Healthcare Is a Social Construction for the Good of All
Dr. Cochran, a professor of political science at Texas Tech University, is a 1998-99 senior research fellow at the Erasmus Institute, University of Notre Dame, Notre Dame, IN.
Common good is one of the most distinctive ideas in the storehouse of Catholic social theory. Other concepts, like solidarity or a preferential option for the poor, as rich in meaning as they are, have a shorter pedigree and are therefore less successful at demonstrating enduring importance. The idea of common good goes back centuries and has been used regularly over time, yet two phenomena obscure the idea's richness: America's individualistic and pragmatic culture and the Church's tendency to use the term as a mantra rather than as a strong analytic tool.
In the first case, Americans find language like "public interest" or "greatest good" more appealing than "common good," because the former terms are reducible to the self-interest of individual citizens or the aggregate interests of a majority. "Common good," however, seems to imply a "good of the whole" that could possibly trample individual interests. In the second case, Catholic scholars, activists, and officials take the phrase "common good" for granted, using it as a synonym for justice, or using it in the aggregate sense, or failing to distinguish different meanings within the concept.
Properly understood, the common good serves as a counterweight in political discussion to the dominant utilitarian, pragmatic, and individualistic paradigms in ethical thought and policy discourse. More than this, the common good reminds providers, patients, and society itself of the social nature of healthcare institutions and systems. In doing so, it can stimulate the energy to extend healthcare access to the entire population.
The Common Good and Its Counterfeits
The "Common Good" in Catholic Social Theory
Quoting Gaudium et Spes (para. 74), the Catechism of the Catholic Church understands the common good as "the sum total of social conditions which allow people, either as groups or as individuals, to reach their fulfillment more fully and more easily."1 This definition, however, is rather misleading apart from its context. The idea of a "sum total" suggests simply adding individual goods. This is not what the Church means; instead, the origin of the common good lies in the nature of human persons, their call through creation to a life in community. Common good is inseparable from the social well-being of the human community, from peace, and from respect for each person. The Catholic concept squares up appreciation for the boundless worth of each person with the full meaning of human life in communion.2 One way to understand how the common good can be both personal and communal is to think of family life or friendship at its best. The joys and sorrows shared reinforce the depth of the relationship and, at the same time, deepen the personal life of each friend or family member.
Misconceptions of the Common Good Americans find it difficult to understand or accept this Catholic teaching, for two reasons. First, precisely because it challenges the dominant individualistic paradigm, commitment to the common good seems to submerge the individual beneath community. To advance the common good, this argument goes, is to restrict individual liberty. There is a kind of "teeter-totter" notion at work — as community (represented by the common good) goes up, individual liberty must fall.
This common view is wrong in two ways. In the first place, liberty and community are not a zero-sum game, such that more of one means less of the other. Think of a neighborhood. The more closely knit the community, and the more frequent and mutually giving their interactions, the more likely it is that the children of the neighborhood are free to play safely in parks and other public places. Community enhances liberty. In the second place, liberty is not license. Persons are most free when they follow the moral order of conscience, one of whose inclinations is respect for the needs of common life; that is, dedication to the common good.
The second misconception confuses the common good with what economists call "public goods." Public goods are indivisible; providing a public good at all entails providing it to all members of society. Familiar examples are clean air, national defense, and air traffic control. Public goods contrast with divisible private goods. Apples, for example, can be provided to some persons without distributing them to all.
Common good, however, is a different concept from public good. Something may be essential to properly functioning social life without being a public good in the strict economic sense. This conclusion is particularly important when the subject is healthcare, which though not a public good nevertheless is crucially a common good.
Thinking about the Common Good One way to understand the common good is to think of a highway. Assuming that the road is well constructed and placed where it facilitates travel, a highway contributes to flourishing community and to individual liberty. Particular persons use the highway to pursue their individual interests — commerce, recreation, entertainment, family visits. But the highway also encourages community enrichment. Families and friends visit more frequently; the cultural riches of a city become more available to rural residents; urban dwellers shop at antiques stores in small towns.
