The Bishops, Justice, Health Care and Social Change

By Dr. Jeff Mirus ( bio - articles - email ) | May 29, 2009

Bishop William Murphy’s letter to members of the US House of Representatives endorsing comprehensive health care for every inhabitant of the United States (including illegal immigrants) raises an important question about the involvement of the United States bishops in politics. Granted, the letter comes from Bishop Murphy as chairman of the Domestic Justice and Human Development Committee of the USCCB. It is not, apparently, a mandate of the body of bishops as a whole. Nonetheless, the letter once again raises the critical question: Where is the line between moral principles, which the bishops must enunciate clearly and forcefully, and public policy, which the bishops have neither the charism nor the competence to formulate?

This question has long haunted the Church in America, especially in the heady post-Vatican II years when many bishops apparently believed that Catholic doctrine itself was in the midst of a major reformulation, resulting in episcopal political statements that were sometimes not so very well grounded in Catholic moral principles. But the main issue is not whether the bishops have a firm grasp of Catholic moral principles, but whether they have a superior grasp of how effectively this or that public policy embodies those principles. According to Church teaching, they don’t. In both theory and practice it is up to the laity, formed by Catholic principles, to determine the best prudential response to various public issues.

The episcopal office does not confer any particular special insight into either the feasibility or the effectiveness of proposed public policies; nor is there any historical warrant for suggesting that, in practice, bishops as a body are better at this sort of thing than laymen. In fact, both by training and experience, one would expect politically active lay persons to have a better grasp of the art of the possible in implementing effective public policies, just as one would expect bishops to have a better grasp of Catholic faith and morals.

Social Justice and Social Change

When the Church involves herself in politics, she is wont to talk about “social justice” rather than charity. However, as Pope Benedict XVI clearly stated in his first encyclical, Deus Caritas Est, the special province of the Church is charity. It is the State which has justice as its proper end. This does not mean that the Church should not teach the principles of justice. Justice derives from the moral law, which Revelation helps the Church to enunciate with unmatched clarity. But there is a blurry line between charity and justice in the public context, even when both aim at the same goal.

For example, consider these questions: Is it a matter of charity or justice that free education should be available to all citizens? Or that the poor should receive a high level of housing and food benefits? Or that health care should be free? There is no “right” answer to these questions; the answers depend very much on the social context. In previous eras, nobody would have argued that the State had an obligation in justice to provide these things. The scope of the State was utterly insufficient to the purpose, and economic conditions were such that it simply could not be expected that a very large percentage of citizens could ever have access to such benefits. But if one person denied to another person a benefit to which he was ordinarily entitled—stealing a noble's inheritance or riding roughshod over a peasant’s right to common acreage and shared equipment—then a matter of justice was clearly present. For the rest, the charity of friends, neighbors and the Church herself was essential to get people through difficult times.

In Western affluent mass societies, the general level of material well-being is far higher, and it is not (in theory) based on rank or class. Universal public education is a fact of life, and in a non-agrarian society education is seen as a key to making one’s livelihood. We tend to think, therefore, that everyone has a right to be educated; hence it is a matter of justice if someone is denied schooling. But we carry this only so far. It does not apply to college or graduate school. In other words, a moment’s reflection reveals to us that issues of justice are not always absolute. Instead, many issues take on a dimension of justice by virtue of the conventions of the social context in which the issues are raised. The most important point to recognize here is that the term “social justice” is very malleable; it is what the ancients recognized as distributive justice, and it must take circumstances into account. Thus it depends only partly on the natural law and to a much greater degree on the expectations, customs and capabilities of the society in question. (In contrast, charity faces no such conceptual problems: It is always a personal response to another’s need out of love.)

Health Care

Health care is an excellent case in point. The very dream that all people should have access to a high level of professional health care depends on the peculiar features of particular societies: the widespread availability of competent professional care; a generalized familiarity with such care throughout the social order; a high percentage of persons already enjoying the advantages of this care; a significant understanding of public health; the advancement of medicine to the point that the difference between those who have medical care and those who do not is both significant and predictable; and of course tremendous affluence.

But for this dream to be the proper province of the State, we must somehow translate it from the sphere of desire to the sphere of justice. One would expect that the special gift of bishops would be to articulate the principles which make a given potential benefit a matter of justice; the case needs to be made because there is very little absolute about this sort of social claim. Thus the bishops might suggest (as I believe they would be right to do) that the claim to health care (or any other social benefit) becomes a matter of justice in a given society when that society begins to perceive, in its own context, that health care is unnecessarily unavailable to defined groups of people who—again, in the culture’s own particular context—would ordinarily be expected to have access to it.

