The U.S. bishops—individually, in one of their committees, or as an entire conference—frequently commit themselves to some specific political policy. Of all the questions that can be raised about such forays into legislative advocacy, the most important is this: Where is the line between moral principles, which the bishops must enunciate clearly and forcefully, and public policy, which the bishops have neither the charism nor the competence to formulate?
The problem of health care is an excellent case in point. It enables us to see fairly easily both a legitimate moral concern and the dangers of addressing that concern in a particular way. The support of the bishops for expanded health care has a long pedigree, but their specific support for federal health care under the current administration began in May with Bishop William Murphy’s letter to members of the U.S. House of Representatives. The letter was not a statement by the entire episcopal conference, but was issued by Bishop Murphy as chairman of the Domestic Justice and Human Development Committee of the U.S. Conference of Catholic Bishops. In it, he endorsed comprehensive health care for every inhabitant of the United States (including illegal immigrants).
In July, Bishop Murphy reiterated to Congress the U.S. bishops’ support for comprehensive health care to include illegal immigrants, but both Bishop Murphy and other bishops have also repeatedly insisted that abortion should be kept out of universal health care (see, for example, the bishops’ Web site at www.usccb.org/healthcare). Therein lies the gravest of many dilemmas, a dilemma which has plagued Catholic support of the federal health care effort, and which may be illustrated with a single telling example: Like all the bishops, Catholic Charities has said abortion should not be included in health care reform and yet, like many bishops, Catholic Charities also has consistently urged support for the federal takeover of health care—even though every federal proposal to date includes abortion coverage.
Matters of Prudence
Now, of course, the prudential wisdom of supporting federal health care under a pro-abortion regime is highly questionable. But this is by no means the only prudential question haunting federal health care. Who should be covered? How much coverage should they have? How much will it cost? Who should pay for it? How should it be administered? The list goes on, but there are other larger issues of Catholic social teaching as well, such as how to reconcile the principle of subsidiarity with a program that may end up totally controlled at the very top.
So what is the line between moral principles and public policy? This question has long dogged the Church in America, especially in the heady, post-Vatican II years when many bishops apparently believed that Catholic doctrine itself was in the midst of a major reformulation, resulting in episcopal political statements that were sometimes not so very well grounded in Catholic moral principles. The main issue is not whether the bishops have a firm grasp of Catholic moral principles, but whether they have a superior grasp of how effectively this or that public policy embodies those principles. According to Church teaching, they don’t. In both theory and practice it is up to the laity, formed by Catholic principles, to determine the best prudential response to various public issues.
The episcopal office does not confer any particular special insight into either the feasibility or the effectiveness of proposed public policies; nor is there any historical warrant for suggesting that, in practice, bishops as a body are better at this sort of thing than laymen. In fact, both by training and experience, one would expect politically active lay persons to have a better grasp of the art of the possible in implementing effective public policies, just as one would expect bishops to have a better grasp of Catholic faith and morals. In his landmark social encyclical, Populorum Progressio, Pope Paul VI made the distinction fairly clear:
If the role of the hierarchy is to teach and to interpret authentically the norms of morality to be followed in this matter, it belongs to the laymen, without waiting passively for orders and directives, to take the initiative freely and to infuse a Christian spirit into the mentality, customs, laws, and structures of the community in which they live. (81)
Before we can take up the prudential questions involved in universal health care, however, we need to figure out a significant moral question. What makes universal health care a moral imperative now when, for example, it was never mentioned as a moral imperative 150 years ago? How is this possible?
Social Justice and Social Change
When the Church involves herself in politics, she is wont to talk about "social justice" rather than charity. However, as Pope Benedict XVI clearly stated in his first encyclical, Deus Caritas Est, the special province of the Church is charity. It is the state which has justice as its proper end. This does not mean that the Church should not teach the principles of justice. Justice derives from the moral law, which revelation helps the Church to enunciate with unmatched clarity. But there is a blurry line between charity and justice in the public context, even when both aim at the same goal.
For example, consider these questions: Is it a matter of charity or justice that free education should be available to all citizens? Or that the poor should receive a high level of housing and food benefits? Or that health care should be free? There is no "right" answer to these questions; the answers depend very much on the social context. In previous eras, nobody would have argued that the state had an obligation in justice to provide these things. The scope of the state was utterly insufficient to the purpose, and economic conditions were such that it simply could not be expected that a very large percentage of citizens could ever have access to such benefits. But, even then, if one person denied to another person a benefit to which he was ordinarily entitled—stealing a noble’s inheritance or riding roughshod over a peasant’s right to common acreage and shared equipment—then a matter of justice was clearly present. For the rest, the charity of friends, neighbors, and the Church herself was essential to get people through difficult times.