The example reveals the central quality of the common good: It is common, in that it brings people together, and it is distributed to individual persons, in that they enjoy its benefits. Although there are indeed cases in which individuals must sacrifice particular goods for the common good (a landowner who gives up a right-of-way, for example), a genuine common good always contributes to particular persons while enhancing community.3
The highway example illustrates three distinctions within one concept, which can in turn illumine the meaning of healthcare in relation to the common good. First, the highway is clearly not "the common good." The term "the common good" is too comprehensive to be contained by something as singular as a highway, or even a system of highways. Rather, "the common good" refers to the overarching goal of social action, the good common life of society itself. In this sense, the common good is never attained. Imperfections are always present; progress is always possible (although never guaranteed).
What about our highway, then? Since it is not the common good, what is it? The second distinction says that the highway is a means to the common good. That is, the highway facilitates social interaction and, therefore, promotes the common good.
But there is a third distinction. The highway is also a common good; that is, its construction and maintenance need social cooperation — in this example, government.
Three Aspects of Healthcare
How does healthcare fit into these three qualities within the concept of common good? What do these qualities tell us about how the healthcare system must change in order to better promote the common good?
Healthcare and the Common Good Clearly, neither particular healthcare institutions nor the healthcare system as a whole is the common good any more than particular highways or the national highway system. But healthcare is part of the proper functioning of community life. People who are free from disease and whose injuries are repaired are better able to pursue their own goods, to contribute to the common good, and to share communal interactions with fellow citizens. Because modern medicine can do much to repair injury and cure illness, it is an essential aspect of the common good of modern societies.
A precondition for the common good is the existence of a civil society in which people recognize themselves as mutual members.4 To deny a person or a class of persons access to healthcare is to treat them as less than full members of the community. It damages the life of the community and denies the reality of the common good. The appalling lack of access to healthcare for millions of uninsured and underinsured Americans represents a major affront to the common good. That good calls on healthcare institutions and on government to make access a reality for all. Catholic healthcare has a triple challenge: to hold the common good up as a social goal, to be an advocate with government for guaranteed universal access to high-quality care, and to organize itself in such a way as to extend care to those who lack it.
The common good has a second important implication for healthcare. Because healthcare is not the whole, but only a feature, of the common good, it has limits. Other goods, too, are essential to the common good — food, education, and transportation, for example. The common good, then, entails another fundamental concept of Catholic social theory, stewardship. In recent decades, escalating healthcare costs threatened to absorb a disproportionate share of social resources. Stewardship of efficient and effective healthcare demands cost control. Stewardship is important also so that healthcare as a means to the common good maintains focus on the quality of healthcare. Public policies or business developments that impair the ability of providers to deliver high-quality care damage the ability of healthcare personnel and institutions to contribute to the common good.
Healthcare as a Means to the Common Good Healthcare serves the common good in additional ways.
The healthcare system encounters community members at their most vulnerable. Indeed, the most vulnerable members of society — the very young, the severely disabled, the aged, and the dying — pose the greatest challenge to healthcare. If a young man of 30 is injured on the job, or a woman of 34 contracts an infection, each is vulnerable; each needs medical care to return to normal functioning. It is easy to see how healthcare becomes a means to the common good by reintegrating them into the community. It makes good economic sense for society to see that such people receive the restorative care they need, and healthcare workers derive considerable satisfaction from their cure.
Consider, on the other hand, a newborn with severe birth defects, a teenager with multiple sclerosis, an 85-year-old Alzheimer's patient, or a retired person in the last weeks of dying from cancer. What do they contribute to the common good? In what sense is care devoted to them a means to the common good? It is precisely here that the Catholic concept of the common good is valuable, because it sees beyond the functional contribution of individuals. It discerns the unique personhood of each. The common life of communities involves far more than external economic and functional relationships. It is more profoundly a web of love and care, of relationships that connect heart and spirit as much as body.
