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BY: ANN NEALE, PhD

Dr. Neale is senior research scholar, Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC. This article is adapted from a presentation she gave, in Palm Beach Gardens, FL, to the February 2004 meeting of the CHA Board of Trustees.

The mission of Catholic health care is to be a sign of God's love and compassion. For those who serve the ministry, the goal is a world in which God would be at home, especially in the person of the widow, the orphan, the stranger, and the poor. Toward that end, we seek reform of the nation's health care system. But I believe that work for such reform gives us, in addition, an opportunity to assume civic leadership—to contribute not only to a more just health care system, but also to have a hand in reinvigorating our nation's democracy.

The nub of the argument I will make in this article is as follows:

• Meaningful, sustainable health care reform involves profound social change that must involve the public. There is no quick fix.
• Resolving this issue will require large-scale civic engagement and revitalization of neglected civic skills; it can mean not only healthier individuals and communities but also a healthier democracy.
• Catholic health care leaders who engage their communities on this important issue are, in so doing, building that better world where God will be at home.

Why the Issue Is So Important
I will not rehearse here the statistics that raise the specter of human suffering: those many millions who need health care. Apparently Oscar Wilde was mistaken when he said it's the mark of an educated mind to be deeply moved by statistics. Appalling data about the incredible toll in anxiety, diminished health status, unnecessary chronic illness, and premature death have not moved our legislators or the larger public.

My contention is that American health care points to a kind of American malaise, having to do with our national character. The injustice of U.S. health care is an affront, indeed a threat, to our sense of community and, ultimately, to our increasingly fragile democracy. Let me explain what I mean.

First, let's take the issue of national character. The Catholic Health Association (CHA) well understands that health care reform is fundamentally a matter of values. Because health care is so central to individual and community well-being, a good society is under a moral imperative to ensure that its people have access to affordable health care. Legislators, interest groups, and those groups' lobbyists debate which technique—single payer, employer-based insurance, vouchers, expanding the safety net—is the best route to health care reform, meanwhile overlooking the fact that they are dealing with an issue that is first and foremost a matter of values and only secondarily a matter of technique. Until Americans come to a shared understanding about what we owe one another in the way of health care services and security, we will not be able to work through the hard choices and compromises that any meaningful strategy for health care reform entails. As a nation, we are not wanting for either the material or the technical resources to transform health care. Where we flounder is in mustering the moral determination to do so. It is our moral resolve, our national character, not our ingenuity, that is on trial.

It would also seem that our sense of community is waning. There is not a robust sense of solidarity in America. How else explain the deplorable health status and statistics in community after community throughout the country? The lack of resolve to realize health care justice reflects on each one of us, not just our elected officials. I believe the larger community (I include myself in this number) is neither sufficiently aware of nor engaged in resolving health care injustice in our local communities. I believe that, were we to undertake serious efforts to become more aware and engaged, we would begin to forge the bonds of community that are a necessary precondition for health care justice.

Disparities in infant mortality rates in the District of Columbia illustrate this point. In 2000, when the national infant mortality rate was 6.9 deaths per 1,000 live births, the infant mortality rate in Ward 3 of the District of Columbia was 1.2 deaths per 1,000. In the district's 6th ward it was 20.1.¹ This disparity occurred, I think, not because we Washingtonians who live in Ward 3 don't care about our neighbors in Ward 6. I believe we are clueless (though culpably so) about the challenges that our neighbors in other parts of the city experience in securing basic necessities—housing, education, job training, transportation, day care, and health care. Our cluelessness is an indication of the diminishing reality of community in the district and throughout the country. This is alarming, because a sense of community and the civic participation it entails are essential for a vibrant democracy.

For nine months in the early 1830s, Alexis de Tocqueville, a young French aristocrat, traveled around America, seeking, as he put it, "the image of democracy itself, with its inclinations, its character, its prejudices, and its passions, in order to learn what we have to fear or hope from its progress."² Intrigued by American democracy, Tocqueville visited 17 of the then 24 states, and interviewed a cross section of people, from presidents to settlers. He was astonished by two characteristics he observed in America, one being what he called the "general equality of conditions." "To an aristocratic Frenchman with close ties to the restored French monarchy, the extent of equality in all spheres of American society was striking. . . .Tocqueville paints a picture of ordinary life in America rich in citizen initiative: people joining together to solve common problems."³

