The Healing Community: A Catholic Social Justice Critique of Modern Health Care 1

Many discussions of the implications of Catholic social thought for health care proceed by setting forth moral principles or themes in Catholic social thought while assuming a general knowledge of medical practice. In this paper I want to take the opposite approach: I want to start from the assumptions of Catholic social thought, and from that perspective elucidate and critique medical practice, and then suggest both some ways that the experience of the hospital might be improved and how the assumptions and practice, and the success, of health care contribute to the injustice and difficulties we experience in the healthcare system today.

I come to this topic like many of you come to the Church, that is, as a very interested consumer of what is being provided but not an expert in any way. I certainly do not have any specialized knowledge of medicine. I have only been in the hospital as a patient once in my life. Call me a healthcare layperson, trying to understand what is going on in health care from the perspective of the faith.

I begin this topic with great regard and thankfulness for the achievements of modern medicine and the dedication of medical personnel. So I wish it were not true that when I consider modern health care in the light of Catholic social thought, what I mostly see are absurdities and dilemmas. What is worse, these dilemmas are not small matters at the edges of health care, but seem to be issues that are central, foundational, that go all the way down to the roots of modern medicine.

Healing is Wholeness

Catholic social thought centers in the notion of human dignity. What does this mean? The philosopher Immanuel Kant defined human dignity by saying that while we can treat objects and animals as means to serve our own ends, we must treat persons as ends in themselves, and never only as a means (Kant 1996, 209). Things can be used, but persons must be loved. Our consumerist culture readily tempts us to reverse this order, to love things and use people. Another way of putting it, favored by Pope John Paul II, is that each person is entrusted to himself—including his body—so that in our care for the body we cannot merely treat people as objects, but must recognize that the other is always a subject of his own life (John Paul II 1993, n. 48).

Right away we see a problem for human dignity in the modern practice of medicine. For medical science views the human body as an object, in a beneficial way to be sure, but as something to be examined, understood and manipulated in the interest of health. The metaphor for the body in modern healthcare education and practice is that of a machine: a set of systems that interact with one another to form a common functioning unit. A glance at any medical text or research report makes this clear. Here are the first three sentences of Tortora and Nielson's Principles of Human Anatomy, a widely used medical text now in its twelfth edition:

You are about to begin a study of the human body to learn how it is organized and how it functions. In order to understand what happens when the body is injured, diseased or placed under stress, you must know how it is organized and how its different parts work. Just as an auto mechanic must be familiar with the details of the structure and function of a car, healthcare professionals and others who work in human performance and care professions must have intimate knowledge of the structures and functions of the human body. (Tortora and Nielsen 2010, 2)

There follows twenty-six chapters on the various systems—the parts—of the body. The objectification here is clear. The body is like an automobile—the most common machine of our age. The circulatory system is like the fuel lines; the heart like a fuel pump; the skeleton, the frame; the nerves, the car's electrical system; and so on.

The problem in this way of thinking becomes clear when we ask what it means to be healthy. If the body is a machine, then diseases can be “fixed” by a sort of repair, like a machine, without reference to any other body or community. Tortora and Nielson's Human Anatomy never defines health, but it defines disease (“an abnormality of structure”), which implies that health is nothing more than the absence of disease. And that is exactly how the dictionary defines it: The Oxford Dictionary informs us that health is “the state of being free from illness or injury” (Oxford English Dictionaries 2013); and the Merriam-Webster Dictionary is similar: “the condition of being free from disease” (Merriam-Webster 2013). Neither of these tell us what health is, just what it is not. When the body is a machine, apparently the best you can say is that health is not being sick, that is, when all the parts of the machine are working.

This way of thinking ignores the most obvious and important fact about the human body: that it is alive. As the social philosopher Wendell Berry points out, a dead body might be like a machine, but a living body is far different. A machine by itself, when it is turned off, is still a machine; but a human body cut off from its sources of air, food, clothing, companionship, etc., is a corpse. To think of the body as a machine is to think of it as something dead, which may be inhabited or motivated by a life force. Behind the image is a body/soul dualism that fundamentally denies the vitality of the body in its own right (Berry 1995, 87).

