What Catholics should bring to the health-care debate.

There were high expectations for healthcare reform in 1995. Sixty years after the 1935 Social Security Act and 30 years after Medicaid and Medicare legislation was passed in 1965, many thought 1995 was the year when Congress would guarantee adequate medical care to all Americans. Unfortunately, this legislative triad of social-policy reform failed to be resolved last year, even though healthcare reform remains one of the most popular topics in private conversation and in the public forum.

It is safe to say that over the past few years most of us aided by infomercials, headlines, and personal experience, have had to reflect on some of the following questions:

* Could a change in employment make me one of the 37 to 40 million Americans who have no health insurance and who stand one illness away from bankruptcy?

* How can I make sense out of all the perplexing bills received from doctors and other providers?

* Can our current system sustain such high malpractice awards and justify such huge attorney fees?

* Why are health-care costs increasing at twice the rate of inflation?

* Is it right that executives of health-care systems earn exorbitant salaries when health care is not accessible to so many people?

* Should I transfer my assets over to my children so that I will be eligible for public funding when I need nursing-home care?

* How can I afford all these expensive medicines the doctor prescribes and still take care of all my other obligations?

* How do I choose the best health-care plan from my employer's benefits menu, which is so confusing with its various options, copayments, and deductibles?

* How do I make decisions about continuing treatment for my spouse or family member in this difficult situation?

These questions, faced by many Americans, assure that health policy will remain a critical public and private issue for some time. Health-care reform did not fail in 1995 from lack of interest of the new GOP majority--the bills had stalled in Congress well before the midterm elections. It failed because of its innate complexity, political polarizations, and a phalanx of special-interest groups in Washington, and it will continue to elude resolution until some very basic philosophical issues--such as those mentioned above--are raised and discussed.

Let's talk it over

Both the 1935 Social Security Act and the 1965 Medicare and Medicaid legislation received bipartisan support, but their passage demanded hours of open-minded discussion of basic moral and societal, as well as economic, issues. Health-care reform calls for even more rigorous study and greater dialogue, if we are to come up with a policy that respects the individual person while achieving the common good, delineates state and federal responsibilities, and recognizes economic realities.

It will take Congress a few years to resume the debate on health-care reform, but dramatic changes are occurring at the regional and state levels. We need to take time to think about some basic philosophical issues--which are at the core of both health-care and welfare reform--and work toward reaching a consensus. This task is formidable in our society, which is becoming more accustomed to making decisions on information gained from 30-second sound bites and the prospect of immediate economic gains. The consistent ethic articulated in and emphasized by the church should encourage Catholics to assume leadership in thinking through this challenging contemporary issue.

Our country lacks a coherent, consistent national health policy to guide legislative activity. We have rather a series of unrelated policies, many of which are conflicting, if not contradictory. While the Eisenhower Commission articulated a "right care"--and Medicare and Medicaid were developed on that premise--subsequent presidential commissions have avoided describing health care as a right.

Know your rights

Recent commissions have preferred to talk about "a societal obligation to provide access" to care. A subtle but substantive shift occurs when a right of an individual is replaced by a responsibility of an undefined "society" with competing interests and demands. Pope John XXIII included the right to medical care in his catalogue of individual human rights in Pacem in terris (1963). The U.S. bishops have always insisted on a right to necessary care, from "On Social Reconstruction" in 1919 to their current criteria for judging health-care reform proposals. The Catholic Health Association also included the right to health care in their reform proposal, "Setting Relationships Right: A Working Proposal for Systemic Healthcare Reform."

Historically, health-care legislation has failed when there is no common philosophy to guide it. There are many examples, but two relevant ones are the passage and then revocation of the federal Catastrophic Health Care Bill and the state-initiated Driver Safety Belt/Helmet laws. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, formed in 1979 and dissolved in 1983, strongly urged that efforts be made to identify the universal ethical principles that should inform health-care decision making in this country. The commission recognized that the traditional moral consensus existing in this country had been unraveling since the 1960s.

The current administration sought to address this by presenting 14 value statements and several criteria with its recent reform proposal. However, no hierarchy of values was established, and the statements that were deemed nonnegotiable varied at different times. Over the past year, several medical ethicists have pointed out that while patient autonomy (What does the patient want?) has traditionally been the principal value directing healthcare decision making, it is quickly being replaced by financial feasibility (Can we afford what the patient wants or needs?).

What's it worth?