The relative political equality Tocqueville found here in the first half of the 19th century has been eroded by money, special interest politics, and the withdrawal of ordinary folks from civic and political engagement. Theda Skocpol, a professor of government and sociology at Harvard University, notes that there is both civic engagement and political advocacy in contemporary America, but it is professionally managed rather than the result of grassroots, cross-class, general public deliberation and participation. Skocpol observes that 19th-century U.S. elites understood that they had to organize ordinary citizens in cooperative endeavors to "get the job done."⁴ Civic associations were numerous. Their membership spanned social and economic classes and was national in scope. These groups nurtured engagement in civic issues and deliberative participation around pressing civic and political issues. They were precisely the associations Tocqueville marveled at as the base of an impressive American democracy. He recognized that these voluntary associations were the vehicle with which citizens gained leverage and expressed their shared identities and values.⁵

The kinds of associations that leading citizens launch and patronize, the shared values and identities they articulate, and the tactics they use to gain and exercise public voice and political leverage—all powerfully influence the menu of possibilities for participation available to most citizens. In a thriving democracy, leaders regularly invite many fellow citizens to join them in important endeavors. Citizens must respond, of course, or leadership initiatives fail. But it is not foreordained that leaders will emerge to offer the most democratically propitious avenues of shared engagement. Over the sweep of history, elites have often cooperated and contended with one another above the heads of most people living in their societies. Only in special circumstances do elites turn to democratic leadership—above all, to the kinds of democratic leadership that involve mobilizing and organizing others.⁶

Nineteenth-century American elites regarded themselves as "trustees of community . . . working closely with and for . . . fellow citizens of modest means."⁷ That sense of solidarity and civic participation across social and economic lines has all but disappeared. Today civil society and politics are shaped out of sight of most Americans. Skocpol notes that our current civic life is "top-heavy, carried on by professional advocates, lobbyists and elite power brokers, so that public policy making is skewed toward theicy making, toward the values and interests of the privileged."⁸ She observes that, "as of the early 21st Century the U.S. has too few associations and leaders able and willing to mobilize citizens for shared national undertakings."⁹

Skocpol concludes that a civic transformation "has diminished America's democracy, leaving gaping holes in the fabric of our social and political life. . . . Critical aspects of the classic civic America we have lost need to be reinvented— including shared democratic values, a measure of fellowship across class lines, and opportunities for the many to participate in organized endeavors alongside the elite few."¹⁰

There exists a clear opportunity for leaders in Catholic health care to engage their communities, helping them find ways to name their shared values around health care as a counter to the dominance of special interests.

Why It's So Hard to Fix
People with vested interests have as their objective the preservation of the status quo. A more significant, because unrecognized, obstacle is that even advocates of reform seem not to appreciate the magnitude of the change that will be involved in achieving just health care. Meaningful, sustainable reform will require profound cultural transformation. Lacking this understanding, proponents of reform tend to adopt strategies that are not adequate to the task.

John W. Glaser, STD, senior vice president, theology and ethics, St. Joseph Health System, Orange, CA, explains this point in public talks with what he calls his "wedge of social change" theory. To illustrate his insight concerning the extent of social change that will be required to achieve health care justice, Glaser places health care reform at the fat end of a wedge. U.S. health care is so complex; it is such a significant part of the national economy; and its current arrangements are so embedded in individual psyches and professional and organizational structures that it is naive to think that substantial changes in it can be easily or quickly accomplished. In fact, traditional advocacy strategies will have to be complemented by massive public education and deliberation. Reform will take ongoing and large-scale civic engagement, in a nation where significantly diminished civic participation is widely documented.

The challenge to health care leaders and CHA, it seems to me, is to find ways to facilitate public deliberation. Furthermore, it is incumbent on reform advocates to draw on social science research to ensure that the desired social change has every opportunity to succeed. I'm thinking specifically of incorporating the research of "strategic frame analysis" concerning effective communication.^* Strategic frame analysts can help reform advocates to effectively "frame" the problem and various solutions. To act in ignorance of this and other scholarship that can assist the profound transformation that needs to occur is to risk undermining the entire reform enterprise.

* Strategic frame analysis, an approach to communications research, studies public opinion and assumptions. For information about it, contact the Framework Institute.

Why Ministry Leadership Is Critical
U.S. health care is already undergoing transformation. For various reasons, the current system is not sustainable. Many individuals and groups are committed to shaping that change. One such group, the Center for Health Transformation, says it will become the principal center for accelerating health care reform. This new organization says that the health care system is broken and systemwide change is needed, because the system's elements, interacting with one another as they do, cannot be dealt with in isolation. The center's leaders intend to begin the transformation, first, by defining their overarching vision and values and, second, by bringing all sectors together within this shared purpose. So far, so good. But I invite readers to visit this organization's website, www.healthtransformation.net, to see whether they are comfortable with having an operation run by Newt Gingrich leading the transformation of U.S. health care.