Natural philosophy can see the problem in the machine body. As Berry points out, if the heart is just a pumping machine, and the skeleton and musculature just moving and lifting machines, then the mind must be just a thinking machine (Berry 1995, 88). The image of body as machine reduces the mind to the brain and the brain to the computer. Following Kant's distinction between love and use, if the body is objectified, reduced to a machine, then we have denied the human dignity of the person expressed by that body. And when we lose sight of human dignity, we cannot possibly understand what it means to be healthy.

Christian revelation affirms the dignity of the body even more forcefully. We see this idea in the New Testament, when St. Paul says, “Now you are Christ's body, and individually members of it” (1 Cor. 12:27), with all the various functions that he lays out in 1 Corinthians 12, comparing us to an eye or an ear or a foot. Against the dualism of the machine body, we affirm the unity of persons in Christ. It was to save the body that God became flesh in the Incarnation. We do not discard this body to live on as an eternal soul, as the Greek philosophers believed (“Phaedo” in Jowett 1965); this body which we now treat and care for is to be resurrected and live forever. The body of Christ, which he offers to us at every Mass, is Christ himself; it is not a machine that Christ inhabited. And the dignity of our body is joined to his, as we are the body of Christ, united with him and members of one another, persons of unity in community.

So what does it mean to be healthy? There is actually a pretty clear definition to be had, from the ancient Greek philosophers of the natural law up to the theologians and magisterial teachings of the Christian revelation. In English, the word “health” comes from the same linguistic root as “whole” and “holy” (Merriam-Webster 2013). To be healthy means, in a very deep sense, to be whole; to be healed is, as the Scriptures say, to be made whole. Health is good because it enables us to live a good life with others. Living before the time of modern machines, the ancients had almost the opposite metaphor for the body. Modern man thinks of the body as a machine; they thought of the community as a body. The modern world reduces the body to something dead in its isolation and inertness; they elevated it to a larger life in its relationships and sensibility.

The first thing we learn about the good life from the ancients and the natural law is that you cannot live a good life by yourself. You can only be good in good relationships with other persons. “Without friends,” said Aristotle, “no one would choose to live, though he had all other goods” (Aristotle 2013, bk. 8, ch. 1); or as Berry says more recently: “Our sense of wholeness is not just the sense of completeness in ourselves but also is the sense of belonging to others and to our place; it is an unconscious awareness of community, of having in common” (Berry 1995, 87).

What is being described here is the common good, that is, the good of the community. In Catholic social thought, the common good is one of the three principles which support human dignity—the other two are solidarity and subsidiarity—and it forms the context for Catholic social thought's treatment of health and health care. The Compendium of the Social Doctrine of the Church, quoting Vatican Council II's Gaudium et spes, number 26, defines the common good as “the sum total of social conditions which allow people … to reach their fulfillment more fully and more easily” (Pontifical Council for Justice and Peace 2004, n. 164). Health is clearly one of these conditions; the Compendium specifically lists health care (along with food, housing, work, and education) as one of the requirements of the common good, which may also be a human right (Pontifical Council for Justice and Peace 2004, n. 166).

In contrast to the individualistic conception of the machine, Catholic thought offers us the rarely acknowledged wisdom that health is participation in and fulfillment in the community. In this sense, all disease is social, and the purpose of healing has to be not just to cure the individual but to restore him or her to the community. There is a natural tendency to shun those who are diseased, but we are called to overcome that with restoration to community. When Jesus healed the leper, he sent him to the priest to be certified clean, i.e., to re-enter society with others.

On this basis we can better understand the specific social justice concerns regarding health care that are addressed by the social teachings. At various points they call for the provision of health care for the poor, the elderly, and children, and assert that all persons have a right to work conditions which are not harmful to their health (Pontifical Council for Justice and Peace 2004, n. 301), to weekly Sabbath rest which promotes health (Pontifical Council for Justice and Peace 2004, n. 284), and to a safe and healthy natural environment (Pontifical Council for Justice and Peace 2004, n. 468). Catholic social thought notes that inadequate health care contributes greatly to underdevelopment of nations worldwide (Pontifical Council for Justice and Peace 2004, n. 447), and calls for the study of biotechnology to address the problems of health care (Pontifical Council for Justice and Peace 2004, n. 477) and for the fruits of biotechnology to be shared to promote health, not just profits, in accord with the common good (Pontifical Council for Justice and Peace 2004, n. 478). Health care not only serves the community, providers of health care serve as a community, so as to address the wholeness of each person in the whole community. The Ethical and Religious Directives of the U.S. bishops states: “Since a Catholic healthcare institution is a community of healing and compassion, the care offered is not limited to the treatment of a disease or bodily ailment but embraces the physical, psychological, social, and spiritual dimensions of the human person” (United States Conference of Catholic Bishops 2009, 14).