We have to consider economics--particularly as we seek to reduce the national debt--but numbers alone thwart effective policy-making because they drive us to short-term objectives, not long-term goals. Health, more than most human goods, suffers from this approach.

We tend to talk about health-care reform in an intensely personal manner. Stories about how individual people are receiving medical treatment carry far more weight than objective research. It is easy to accept reasonable standards of care and the declaration of "clinical futility" in an abstract case study, but not easy when the situation is personal.

Self-interest and protectiveness can hinder a rational approach to health-care reform, however. Choice of provider, especially one's physician, has become a real sticking point for many. People living on fixed income want to be certain that their total health-care expenses will be capped at a reasonable percentage or actual dollars. People with chronic illnesses want assurance that long-term care will not pauperize their families if they are forced into institutions.

Small-business owners inveigh against the employer-mandate provision, which they claim will erode their bottom lines and destroy private enterprise. Larger corporations, including some health-care providers conducting business in several states, express concern about the administrative burden of diverse state regulations. Younger citizens worry that their standard of living will be eroded by seniors' demands, and some predict intergenerational conflict. Finally, many individuals and institutions rightly demand assurance that their contributions will not find their way into revenue streams that fund procedures such as abortion or nontherapeutic genetic engineering. Regional self-interest also must be acknowledged because the views of residents of Miami, New York, and Los Angeles, with their large immigrant populations, diverge greatly from those of people in Little Rock and Anchorage.

Those beginning serious discussions on health-care reform need to recognize some very basic realities. First, health and medical needs are not neatly distributed across the population. In addition to genetic inheritance, studies show that health is directly related to education, which is related to economic status. In other words, the poorer and less educated a person is, the higher the probability that a person will have greater medical needs and will consume a disproportionate amount of health-care resources.

Is supply determining demand?

Older Americans are also consuming a larger proportion of medical resources. Some studies show that 10 percent of our population may account for as much as 70 percent of our health-care costs, with just 1 percent accounting for 10 percent of the total costs. Health care is not like dietary or shelter requirements, which can be established within reasonable parameters for all persons.

Second, our medical-industrial complex has cultivated an insatiable appetite for medical technology, a preference for specialization over generalization, and a penchant for complicated corporate structures in both the nonprofit and profit sectors. Expectations have been molded and stretched beyond limits in the Madison Avenue school of instant pain relief and the attitude that any problem can be fixed. Just because we can do something does not mean we should do it. This, of course, requires major adjustments in medical liability, which is driven in great part by defensive medical practice.

These two factors--need disparity and high expectations--tend to frustrate reformers, but they also point to another dimension of health-care reform that must be faced. Are we addressing the right issue in our reform efforts? Despite some very serious clinical and financial problems in our contemporary delivery system, medical care in our country is quite good, and preventive care is yielding health profits despite the dire predictions that the prevention gains of the 1980s are in regression.

However, we cannot be as sanguine about the social and moral health of our nation. Solutions must be found for drug abuse, violence, sexual promiscuity, adolescent pregnancy, and fractured families. These cause moral pain and societal devastation, but they also contribute significantly to spiraling health costs and must be factored into discussions of health-care reform. It is encouraging that there appears to be a growing readiness to replace the medical model of human services with a social model.

The traditional medical model concentrates on the physician and the hospital and focuses attention on curing illness and disease. The social model focuses attention on disease-prevention and stresses wellness in a holistic way. Historically, the greatest gains in health status in this country have not been the result of individual medical interventions but public-health initiatives, environmental improvements, and personal lifestyle changes.

A social model seeks to address the systemic issues as well as personal needs through such means as vaccinations and stress management. This shift from the medical to social model does, however, raise monumental organizational and philosophical questions about the right of the human person and the society and the state.

Handle with care

Health-care reform in this country will also be made more difficult by the policy patchwork across the nation as states initiate reform, particularly with the Medicaid population. One must dismantle and rearrange the current health system with great care because we are speaking of an essential community service of great economic importance. Now is the time to do more thinking than acting, and this thinking must focus on basic convictions and long-term objectives about the human person and state responsibility.

Nineteenth century French statesman and author Alexis De Tocqueville described the American challenge as the struggle to relate liberty and equality, individual rights with the common good. This is a task for thinking people first, pragmatic politicians second. The current tension between the rights of the individual and the obligations of the federal and state governments is healthy and creative, but it demands rigorous reflection, respectful dialogue, and consensus development if health-care reform is to be passed and implemented successfully before the millennium.

