Among the many debates triggered throughout America by Obamacare, one concerns whether access to healthcare may be described as a “right.” Assuming such a right exists, a related issue is what this means for public policy.
For Catholics, the answer to the first question seems clear. In a 2012 message to a conference for healthcare workers, Benedict XVI referred explicitly to “the right to healthcare.” This right is grounded, the pope specified, in the truth that “health is a precious good for the person and the community” that must be “promoted, preserved and protected.” Here the pope followed the classic Catholic and natural law understanding of the derivation of rights: they are grounded in those goods which are central to human flourishing.
So far, so good. But the real debate for Catholics starts when we consider how to realize this right. Rights are a matter of justice, and justice is a primary concern of the state. Indeed Benedict XVI noted in his 2012 message that healthcare is subject to the demands of justice—specifically distributive justice—and the common good.
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Some Catholics may believe this implies we’re obliged to support a more-or-less socialized healthcare system such as Britain’s National Health Service. Yet nothing in Benedict’s message or Catholic social teaching more generally implies this is the only possible path forward.
In the first place, it’s hard to deny the mixed track-record of nationalized healthcare regarding what Benedict called “render[ing] effective” the right to healthcare “by furthering access to basic healthcare.” Surveying the NHS’s performance, for instance, the British social commentator, medical doctor and psychiatrist Theodore Dalrymple commented in 2011:
The cumulative increase in spending on the NHS from 1997 to 2007 was equal to about a third of the national debt. After all this spending, Britain remains what it has long been: by far the most unpleasant country in Western Europe in which to be ill, especially if one is poor. Not coincidentally, Britain’s healthcare system is still the most centralized, the most Soviet-like, in the Western world. Our rates of postoperative infection are the highest in Europe, our cancer survival-rates the lowest; the neglect of elderly hospital patients is so common as to be practically routine. One has the impression that even if we devoted our entire GDP to the NHS, old people would still be left to dehydrate in hospitals.
Obviously efficiency-issues aren’t the only questions Catholics should address when judging how to widen access to healthcare. Justice and efficiency are different. Yet Dalrymple’s analysis underscores how the ineffectiveness of socialized healthcare has helped facilitate significant injustice.
Looking then at justice, the idea that everyone has a right to healthcare means that all of us have some positive duties concerning others’ healthcare. Sometimes these duties are clear. Parents, for instance, have the primary responsibility to meet their children’s healthcare needs, consistent with the use of family resources to promote all of its members’ overall flourishing.
At the same time, justice requires us to consider precisely what everyone in a given society owes to everyone else with respect to people’s often different healthcare needs. Must, for instance, a man sacrifice his entire family’s resources (and thereby severely compromise his family’s ability to support all of its other members’ capacity to participate in goods that include but also go beyond health) in order to provide his alcoholic father suffering from terminal liver-cancer with a treatment that has a 15 percent success-rate at keeping patients alive for another six weeks?
Certainly distributive justice is about need. But distributive justice also embraces questions of merit. As Donald Condit notes in his monograph A Prescription for Healthcare Reform, “we can expect to be held accountable for choices we make, including those regarding our personal health…. A Christian discussion of health care reform cannot neglect the role of personal responsibility when considering the prevalence of obesity, alcohol abuse, smoking, and lack of exercise.”
Clearly there are many issues that even a well-founded recognition of a right to access healthcare cannot resolve by itself. Nor is it obvious that government top-down control of healthcare is the only (let alone the most optimal) way of actualizing such rights.
Here an analogy might be made with the state’s responsibilities concerning the right to work. In his encyclical Centesimus Annus, Blessed John Paul II affirmed that the state has responsibility for “overseeing and directing the exercise of human rights in the economic sector.” Immediately, however, the pope qualified this statement by noting that “primary responsibility in this area belongs not to the State but to individuals and to the various groups and associations which make up society.” Part of the pope’s reasoning was that “The State could not directly ensure the right to work for all its citizens unless it controlled every aspect of economic life and restricted the free initiative of individuals.”