It's my belief that, given the opportunity to adequately consider the issues at stake, the American people would identify a different vision and set of values to guide the transformation of health policy in the United States. I further believe that Catholic health care is uniquely positioned to facilitate such deliberation. I would argue, in light of the foregoing analysis, that:

• Health care reform is first and foremost a matter of values.
• Profound social change is required because current arrangements are deeply embedded, planted at a "subterranean depth" (to use a phrase of Margaret Wheatley's).
• There are leaders with not just different, but opposing, visions and values ready to lead a conversation about the values that should drive health care reform.
• Leaders in Catholic health care and CHA have important roles to play in mobilizing citizens nationwide in that conversation.

What I am proposing is this: Our communities need to come together and talk. If we are ever to achieve health care justice, we first need to have a rich and robust conversation about how we ought to live with one another. To develop this argument I am going to draw on two sources, one religious and one secular. Both assume, first, that the United States requires public participation in setting national policy, and, second, that dialogue is the way to achieve it.

Why Dialogue?
Dialogue is important because health care injustice is primarily a matter of community conscience, and only secondarily one of strategy and technique. We need to explore our fundamental beliefs and values as a society and reflect on our responsibility for one another. I'm not talking about abstract philosophical discourse. I'm talking about facing the harsh realities our neighbors experience in their attempts to get basic health care and other necessities, and then examining what our individual and collective response ought to be. I believe that, to the extent we avoid engaging the issue from a values and community perspective and rush to a particular solution (single payer, employer-based coverage, and the others), we short-circuit the arduous job of transforming our hearts and minds. Furthermore, we kid ourselves that deeply entrenched professional and commercial practices and institutions will willingly change to eliminate injustice. Only when we dare to face what a good society's responsibility is concerning health care for all its members, will we have begun to establish the solid ground on which the necessary changes can be built.

The Jesuit theologian John Courtney Murray was an important figure in the commitment of the American Catholic Church to constitutional democracy and human rights. Two insights clearly emerge in Fr. Murray's thought:

• Moral purpose should guide policy.
• Human societies are held together over time by a common conversation . . . out of which emerge commonly affirmed commitments and programs for action."¹¹

Daniel Yankelovich, a public opinion expert who happens to have much in common with Fr. Murray, also recommends dialogue that focuses on normative issues as the means to overcome the impasses experienced on issues like race, the environment, and health policy.¹² Yankelovich decries a creeping "expertism," which he sees undermining self-governance. By "expertism," he means a tendency for policy elites, attending exclusively to empirical, factual information, to pose technical solutions to complex social issues without either engaging the public or dealing with the moral dimension of these issues. Recognizing that the issues require more thoughtful consideration, Yankelovich calls for a public dialogue that explores the values implications of alternate solutions and grapples with the tough choices and trade-offs inevitably entailed in these matters.

Fr. Murray on the Church and the World
Fr. Murray was influential in the rejection by the Second Vatican Council of the notion that the modern world is anti-Christian and dehumanizing. Indeed, he was struck by the similarities between Catholic social thought and the high ideals of the founders of our republic. For instance, America's commitment to freedom of expression, religious liberty, procedural justice, participation in government, racial equality—all of these values and their expression, Fr. Murray saw, are wholeheartedly endorsed in Catholic social thought.¹³ Citing the natural-law basis of the American political tradition, Fr. Murray noted that respect for human dignity is the common ground between the American political tradition and Catholic social thought. That commonality offers a framework for discussion and a point of entry into the public sphere where we need to ponder such questions as, "What is the good society?" "What do our social systems and structures do to and for human persons?" "How can we achieve health care justice?" Fr. Murray understood that, just as the American experience has informed and enriched Catholic theology, Catholic social thought can influence the highly individualistic American ethos that, falling back on procedural approaches to justice and fairness, has abandoned substantive notions of human dignity and human rights. It is important, Fr. Murray knew, that we Catholics find ways to exert that influence.

Conversation as the Mode of Engagement
Fr. Murray was a strong proponent of conversation between the Catholic community and the American polity because he believed that conversation generates the social meaning and ethical direction that are so wanting amid our technical, ethical, and theological pluralism.¹⁴ He perceived the mutual benefit such dialogue could offer, recognizing that the politics and culture of the United States would provide the basis for new insights in Catholic theology. For instance, Fr. Murray was the prime mover in helping our church to recognize the value of religious freedom. Fr. Murray believed that the Catholic tradition's emphasis on communitarian values could help rein in American individualism.