Healthcare is a sacrament of community, a means to the common good in its visible, tangible witness that even the most vulnerable and damaged people are part of the community's identity. Neonatal intensive care nurses, physicians who refuse to abandon the dying, aides who gently bathe Alzheimer's patients, therapists who help the severely damaged to communicate — all are sacramental ministers of the mystery of common life. That mystery is the same as the mystery of the cross: God's love and God's power to bring wholeness out of brokenness find their most profound spectacle in the sacrament of Jesus' weakness on the cross.5 Paradoxically, healthcare is most precious to the common good when least able to cure, but most committed to the ministry of care.
Healthcare as a Common Good In many regards, the idea of healthcare as a common good is the most difficult to accept. Both providers and patients want to see healthcare as an individual good. Here the idea of public good often produces misunderstanding. Healthcare, it might be claimed, is divisible in that individual persons receive discrete units of care (pints of blood, capsules of medication, surgical procedures) not given to others. Healthcare cannot, therefore, be a public good in the same way as national defense. Individual providers and patients, this argument goes, partake primarily in an exchange of private goods, and their personal choices and judgments are the most important criteria for access to these goods.
This claim contains some truth. Providers and patients rightly concentrate on the good of the patient, seeking the healthcare resources necessary to cure or care for that individual person. Moreover, because healthcare is not a public good, it can seem that a scheme in which individuals are responsible for finding and paying for their own care is justified.
Precisely here is the importance of recognizing healthcare as a common good, which supports both the idea of healthcare as an essential part of the common good and as a means to the common good. The idea of healthcare as a common good points to the social construction of healthcare and healthcare institutions. Individual responsibility for healthcare, important as it is, takes place within communal generation of healthcare skills and assets. And public authorities have the responsibility for ensuring that social resources are not appropriated for the private benefit of patients or providers.
These are strong claims. What justifies them? During the times in which the primary form of medical education was the apprenticeship of physicians-to-be with older physicians and in which the individual physician practice was the primary locus of treatment, it might have been arguable that healthcare was a private good. But, even then, rudimentary schools disseminated knowledge, governments often licensed practitioners, and public and philanthropic funding supported hospitals for the poor. Today, the social context is even stronger:
- No one gets to be a healthcare provider without considerable public support. Federal and state (and even local) grants, scholarships, and loans directly finance training for physicians, nurses, and allied health professionals. Public subsidies to state and private medical and other professional schools indirectly support this training. Healthcare professionals are then, in a sense, common goods themselves; their training — now inseparable from themselves — is an asset produced and nourished by the community.
- Healthcare facilities — hospitals, clinics, and physicians' offices — are sometimes publicly owned, but even private institutions often receive government subsidies or tax-supported private grants and donations to finance their construction. These become, then, common goods.
- Medical knowledge is today a social artifact. Few autonomous, isolated, self-supporting researchers make medical breakthroughs. Government funding and tax-favored private foundations support nearly half of all healthcare research and development. It would be wrong, then, to regard such knowledge as the private preserve of individuals or companies. Knowledge is, rather, a common good that, although legally perhaps private, must in justice serve the good of the community. "Private ownership; common use" is the old Thomistic slogan.
- The community, through its political systems, directly pays for about 45 percent of healthcare through Medicare, Medicaid, the Veterans Administration, local hospital tax districts, and state subsidies for charity care. Indirectly, the public subsidizes healthcare through tax exemptions for not-for-profit institutions and tax benefits to companies and individuals that provide or purchase health insurance. These financing schemes reinforce the common character of the goods that constitute the American healthcare system.
- A wide variety of federal, state, and local laws and regulations affect the ways in which care is delivered and the quality of that care. For example, the licensing of professionals, insurance products, and pharmaceuticals are all subject to laws and regulations.
This brief summary demonstrates the extent to which medical art and science depend on the community. Professionals tempted to regard their skills as private goods salable to the highest bidder or patients tempted to view their own desires as all-controlling need a reminder of the larger picture. Although much healthcare has a narrow focus, and although many institutions in the system are legally private, healthcare is a common good destined for the building up of the community and all its members. Denying some members access or regarding one's own skills or business as wholly private violates the common good.
