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BY: FR. CHARLES BOUCHARD, OP, STD

Four Basic Principles Will Help Us Keep Our Balance

The short answer is no. There is no single Catholic policy position on the Affordable Care Act or on health care reform in general. However, we do have basic theological convictions that help us assess various policy proposals. Our convictions about four things in particular — the human person, justice, the role of the state and individual rights — are fundamental to the discussion.

WHAT IS THE HUMAN PERSON?
After wondering if God exists and what the purpose of life is, the most basic question we can ask is, "What does it mean to be a person?" That's not the kind of question we sit around discussing over a beer, but it is key to assessing health care reform proposals.

There are two extremes of thought about the person. On one end of the spectrum is an individualist and highly self-sufficient view favored by many Americans: You leave me alone, and I'll leave you alone. This view maximizes human freedom and minimizes our connections with one another.

Totalitarianism is at the other end of the spectrum. It sees the person as a dispensable cog. Totalitarian systems view people in materialistic and economic terms, so that people are valuable only to the extent that they produce for the government. Personal freedom and self-determination have little role to play and often are suppressed for the sake of the state. Decisions generally are made from the top down, leaving no need for individual initiative or striving for transcendental goods (heaven, for example).

Catholic anthropology rejects both of those extremes. We see the person as a unique individual, a union of body and soul, who is made in the image of God. We also hold that each person possesses an inherent human dignity that includes freedom, the right to self-determination and a supernatural destiny. Our dignity is not earned or granted. It is part of who we are.

In the Catholic tradition, however, we view this dignified person as essentially social and interdependent. We become persons through our relationships with others. Personhood is incomprehensible apart from community. That is a countercultural assertion in the United States, where many people have enough resources to provide most of what they need. They can create the illusion of self-sufficiency.

Even though our belief in a transcendent, supernatural destiny is key to Christian thought, we take our bodily existence, and therefore health care, seriously. Salvation is not some distant heavenly playground; we believe that even now, salvation is partially available through the goods of human life. Health care, education, community and friendship all are sacramental, that is, they reveal God to us in tangible ways and foreshadow the reign of God. So when we talk about human dignity, we are not talking about some abstract attribute, but about an embodied being whose value and worth must be supported by real, tangible things.

WHAT IS JUSTICE?
Justice is one way of talking about who gets what and who decides. This is obviously important for health care, where there is a lot of disagreement about both.

The most basic definition of justice is that "each person receive his or her due." This is elegant in its simplicity, but it is not very helpful. Justice is multifaceted, a shifting set of relationships, obligations and responsibilities among persons and groups. It changes constantly in different social, economic and cultural circumstances. It is always a work in progress, because in this world, we achieve only a certain sort of justice, a relative justice, while we wait for God to bring it to perfection. We'll never get it right, but we have to keep trying.

Our view of justice starts with ultimate ownership of the earth's goods. Are these goods available to be bought and owned by persons with the ability to do so? Or do they belong to all of us?

In the Catholic tradition, we talk about the "universal destination of human goods" because we believe they were created by God and given to all.¹ We steward them rather than own them. Our job — much harder than it sounds — is to see that they are shared equitably.

Justice essentially is relational because it always involves at least two persons, one who is entitled and one who is obligated. The most basic kind of justice is what we call transactional or contract justice, which occurs when two persons make an agreement: I hire a contractor to paint my house, or a personal trainer to help me get into shape, and I pay a mutually agreed-upon amount in exchange.

Everyone understands this kind of justice. Some might argue that it is the only kind of justice we need, because it maximizes human freedom. They might say that if every individual transaction or contract is just, we would have a just society. That is the thinking behind certain kinds of free market economic theory in which an "invisible hand" or "trickle-down" effect naturally brings about a healthy economy without outside influence.

The Catholic view acknowledges transactional justice but says that it does not go far enough. Our view of the person as essentially social draws us beyond individual transactions ("parts to parts") to consider the relationship of the parts to the whole and the whole to the parts.² The assumption is that if we are essentially social, part of a group, then we owe something to that group. We are expected to obey laws, respect the environment, vaccinate our children, offer military service and pay taxes to ensure public safety and provide education and health care for others.

This view is more controversial than transactional justice, because it requires us to acknowledge a reality above individual persons and to grant that reality some authority in our lives. It requires that we relinquish some of our resources to this entity for the sake of the whole. It is based on the virtue of solidarity, which means we acknowledge that we are essentially related to others and have some obligation to them as a group.

Many oppose the Affordable Care Act's insurance mandate because it goes beyond the requirements of contract justice. It requires a contribution, and therefore a restriction on freedom, for the sake of the common good. Libertarian writer Damon Root articulates the problem when he says "the individual mandate threatens the foundations of contract law," because contracts require mutual consent, and "there's nothing mutual about the government forcing you to enter a binding contract with a private company."³

Distributive justice is another aspect of this complex reality. It involves the relationship of the whole to the parts. The question here is not what I owe to society, but what society owes to me. For many, it goes right to the question of big government. One critic says the entire ACA is based on "the sort of redistributive economics that is anathema to the party of small government."⁴

ROLE OF THE STATE
Another concern about distributive justice is that it will weaken individual initiative and create an unhealthy dependence on the state. Regarding health care reform, critics often use the phrase "socialized medicine," a term created by the American Medical Association in opposition to President Harry S. Truman's 1945 proposal for national health insurance. "Socialized medicine" was political shorthand for the AMA's concerns about a big government that provides too much.