Murray was confident that there was common ground to be found in the natural-law basis of both Catholic social thought and the American political tradition. Pope John Paul II's October 1995 sermon in Baltimore pointed to the same common ground. On that visit the Pope said:

America has always wanted to be a land of the free. Today the challenge facing America is to find freedom's fulfillment in the truth . . . that is intrinsic to human life created in God's image and likeness. . . . One hundred thirty years ago, President Lincoln asked whether a nation "conceived in liberty and dedicated to the proposition that all men are created equal could long endure." President Lincoln's question is no less a question for the present generation of Americans. Democracy cannot be sustained without a shared commitment to certain moral truths about the human person and human community. The basic question before a democratic society is, "How ought we live together?" In seeking an answer to this question, can society exclude . . . moral reasoning? Can the biblical wisdom which played such a formative part in the very founding of your country be excluded from that debate? Would not doing so mean that America's founding documents no longer have any meaning, but are only the formal dressing of changing opinion? . . . Surely it is important for Americans that the moral truths which made freedom possible should be passed on to each new generation.¹⁵

The bishops of the United States have consistently identified participation in the civic and political life of our country as an obligation of our faith. They have identified the blessings Americans share—vibrant democratic traditions, unprecedented economic strength, abundant resources, and generous impulses—while also noting that "all is not right with our nation. Our prosperity does not reach far enough. . . . We are still falling short of the American pledge of ‘liberty and justice for all.'"¹⁶ The bishops cite, as signs of the cultural challenges facing civic-minded believers, the high poverty rate among our children, the widening gap between rich and poor, the fact that millions do not have basic health care and cannot afford housing. The bishops call us to faithful citizenship, noting that "one of our greatest blessings in the United States is our right and responsibility to participate in civic life."¹⁷

An abundance of literature and our own experience, however, demonstrate the diminishment of citizen involvement in the community. Catholic social thought remains a well-kept secret among Catholics, most of whom are not aware of their transforming mission in the world. Fr. David Hollenbach, another Jesuit, refers to "ominous signs today of a thinning of the sense of community and solidarity that holds the people of the United States together, with the resulting impoverishment of our capacity for self-government."¹⁸ It would seem that Fr. Murray's vision of an ongoing, mutually beneficial dialogue between Catholic social thought and American society is even more pertinent today.

I have just explained why I believe the church can and must engage the larger public and speak to it meaningfully. In citing Fr. Murray, I am also suggesting that the way to accomplish that is through conversation—not pontification.

A Secular Perspective on Dialogue
Daniel Yankelovich, in his important book, Coming to Public Judgment: Making Democracy Work in a Complex World, insists that scientific knowledge is not the only genuine and legitimate form of knowing. Citing the German philosopher Jurgen Habermas, Yankelovich argues that science is in fact entirely inadequate to the challenge of grappling with the "great philosophical questions of how to live, what values to pursue, what meaning to give life, how to achieve a just and free society, and how to be a fully realized and free human being."¹⁹¨For those questions, he believes, we need a notion of reason and human discourse different from the post-Enlightenment's narrow, nonnormative understanding of reason.

Yankelovich has confidence in the human ability to "reason together." He affirms Habermas' belief that, through reasoned discourse, people have the ability "to reach mutual understanding even when interests, cultural frameworks and languages conflict."²⁰ Such reasoning is the key to building democratic consensus. According to Yankelovich, this human capacity to engage in genuine communication can and should lead to "open dialogue among the public, experts, and leaders in which there is give and take, two-way communication rather than monologue and the genuine encounter between leaders and citizens on which true democracy depends."²¹

Such dialogue enables citizens to participate in decisions that shape their common destiny as a community and as a nation. Yankelovich contends that when such dialogue occurs it generates "public judgment" that, in certain circumstances, has more legitimacy in a democracy than expert opinion—and not just because it carries the weight of superior numbers, but, rather, because "the public's claim to know is actually stronger than the experts'."²² This is true because the truths of public judgment are "value truths," that is, truths related to questions about which goals and values and beliefs are best suited to help us live together in organized society.²³

Following Fr. Murray and Yankelovich's line of thought, then, it's clear that AT&T is right—"Talk is good!" The larger community has taken a pass on matters of great social import, such as health care, tending to leave their resolution to others—policy wonks, economists, and other experts. Even those elites don't venture much out of their own silos, so what it comes down to is that political strategists and special interests hold the power and shape the decisions, with the community on the sidelines. The current reality, in which elites shape these important issues, not only ignores the larger public's competence, commitment, and responsibility to participate; it also undermines community and democracy.