- Catechism of the Catholic Church, nn.1906.
- See Catechism of the Catholic Church, nn.1907-1912, and David Hollenbach, "Common Good," in Judith A. Dwyer, ed., The New Dictionary of Catholic Social Thought, Liturgical Press, Collegeville, MN, 1994, pp. 192-197.
- These points come from philosopher Yves R. Simon's discussion of the common good. See Clarke E. Cochran, "Yves R. Simon and 'The Common Good': A Note on the Concept," Ethics, April 1978, pp. 229-239.
- Michael J. Schuck, "Response to David Hollenbach's 'The Common Good in a Postmodern Epoch: What Role for Theology?'" in James Donahue and M. Theresa Moser, eds., Religion, Ethics, and the Common Good, Twenty-Third Publications, Mystic, CT, 1996, p. 25.
- 1 Cor 1:17-2:9.
Catholic Theology Informs Thinking on Healthcare Reform
In the Catholic social tradition, the healthcare system can be seen as a common good, something necessary for people to live fully as part of the community. As such, access to healthcare is a basic requirement for a just society, Rev. David Hollenbach, SJ, PhD, concluded in a discussion with CHA's board of trustees last March.
"When we think about social justice, it's not enough to ask whether the slices of the healthcare pie are fairly cut," he said. "We have to ask, Who's at the table? Who's going to get a slice at all, whether it's big or small? Who has membership in the community?"
Fr. Hollenbach, who is the Margaret O'Brien Flatley professor of Catholic Theology at Boston College, met with the board in a "visioning" session preparatory to CHA's strategic plan initiative directed to achieving accessible and affordable healthcare for all. He outlined two Church principles — solidarity and subsidiarity — that have a direct bearing on our system, where 43 million people are uninsured.
The Church sees the virtue of solidarity as a commitment to the common good and participation by all, Fr. Hollenbach explained. "The basic meaning is the commitment of a person or group to building up the common good (contributive justice) in such a way that all persons have access to sharing in the common good (distributive justice). It's a commitment to being a community," he said.
This commitment to justice generates what is sometimes called a "fundamental option for the marginalized." Quoting Pope John Paul II, Fr. Hollenbach said this means "the needs of the poor take priority over the wants of the rich; the freedom of the dominated takes priority over the liberty of the powerful; and the participation of those who are marginalized takes priority over the preservation of an order that excludes them" (Origins, vol. 14, 1984, p. 248).
Another important Catholic principle, subsidiarity, is useful in discerning an appropriate solution to the country's current healthcare crisis. Referring to concepts put forth in a pamphlet by Richard John Newhouse and Peter Berger 15 years ago, Fr. Hollenbach explained that at the top of society are "mega-institutions" — for example, the global economy, communications media, federal government, and the overall healthcare delivery system.
"The vast majority of people are virtually powerless in the face of those huge institutions," he said. "The traditional way of understanding subsidiarity is that we have some mediating institutions close enough to individuals so they feel they have some capacity to influence them but large enough so that those institutions are in turn capable of influencing larger mega-institutions in society."
Examples of mediating institutions are churches and voluntary associations such as the National Rifle Association and Amnesty International. Fr. Hollenbach said that the interesting question is, What can the Church and the healthcare ministry do to help people influence those larger structures in healthcare and to help them feel they have some stake in these mega-institutions? "Do people at the local level feel a stake in their Catholic hospitals, or is it just another part of the healthcare machinery that they're nervous about?" he asked.
Subsidiarity does not necessarily mean that "small is beautiful," that all decisions should be kept close to the people. The principle really means "no bigger than necessary," a phrase coined by Rev. Andrew Greeley, he said. "The principle of subsidiarity does not tell us in advance whether the government should be involved. It does not say that single-payer plans are bad," Fr. Hollenbach said. Instead, subsidiarity says that a highly decentralized, localized, private way of delivering healthcare is appropriate if it works; but the federal government should be involved to the extent necessary to ensure appropriate healthcare is available for all.
Copyright © 1999 by the Catholic Health Association of the United States
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