BY: FR. KENNETH R. HIMES, OFM, PhD
Fr. Himes is associate professor, theology department, Boston College, Chestnut Hill, MA.
Viewed from Catholic Social Teaching, the Current U.S. Situation Represents a Moral Failure
Access to health care is a human right. That straightforward claim in Catholic teaching has been made for some time now, and it has garnered wide support from within the Catholic community.
It was in 1963, that Pope John XXIII stated, in his final encyclical, Pacem in Terris: "Every person has the right to life, to bodily integrity, and to the means which are suitable for the proper development of life; these are primarily food, clothing, shelter, rest, medical care, and finally the necessary social services."1 Pope John XXIII's claim that health care was a right by virtue of being one of the essential goods required for the "proper development of life" has been echoed on many occasions by statements of the hierarchy and by Catholic organizations involved in health care ministry.
The U.S. bishops in their 1981 pastoral letter on health care stated: "Every person has a basic right to adequate health care. This right flows from the sanctity of human life and the dignity that belongs to all human persons, who are made in the image of God."2 In 1985 the bishops initiated a "Catholic Campaign for Health Care For All," an educational and advocacy program aimed at assuring access for all people in the country to essential medical services.
For its part, the Catholic Health Association's mission statement reads: "Health care is a basic human good essential to human flourishing. The direct impact health has on one's ability to flourish is what inspires the Catholic social teaching tradition to afford proper health care the status of being a fundamental human right."3 Recently CHA joined 15 other major groups involved in providing health care to form the Health Coverage Coalition for the Uninsured, an alliance that will press the federal government to greatly reduce the number of uninsured citizens.
Of course, many people, far beyond the boundaries of Catholicism, maintain that each and every person should be provided with access to basic health care. And yet, our nation continues to ignore this conviction. It is important to recall that the language of human rights can be an exhortation and a moral appeal rather than a description of an actual legal recognition of a person's rights. Ideally, the civil law of a nation would enshrine human rights, but that is not always the case. Some human rights remain outside the realm of civil law.
When Catholic social teaching uses the language of human rights, it is speaking about a basic set of freedoms, goods, and relationships that protect human dignity and promote human flourishing. These basic rights are so integrally related to human well-being that to deny them is to undermine the dignity of the person. Unfortunately, however, not all nations have enshrined in law the basic human rights that Catholicism upholds. When human rights are violated, there may not always be a basis for legal redress in a political community, but there are moral grounds to protest the violation of human dignity.
Catholic Social Teaching on the Human Person as Sacred and Social
From whence comes the conviction in Catholic social teaching (CST) that health care is a basic human right? It may be useful to examine the rights-language of CST, to see how the tradition has come to endorse universal access to health care.
The argument for a right to health care is fairly straightforward. Human beings possess a dignity that is inalienable and rooted in the doctrines of creation, incarnation, and salvation. The book of Genesis teaches that we are creatures made in the image and likeness of God. Our dignity is due to each of us bearing within our truest self the image of the Creator who made us all. This divine image is neither earned by us nor bestowed by others. It is God's work and cannot be eradicated.
Because our faith affirms that in the person of Jesus of Nazareth the Creator and creature became one, there is also a second rationale for the dignity due the human person. The mystery of the incarnation is that the Infinite entered into the realm of the finite. When God became something other than God, the meeting place between Creator and creature was the human person. It is through the human that God entered into history. There is an essential goodness and dignity given expression in the claim that, in Jesus, God became human. Here we see another reason to honor the dignity of the human: To recall the ancient formula, homo capax infiniti, the human person is capable of the infinite.
Finally, the doctrine of salvation reminds us we are made for God. Salvation, eternal life in communion with God, is not an add-on to human experience. Salvation is not extra frosting on an already prepared cake. Salvation is not extrinsic, that is, nonessential to human beings. Rather salvation is intrinsic; it brings to fulfillment what we have always sought and hungered for throughout our lives, whether we are able to name the hunger or not. As St. Augustine famously said, "Our hearts are restless until they rest in you, O Lord." The fact that we are made for God provides a final support for human dignity: All people have a common destiny for we are all called to share in God's eternal life.
Now human dignity, rooted as it is in central beliefs of the Christian tradition, is not an idle intellectual claim. It is meant to be an experienced reality. Human dignity is not a future state that awaits us; it is what marks us even now as God's beloved creatures. Our human dignity is meant to be a present experience that we know as incarnated within creation.
Here is where CST moves in a direction that differs from many of the assumptions of classical liberalism, the formative public philosophy of American life. For John Locke and John Stuart Mill, as well as for Thomas Jefferson and James Madison, the focus was on the individual as a bearer of rights. Liberalism's great strength was the protections it secured for individual liberty when faced with the dangers of an overreaching monarch or state.
