightenment; to others it amounted to an overdue encounter with the secular (western) world."² Rights language functioned as both a means of expressing humanity's need to rid the world of oppression and to align the language of the Catholic Church with other groups that had the same goals.

But Pacem in Terris does not simply refer to rights alone; duties remain important. Specifically, there is a duty of society to recognize and support each person's rights. "Hence, to claim one's rights and ignore one's duties, or only half fulfill them, is like building a house with one hand and tearing it down with the other" (9,30).³ The Christian duty to care for humanity is foundational. More specifically, emphasis on the duty to care for those without the means to care for themselves (widows, orphans, aliens, family members, prisoners, neighbors) shines through both Old and New Testaments. This duty, as acknowledged, affirmed and accepted by caretakers, is the spine that allows rights to stand erect. We should not discuss rights without discussing duties. Frederick Bauerschmidt illustrates the dangers of taking rights language out of the context of duties language in his discussion on abortion, for "what seems like common ground, human beings as possessors of rights, yields virtually nothing by way of agreement on the question of abortion. Whatever the merits of 'rights talk' in other contexts, in the context of abortion it has proved perplexingly unfruitful."⁴ In a similar, though less obvious way, rights language may be detrimental to gaining constructive physician participation in health care reform.

Yet, rights language dominates the conversation today. While the sixties birthed human rights as a concept in the face of abundance and hopeful liberation, the third millennium is heralded by the global realization that our resources are limited, and our rights, while theoretically considered equal for all, really compete. In contrast to the 60s' androcentric view of creation and economics, today's environmentalists remind us that we must be good stewards of our interdependent natural resources, and medical professionals are particularly sensitive to finite health care resources. For this reason, it is imperative to include another core concept of the encyclical: volition. Although Pacem in Terris clearly expresses that every person must freely choose to do what is good, without coercion (9, 34), there is little written on this portion of the document.⁵

Humanity's relationship with God has always allowed for our failure, while remaining hopeful of our good choices. There was no fence around the tree in the middle of the garden, and there can be no real relationship without the possibility of failure. If we only discuss rights without considering duties and volition, then we are left with unresolved conflict — competing interests — and the course of action is lost in the dogged determination to assert exclusively one's individual or group interests. According to the Catechism of the Catholic Church, "as long as freedom has not bound itself definitively to its ultimate good which is God, there is the possibility of choosing between good and evil, and thus of growing in perfection or failing and sinning. This freedom characterizes properly human acts. It is the basis for praise or blame, merit or reproach .... The more one does what is good, the freer one becomes."⁶ Advancing the idea of rights without concomitantly emphasizing duties and volition sets us up for failure because, if the goal is God, humanity must choose to tend to its duties in support of others' benefit, rather than one's own, and choosing that option once, leads to choosing it many times.⁷

How important is human will — physician will — in health care reform? Is volition really essential to the blessing of right relationship in health care or is this notion just the obstinate insistence of one willful physician? At a foundational level, humans retain the same free will that God wove into the first couple in the garden, but is that a good thing? Augustine of Hippo asserted early in the fifth century that free will is a good thing that God bestowed upon humans in order to enable us to "live rightly."⁸ Still, why is there even an option to live wrongly? Simple answer: God wants a genuine relationship with humanity. We are to be God's servants, but we are not intended to be God's minions or drones. The difference in being God's willing servants and being a drone is not just in the exertion of will, but in the richness of relationship. We see in Genesis 1 that God is omnipotent and can create and control from a distance, but we see in Genesis 2 and 3 that God actually touches and walks in the garden with Adam. It is not so much that God allows Adam and Eve to fail and fall as it is that God cultivates a real relationship, and that is a risky venture. Indeed, God's desire for and investment in relationship with humanity is superlatively exemplified by the incarnation of Jesus.

