Of Means and Ends: The Financialization and Regulation of Health Care

There is a truism in business that states that whoever pays and measures dictates what is going to get done to whom and by whom. Unfortunately, this truism in business has become applicable to medicine. But medicine is a profession, not a business. As the great physician and Catholic thinker Sir William Osler taught,

The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.

I find it interesting that much of the debate about health care has focused on the choice between public or corporate solutions. My problem with that debate is that it serves up a false dichotomy, and imposes a Machiavellian solution. The false dichotomy is that we are only considering the two strongest players in the market:big government and large corporations; but not the actual protagonists: the doctors and the patients. The real question is not what solution caters best to the most powerful, but what solution produces sustainable human flourishing and contributes best to the common good. The Machiavellian aspect arises because the two strongest players are defining the rules and splitting the spoils. The government apparatus grows more powerful and mega-corporations flourish. Stating the problem as a dichotomy guarantees that these two would win either way. Human flourishing is not considered and is the de-facto loser.

In September 2004, the Catholic Medical Association (CMA) published a Catholic proposal for renewal of health care in America in which it stated,

the crisis in American health care … is a crisis afflicting the patient-physician relationship, which has been eroded by factors that include the financing of health care, but that are more properly understood as having their root in the loss of a common understanding, within and without the medical profession, of the sanctity and inviolability of each human life. (CMA 2004)

Pope St. John Paul II wrote in his March 25, 1995, encyclical Evangelium vitae, “A unique responsibility belongs to health-care personnel: doctors, pharmacists, nurses, chaplains, men and women religious, administrators and volunteers. Their profession calls for them to be guardians and servants of human life” (John Paul II 1995, no. 89). Yet in the twenty years since he penned those words, for the first time in our history, Catholic hospitals are being pushed out of their independence, most markedly where life issues are concerned, both financially and in terms of their decision rights over what procedures to perform. Doctors are being used as a means to an end, rather than being able or even encouraged to follow their calling. The medical profession in America is clearly in crisis.

Just think of the state of individual physicians in our country. According to the Catholic Health Association,

Physician burnout is widespread … a study published in September 2009 in The Journal of the American Medical Association [found] up to 60 percent of primary care physicians reported symptoms of burnout, including emotional exhaustion, a low sense of accomplishment and a feeling they were treating patients as objects. [More recently the same journal] published a report based on 50 years of peer-reviewed studies that concluded nearly one in three medical students and newly minted doctors experience depression. Another paper on physician depression, this one published in Medscape in July [2015], said reliable estimates are that about [300 to] 400 physicians commit suicide each year [in the United States]. (Vandewater 2016)

Adding to the stress of the vocation, with the advent of government and large corporate controls comes the reporting and command structures that render not only the physicians but all hospital staff a means to an end. The reporting structures and requirements are so vast that they disrupt organic patient relationships and substantially interfere with the full flourishing of doctors. Even if the end were superior health, this would still be a blatant violation of human dignity. The center of the doctor/patient relationship moves to the government/corporate relationship. The truth is that the end goal is accumulation of power. On the one hand is power of government, and on the other power of corporations. The system is unjust:

to patients because they are de-personalized; and

What is a better solution? I cannot recommend a particular solution. I am not a healthcare expert. I am a Catholic business executive with experience in management and ministry. With this paper, I merely attempt to point out what a constructive debate should be built upon.

It is important to begin, as St. Thomas Aquinas counsels, with a correct understanding of the issue since “a small mistake in the beginning is a big one in the end” (Aquinas). Health care is a prime example of how solidarity and subsidiarity have to have interplay in order to produce a just result. On the one hand, those who are healthy treat, or contribute to the treatment, of those who are ill. On the other hand, we want to provide personal freedom and allow the doctor/patient relationship to have the flexibility to create the most effective treatments and solutions. The two principles are in tension with each other, but that tension is exactly what allows us to come up with a just and adequate solution. Health care also tests our commitment to human dignity, work, the poor, and the family. It is in fact a true laboratory for Catholic social doctrine.

I suspect that following these teachings is exactly the reason for the past success of Catholic health care: Catholics are involved in this field as a means to affirm human dignity. History counts many Catholic physicians, both lay and ordained, who in solidarity with the suffering selflessly gave their entire work life to the advance of medicine. Catholic medical care has an excellent record in terms of balancing service and profit, often serving the poor with the surplus created from serving the wealthy. Doing well by doing good works only when we practice subsidiarity; it is the local solution that allows each doctor to meet the needs of every patient. Once-size-fits-all solutions end up fitting no one. Solidarity (common resolve for everyone) works when it engages localized solutions. It is what the Church calls the pastoral approach. It is not easy, but well worth the effort.

