Bioethike

My week four submission to Creighton University:

A state which is not governed according to justice would be just a bunch of thieves.
Augustine, De Civitate Dei

Strip away acrimonious speech, political grandstanding, and the now infamous August “town maul” meetings and what do you have? Health care. At least a national debate about health care, a conversation the United States has been having with itself for over forty-five years but, as of late, one that has become inflamed with red-faced urgency and white-hot passion.

You see, we’re running out of time. And money. And more and more people are hurting.

Regardless whether we want to face it or not, this unenviable and unfortunate trifecta is an occasion to which history is now asking us to rise. Medicare, primary insurer of persons over 65 years of age in the United States, will be insolvent in less than ten years. Many beneficiaries survive on modest incomes. Although there is some disagreement as to the number, approximately 45 million people, or seventeen percent of the general population, lack health insurance. Eleven percent of children, many of them already burdened with attendant poverty and educational issues, have no coverage. Poor parents whose children benefit from Medicaid coverage may not qualify for insurance themselves. Medicaid itself is strained, having taken on numerous new enrollees due to the recent economic downturn.

And even those who work and who dutifully contribute towards an uncertain and unhealthy future hopefully ameliorated to some degree by Medicare, may find themselves or their dependents without coverage now due to preexisting conditions or as the result of changing jobs. Even if they are covered, they may face their claims being denied when their insurance company, tired of doling out yet more cash for expensive and in their view unnecessary medications or treatments, decides to call it quits.

It makes one pine for the good old days of health care. Say, the days of Dr. Quinn, Medicine Woman.

Although the television show idealized life in 1860’s Colorado, it is not incorrect to surmise that there was a different spirit then when came to dealing with one’s neighbor and his or her needs. When Johnny broke his arm or when Lou Ellen was experiencing difficult labor, Dr. Quinn was there tending to the situation and using her education, experience, and perhaps even creative ingenuity to provide the best care possible. And payment? Of course, there were no forms to fill out and no faxes to send, but Dr. Quinn had not entered the profession to make money. Cash up-front if you had it. If not, pay a little bit a month. And if no cash were available, a chicken would suffice. Dr. Quinn knew that there would be those times, too, when she wouldn’t be paid at all. Naturally, those where the days when neighbors would raise a barn after lightening had struck and burned, when loose cattle would lead to the ringing of a neighbor’s bell, and when renegade thieves making their way through town made hands–both men’s and women’s–reach for their guns.

That all-encompassing sense of justice, of neighbor helping neighbor, of realizing the intricate web of relationships and the connections of individuals and institutions required to make a flourishing community has not, I believe, been lost. Although there are numerous theories of justice treating health care issues such as what we are dealing with today, the vision of social justice by Madison Powers and Ruth Faden come the closest, in my opinion, to offering some insights as to whether current US health care system satisfies the needs of justice.

In Social Justice: The Moral Foundations of Public Health and Health Policy (2006), Powers and Faden present six “irreducible dimensions” of well-being: health, personal security, reasoning, respect, attachment, and self-determination. For the purposes of this brief paper, I would like to touch briefly on two of the them here: health and attachment.

Powers and Faden “work with what is essentially an ordinary-language understanding of physical and metal health that is intended to capture the dimension of human flourishing” (17). Universal access to health care is related not only to the positive effects such access provides, but also to what a just society considers “necessary for being respected as a moral equal” (18). In other words, there is more to justice than simply access to what any individual in society needs. Needs are comprehensive and interrelated, therefore care should be comprehensive and interrelated. Otherwise, we are not treating all people as equal, which is a definitive American virtue.

Powers and Faden also note attachment as an irreducible dimension of well-being. For them, the attachments we experience as human beings is not only important to us as individuals, but they “also are prerequisites for the formation and perpetuation of a just society” (24). Powers and Faden’s holistic, non-ideal approach to the need for and the benefits of human connectedness comes far closer to encompassing the American ideals espoused not only in the Old West, but still today. For example, Medicare and Medicaid were established in 1965 in order to care for some of the most vulnerable people in our society: the aged, the infirm, and the destitute. The desire to care for others is glue, if you will, that goes to bind people together. Knowing that someone has got your back when the chips are down encourages cohesiveness and mutual support.

Which brings us back to the current debate about health care. If we weren’t concerned about justice, we wouldn’t be having it. Call it what you will–justice, fairness, equality–in the end it all means the same thing. Either we work together and support one another, making concessions for our most vulnerable members, or we don’t. And those concessions require sacrifice. They always have. The American health care system is just in the sense that is working for some, and in the sense that we’re working to make it better. But it is unjust in the sense that it is not working for others. We have only a few years left before our current means of caring for our neighbor may be beyond repair. And stories abound about human suffering in a system that is supposed to relieve human suffering.

So, let me ask you this. Would you pay for part of Johnny’s cast, or give an extra chicken to Dr. Quinn to cover for Lou Ellen’s baby? If not, why not? Because if you say no, then I’ll begin to wonder if justice hasn’t left our little Colorado town to just a bunch of thieves.

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Sources:

Augustine, De Civitate Dei, IV, 4: CCL 47, 102. Quoted in Deus Caritus Est (2005) http://www.vatican.va/holy_father/benedict_xvi/encyclicals/documents/hf_ben-xvi_enc_20051225_deus-caritas-est_en.html (accessed September 24, 2009)

The Henry J. Kaiser Family Foundation, “Health Insurance of the non-Elderly Population” (2007) (provided)

The Henry J. Kaiser Family Foundation, “Medicare: A Primer” (2009) http://www.kff.org/medicare/upload/7615-02.pdf” http://www.kff.org/medicare/upload/7615-02.pdf

The Henry J. Kaiser Family Foundation, “Medicaid: A Primer” (2009) )http://www.kff.org/medicaid/upload/7334-03.pdf” http://www.kff.org/medicaid/upload/7334-03.pdf

Powers, Madison, and Faden, Ruth. Social Justice: The Moral Foundations of Public Health and Health Policy. (New York: Oxford University Press, 2006)

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