Augustine's equivalent of a minion or drone in its simplest form is a stone. Both a stone and a human may move, but a stone does not will its movement in any direction. Augustine refers to the stone's passive movement as "natural," but "nothing can make the mind a slave to inordinate desire against its own will ... the movement by which the will turns from enjoying the Creator to enjoying his creatures belongs to the will itself." For this reason, Augustine refers to the mind's movement as "voluntary." There is nothing blameworthy or praiseworthy about natural movements; only voluntary movements can be so described.⁹

Still, patients might be better served than they currently are even with unwilling, forced participation of physicians, right? Yes, patients' physical health might still be better served, but is it not reasonable to hope that care providers also benefit from the fullness of relationship? Unidirectional service cannot be the only goal.

God knows and has always known that we will frequently fail, but apparently God delights in the few moments of success in our relationships with each other, and therefore with God, enough to constantly and repeatedly endure our failure and offer grace. The reason it is important to willingly see the face of God in every patient is that our relationships with patients are really modeled after and indicative of our relationship with God. We were not created as drones, but we were created, seemingly intentionally, as willing servants, and authentic relationship should be our goal. As Aquinas explains, there is an ultimate end (goal) for human life, which is good, and that end is sought through our willing relationship with our creator: "For man and other rational creatures reach their ultimate end by knowing and loving God."¹⁰

The current state of overall health in America begs the question — does the medical system we operate in today help or harm our nation's overall health? Somehow all our effort, education, and resource investment do not translate to a healthier population or better outcomes. The richest potential aspects of relationship seem to be unrealized, for the most part, in American medicine. Trust, concern, and intimacy are no longer assumed to be integral to the interaction, and the relationship has become less genuine and less fulfilling for both parties. As physicians, the reason we must willingly perform our duty to uphold society's right to health care is that we then work toward our own blessing within the context of humanity, and it is in cultivating relationships that Catholic health care can improve on reform. We can acknowledge with physicians that, whatever the new legislation imposes, there is no relationship without willing service, and God's example to us is relationship. For this reason, we must train our wills to strive for unchangeable good rather than temporal good.

Little commentary exists about the concept of volition in Pope John XXIII's encyclical, but there is commentary on another aspect of Pacem in Terris that can only be considered as volitional — love. "That is, Christian love enables one to see in the ambiguous historical developments opportunities and positive accomplishments ... which contribute to the growing unity in the human family."¹¹ Without love we are caught in a downward spiral of competing rights: humanity can assert its right to health care, but physicians have the right to compensation for their work, and physicians have the right to refuse to work. This battle of competing rights makes no progress toward the blessing that willingly caring for each other approaches. The opportunity for rich, interdependent blessing - for right relationship - in health care delivery gets lost in the midst of the seemingly perpetual struggle for individual or collective rights.

If we discuss rights in the context of duties and volition, we become relational and less confrontational; choices become clearer, and our will is drawn to unchangeable good. We see our goal through a different lens and realize that all of humanity has a right to medical care, and all of humanity has a duty to care for each other. Then the question that confronts physicians is: are you willing to care for humanity, regardless of social status, ethnicity, citizenship and ability to pay? In short, can you participate in the right relationship that Aquinas called friendship by offering Christian love? The conversation becomes richer, as does the potential blessing of doing the transformational work we accomplish together each day in Catholic health care.

If physicians are to will well by Aquinas' standards -that is, if physicians are to choose Christian love and friendship and God over competing interests, then Catholic health care needs to do what the Church has done well for centuries. We must be pastoral in our language and recognize that physicians need shepherding just like the rest of the flock. In particular, physicians facing uncertainty need shepherding now. Aquinas explains that, while the ultimate end of the will is reached by knowing and loving God, "one need not always be considering the ultimate end when desiring or doing something."¹² Indeed, for the ultimate end to be achieved we need to develop "well-disposed affections" because we frequently "mistakenly seek [it] in other things" and "turn away from that in which the ultimate end is truly found."¹³ That is, we sin.

The language of the Affordable Care Act presumes that physicians already have "well disposed affections." This legislation is not the equivalent of determining new traffic regulations or interstate commerce. This legislation demands that one particular profession rethink its affections. Catholic health care can improve on the limited, linear language of legislation by recognizing and validating the profound moral struggle many physicians are experiencing with health care reform. Rights language alone is not pastoral, but rights coupled with duties and volition allows us to occupy a moral space, a relationship. So, physicians may reframe the above question from their own perspective: do I value and seek to offer and receive the blessing?

