BY: JOHN W. GLASER, STD, and BRIAN B. GLASER, PhD
John W. Glaser is senior vice president, theology and ethics,
St. Joseph's Health System, Orange, CA; Brian B. Glaser is a
poet and faculty fellow at the University of California at Berkeley.
For many years, those of us who serve Catholic health care
believed that the primary place to work on the ministry's moral
identity was the institutions themselves. The authors of this
article have come to view that notion as mistaken; the institutions
constitute a secondary arena. The authors now believe that the
primary moral identity of Catholic health care is determined
by U.S. health care policy and practice. Without reform of U.S.
Health care, the ministry's intra-institutional efforts will
merely tinker at the edges of its moral identity, leaving its
substance deeply flawed.
Put concretely, a nonreligious hospital in Germany has a far
better chance of making biblical priorities present in German
society than does a religious hospital in the United States.
That is because the public policies shaping hospitals in Germany
are significantly closer to biblical priorities than are similar
parallel policies in this country. As Uwe Reinhardt wrote in
1994, "The ethical principles driving German health policy just
do not square with the American way."1 For the authors,
this thesis and the evidence supporting it have been sobering
In developing the thesis, we will trace it through five steps.
Identify respect for human dignity as the heart and foundation
of moral identity.
- Develop a moral paradigm that distinguishes three different,
but related, realms of respect for human dignity: individual,
institutional, and societal.
- Focus on a critical law of this three-realm model: Society
shapes and limits an institution's ability to respond to human
dignity by setting the rules according to which the institution
will survive and succeed.
- Identify some major biblical priorities that should
shape Catholic health care institutions, and contrast them
with priorities-in-practice that, in fact, shape U.S. Health
- Conclude that reform of U.S. Health care is essential for
improving the moral integrity of, and presence of biblical
priorities in, Catholic health care institutions.
Moral Identity and Human Dignity
What language does Catholic tradition use to measure moral
character? That depends. The dominant language varies at different
points in the tradition. A few examples will illustrate this
In the New Testament, the dominant parables, images, and language
concern love of neighbor. Romans 13 captures this idiom: "If
you love your neighbor you have carried out your obligations.
All the commandments: You shall not commit adultery, you shall
not kill, you shall not steal, you shall not covet, and so on,
are summed up in this single command: You must love your neighbor
Later, during the centuries when Catholic morality found its
center revolving around the tribunal of confession, the manuals
of moral theology cast moral character in terms of obedience
to the Ten Commandments.
More recently, as the church applied the commandment of love
to "the social question" — to society and its structures — the dominant
language came to concern human dignity and the respect it deserves.
For example, the U.S. bishops' pastoral letter on the economy
says, "The dignity of the human person, realized in community
with others, is the criterion against which all aspects of economic
life must be measured."2
Although history shows that evolving pastoral emphases have
tended to develop their own preferred languages and conceptual
systems, Jesus' great double commandment of love underlies all
these languages and conceptual systems.
Because our topic concerns institutional ministry and social
morality, the recent language of Catholic social teaching — respect
for dignity of persons — suggests itself as the preferred way
to discuss moral excellence and moral identity.
Three Realms of Respect for Dignity
Scattered throughout the Catholic moral tradition — though often
concealed in language that sometimes obscures its contours and
basic coherence — is a model of three different, but related,
realms of respect for dignity/love of neighbor. Raising this
paradigm to an explicit level and developing its structures
and implications can be very fruitful for Catholic moral thought.3
The following line of thought is one example of the light it
can shine on issues (see Figure below). Only a few of the paradigm's
elements are relevant to our present discussion. The paradigm
- The fact that the human person is both indivisibly individual
and social. Whether we humans realize it or not, we
constantly live as individuals in interdependence with mediating
social communities that are in turn interdependent with the
- The fact that there are three "nested" realms of love of
neighbor and respect for his or her dignity: societal, institutional,
individual, each of which is essentially interdependent with
the others but also significantly different from them.
- The growing complexity and magnitude of these realms as
one moves from individual to institution to society.
- The fact that — and this point is the most germane to what
follows — the larger realms have enormous power to shape the
moral possibilities of those they encompass.
Social Structures and Moral Possibilities
A major principle of the three-realm paradigm is this: A society's
systems and structures (financial, legal, scientific, cultural,
etc.) so firmly set the moral parameters of successful mainstream
institutions that those institutions can differ only marginally
from this socially defined moral level. Not all institutions
are equally imbedded in the larger society. But the more mainstream
an institution is — that is, deeply interdependent with society's
major dimensions — the more it will be shaped by society's forces.
The more marginal an institution is to society, the more it
will be shaped by its own inner vision and goals. Compare,
for example, the defining influence of society on a national
hotel chain, on one hand, and on a volunteer-based hostel for
domestic violence victims, on the other.
