Ethics - Market-Driven Health Care: Can Mission Survive?

July-August 2009


Dr. Hamel is senior director, ethics, Catholic Health Association, St. Louis.

Is it possible to maintain the mission of Catholic health care in a market-driven health care environment? If so, how do we ensure that we maintain our identity and our integrity, that we don't lose our soul? Theologians and ethicists from across the ministry considered these questions during the 23rd annual CHA Theology and Ethics Colloquium this past March in St. Louis.

Although there is much that could be reported about the content of the colloquium, two things in particular struck me and continue to disturb me. The first was a presentation by Charles Clark, Ph.D., a professor of economics at St. John's University in Queens, N.Y. After outlining constitutive elements of "the market" in his first talk, Clark examined the foundations of the market from the perspective of the Catholic theological tradition, especially Catholic social teaching.

What struck me was the radical contrast between the anthropological presuppositions of the market and those of the Catholic tradition. The market views human beings as fundamentally autonomous individuals driven by self-interest in the pursuit of maximizing gain and avoiding costs. They are "utility maximizers." Society is a mental fiction, in reality only a collection of atomistic individuals. There is no sense of inherent relatedness to a community; no sense of contributing to the common good (except as a possible side effect of pursuing self-interest); no sense of responsibility to and for others. Equity gets no play, nor does concern for the disadvantaged and marginalized. What matters for "homo economicus" in the market are income, profit and wealth maximization through free enterprise and competition.

This view of human beings stands in such stark contrast to the one that we know so well within the Catholic tradition. Human beings are made in the image and likeness of God and for ultimate union with God. They have an inherent dignity that demands respect and that gives rise to basic human goods necessary for human flourishing. They are fundamentally social, inherently related to others, requiring participation in communities and in society to truly flourish. Because of their inherent relatedness, humans have responsibilities to and for others, and a responsibility to contribute to the common good. They must be concerned about right relationships and equity, about the marginalized and the vulnerable. Solidarity is a fundamental value.

These are diametrically opposed worldviews, anthropologies and value systems. Although it is surely true that we don't think about market assumptions and market values in our day-to-day immersion in various markets, including the health care market, it is still the case that markets are not value free. We would be hard pressed to make a case that the beliefs and values that saturate the reality of markets do not "rub off" on us as individuals and organizations.

How can Catholic health care continue to play the game, without playing by the rules of the game, and eventually becoming a game-player like everyone else? To what extent do we sacrifice our souls in order to be in the game?

The second item of interest from the colloquium was a presentation offering an overview of market-driven health care. Health policy analyst Emily Friedman (see her article in this issue) included a quote from Philip Hallie that went something like this: "The good end up like the bad as a matter of survival." The point here is not that Catholic health care is good and market-driven health care is bad. Rather, in the effort to survive, we are in danger of becoming something other than who we are. Survival can lead us to compromise and, perhaps, even to sell our souls. Survival in order to continue the healing ministry of Jesus — but who do we become in the process?

This reminds me of an episode in George Orwell's Animal Farm, described in the following excerpt by theologian/ethicist Michael Panicola, Ph.D., in an article titled "A Cautionary Tale: Can Catholic Health Care Maintain Its Identity and Integrity while Meeting the Challenges of the Marketplace?":

"[T]he animals of Manor Farm found themselves oppressed by their depraved and gluttonous master ... No longer willing to tolerate injustice, the animals liberated themselves by taking control of the farm. Once the farm was securely in their possession, the animals gathered as equals, agreed never to resort to human ways and ironed out a vision for the farm, which they renamed Animal Farm. This vision was codified in seven commandments. …

"At first, the commandments were observed, and the animals of Animal Farm lived in relative peace. But, as the pigs came into power — because of their superior intelligence and knack for running the farm — they started to exert dominance over other animals. Gradually, the pigs altered the original commandments under the pretense that they were doing this for the sake of the farm and the other animals. … Seeking personal gain and responding to the mounting challenges of running the farm, the pigs modified the commandments, and Animal Farm came to deviate significantly from its utopian vision. Even worse, the pigs ultimately became indistinguishable from the iniquitous humans whom the animals had vowed never to resemble."1

The lesson here is fairly obvious. In order to survive in the marketplace, Catholic health care may need to compromise its core convictions, its practices. It may need to adopt some of the values and the ways of the health care marketplace in order to "compete in the market" and to "secure its market share." It is difficult to play in the game without playing by the rules of the game and adopting the ways of the game.

Already much of the language of Catholic health care reflects the language of the marketplace. Moral theologian Fr. Richard McCormick, SJ, S.T.D., observed 14 years ago: "The vocabulary surrounding hospital policy and decision making is relatively recent: downsizing, market share, utilization review, mergers, joint ventures, networking, acquisitions, integrated delivery networks, capitation, etc. I have the distinct impression that much of this institutional maneuvering is driven by the survival instinct"2 Many other terms reflecting the current health care marketplace could be added to his list.

At some point, does Catholic health care begin to look indistinguishable from other not-for-profit health care organizations or even for-profit health care? And would we even realize it before it happened? Market-driven decisions are made one at a time. They are judged to be of benefit to the ministry, regarded as vehicles for carrying out the ministry. No one decision is decisive or formative. But what is the cumulative effect of these individual decisions? What do they eventually add up to?

Perhaps it is possible for Catholic health care to maintain its identity and integrity in a market-driven world. But the challenge of doing so is huge.

At the end of her presentation, Emily Friedman raised important questions: How deep does commitment [to the mission] go? Which imperative will dominate? Which values will dominate?

The jury is still out, despite all the efforts currently underway to maintain mission identity. Fr. McCormick concludes his article in Origins by quoting Charles Dougherty, now president of Duquesne University: "How do we save the souls of these institutions as they maneuver through a competitive minefield?"3 Yes, how do we save the souls not only of our institutions, but also of the ministry itself as what we do is increasingly driven and defined by the marketplace?

The answer, ultimately, is "in our hands."


  1. Michael Panicola, "A Cautionary Tale: Can Catholic Health Care Maintain Its Identity and Integrity while Meeting the Challenges of the Marketplace?" America 186, no. 14 (April 29, 2002): 13-15.
  2. Richard McCormick, "The Catholic Hospital Today: Mission Impossible?," Origins 24, no. 39 (March 1995): 648-653, at 651.
  3. McCormick, 651.


Copyright © 2009 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Ethics - Market-Driven Health Care Can Mission Survive

Copyright © 2009 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.