What about the danger of failure? What about the physicians who choose not to participate willingly in health care reform? That is the risk of relationship. The book of Genesis further illustrates the willing struggle of man following God's call in the person of Jacob. When God called Jacob to leave Laban's house and return with his family to the land of his birth, Jacob knew that he would have to face Esau, the twin brother that he essentially swindled out of both birthright and blessing. Jacob was scared of Esau's strength and likely resentment. As Jacob neared his homeland, he became more worried about following God's call. Finally, Jacob reached the Jabbok River that marked the entrance to his homeland. He sent his family and possessions across, but he remained another night on the safe side of the river. A man - or spirit, or will - approached in the dark, and Jacob wrestled with him until morning when the man declared that Jacob had prevailed and should let go. Even though the man had dislocated Jacob's hip, Jacob refused to let go until the man blessed him. So, the man blessed and then renamed Jacob Israel, which means "strives with God." Indeed, Jacob prevailed not in defeating the spirit of God but in enduring pain and staying in the struggle through the darkness of night and into the light of day — the day that marked the brothers' peaceful reunion, the mending of their relationship. We all wrestle with our own spirits and bear the scars of the blessings we seek. Indeed, the only way to achieve the blessing is to continue to strive, to struggle, with our own spirits and our own wills in our relationship with humanity and God.

After about a generation of rewarding smart business practices as much or more than good medical skills, our country now demands that physicians change their entire way of practicing and receiving compensation. Physicians are being told to change their culture and to reconsider what we value, but if we are to change our values we should probably change our language, too. If we are to consider health care a right and accept this change as our duty and calling, we should struggle with our spirits, come to the conclusion of love, and find our blessing in willing relationship with humanity and God. Jacob did not defeat the spirit but rather struggled with it until the morning came. Similarly, physicians rather than defeating health care reform might insist on our blessing in it. Some doctors have crossed the river with their hands ready to work, but others are still struggling on the safe side. Like the United States government, Catholic health care is concerned with the physical well-being of its patients, but Catholic health care is not limited to that end or that language. Using rights language without acknowledging duties and volitional love fails to convey blessing. If we allow and encourage providers to struggle with their spirits and willingly come to the blessing, we will do so much more than address our physical needs. Pope John XXIII described more than peoples' right to medical care. Pacem in Terris puts forth a plan for the full blessing. Isn't that the real reason we became doctors?

1. Pope John XXIII. "Pacem in Terris," www.vatican.va/.../hf_j-xxiii_enc_11041963_pacem_en.html
2. Drew Christiansen, "Commentary on Pacem in Terris ," in Modern Catholic Social teaching: Commentaries and Interpretations, ed. Kenneth R. Himes, (Georgetown University Press: Washington, DC , 2005): 224.
3. Pacem in Terris, no. 30.
4. Frederick C. Bauerschmidt, "Being Baptized: Bodies and Abortion," in The Blackwell Companion to Christian Ethics, ed. Stanley Hauerwas and Samuel Wells (Blackwell: Malden; 2006): 250.
5. Pacem in Terris, no. 34.
6. Article 3: Man's Freedom. Catechism of the Catholic Church, United States Catholic Conference (Liguori: Liguori MO, 1994): 430, nos. 1732-3.
7. Thomas Aquinas, "Treatise on Happiness," Summa Theologica, trans John Osterle (University of Notre Dame Press reprint 1983. Prentice Hall; Englewood Cliffs, 1964): 8-14
8. Augustine, "On Free Choice of the Will," trans Thomas Williams (Hackett; Indianapolis, 1993): Book 2, nos. 1 and 18, pp. 30, 64.
9. Augustine 72-3; Book 3, sections 1, 2.
10. Aquinas, "Treatise on Happiness," Summa Theologica trans John Osterle (University of Notre Dame Press reprint 1983. Prentice Hall; Englewood Cliffs, 1964) 8-14.
11. Christiansen, 226.
12. Aquinas, 12.
13. Aquinas, 13.

Copyright © 2013 CHA. Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purposes. For reprint permission, contact Betty Crosby or call (314) 253-3490.