In Western affluent mass societies, the general level of material well-being is far higher, and it is not (in theory) based on rank or class. Universal public education is a fact of life, and in a non-agrarian society education is seen as a key to making one’s livelihood. We tend to think, therefore, that everyone has a right to be educated; hence it is a matter of justice if someone is denied schooling. But we carry this only so far. That right does not apply to college or graduate school. In other words, a moment’s reflection reveals to us that issues of justice are not always absolute. Instead, many issues take on a dimension of justice by virtue of the conventions of the social context in which the issues are raised.
The most important point to recognize here is that the term "social justice" is very malleable; it is what the ancients recognized as distributive justice, and it must take circumstances into account. Thus it depends only partly on the natural law and to a much greater degree on the expectations, customs, and capabilities of the society in question. (In contrast, charity faces no such conceptual problems: It is always a personal response to another’s need out of love.)
Health care is an excellent example of how distributive justice works. The dream that all people should have access to a high level of professional health care depends on the peculiar features of particular societies: the widespread availability of competent professional care; a generalized familiarity with such care throughout the social order; a high percentage of persons already enjoying the advantages of this care; a significant understanding of public health; the advancement of medicine to the point that the difference between those who have medical care and those who do not is both significant and predictable; and of course tremendous affluence.
In other words, the dream of universal "distribution" relates closely to how distributed certain benefits already are in a particular culture, as compared with how distributed they could be if things were organized differently. In some societies, certain specific questions of distribution will not arise for the simple reason that it is not realistically possible for those societies to imagine, or understand, or manage, or extend the distributive "item" in question. With respect to health care in our particular culture, however, it is certainly possible for us to imagine, understand, manage, and extend it.
But note carefully that for this dream of the universal distribution of health care to be the proper province of the state, we must somehow translate it from the sphere of desire to the sphere of justice. Here Catholic moral teaching can play an indispensable role. One would expect that the special gift of bishops would be to articulate the principles which make a given potential benefit a matter of justice; again, this case needs to be made because there is very little absolute about this sort of social claim. Thus the bishops might suggest (as I believe they would be right to do) that the claim to health care (or any other social benefit) becomes a matter of justice in a given society when that society begins to perceive, in its own context, that health care is unnecessarily unavailable to defined groups of people who—again, in the culture’s own particular context—would ordinarily be expected to have access to it.
The example of education cited earlier may again prove useful. At a certain point in history, it became a feature of our common Western culture that the vast majority of people could be formally and academically educated. A variety of philosophical, social, and economic circumstances led to this cultural shift, and it took a very long time for the availability of education to reach anything like what we might call critical mass. Once critical mass was reached, it became the norm that all persons should be educated in a certain way (so much so that people gradually lost a great deal of personal control over the matter). Once this had happened—and not before—society was in a position to judge it an injustice if anyone was prevented from going to school. Health care is now on a similar trajectory.
The primary role of bishops is not to endorse a particular policy proposal or a particular demographic result, but to explain the various principles and related considerations which are sufficient to make health care a justice issue. Clearly, the bishops ought to be uniquely qualified to make this case.
However, the specific level of health care our culture must justly provide and the best way to provide it are not matters of principle but of socioeconomic-political judgment. In other words, while the moral imperative to extend health care can fairly easily be established in the current circumstances of the United States, the precise degree to which it ought to be extended and the manner in which it ought to be extended are prudential issues that remain to be resolved. Moreover, such issues are best resolved by laymen, under whose responsibility these issues fall. Bishops are by the very demands of their office generally unqualified to handle such issues.
After all, there are grave potential problems with any specific implementation of distributive justice in health care. Costs, quality of care, and personal liberty in determining the nature and scope of medical treatment are among the more obvious. But the very involvement of the public order in medical care raises problems of its own, just as it has in education. It has often been noted that a very large number of American bishops were reared in the social traditions of modern liberalism. Perhaps as a result, many bishops assume that if a social problem exists, the federal government must be put in charge of solving it. But he who lives by the federal government may well die by it, for the federal government is deeply involved in and supportive of quite a few grave moral evils in the realm of standard health care.
Bishop Murphy has recognized this difficulty, in his own way. Even in his initial statement he warned that "no health care legislation that compels Americans to pay for or participate in abortion will find sufficient votes to pass." But this is only another political judgment that no bishop is qualified to make. The smart money, I think, suggests that a universal medical system, if it were to pass all the other objections, would not be long subverted by such "petty" concerns as contraception, abortion, and the use of aborted embryos in medical treatments—or even by euthanasia and assisted suicide, should these become the secular norm. One needs only to consider how we have fared in keeping such things out of insurance coverage.