I now want to apply this integral understanding of health in two specific critiques of modern health care in the United States. Following the reciprocal principles of solidarity and the common good, that is, action oriented to both the personal good and the social good, respectively, I will try to suggest some ways in which the loss of the understanding of healing as wholeness has degraded both the personal experience and the social context of health care in the United States.

Treating the Whole Person

Our faith, as just noted, holds us to the highest standard of care, which is love. The Ethical and Religious Directives says “Christian love [is] the animating principle of healthcare” (United States Conference of Catholic Bishops 2009, 6). As Pope Benedict XVI taught us in Caritas in veritate, love is also the heart and the standard of social justice (Benedict XVI 2009, n. 1). The question of justice for our hospitals and medical practices must be, can we communicate love?

Rather than talk in general terms about hospital experience, let me share the experience itself. As I mentioned, I have only been in the hospital one time as a patient. It so happens it was right here in Santa Barbara. I came here in August 2008 to visit my mother, who lives in a retirement community here. On the second night of my visit I had intense pain in my stomach and went to the emergency room. It was a busy night and after ninety minutes waiting in the emergency room I passed out. When I woke up I had been admitted to the Santa Barbara Cottage Hospital. They gave me pain medicine and a series of tests through the night, and the next afternoon removed my gall bladder.

I thankfully acknowledge my great debt to the hospital and to the fine doctors and nursing staff that attended me. I surely would not be alive today but for their skill and care. But going into the hospital was like a foray from the world of love and care and community into becoming an isolated focus of machines and chemicals and specialists. All of a sudden I was utterly anonymous, passive, and powerless. My life depended on doctors, surgeons, and specialists I had never met and had no way of knowing. I had to trust them blindly. Consent, I discovered, can never be fully informed. The complexity of my condition was far beyond my ability to understand, never mind that I was impaired by medications and lack of sleep.

If health is wholeness, then disease involves a sense of disintegration, of being broken down into parts. This is exactly what secular modern medicine does when it tries to heal us. Not only does it isolate us from others, it isolates us from ourselves, by disintegrating the body into a parcel of parts, each addressed by a specialized form of medicine. To quote Berry again:

The modern medical industry faithfully imitates disease in the way that it isolates us and parcels us out. If, for example, intense and persistent pain causes you to pay attention only to your stomach, then you must leave home, community and family and go to a sometimes distant clinic or hospital, where you will be cared for by a specialist who will pay attention only to your stomach. (Berry 1995, 88)

We need to affirm, contrary to Berry, that such specialization is not a bad thing; it brings us huge advantages in treating disease and healing persons. But he has a point. There is something undignified about being a patient. A patient experiences the loss of control, of autonomy, of privacy, of self-determination, of normal reciprocity with others; in the interest of healing the body. Sometimes there is no question that the trade-off is worth it; sometimes it is not so clear that it is; but we must never forget that there is a trade-off. Medicine is surely curative, but at the same time it is iatrogenic. The patient is not only gaining things by treatment but also losing things. And the things he or she is losing are very close to what is meant by this idea of human dignity.

The hospital treated my condition very well, but did not treat me well at all. Despite its competence, it seemed, ironically, a very inhospitable place. My family came to remind me of another world, a world of love and care; but there was no provision for them to stay with me, and that world seemed to be distant. The machine that was the hospital standardized my disease, and treated me with the technical experience that comes from focusing on that disease and overcoming it. This is no small achievement. But in the community of love I am an utterly unique person, not reducible to any other person that God has made. Love is never standardized. My body is like all other bodies in some respects, but also unlike them in others. Would it not be possible to treat persons with both great skill and great love? Could hospitals not also welcome the community of the patient, to bring the power of love also to bear? Can we marry the technical excellence of hospitals with a human scale that permits them also to be places of love? It seems to me that this is a fundamental challenge of Catholic healthcare practice.