John Paul’s careful delineation of the responsibilities of different social groups (of which the state is obviously a unique entity) vis-à-vis facilitating people’s participation in the good of work is applicable to realizing the rights flowing from the good of health. His distinctions arise from attention to what is objectively owed to others (justice), how we would want others to treat us (love), and the requirements of human freedom. These questions of love, justice, and liberty direct us in turn to two key foundational—and inseparable—principles of Catholic social teaching: solidarity and subsidiarity.
Though it is invoked regularly across the political spectrum, Catholicism understands solidarity to be the virtue of living the commandment to love our neighbor. Speaking of solidarity in Gaudium et Spes, the Second Vatican Council stated that Christ “clearly outlined an obligation on part of the sons of God to treat each other as brothers” (GS 32). Solidarity thus involves not only fulfilling the duty to be just to each other, but also to love one another—and love is something that takes us beyond the demands of justice.
What might this mean with regard to healthcare? Insofar as governments have responsibilities to promote solidarity, they have a part to play in expanding access to healthcare. But living the principle of solidarity doesn’t absolve individuals and other communities from their responsibilities to help others access healthcare. Nor does it imply that these particular responsibilities may be delegated to the state, let alone that they are somehow fulfilled by voting for those who promise to provide more healthcare through the state.
Herein lies the significance of the principle of subsidarity in operationalizing solidarity. At its core, subsidarity is concerned with providing a way of thinking coherently about how we help others in a manner consistent with everyone’s need to make free choices if they are to participate in goods like health. Subsidiarity also reminds us that there are numerous communities that precede government institutions and which help establish many of the conditions that assist people to promote, protect, and freely choose the good of health.
Taking this background into account, it would seem that policies which attempt to realize all the rights and responsibilities of all individuals and communities associated with health more-or-less exclusively through the state are hard to reconcile with Catholic teaching. Certainly, where no other community is capable of fulfilling a particular healthcare requirement, subsidiarity indicates such needs may be met directly by the state. Thus the government’s provision of a healthcare safety-net is legitimate—provided such a safety-net is focused upon addressing emergency situations and helping those people with no other community to care for them. Nevertheless the government’s assumption of total control (direct or indirect) of a society’s healthcare arrangements would normally be excluded.
Within these parameters, there remains considerable room for reasonable differences among Catholics concerning how to promote the right to access healthcare. Indeed, although Catholics can often identify many options that meet the requirements of the principles stated above, there is no system of providing healthcare that’s uniquely correct in promoting these principles.
Thus, when addressing a question such as “how can I promote better access to health care,” living the Church’s teaching does not always mean that Catholics can only support one particular healthcare policy. I would even venture that the same framework of analysis suggests that no Catholic would be obliged, as a matter of informed conscience, to support an Obamacare stripped of elements such as the HHS mandate that directly violate Catholic teaching. When it comes to healthcare—and, in fact, most public policy issues—there are often many legitimate ways for Catholics to do good: ways that may be incompatible with each other but are nevertheless fully consistent with Catholic teaching. As Aquinas and the entire Church tradition from apostolic times onwards has emphasized, while one may never intentionally choose evil, the doing of good doesn’t always mean there’s just one right path to follow.
No doubt, some believe such arguments risk weakening the Church’s effectiveness in promoting the right to healthcare in the public square. The point, however, of Catholic moral reasoning is not to maximize political effectiveness, let alone ensuring that the Church remains a “player” in Washington, D.C. Rather it is about helping Catholics to live Christ’s way through all our free choices, thereby contributing to the substance—starting with ourselves—that He will raise up at the end of time, as Gaudium et Spes states, “freed of stain, burnished and transfigured, when Christ hands over to the Father: ‘a kingdom eternal and universal, a kingdom of truth and life, of holiness and grace, of justice, love and peace’” (GS 39).
Granted, this may mean little in worldly-terms. It is nonetheless the ultimate horizon to which Christ calls us—including in healthcare policy.
Author’s note: This essay is based on a 2012 paper published in the Notre Dame Journal of Law, Ethics and Public Policy.