The next step

The church has a well-defined, consistent, and coherent ethic that integrates moral and social values and provides full or partial responses to these questions. The church's carefully articulated and nuanced statements on the dignity of the human person, provision for the common good, religious freedom, the importance of work, participation in government, human community, and human solidarity are starting points for gaining readiness for reform.

It is imperative that Catholic groups measure health-care reform proposals through the ethical lens of humanity, stewardship, and responsibility, rather than through the shifting focus of economic constraints, technical designs, and personal interests. It will take wisdom and courage to build a health policy that balances the rights of the individual and the common good. This task is upon us even if we don't yet know how the reforms will proceed.

Such "light to know and grace to do" comes only from deep study and reflection and efforts to form consensus before framing policy or advancing proposals. Because some of these same values and issues will be relevant in discussions on comprehensive welfare reform, such philosophical reflection and dialogue now is really a double investment in the future of our country.

Haste now could waste a great deal beyond opportunity, so let's take time out for thinking.

RELATED ARTICLE: Ten questions to ask about health care

1 Is health care a social good or a consumer good? Can it be both? There is genuine ambiguity about whether the individual, the government, the market, or society in general should assure access to and provide health care. While the cries of "socialism" are heard at varying decibel levels, attacks on the "commercialization" of health care are equally vociferous. The voice of moderation speaks of "managed competition," which seems to be an effort to have it both ways and exhibits the weak points of such a compromise.

Should health care be a public service available to aU or should it be a commodity subject to the market forces? Should any basic human need be conditioned by the profit motive?

2 Is there a right to health care? Should this be considered a legal right, such as the current court-created right to emergency medical care, or is it a moral expectation? Some legislative proposals prefer the language of "universal access" and "universal coverage," two distinct terms and concepts that are often used interchangeably.

Many would ignore talk about rights and suggest that financial barriers are the only ones limiting both access and coverage, but the barriers to health care and medical care range from geography to language, from culture to transportation. If there is a right to health care, who bears the responsibility to remove the barriers and assure access? Should that access be equal or equitable?

3 Should health care be a benefit tied to one's employment status? Personnel trends suggest that this yoking, which has caused job lock, lapses and inequality in coverage, and unfairness in taxation benefits, may no longer be appropriate. Corporate America continues to downsize and encourage early retirement, while social scientists remind us that in a lifetime one will not only change jobs five to eight times, but will also change careers several times. Many people see health care that is offered strictly as an employment benefit as inherently unjust.

4 What health and medical benefits must a society or its government assure its people? What should be included in the basic package available to all? Is there a floor of benefits below which no one can fall? This is a critical question of distributive justice and requires careful delineation of what is necessary and what is appropriate.

There is a large area between what must be included as basic and what can obviously be excluded as nonessential or cosmetic. This question also includes the complex decision making required to determine what in any given case is "clinically appropriate" or "medically futile." This is the crux of medical ethics now that patients' individual needs are being challenged by the broader social question of allocation of medical resources nationally as well as globally.

5 Can we hold people responsible for their health behaviors, and can the right to health care be revoked or qualified? Can a health-care provider, insurer, or the government impose punitive sanctions on people who abuse drugs, who freely choose poor nutrition, or who are obese, smoke, or persist in high-risk activities? Could certain procedures be denied individuals because of their lifestyles, and who would make such determinations? How would genetic and environmental factors be incorporated into such decisions?

6 As economic resources decline and expectations rise, what ethical principles should guide the presumably inevitable rationing? The question is extremely important in our litigious nation, which also has the advanced medical technology to extend life beyond what was possible even a year ago. The 1990s opened with a flurry of activity over the Patient Determination Act and Advanced Directives as well as with renewed efforts by the Hemlock Society and Dr. Jack Kevorkian to legalize euthanasia.

The ethicist Daniel Callahan has proposed, along with former Governor Lamm of Colorado, that age, rather than an individual's social value or quality of life, should serve as the criterion for the rationing of care. In some nations, the unofficial cutoff age for more sophisticated therapies is age 55. Oregon's recent implementation of a rationing system based on medical efficacy and economic resources raises many ethical questions. As work on the Human Genome Project continues and carriers of "expensive disease entities" are identified, these questions will increase in number and ethical importance.

Here particularly, the rights of the individual and the good of society or the values of liberty and equality will come into conflict. Standards need to be developed within a moral framework even now while health-care reform is being discussed. Who should have the power to make such life-and-death decisions for the individual and to assign priorities for the nation? This question of rationing also raises the global stewardship question of national restraint and international responsibility.