CST, however, does not hearken back to classical liberalism to support its claims about rights. Rather, it looks to the older spirit of organic community that marked ancient and medieval societies. That is, the context for rights is not the individual versus the state, but rather the individual who has obligations within a community. Rights-language within CST is best understood as a set of freedoms, goods, and relationships that must be nurtured and protected if the individual is to be able to participate fully in the life of a community. To put it succinctly, we might recall the statement of the U.S. bishops in their 1986 pastoral letter on the economy: "Human dignity can be realized and protected only in community."4
Most Americans, thoroughly rooted as they are in classical liberalism (whether they know it or not), would agree with CST about the dignity of the person. This is true even if those same people would not use the arguments that CST employs to establish the person as sacred and thus possessing dignity. But where the real divergence between CST and much of American public philosophy emerges is on the equally strong claim in church teaching that the person is not only sacred but social.
As the bishops taught at the Second Vatican Council, the doctrine of creation is also a teaching about human sociality. "For from the beginning 'male and female he created them.' Their companionship produces the primary form of interpersonal communion. For by their innermost nature persons are social beings and unless persons relate to others they can neither live nor develop their potential."5
Further support for CST's emphasis on the communal or social nature of the person can be found when examining the biblical understanding of salvation. "God did not create humankind for life in isolation, but for the formation of social unity. So also 'it has pleased God to make people holy and save them not merely as individuals, without any mutual bonds, but by making them into a single people.' . . . He has chosen humankind not just as individuals but as members of a certain community."6
According to CST, the dignity of the person requires that those fundamental freedoms (e.g., of religion), goods (basic nutrition), and relationships (to establish a family) necessary for a person to live decently in community are the domain of human rights. CST uses rights-talk to put flesh on the skeleton of human dignity, to specify what is entailed when affirming that the human person is both sacred and social.
Catholic Social Teaching and Human Rights
If one looks at the list of rights endorsed by John XXIII in Pacem in Terris or Pope John Paul II in his 1979 speech at the United Nations General Assembly, one finds a long and comprehensive roster of rights. Given the importance of health, it is no surprise that among the goods declared a human right in papal teaching is a right to medical care.
To understand CST properly it is helpful to delineate the five elements of a proper theory of human rights: the subject (who possesses the right?), the title (what is the basis for the right?), the object (what is the basic freedom, good, or relationship to which the right refers?), the range (what is to be included in satisfaction of the right?), and the term (who has the obligation or duty to secure the right?).
If we are talking about human rights, the subject is every human person. No person is to be excluded from the human community as a nonbearer of rights. That is the reason for saying that rights are inherent; they are not earned or bestowed but are intrinsic to the person. Human rights are also inalienable; they cannot be transferred, surrendered, or lost. It is possible for them to be overridden for the sake of a higher good, but this should be unusual. It must be done not by denying the existence of the right but by argument that there is a greater good at stake that overrides the right. There is a strong presumption against overriding a basic human right.
To ask about the object of the right is to inquire into the connection between human dignity and the freedom, good, or relationship under scrutiny. A danger for any human rights theory is that human dignity can become an undefined container out of which advocates can pull rights for whatever they wish. It is important, therefore, to establish how the alleged right is to be understood as necessary or essential to the experience of human dignity.
The range of the right describes the extent to which a person is entitled to a freedom, good, or relationship. For example, to support freedom of religion as a human right does not logically require one to support human sacrifice if a particular religious community practices it. Nor, to put it less dramatically, does support for a right to health care logically require everyone to be given access to a plastic surgeon for Botox injections that remove facial wrinkles. Determining what it is that is to be provided a person if the right is to be respected is the purpose of specifying the object.
Finally, the term of the right refers to the person or persons who have an obligation to satisfy the rights-claimant. Who has the duty if somebody else has the right? A given case may lead to the conclusion that a particular individual has the duty (a parent in regard to a child's care, for example), or, it may lead to the claim that a group has the duty (a municipality in regard to police protection for a city's residents, for example).
Catholic Social Teaching and the Right to Health Care
If we examine CST on the right to health care we find the following. The subject of the right is each and every person. No one ought to be excluded from possession of the right on the basis of race, gender, ethnicity, religion, or ability to pay.
The question of title or rationale for a right to health care is contested ground. Although a right to health care is widely supported by philosophers and theologians from various traditions, it is not unanimously acknowledged, and at a popular level is often opposed by various groups in American society. In CST the framework of the argument would begin with the claim of human dignity and then proceed to an examination of what are the necessary conditions for upholding that dignity. The particular slant that CST brings to the question is the situating of human dignity within the context of community. What freedoms, goods, and relationships are closely interrelated to people's ability to function appropriately in their respective communities?
Despite the best level of caregiving, there are some things that cannot be remedied; no one can guarantee health, so the object of the right is access to care. A basic level of health care allows people to function effectively in their environments. Put negatively, we can ask: Does the lack of access to basic health care frustrate and even prohibit people from flourishing within their community? The answer given by CST is that health care addresses a basic need that each person has for decent living within a particular historical community. Thus health care is a basic human good that ought to be a human right, for it is necessary to the experience of human dignity.