In any case, the main point is this: It is not at all clear that Bishop Murphy, significant numbers of other bishops, and Catholic Charities (which ought to be guided by the bishops) see abortion and related moral evils as something that would deter them from demanding that the federal government institute comprehensive health care now. Yet the same ideological values that create grave problems for the American citizenry in public education will be at work in the actual giving and taking of life in public medicine. The very first prudential question, therefore, is at what point does it become too dangerous to put health care in the hands of a government which, over the past generation, has consistently allied itself with the culture of death?
There are other prudential issues as well. It probably isn’t necessary to raise the question of costs; the public is very sensitive to cost issues at the moment anyway. But Bishop Murphy’s original statement did endorse the provision of "comprehensive and affordable health care for every person living in the United States" and later messages to Congress have emphasized the need for inclusion of illegal immigrants. This hides a hornet’s nest of questions, many of which revolve around the question of how much health care we can afford for how many. Another huge consideration is the impact on illegal immigration of ever-greater public benefits for every man, woman, and child residing on American soil. We are not talking about emergency treatment but comprehensive care and, alas, revelation does not touch upon these issues. They are, to a very large extent, prudential.
Questions of efficiency and quality are equally complex. For example, would it be unjust to allow persons of means to seek additional or better health care than the universal system provides? This would, after all, give them a social advantage. And would doctors and hospitals be permitted to provide such health care outside the system?
Catholic Medical Association
As a lay Catholic association of health care experts, the Catholic Medical Association is an important voice in the contemporary debate over health care. And the CMA sees many problems with current federal proposals, not all of which hinge on moral principles that bishops should address. In its statement on all currently available proposals in late July, the CMA argued that the entire process needed to start over, for five serious reasons:
- Inadequate Medically: Existing proposals cover the uncovered by moving them into Medicaid, a system which is already bankrupt in many states, and a system under which 40 percent of physicians cannot provide services because the payments are inadequate to cover even overhead.
- Destructive of the Private Sector and Personal Insurance Ownership: No insurance carrier can hope to compete with a proposed "public option" which can make ends meet by raising taxes or expanding the deficit.
- Ineffective Cost Control: Federal proposals seek to control costs primarily by adding bureaucratic control under the Secretary of Health and Human Services and a new "Health Choices Commissioner." Past experience suggests that bureaucratic entrenchment will increase costs while reducing patient options and patient freedom.
- Ethically Bankrupt: Proponents of federal health care legislation have proven completely unwilling either to exclude abortion or to protect the consciences of those health care personnel who oppose abortion. Where abortion enters, euthanasia and similar moral horrors will follow.
- Fails to Observe Subsidiarity: CMA points out that 85 percent of Americans already possess their own health insurance plans, giving them a profound sense of ownership in their own medical care. The Catholic principle of subsidiarity demands that higher levels of government stimulate, support and assist what can be done on a lower level, rather than destroying and replacing it.
The CMA’s conclusion:
The Catholic Medical Association supports health-care reform that increases access and quality, and respects the values of providers and patients. These goals can best be achieved by legislation that empowers people to own their health insurance policies (as contrasted with government- or employer-controlled health-care insurance), and using targeted measures to help people who cannot afford the entire cost of their insurance premium . . . In the meantime, current bills require such substantial amendment that it would be better to scrap them and start again. (Statement on Health-Care Reform, www.cathmed.org)
Morality and Policy
Again, my point is not to argue against a better solution to health care in our society. As I have indicated, I am convinced that, although the best specific course is far from clear, our society does possess the combination of characteristics which make it morally necessary to think hard about this question, and to take steps to assist those who unfairly lack health coverage. As societies grow and change, along with their resources and their methods of using resources, different questions come to the fore, and sometimes circumstances do change enough to require the application of principles of justice to new areas of life, areas in which the question of justice was quite rightly inapplicable in another place and another time. This is the nature of distributive justice.
But it goes well beyond what we can know in our current context to assert that concrete decisions about the nature and scope of universal health care can be easily reached or that one particular solution is obviously the best course. By all means, the bishops should lead a penetrating discussion of how and when certain social realities push new questions into the sphere of distributive justice (which we might also call relative justice). The bishops should apply this discussion very particularly to health care. And they should also point out clearly any absolute moral imperatives they see as critical to the discussion, such as not being forced to participate in murder.
But the bishops need to avoid expending their precious moral capital on concrete political solutions. With respect to health care and every other problem, the bishops are actually called by their office to back away from concrete proposals. Instead, having taught clearly the relevant moral principles, the bishops must then allow the laity to do their own proper job, which is the formulation and implementation of specific public policies.