In the summer of 1988, after a 12-year stay in Canada, I brought my family back to the United States. Our return required no great adjustment from us—until it was time to see a doctor. In Canada, the government had paid for all necessary medical expenses, except for a deductible amount on prescriptions; so we had gotten into the habit of going for medical help whenever we needed it. In the United States we were more reluctant to go, more inclined to wait out an illness. My group insurance here, good by American standards, did not begin to cover costs until after I had paid from my personal resources a substantial deductible sum on all medical expenses. The addition of a significant cost factor distorted a decision that ideally should have been made on the grounds of need alone.
The important ethical distinction to be drawn between the approaches of the two countries to health care is not between their public and private systems. Public or private, as such, is not a Christian concern; the ethical distinction is one of ethos and motive—between health care as ministry and health care as business. In a ministry approach, the welfare of the ill, the injured, and the helpless is the controlling principle of their care. In a business approach, financial consideration is the controlling principle. As Christian citizens with a duty to shape public policy, ministry must be our style because we live under the second great commandment, to love our neighbor.
But who is our neighbor? In relation to health care, Canadians answered the question by saying that every permanent resident within their borders was a neighbor. Thus, mercy became a national priority. It did not mean—it can never mean—that there were unlimited funds available to care for people, but that the care the country could afford was accessible to all. The rich nations of the world, with the exceptions of the United States and South Africa, have come to similar conclusions.
For Canada, this answer to the neighbor question did not come easily—universal health care was, arguably, the most troubling social issue in its history. In 1947 it was adopted in Saskatchewan by the government of a Baptist minister named Thomas C. Douglas, premier of the province from 1944 to 1961, who had entered politics after seeking to deal pastorally with the hardships of western Canada during the Great Depression. In 1961, national health insurance took effect during the government of another Baptist from Saskatchewan, John Diefenbaker. Though one of these Christian leaders was a socialist and the other was a conservative, mercy was their shared priority.
A Matter Of Motive
In Canada, the health-care neighborhood encompasses the entire population. In the United States, with the exception of Medicare and Medicaid, our health-care neighborhoods are voluntary groups established by business contracts. My insurance group is not a fellowship of mercy—it is a consumer cooperative. And that’s a business!
When Jesus told about a health-care crisis somewhere on the road between Jerusalem and Jericho, he was clear that the neighbor was neither a customer nor a business partner. The merciful action of the Samaritan, as he took both physical and financial risks for the injured traveler, defined who his neighbor was; the businesslike responses of the priest and Levite defined who their neighbor was not. They ignored the victim for the same reason anyone does—they thought they could not afford to stop. Whether it was the time, the money, or the risk, they felt they could not afford it.
Our crisis in health care, though more complex than one injured traveler lying in the ditch, poses the neighbor question to us just as vigorously. Who is your neighbor in a rural community where the only hospital accessible to the elderly and disabled is shut down? Who is your neighbor in a city where the surviving hospitals are competitively searching, not for sick people, but for a share of the “health-care market”? Who is your neighbor when you belong to a comfortable, low-risk insurance group, while many in your community are uninsured or “uninsurable”? If you are a health-care administrator, who is your neighbor when you are short of nursing personnel and your overhead is escalating? If you are in government, who is your neighbor as you ponder your twin constitutional mandates to “provide for the common defense” and to “promote the general welfare”? If you are a private insurance carrier, who is your neighbor as you consider the plight of high-risk groups impossible to underwrite at today’s costs? These questions are more easily asked than answered, but the basis of the answer is clear in the story: neighborliness is defined by the ministry of the Samaritan. He was businesslike in his method, but not in his motivation.
Some will object that the issue is not motive, but limited resources. “We cannot give the same level of care to everyone with the resources we have,” they say. We are still not released from the biblical hook. The Samaritan’s example gives us no warrant for treating mercy like a marketable commodity. When there is a choice to be made because of limited resources, the ability of the patient to buy them is irrelevant to Christian ethics. The ethical questions posed—“How will our limited resources do the most good?” “Who was here first?”—painfully deal with the identity, needs, and claims of neighbors. But “who can pay?” has nothing to do with neighbors. That question doesn’t ask, “Who is my neighbor?” but “who is my customer?”
Neighbors Or Customers?
The idea of the patient as customer is relatively recent. For a thousand years or so, hospitals did not have customers. The continuous history of the hospital movement in Western civilization began when the monasteries and cathedrals of medieval Europe established hostels for the indigent. Though they did not much resemble modern hospitals, they were for the poor, and they were free. Not until the nineteenth century did hospitals start renting space to private patients. Increasingly, hospitals were transformed from refuges for the poor to conveniences for the middle class. During the same period, no doubt in part because of their new revenues, they developed into the efficient healing institutions we know today.
Today, health care as ministry obviously does not mean a return to the appalling conditions that accompanied eighteenth-century charity. Its performance did not match its intention. We must reach much further back for our example, to Jesus, who commands us to love our neighbors as ourselves—to offer mercy to others just as we would wish it for ourselves.
One way or another, changes will cost us. No ministry pays its own way; that is why it is a ministry. Let’s take one group as an example—high-risk people who are not old enough for Medicare or poor enough for Medicaid. For them to be served, their risks must be spread among very large groups of people; so we lose the personal advantage of our low-risk, low-cost group. Or perhaps Medicare must expand to include them; so taxes will go up. Or a charitable trust must be established to underwrite their care, occasioning the largest single fund drive in the history of the nation. The hospitals, health-care professionals, insurance carriers, and the government could cooperate for the welfare of people rather than compete for the available dollars in the system; so prices and taxes would both go up. (Twice in recent months I have seen people sent home from the hospital, not because discharge was medically indicated, but because their Medicare coverage had expired. If there is cooperation—or collusion—now, it is not always for the welfare of people.)
Better suggestions may be forthcoming, but they won’t necessarily be cheaper. It is time to face them. After all, the population of the world is our true neighborhood; if we cannot confront the limited problems of a rich nation, who will ever confront the massive problems of the world’s poor?
When mercy becomes a business, giving only some people access to basic services while others are denied for no better reason than lack of money, it stinks of privilege. And when anything stinks, it is a summons to change.