CST does not address the specifics that constitute the range of a right. What goods and services are to be covered by a right to health care will vary according to the resources available. Clearly there will be variations. Still, it is expected that certain public health measures and some basic medical care can be made available to all people. It is certainly the case that in the United States basic health care would include access to preventive services, some prescription drugs, mental health care, and outpatient and hospital care.
With regard to the corresponding duty to a right to health care, one ought first to distinguish between what theologians call in personam and in rem duties. The first pertains to duties that are incumbent on specific individuals to fulfill, such as claims that employers and employees may make towards each other. In the case of in rem duties, the obligation cannot be ascribed to a specific individual, but applies to all. If there is a "No smoking" sign in a lobby, each person has the same obligation not to smoke in that locale. So a right to health care does not mean that any individual can approach a doctor and demand to be examined. Nor does it mean that only health care professionals bear the burden. In rem duties require concerted action by a group. Within a given community, an agent is often assigned the task of organizing and directing the community's resources to adequately meet the obligation. The agent for large communities is often the state, at some level of government — federal, state, or local.
To establish a right to health care for all U.S. citizens, it would appear that the federal government is the necessary vehicle. The scope of the problem is so vast that smaller agents with lesser resources will likely be unable to satisfy the obligation. This does not settle the question of "how" the duty will be addressed; it merely suggests that the federal government will have to be involved in the planning and oversight, not necessarily the actual execution of the action that satisfies the right.
Other Lessons from CST
There are other themes of CST, such as the option for the poor, that must shape our understanding of a right to health care. From ancient times down to the present, there is a consistent theme within the Jewish and Christian traditions that a crucial test for any community's fidelity to God is its treatment of the poor. This would suggest that our present system for accessing health care must be evaluated by how well it serves the poor in obtaining basic care rather than assessing U.S. medicine on the basis of its ability to provide splendid care for the very wealthy.
Solidarity is another theme that speaks to the present health care crisis. Some may be indifferent to the problem of health care access. Such a mentality illustrates a problem that health care reformers must face. Our present health care system reflects our society at large. It is of a piece with the failing of our other systems — educational and legal systems, for example — in our treatment of the poor and marginal. Solidarity reminds us that there is a moral obligation to see our neighbor, even our distant and anonymous neighbor, as a human person endowed with dignity and a subject of basic rights.
Distributive justice requires that benefits and burdens of social life must be shared fairly. Distributive justice in CST is proportional; those most in need should get more, while those most capable of shouldering a burden should carry more. Any proposal for reform must be careful not to place an undue burden on one segment of society, nor be fearful of asking those who are better off to accept a higher proportion of the cost.
The theme of the common good reminds us that more than health care is needed for a community's members to flourish. A right to health care must be reconciled with other competing goods that are also essential for the common good of the community — education, housing, security, food, for example.
Finally, subsidiarity refers to the proper mix of small and large organizations. When a problem can be resolved at the local level with local resources it should be done. However, when the local agent either cannot or will not resolve the difficulty, then a higher organizational level will need to provide either additional resources or more direct involvement in addressing the problem.
A Moral Failure
Providing access for all to health care continues to be a difficult challenge for the United States. Despite enormous expenditures, this country is the only one among the wealthy industrialized nations without a health care system that ensures universal access for its citizens. According to Stephen Schroeder, former head of the Robert Wood Johnson Foundation, the best-case scenario for 2010 envisions 30 million U.S. citizens without medical insurance. A worst-case scenario envisions 65 million people lacking insurance.7 At present, we have approximately 45 million Americans without insured access to health care. Faced with these facts, and in light of Catholic social teaching, the present situation of health care in our nation can only be considered a moral failure.
NOTES
- Pope John XXIII, Pacem in Terris (Peace on Earth), 1963, para. 11.
- U.S. Conference of Catholic Bishops, Health and Health Care, November 1981, Washington, DC, pp. 17-18. For a copy of the pastoral letter and additional materials regarding the American hierarchy and health care, go to www.usccb.org/sdwp/national/health1.htm.
- Catholic Health Association, "It's Our Mission."
- U.S. Conference of Catholic Bishops, Economic Justice for All, November 1986, Washington, DC, para. 14.
- Genesis 1:27, in "Gaudium et Spes," in Austin Flannery, ed., Vatican Council II: The Conciliar and Post-Conciliar Documents, vol. 1, Costello Publishing, Northport, NY, 1975, para. 12. Here and in the subsequent quotation from church documents, I have altered the wording, but not the meaning, of the text in order to avoid sexist terminology.
- Flannery, para. 32.
- "Schroeder Reflects on the Uninsured," in Lisa Sowle Cahill, Theological Bioethics: Participation, Justice, Change, Georgetown University Press, Washington, DC, 2005, p.139. The Schroeder interview is available at the Robert Wood Johnson Foundation website, www.rwjf.org.