Health care is not like car insurance. Specific physicians treat individual patients. Medical insurance must conform to that relationship, never hinder or obfuscate it.

In our discussion about health care, we tend to forget that the doctors are the key “workers” of their field. It is their vocation that allows patients to recover and heal. This is summed up most beautifully in the Book of Sirach:

Honor the physician with the honor due him, according to your need of him, for the Lord created him; for healing comes from the Most High, and he will receive a gift from the king. The skill of the physician lifts up his head, and in the presence of great men he is admired. (Sir 38:1–3)

To consider how to flourish at work, let us take a step back and think about our vocation to work in general. God is a worker. The first fact about God that we learn in the Bible is that He is creative. He conceived of and formed the world out of nothing. Then He made humans. He says that He wanted to make them in His image: a subject (as in protagonist), immortal, a worker. This is where we find the primary purpose of our work: God invited us to participate in His creative power. Every time we go to work, we accept that invitation and in fact, imitate God. This is how Saint John Paul II can say that when we work, we do not just make more, but we become more. Work makes us more fully human. Work is a path to holiness.

This is important because we instinctively seek meaning in our work. We seek meaning not just in a “noble end,” something greater than ourselves. We also crave meaning in the actual process, in what we actually do to achieve that noble end. There should not be a dualism between the process and the end, a struggle between the physical work and the idea being pursued—the objective and the subjective meaning of work—treating the patient and healing the patient. If we separate the two, we end up with either a purely utilitarian view of our work (efficiency and profit driven), or with a relativist condemnation of higher ideals (healing only some chosen ones). For human flourishing, we need both a noble end and a dignified process; we cannot find meaning without both.

Successful solutions lead through innovation and human excellence—neither of which can be artificially simulated. As Saint John Paul II tells us,

Through work man must earn his daily bread and contribute to the continual advance of science and technology and, above all, to elevating unceasingly the cultural and moral level of the society within which he lives in community with those who belong to the same family. (John Paul II 1981)

Healthcare solutions with a competitive advantage must focus on the human person providing the service, in order to help the human person receiving the service. The human person is the only investment that yields an infinite return. Investing in human ingenuity produces tenfold returns rather than 10 percent improvements. But human ingenuity cannot be forced. It is the result of human flourishing. It has to be willed by each individual for him- or herself. No one can want for another person. No one can force the pursuit of excellence. All we can do is encourage, lead, and create the conditions that enable this desire.

A commitment to the person does not necessarily have to come at the cost of profit. This dichotomy is often presented as inevitable, but I believe that this is a false choice. This is not an all-or-nothing equation. Catholic doctrine involves a principle that proposes that we can at once hold two apparently opposing principles and thus avoid the characteristic pitfalls of either extreme. G.K. Chesterton said that “Catholicism is marked through and through by the great ‘both/and’ principle … The Church is [both] radically devoted to this world and radically devoted to the world to come” (Barron 2012). As Bishop Robert Barron writes: “Not one or the other, nor some bland compromise between the two, but both, advocated with equal vigor” (Barron 2012). Applied to the medical profession, this “both/and” principle can create a culture of excellence, meaning, and innovation. We can have a medical system that both meets financial objectives and makes a radical commitment to the person. Indeed we must. The Catholic Medical Association works precisely toward this goal. In a Catholic Proposal for Renewal, the CMA laudably writes, “we conclude with practical suggestions to help correct past errors and to build a new healthcare system shaped as much by faith, hope, and love as by financial and regulatory forces” (CMA 2008; emphasis added). That shaping is the “both/and” principle at work.

Our impulse when facing a complex issue is to delegate or abdicate our decision “upward.” When faced with an emotional issue, we tend to react with extreme solutions. Health care is both complex and emotional. Church teaching recommends we do not abdicate our responsibility to decide and to take great care to choose “the way of the middle” as opposed to choosing opposite extremes. We must commit to find a solution that remains Catholic, just as generations of Catholics before us did. A Catholic solution allows doctors to heal patients in light of their human dignity.

There is unfortunately an immense draw toward short-term utilitarianism in health care, and I know of only one effective weapon against it: a radical commitment to each person at every level. Put the person back at the center of our activities, and we will find meaning and sustainable success. For what Sir William Osler observed over a hundred years ago still holds true today:

There seems to be no limit to the possibilities of scientific medicine, and while philanthropists are turning to it as the hope of humanity, philosophers see, as in some far-off vision, a science from which may come, in the prophetic words of the Son of Sirach, “Peace over all the earth.”