Some may think this is silly sentimentality, but it is not: It is the most important task of health in our age, because eventually technical efficiency will be overcome by death, but the world of love will overcome death itself. Efficiency will ultimately lose, love will ultimately win, the battle for health. What good is extending and restoring natural life if all life means is the attempt to make it safely to death? If in our efficiency, our machinery and chemicals, we lose the place of love, we lose everything.

Balancing Generations

Communicating love to patients is essential for expressing human dignity in health care, but Catholic social thought urges us to take a further step. It should not surprise us that the Church's social teachings also call us to address the social context or conditions of health care. Since (at least) St. Augustine first addressed the Church's relation to society in the fourth-century City of God (Augustine 1958), the Church has taught that the gospel calls us not only to personal virtue and charity, but also to build a society in which virtue can flourish. In the language of the modern social teachings, solidarity is not only a personal virtue but also a social principle (Pontifical Council for Justice and Peace 2004, n. 193); indeed, the virtue of solidarity is defined as “a firm and persevering determination to commit oneself to the common good” (John Paul II 1987, n. 38, cited in Pontifical Council for Justice and Peace 2004, n. 193.) A 1971 global synod of bishops declared “[a]ction on behalf of justice and the transformation of the world” to be “a constitutive element of the preaching of the Gospel or, in other words, for the Church's mission for the redemption of the human race” (World Synod of Bishops 1971, n. 6). More recently Pope Benedict emphatically reaffirmed this idea in the 2009 encyclical Caritas in veritate, which teaches that true charity must include justice and, following Paul VI, calls Catholics to promote human dignity through ethical social development (Benedict XVI 2009, n. 6).

The Church's social teaching has long affirmed, as the foundation of social justice in health care, that access to basic medical care is a fundamental human right, which should be freely available to all (John XXIII 1963, n. 11). The Ethical and Religious Directives states:

A just healthcare system will be concerned both with promoting equity of care—to assure that the right of each person to basic healthcare is respected—and with promoting the good health of all in the community. (United States Conference of Catholic Bishops 2009, 11)

In the United States, access to medical care is obstructed by the high cost of care at all levels. There are many differences of opinion over how to solve this problem, but can be little question about the existence of the problem itself. The facts speak for themselves. This year over two million Americans will declare bankruptcy due to medical costs, indeed, healthcare expense is the most frequent cause of personal financial collapse in the United States (Himmelstein et al. 2005).

That a medical crisis also often becomes a financial crisis is not only a social injustice, it also undermines the goals of health care. How is someone supposed to get well when he or she is worried sick about money (Berry 1995, 94)? How many persons forego needed care because of the cost? One of the primary motivations cited by elderly patients, such as stroke victims, for the decision or advanced directive to pull the feeding tube is the prospect of becoming a steep financial burden on their family. They should not have to face that choice.

To say that this is a social injustice is to understand that the roots of the problem are social, not personal. For this reason, improved management of health care, whether through market forces or government intervention, will not be very successful in solving the problem, neither will improving hospital treatment or clinics or medical missions or charity to help the poor. These are all commendable and important, and we should all be involved in them as best we can. But social injustice is a result of social conditions, and it can only be redressed with social change and changes in social attitudes. So what are the root social conditions that have caused our healthcare crisis in finances? Though it may surprise, I suggest that the two major social causes are rising longevity and widespread abortion.

Rising Longevity

Permit me to introduce this point with an anecdote. Recently a colleague and friend, a good Catholic priest, died suddenly and unexpectedly from a heart attack, leaving uncompleted plans and projects and a jagged hole in his community. Among the expressions of sympathy, I noticed a recurring refrain of how tragic it was that his life had been cut short prematurely, how much more he could have accomplished if he had only had a few more years. He was seventy-eight years old. It happens that, according to the U.S. Centers for Disease Control (CDC), seventy-eight years is the current statistical life expectancy at birth in the United States (CDC 2013). When this man was born, seventy-eight years ago, life expectancy at birth was just sixty-two years. How is it (I wondered) that a man can pass away at the best predicted time of death of our era, outliving the healthcare expectations of his era by at least a decade and a half, and yet people feel that his life was cut short?

This priest, of course, is hardly an isolated example; many of us, I expect, have living parents or other relatives above that age, and our gratitude is mixed with a sense that it has become almost normal to expect that kind of vitality. I might point out that our cardinals recently elected a pope who is seventy-six years old, from whom we expect years of active service; who in fact is seen as a younger, more vital successor to the previous pope, who was himself elected when he turned seventy-eight, and who, now eighty-six, is still living, having exited the office, for only the second or third time in history, by a means other than death.