It would be hard to imagine more mainstream institutions than
U.S. Health care facilities. They are bonded in every way imaginable
with the major forces of U.S. society — banks, rating agencies,
the job market, state and federal laws and regulations, unions,
professional licensing agencies, government budgets and crises,
social programs, the business community, the pharmaceutical
and insurance industries, all forms of media, and public expectations
The three-realm model says that such mainstream institutions
are inexorably mirrors of societal priorities. Therefore health
care organizations will serve those persons defined as worthy
of service by society. Such organizations will be rewarded for
providing services that society prizes and punished for providing
those that the culture does not esteem. Such organizations will
staff and pay at levels determined by society. They will manage
their finances under the scrutiny of their state capitals; Washington,
DC; and Wall Street. Their boards of trustees and executives
will spend the preponderance of their time and energy dealing
with issues generated by the systems and structures of society
rather than those generated by their mission and values.
As for respecting human dignity, a successful U.S. hospital
can differ only marginally from the way society at large respects
it. An organization that attempts to deviate significantly
and consistently from these societal priorities will, in due
time, be destroyed. To be a "provider of preference" is
to substantially conform to the priorities of the society.
Robert Kuttner's observation offers empirical confirmation
of this ethical dynamic: "All segments of the health care industry
and profession, even those with a sense of mission very different
from that of for-profit enterprises, found themselves in a new
world where the pursuit of market share, the development of
referral networks, the search for profitable admissions and
subscribers, relentless cost cutting, and other practices pioneered
by shareholder-owned firms came to predominate."4
One might conclude that such hostile pressures give Catholic
organizations a reason to exit American health care. But flight
into sectarian isolation runs counter to Catholic tradition.
We Catholics are called to change the system, not flee from
it. In 1984 the U.S. Catholic Conference summarized this growing
It is appropriate in this context to offer our own reflections
on the role of the Church in the political order. Christians
believe that Jesus' commandment to love one's neighbor should
extend beyond individual relationships to infuse and transform
all human relations from the family to the entire human community.
Jesus came to "bring good news to the poor, to proclaim liberty
to captives, new sight to the blind and to set the downtrodden
free" (Lk 4, 18). He called us to feed the hungry, clothe the
naked, care for the sick and afflicted and to comfort the victims
of injustice (Mt 25). His example and words require individual
acts of charity and concern from each of us. Yet they also require
understanding and action on a broader scale in pursuit of peace
and in opposition to poverty, hunger and injustice. Such action
necessarily involves the institutions and structures of society,
the economy and politics.5
Biblical Priorities and Other Priorities
The Bible does not speak explicitly about health policy, of
course. But Catholic societal teaching provides conceptual tools
that enable one to translate biblical priorities into some elements
of a biblically just health care system.
Unlike other "first-world" nations, the United States has
not developed an overarching theory and policy for health care.
We have preferred to allow our health care delivery and financing
to evolve in its own way, driven by various independent social
forces. But a nation that spends over $1.5 trillion annually
for health care certainly can be said to have priorities-in-practice,
however unarticulated these may be.
Let us compare biblical priorities in health care, on one
hand, with U.S. priorities-in-practice, on the other (see Box,
below). Of course, biblical and U.S. priorities are identical
or at least harmonious in many areas. U.S. Health care is, in
many ways, a splendid and compassionate effort. But from a biblical
perspective, it is also deeply unjust, gravely flawed, and — in
its impact if not in intent — extensively cruel.
If we stop and examine a single aspect of our system, we see
that this claim is not hyperbole. U.S. Health care spends prodigiously — now
more than $1.5 trillion, multiples of most other developed countries'
per capita spending. But we systematically exclude about 11
million children from this prodigal outpouring. When we look
at the potential consequences of such policy neglect — stunted
neurological development; immune system compromise; impairment
of the child's capacity to become a self-confident adult as
worker, partner, parent, and citizen — the characterization of
our system as "extensively cruel" seems merited.
Reform Is Morally Vital
The logic of our argument so far brings us to the following
conclusion: The most significant factors in a health care institution's
primary identity are the systems and structures on the
societal level that define success for such institutions. Catholic
health facilities are like all others in this regard.
Thus the path to deep and abiding improvement of the moral
integrity of Catholic health facilities leads to reform of the
larger system. We must work to build a system that moves significantly
away from the current priorities-in-practice and toward one
that more robustly honors human dignity and expresses biblical
The main lines of the agenda, though not obvious in every
detail, are clear enough. But the agenda itself is daunting
because the current situation involves more than programs, funding,
and political maneuvering. Health care today is rooted in deep
and abiding attitudes and assumptions of U.S. culture. Some
of these attitudes and assumptions can fairly be described as
cultural addictions — patterns of dysfunction that Americans cannot
relinquish despite irrational and punishing consequences. These
addictive patterns have, in turn, resulted in kingdoms and constituencies
that benefit from the status quo. The ranks of those resisting
reform are long and deep — and we who work in Catholic health
care ourselves can be recognized in that crowd.