7 Because the administrative costs in health care escalate as the diversity in health-care-insurance plans increases, should not the single-payer option get more attention? A single-payer system eliminates underwriting and marketing costs and assures community rates, but many label it socialistic and fear that health care would be subject to bureaucratic inefficiencies. Some ethicists say that the single-payer model best fulfills a sense of distributive justice, so the trade-offs gained by multiple financing and payment sources need to be carefully analyzed.

There is a related ethical question that is not getting sufficient attention. Does the merging of the delivery of health care with the financing of health care within one entity or in mutually dependent entities--as is the case in most managed-care arrangement--create a serious conflict of interest? Are we replacing the temptation to overtest and overtreat, which was inherent in the indemnity insurance model, with the temptation to undertest and undertreat?

Does each approach emphasize economic interests (frequently those of investors and providers) at the expense of patient concerns?

8 What is a reasonable percentage of a nation's economy to be assigned to health care? Most people say that our current 14 percent is too high, but those judgments are based principally on comparisons with other nations where there are significant variables. How do economists, social scientists, health providers, political leaders, and, yes, philosophers collaborate to develop standards? These standards need to include the ever-broadening parameters of health care, our unique national demographics, and the fact that the medical field is labor-intensive and increasingly highly specialized and technologized.

9 Who will have the oversight power for the provision of health care, the educational preparation and distribution of providers, and the maintenance of medical records? Will the traditional preference for self-regulation be permitted, or will politically appointed boards assume a greater federal and regional role? Is there a danger that personnel distribution and fiscal constraints win curtail freedom of vocational choice and open the door to abuse of administrative power?

Will privacy rights be violated on the information highways? Does health care, like education, demand a pluralistic system of oversight and providers to assure the rights of the individual?

10 How will consciences, both personal and institutional, be respected in the various reform proposals? Will individual and private facilities, particularly those with more restrictive moral codes, be protected against elimination or marginalization because of their unwillingness to provide certain services?

Will Catholic institutions maintain the right to determine what services they will offer and not be pressured by communities or regulations? Will the religious convictions of individuals and corporations be respected?

RELATED ARTICLE: A Sign of hope

The following is an excerpt from "A Sign of Hope," a pastoral letter on health care by Cardinal Joseph Bernardin of Chicago.

Several months ago, I decided to write this pastoral reflection on Catholic health care to bring together several of my concerns and to give some direction to health-care ministry in the Archdiocese of Chicago. However, before I was able to begin the project, I was diagnosed with pancreatic cancer. After surgery at Loyola University Medical Center in Maywood, Illinois, and a brief period of recuperation, I underwent nearly six weeks of radiation therapy and chemotherapy.

Now I return to this project not only as a bishop with an abiding interest in, and commitment to, Catholic health care, but also as a cancer patient who has benefited greatly from this competent, compassionate care in the model of Jesus the healer.

When I entered the Loyola University Medical Center last June, my life had been turned completely upside down by the totally unexpected news that what I had been experiencing as a healthy body was, in fact, housing a dangerous, aggressive cancer. The time since the diagnosis, surgery, and postoperative radiation and chemotherapy has led me into a new dimension of my life-long journey of faith.

I have experienced in a very personal way the chaos that serious illness brings into one's life. I have had to let go of many things that had brought me a sense of security and satisfaction in order to find the healing that only faith in the Lord can bring.

Initially, I felt as though floodwaters were threatening to overwhelm me. For the first time in my life I truly had to look death in the face. In one brief moment, all my personal dreams and pastoral plans for the future had to be put on hold. Everything in my personal life and pastoral ministry had to,be re-evaluated from a new perspective. My initial experience was of disorientation, isolation, a feeling of not being -at home" anymore.

Instead of being immobilized by the news of the cancer, however, I began to prepare myself for surgery and postoperative care. I discussed my condition with family and friends. I prayed as I have never prayed before that I would have the courage and grace to face whatever lay ahead. I determined that I would offer whatever suffering I might endure for the Church, particularly the Archdiocese of Chicago. Blessedly, a peace of mind and heart and soul quietly gooded through my entire being, a kind of peace I had never known before. And I came to believe in a new way that the Lord would walk with me through this journey of illness that would take me from a former way of life into a new manner of living.