We live in a time of rising longevity, but our expectations for longevity are rising even faster. Life expectancy, of course, is a kind of global metric for health, and thus for the effectiveness of health care. Clearly our cultural or emotional expectation for longevity exceeds the facts of medical science. Not only this, but as every practicing physician can attest, most of us tend to think that good medical care can deliver us from the effects of poor health habits; that medical interventions, particularly painless and quick medical interventions, can overcome the debilitating effects of obesity or smoking or poor diet or lack of exercise.

By good medical care we presume that we can extend the time of death into the future seemingly indefinitely. This hubris, what the Protestant ethicist Stanley Hauerwas calls “the presumption that through medicine we can get out of life alive” (Hauerwas 2012) is a result of the success, not the failure, of medical science. Medicine has delivered so many miracles in the past century that we have come to expect miracles as commonplace.

Missing Children

Readers of this journal are probably well aware that about a fourth of prospective births in the United States are prevented by putting to death innocent unborn human beings in the wombs of their mothers. This is not only a moral tragedy of the first order but also, though less widely recognized, a social tragedy that disorders the shape of our society in a way that degrades health care overall.

The natural pattern of the generations is for the young, who tend to be healthy, to care for the old, who tend to lose their health. There is a natural reciprocity between the generations, where those in their prime care for the very young, who in turn, when they reach their prime, care for the very old. The older welcome the younger with joy and support them as they enter this life, and the younger support the older and grieve for them as they leave this life for the next one.

Our society has upset that natural balance and progression by extending the time of death to the point where the expectation of death is replaced with the expectation of indefinite life, and refusing life to many who are yet to be born. We have undermined both welcome for the unborn and grief for the departed. The young complain that they do not want to be tied down with children; the old complain—an almost universal complaint in nursing homes—that their children do not visit them enough.

The high and rising cost of health care is a direct result of these twin forces on the population, that is, rapidly increasing the old and infirm through life-extending medical technology while reducing the proportion of young and healthy persons through widespread abortion. Mere technical fixes, such as the newly enacted Affordable Care Act, as with social security and Medicare, attempt to force the young and healthy, through taxation and penalties, to pay in enough to support the old and infirm. These efforts may reduce the negative effects, but they will not solve the problem posed by these social forces; for both abortion and elderly hubris about death stem from the problem noted at the beginning of this article, that is, a profound lack of awareness that healing and health come from God.

Conclusion

Health means wholeness, but also holiness. As God usually works through material means in the created order, so healing is a natural process that is built into the character of the body and of the community. The fact that the technical means of healing require great skill and dedication in our day does not mean that they have acquired the power to confer life and health. I do not begin to know enough about health care from a practitioner's perspective, as already noted, to presume to offer solutions to the problems noted; but to those who do have that expertise, the Church's social teachings can point the way. A recovery of the awareness of the divine origin of health is at the heart of both humanizing the healthcare experience and reducing or reversing the social forces that have led to the unacceptably high cost of today's health care.

The depersonalization and unacceptably high costs of health care are not, of course, caused by doctors, who are themselves often subject to the same dehumanizing forces as their patients. But the providers of medical care in our day are complicit to the extent that they prime us to believe that healing and health are the results of medical science. To think that, by themselves, a drug will cure a disease or an operation will correct a malady is to adopt a fundamentally false and idolatrous perspective on life and health. In the same way that the conjugal couple must be open to God in the natural process of conception, so the physician and the patient must always be open to God in the natural process of healing. Otherwise the means which is given as a blessing to help us heal becomes a curse to displace God, as in the deadly act of abortion.

How blessed and how different is the healthcare professional who recognizes that the life he or she works to preserve is the breath of the living God! It is holy and belongs to God; and for this reason neither birth nor death is ever a defeat, or a failure of health care, to be obsessively avoided. Persons of Christian faith recognize that death is, in fact, a kind of birth. “Catholic healthcare ministry,” says the ERD,

bears witness to the truth that, for those who are in Christ, suffering and death are the birth pangs of the new creation. (United States Conference of Catholic Bishops 2009, 7)