Rooting out deeply imbedded injustice is always a project
that takes decades, sometimes generations. This was true of
the abolition of slavery and the achievement of women's suffrage.
But we Americans did finally accomplish both goals, making our
societal systems more deeply respectful of the dignity of all
persons. We should also take hope from the fact that that every
other first-world nation has a health care system significantly
closer than ours to biblical priorities. So there are solid
reasons — to be found in history, in the example set by other
nations, in biblical faith — for us to hope for success in this
effort. But we need to begin this long journey now, rather than
postponing it until crises involving the Balanced Budget Act
of 1997, seismic retrofitting, and other problems have been
dealt with. If we who serve the Catholic health ministry do
not find a way to deal, at one and the same time, with both
short-term crises and this long-term moral challenge, our own
essential moral character will continue to be gravely compromised.
As unlikely as it may seem, the reform of U.S. Health policy
is the reform of our own moral identity.
- Uwe E. Reinhardt, "Germany's Health Care System: It's Not
the American Way," Health Affairs, Fall 1994, p. 24.
- National Conference of Catholic Bishops, Economic Justice
for All: A Pastoral Letter on Catholic Social Teaching and
the U.S. Economy, U.S. Catholic Conference, Washington,
DC, 1986, para. 28.
- See John W. Glaser, Three Realms of Ethics, Sheed
& Ward, Kansas City, MO, 1994, which the author is currently
- Robert Kuttner, "The American Health Care System: Wall
Street and Health Care," New England Journal of Medicine,
February 25, 1999, pp. 664-668.
- U.S. Catholic Conference, "Political Responsibility: Choices
for the '80s," Origins, April 12, 1984, pp. 732-736.
Biblical Priorities vs. U.S. Priorities-in-Practice
Common Good Context Health care is seen as part of
the common good — that network of basic social goods (education,
employment, housing, health care, etc.) needed for individuals
and society to flourish with consistency over the long haul.
This network is the foundation and context for understanding
and making decisions about health care.
Sustainable Growth Progress and growth are highly valued.
But progress is the servant of the common good, not its master.
To serve the common good, individual conscience, cultural awareness,
and societal structures will have to restrain the virtually
endless possibilities of health care.
Health as a Right/Responsibility for All As a social
good, required by society and individuals for long-term flourishing,
health care must be equitably accessible to everyone. For the
individual, this grounds the right to access; for society, it
grounds the duty of provision.
Explicit Hard Choices Because health needs are virtually
infinite but resources are finite, hard choices cannot be avoided.
Such sacrifices should be made explicitly and in a way that
permits examination. Hard choices made implicitly unavoidably
hide and empower bias and injustice. Infrastructure is needed
for explicit decision making.
Priority to Basics Keenly aware that many potential
goods must be sacrificed, biblical allocation demands explicit
priorities. The most fundamental priority is resources for universal
basic health care.
Pursuit of Explicit Integration and Oversight Like
national defense, national health care has an organic integrity,
but also enormous complexity requiring explicit attention and
systematic, identified responsibility. Scattering responsibility
(and incentives) can be compared to assigning the care of an
ICU patient to a gang of subspecialists who refuse to talk to
each other. The forces of entropy and dysfunction must be harnessed
to serve the individual and common good.
Individual Context Health care is seen primarily as
an individual good. Its predominant relationship is that between
individual physicians and individual patients. Bioethics sees
personal autonomy as its first principle. Treatments providing
no more than modest benefits are fought for as medically justified,
regardless of their aggregate impact.
Maximum Tolerated Growth U.S. practice promotes maximum
growth in quantity and pace. Newer forms of care and ever-larger
amounts of it are assumed to be better care. Limits tend to
be set in a crisis-management mode by major payers with narrow
criteria lacking a larger context or long-term perspective.
Health Care as a Commodity for Most Only for some — for
example, those 65 and older, members of the military, penitentiary
inmates, patients in end-stage renal failure — is health care
an established right. For most people, access to health care
is a commodity, directly related to wealth and power. At present,
at least 40 million Americans cannot afford this commodity.
Implicit Hard Choices U.S. Practice prefers to make
hard choices implicitly, nurturing the illusion that we do not
ration health care. Deeply punishing results — children constitute
more than 11 million of the 40 million uninsured Americans — flow
from diffuse decisions for which no one owns responsibility.
Priority to Frontiers Pursuit of innovation and a dream
of a disease-free future tend to divert attention and resources
from universal basic care. Rescue/research/technology imperatives
overwhelm the basics/prevention/promotion imperative.
Strong Resistance to Integration and Oversight Because
health care is seen as care for individuals; because personal
freedom is highly prized by both professionals and patients;
because maximum, unfettered growth is valued; because the free
play of market forces are viewed as the answer to social problems — for
all these reasons, society reject efforts to integrate and rationalize
health care as "inappropriate."
Copyright © 2002 by the Catholic Health Association of the United States
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