The example of education may again prove useful. At a certain point in Western history, it became a feature of our common Western culture that the vast majority of people could be educated. A variety of philosophical, social and economic circumstances led to this cultural shift, and it took a very long time for the availability of education to reach anything like what we might call critical mass. Once critical mass was reached, it became the norm that all persons should be educated in a certain way (so much so that people gradually lost a great deal of personal control over the matter). Once this became the norm—and not before—society was in a position to judge it an injustice if anyone was prevented from going to school. Health care is perhaps now on a similar trajectory. However, it is not a matter of absolute principle but of socio-economic-political judgment whether, in fact, our culture is in a position to demand a certain level of health care as a matter of justice.

Problems

Once again, the primary role of bishops is not to endorse a particular policy proposal or a particular demographic result, but to explain the various principles and related considerations which might be sufficient to make health care a justice issue. Such a case may well be worthy of serious consideration, given the current characteristics of our society. Moreover, I would suggest that the bishops ought to be uniquely qualified to make this case—just as they are generally unqualified to endorse any particular method of embodying such principles of justice in public policy.

After all, there are grave problems with any specific implementation of these principles in health care. Costs, quality of care, and personal liberty in determining the nature and scope of one’s medical treatment are among the more obvious. But the very involvement of the public order in medical care raises problems of its own, just as it has in education. It is no secret that a very large number of bishops were reared in the social traditions of modern liberalism. Perhaps as a result, many bishops assume that if a social problem exists, the Federal government must be put in charge of solving it. But he who lives by the Federal government may well die by it, for the Federal government is deeply involved in and supportive of quite a few grave moral evils in the realm of standard health care.

Bishop Murphy recognizes this difficulty, sort of. He warns that “no health care legislation that compels Americans to pay for or participate in abortion will find sufficient votes to pass.” But this is only another political judgment that no bishop is qualified to make. The smart money, I think, suggests that a universal medical system, if it were to pass all the other objections, would not be long subverted by such “petty” concerns as contraception, abortion and the use of aborted embryos in medical treatments—or even by assisted suicide, should that become the secular norm. One needs only to consider how we have fared in keeping such things out of insurance coverage. In any case, the main point is that Bishop Murphy, who only “sort of” sees the problem, does not see it as something that would deter him from demanding that the Federal government institute comprehensive health care now. The same ideological problems that undermine the values of the American citizenry in public education will be at work in the actual giving and taking of life in public medicine.

It probably isn’t necessary to raise the question of costs; the public is very sensitive to cost issues at the moment anyway. But Bishop Murphy’s letter does endorse the provision of “comprehensive and affordable health care for every person living in the United States.” This hides a hornet’s nest of questions, many of which revolve around the question of how much health care we can afford for how many. Alas, Revelation does not touch upon this issue. Questions of efficiency and quality are equally complex. For example, would it be unjust to allow persons of means to seek additional or better health care than the universal system provides? This would, after all, give them a social advantage. And would doctors and hospitals be permitted to provide such health care outside the system? Another huge consideration is the impact on illegal immigration of ever-greater public benefits for every man, woman and child residing on American soil.

Willy Nilly Doesn’t Cut It

Again, my point is not to argue against a better solution to health care in our society. As I have indicated, my personal assessment is that, although the best course is far from clear, our society does possess the combination of characteristics which make it morally necessary to think hard about this question, and to consider what might be done. As societies grow and change, along with their resources and their methods of using resources, different questions come to the fore, and sometimes circumstances do change enough to require the application of principles of justice to new areas of life, areas in which the question of justice was quite rightly inapplicable in another place and another time.

But it goes way beyond what we can know in our current context to assume willy nilly that these questions of justice are clear and easily applicable, or that one particular solution is obviously the best course. By all means, the bishops should lead a penetrating discussion of how and when certain social realities push new questions into the sphere of what we might call relative justice (typically these are considerations of justice arising from the principle—and indeed the problem—of equity). The bishops should apply this discussion very particularly to health care. And they should also point out clearly any absolute moral imperatives they see as critical to the discussion, such as not being forced to participate in murder. Then, based on an ever-deepening understanding of moral issues provided by cogent episcopal teaching, the bishops need to back away and allow the laity to do their own proper job: The formulation and implementation of specific public policies.