Nevertheless, during my convalescence I found the nights to be especially long, a time for various fears to surface. I sometimes found myself weeping, something I seldom did before. And I came to realize how much of what consumes our daily life truly is trivial and insignificant. In these dark moments, besides my faith and trust in the Lord, I was constantly bolstered by the awareness that thousands of people were praying for me throughout the Archdiocese and, indeed, the world. I have been graced by an outpouring of affection and support that has allowed me to experience ecclesial life as a "community of hope" in a very intimate way. I have also felt a special solidarity with others facing life-threatening illness.

I have talked and prayed with other cancer patients who were waiting in the same room for radiation or chemotherapy. I have been contacted by hundreds of people seeking my advice and prayers on behalf of family or friends suffering a serious illness, often cancer. . . .

Life in the midst of chaos

People who are ill sometimes speak of being attacked and ravaged by a disease that slowly but inexorably conquers them. They may even speak of their own body betraying them, as they begin to lose control of simple bodily functions, or become weaker, frailer, and more dependent on others. Illness can bring people to question if God has punished or abandoned them. Recently, a 13-year-old girl who has cancer asked her parents "I go to church every Sunday, an many of my classmates don't. Why d I have cancer, and they don't?"

We begin to ask: How can we live with Alzheimer's disease, cancer heart disease, a disability, or an HIV related disease? A life of illness o disability may seem to be, for the ones who are ill and/or for those who care for them, virtually impossible to live. And in this desperation some seek a solution in euthanasia or assisted suicide. The question that believers and nonbelievers alike have often faced is: How can I continue to live like this?

None of this is new. Believers through the ages have faced the desperation that sometimes accompanies the chaos of illness and suffering. The many laments in the Book of Psalms give eloquent expression to this pain, panic, and desperation. However, the laments also express a firm belief in the power of God to make it possible for us to live our lives despite the chaos. The first chapter of Genesis lays the foundation for this comforting reminder that God's creative activity includes the promise that we are able to live our lives' even in the face of the chaos of illness and death. God's promise of life is the basis for Christian hope. . . .

As Christians, we are called, indeed empowered, to comfort others in the midst of their suffering by giving them a reason to hope. We are called to help them experience God's enduring love for them. This is what makes Christian health care truly distinctive. We are to do for one another what Jesus did: comfort others by inspiring in them hope and confidence in life. As God's ongoing, creative activity in the world and the love of Christ make it possible for us to continue to live despite the chaos of illness, so too our work in the world must also give hope to those for whom we care. Our distinctive vocation in Christian health care is not so much to heal better or more efficiently than anyone else; it is to bring comfort to people by giving them an experience that will strengthen their confidence in life. The ultimate goal of our care is to give to those who are ill, through our care, a reason to hope.

Let's hope

Our witness to hope is increasingly important in today's commercialized health-care environment. There are strong economic pressures to pursue income at the expense of the patient and, in fact, to reduce the patient to a commodity. In this context one of the ways in which we witness to Christian hope is through fidelity to our charitable mission within the healthcare industry. Our primary service to those who come to us cannot be for sale. We can sell pharmaceuticals and surgical services, it is true, but these are secondary. Our distinctiveness cannot be turned into a commodity and sold. The moment we shift our motive to one of profit, we will, in fact, undermine our primary mission. Few will find hope in God's love for them if others make a profit from such care.

More importantly, we must recognize the absolute necessity of being present as a community to others in their need if they are to gain confidence in life. Human life is not meant to be lived in isolation. To be fully human, we must live in community. It is very important that a person who is ill have others with whom to communicate. Those who are ill experience God's enduring love for them through the loving care and concern of the Christian health-care community. We also serve as a community of conscience for the rest of health care.

We are also to give people an experience of God's enduring love for them through a nonjudgmental approach to illness. We do not make a theological or moral distinction between health and sickness. We do not, as jesus did not, suggest that illness is a punishment for sin (John 9:2-7). Our nonjudgmental welcome of the person who is ill, like Jesus' nonjudgmental welcome of the Samaritan leper (Luke 17:11-19), gives people an experience of hope by delivering them from the isolation or abandonment that the sick fear most. A judgmental attitude toward illness and disability cuts people off from community and erodes or even destroys hope. Our hospitality saves people from such isolation. Like Jesus, we strive through our hospitality to give people the strength, comfort, and consolation of hope.

We seek to do more than simply cure a physical illness. Like Jesus, we heal the whole person. We care for people in such a way, that, whether or not we can physically cure their illness, they find strength and comfort in knowing God's abiding love for them, despite their experience of chaos.

By Sister Margaret John Kelly, D.C., a professor at St. John's University in Jamaica, New York and former vice president of the Catholic Health Association.