Even though the ACA is largely based on private insurance so does not qualify as socialized medicine, the term remains effective because for some Americans, it conjures up images of the British National Health Service, Canada, incompetent federal bureaucracy and communism all at once.⁵ In a candid admission of his own fears about the ACA, Sen. Orrin Hatch, R.-Utah, alluded to the danger of economic dependency in May 2017 when he warned that the ACA is already entrenched and will be hard to change because people won't want to give up what they have.

"Let's face it," Hatch said, "once you get them on the dole, they'll take every dime they can."⁶

IS HEALTH CARE A RIGHT?
The idea of individual rights did not exist until modern times.⁷ For most of history, people lived in small, compact cities or villages and were so tied into communal networks of relationships that they would not have thought of claiming an individual right. Only after the Enlightenment in 17th- and 18th-century Europe did the idea begin to emerge of individual persons possessed of rights. Individual rights became the foundation of the U.S. Constitution, but once the discussion moves beyond life, liberty and the pursuit of happiness, rights become disputed. Americans tend to favor "negative" rights — for example, I have a right to be left alone, or to purchase, free of interference, as many guns as I want.

Entitlement rights are seen as an entirely different matter. Writer and physician Atul Gawande, MD, captured this sentiment and its ongoing appeal in an Oct. 2, 2017, essay in the New Yorker.⁸ He went back to his hometown of Athens, Ohio, and interviewed several contemporaries. He found that few of them objected to Medicare, because they had all paid into it and all were being treated equally. But when health care as "right" came up, they stiffened. To them, a right to health care is part of a liberal agenda that means undeserving people (namely, the unemployed or noncontributing) get free stuff like health insurance. They did not see themselves as benefiting from this right. In fact, they thought they would be paying higher taxes if it became a right to others.

"Would I love to have health insurance provided to me and be able to stay home? Of course," one woman said. But then she asked, "Where does it end? I mean, how much responsibility do tax-paying people like me have?"

This is a very important insight, because it goes to popular, widespread perceptions regarding fundamental notions of justice and equity.

WHAT IS THE ROLE OF THE STATE?
There are two basic views of the state's role. One sees government as a necessary evil designed to restrain human greed and sinfulness, therefore, the less of it the better. The state's role should avoid mandates and be limited to essential things like public safety and national defense. As Joe, one of Atul Gawande's interlocutors, said, "Any time the government steps in and says, ‘You must do this,' it's overstepping its boundaries."

The Catholic tradition favors human freedom and subsidiarity (an old Latin axiom says "Lex minima optima est" — the best law is the least law). However, because of our understanding of humans as social and our commitment to the common good, we also see government as more than a restraint on sinfulness. Our relatively optimistic view sees legitimate government as a way of assuring circumstances in which individual persons can achieve their purpose. It gives legitimacy to the state, its power to require participation from citizens and even to redistribute those contributions for the common good.

These basic theological convictions do not provide detailed policy guidelines, but they should shape our overall view of basic human goods like health care. Health care reform requires not only good policy, but virtue. Given the clinical, organizational and financial complexity of health care, the constantly changing policy proposals, and the slogans and half-truths that politics creates, it is good practice to return regularly to these basic convictions to keep ourselves ethically and spiritually focused.

FR. CHARLES BOUCHARD, OP, STD, is senior director, theology and ethics, the Catholic Health Association, St. Louis.

NOTES

1. This is an aspect of the Catholic Church's social teaching. See John Paul II, Compendium of the Social Doctrine of the Church, (April 2, 2004): paras. 177-79.
2. When I say "whole," I do not mean government, but society. A society, whether big or small, may use various forms of government to assure justice, but it is not the same as government.
3. Damon Root, "The Four Best Legal Arguments against Obamacare," Reason (March 24, 2012). Root also argued that the government did not have the power to impose the individual mandate because it did not involve "commerce among the several states" as the Constitution requires.
4. Staff, "The Economist Explains," The Economist (Dec. 11, 2016). www.economist.com/blogs/economist-explains/2016/12/economist-explains-1.
5. T. R. Reid, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (New York: Penguin Books, 2009), 11.
6. Ted Barrett, "Sen. Hatch: ‘The Public Wants Every Dime They Can be Given'," CNN Politics (May 9, 2017). www.cnn.com/2017/05/09/politics/orrin-hatch-public-money/index.html.
7. See David Hollenbach, Claims in Conflict: Retrieving and Renewing the Catholic Human Rights Tradition (New York, Paulist Press International, 1979), 14-15. Hollenbach cites John Locke as a key figure in the development of modern rights theory. Locke says human rights involve "perfect freedom to order their actions and dispose of their possessions and persons, as they see fit within the bounds of the law of nature, without asking leave or depending upon the will of any other man." He also notes that classical and medieval theorists of natural law insisted upon the reality of positive duties toward others within a stable social order. This view unraveled after the Enlightenment, and the United States is heir to the new view.
8. Atul Gawande, "Is Health Care a Right?" The New Yorker (Oct. 2, 2017): 48-55. www.newyorker.com/magazine/2017/10/02/is-health-care-a-right.