A Different Approach to Reform
Our nation needs a deeper, more broad-based approach to health care reform, one in which the larger community participates. Citizens have an obligation to contribute to the life of the community, to take responsibility for the moral values that develop in civil society, and to participate in shaping public policy. Fr. Murray thought the main task of the church was to engage the active moral will of the people and suggested that the forum for the church's understanding of ethical issues is the general body of the faithful.²⁴

Furthermore, deliberative conversation is necessary for the sense of solidarity of any group—it builds community. "A central judgment or principle of the Western liberal tradition of ethical reflection has been the affirmation that the people, not directly the wise, are the immediate source of moral validation of specific institutional forms."²⁵ (Alexander Hamilton said as much in the Federalist No. 71, where he declared, "The deliberative sense of the community should govern.")²⁶ For Fr. Murray, who understood American society to be based on a commitment to the people's social and moral primacy, dialogue around the question of how we should live together is necessary for us to be faithful to the founding assumption of our country, which he called "a great act of faith in the moral sense of the people"²⁷

I propose that we engage our communities in conversation, because it is through the mature exercise of public discussion that the moral direction of society is initially and continually shaped.²⁸ That is also the point made in Habits of the Heart by Robert N. Bellah and his coauthors, who insist that if any large-scale social institution is to hold together, it must have some shared values and goals.

I urge Catholic health care to seize the day and engage the people on health care justice, understanding that while for some this will be responding to a baptismal call, it is for us all a civic duty.

NOTES

1. State Center for Health Statistics Administration, Department of Health, draft paper on the 2000 infant mortality in the District of Columbia, p. 1.
2. Alexis de Tocqueville, "The Author's Preface to the First Part," Democracy in America, Oxford University Press, New York City, 1947, p. 16.
3. James S. Fishkin, The Voice of the People: Public Opinion and Democracy, Yale University Press, New Haven, CT, 1995, p. 144.
4. Theda Skocpol, Diminished Democracy: From Membership to Management in American Civic Life, University of Oklahoma Press, Norman, OK, 2003, p. 61.
5. Skocpol, p. 176.
6. Skocpol, p. 177.
7. Skocpol, p. 213.
8. Skocpol, p. 236.
9. Skocpol, p. 253.
10. Skocpol, p. 254.
11. J. Leon Hooper, "A Closing Reflection on Our Academic Praxis," in J. Leon Hooper and Todd David Whitmore, eds., John Courtney Murray & the Growth of Tradition, Sheed & Ward, Kansas City, 1996, p. 157.
12. Daniel Yankelovich, Coming to Public Judgment: Making Democracy Work in a Complex World, Syracuse University Press, Syracuse, NY, 1991.
13. Robert McElroy, "Catholicism and the American Polity: Murray as Interlocutor," in Hooper and Whitmore, p. 15.
14. J. Leon Hooper, The Ethics of Discourse: The Social Philosophy of John Courtney Murray, Georgetown University Press, Washington, DC, 1986, p. 157.
15. The homily's text .
16. U.S. Conference of Catholic Bishops, Faithful Citizenship: Civic Responsibility for a New Millennium, aashington, DC, 2003, p. 2.
17. U.S. Conference of Catholic Bishops, p. 4.
18. David Hollenbach, "Afterward: A Community of Freedom," in R. Bruce Douglass and David Hollenbach, eds., Catholicism and Liberalism, Cambridge University Press, New York City, 1994, p. 323.
19. Yankelovich, p. 215.
20. Yankelovich, p. 217.
21. Yankelovich.
22. Yankelovich, p. 220.
23. Yankelovich, pp. 224-225.
24. Hooper, The Ethics of Discourse, p. 183.
25. Hooper.
26. The Federalist Papers, Henry Steele Commager, ed., Mentor, New York City, 1961, p. 432.
27. Hooper, The Ethics of Discourse, p. 157. This very American conviction may be compared to the Thomist authorization principle, which says that the people are the ultimate judge of the king's peace.
28. Hooper, p. 158.

A Tool for Organizing Public Dialogues on Health Care Reform

Over the coming year, the Center for Clinical Bioethics at Georgetown University, Washington, DC; St. Joseph Health System, Orange, CA; and NETWORK, a Catholic social justice lobby in Washington, DC, will field test, revise, and publish a guide for organizing, hosting, and facilitating public dialogues on health care reform.

By early 2005, a well-developed resource will be available to provide everything needed to gather together diverse groups of community members to engage in meaningful dialogue on health care reform. For more information, contact Ann Neale, Center for CliQical Bioethics, Georgetown University, at 202-687-8997.

For a preview of this resource, see the March-April issue of NETWORK Connections. The issue contains, along with articles by John W. Glaser, (p. 30) and Michael Culliton and Ann Neale (p. 13), a sampling of questions that people interested in health care reform might ask of candidates for public office.