Stanley Hauerwas explores the ways in which the fear of death, or more generally the fear of human limitation, shapes the discourse in medical ethics insofar as often the underlying presumption is that medicine’s ultimate aim is to put an end to human limitation – even death. Drawing on the work of Paul Ramsey, Hauerwas examines the complexity involved in attempting to do medical ethics when “we do not make explicit or acknowledge the forces that are ordering our priorities.” In a free market economy, Hauerwas suggests, justice with regards to medical practices is determined according to the individual’s ability to pay. In other words, doctors can practice medicine “justly” if they are limited to seeing patients who can pay for the care. But this conception of justice does not take into account the patients who are unable to see the doctor because of their inability to pay. He concludes by suggesting the Christian community can provide a witness to the medical community first by accepting human finitude as a gift, and second by existing as a community whose justice is found decisively in the care of the other—regardless of their ability to offer compensation. Mr. Hauerwas is the Gilbert T. Rowe Professor of Theological Ethics at Duke University.
I joined the faculty of the Divinity School at Duke University in 1984. I arrived just in time to witness a debate in the Duke Medical Center that centered on questions of organ transplants. The medical center was to begin liver transplants that were projected to cost $140,000 per operation. Harvey Estes, chair of Duke’s department of community and family medicine, questioned whether the money spent on organ transplants could not be spent more wisely in other ways. In response, Clark Havighurst, a professor in Duke Law School, observed, “It is very hard for society to face the death of someone who could be saved but we will have to face this more and more.”1
I call attention to this brief scrimmage at Duke in 1984 because I think the issues remain with us, but contrary to Havighurst, we still have not faced them. Indeed, if anything, the problems have gotten worse. Every center dedicated to high-tech medicine knows it must compete with other centers if it is to command research funds requiring the development of more exotic forms of care. Just as anyone who is facing surgery wants to believe that they have the best surgeon available, so it seems that every medical school and center must give the impression that they represent the “cutting edge” of research medicine.
The result, as Estes suggested, creates a bizarre world. Why should we develop extraordinary forms of therapy when we are increasingly unable to give even the most minimal medical care to the poor? The result is a multi-tiered system forthe delivery of medical care – one for people with plastic and the other for those without plastic. Faced by this kind of discrepancy, we assume that someone must be at fault. I do not want to exclude that possibility, but first I want to try to understand why we seem caught in this unhappy dilemma.
Paul Ramsey I think put the issue about as well as it can be put in 1970 in hi sbook The Patient as Person. 2 Ramsey observed:
With sufficient resources of money and personnel, any one or more remedy could be extended to all in need. But not all remedies can together be effectively extended in the social practice of medicine in this day of extraordinary treatments. Since health needs are almost by definition unlimited in any given society, and since the health needs of the world as a whole are infinite, choices must somehow be made among them. How shall sparse medical resources be allocated? Which needs should be given priority in medical practice and medical institutions generally? Beyond this, there is the question of the priority that should be given to medical needs among the many social causes having valid claims upon a nation’s resources. Ideally, any one of these could be satisfied, but not all at the same time or in no order of priority. The needs of men (of which health is only one) are certainly unlimited; and, by comparison to the felt-needs or demand, the supply of resources of any society are irremediably sparse. There is no avoiding this question of choosing societal priorities. We must choose how we shall go about choosing and ordering our medical and societal goals.3
Ramsey argues these questions are even more intractable than the challenge of how to choose who is to live and die when, for example, there is a limited number of dialysis machines for people with kidney failure. Faced by such a choice, we can argue whether a lottery or some other selection procedure is appropriate. But Ramsey argues that we have no way to determine whether we ought or ought not to develop dialysis technology in the first place. Faced with such a question, Ramsey notes that “the larger questions of medical and social priorities are almost, if not altogether, incorrigible to moral reasoning.”4
Ramsey illustrates this dilemma by discussing Warren Warwick’s satirical article on organ transplants which bore the subtitle: A Modest Proposal. The subtitle is meant to suggest Jonathan Swift’s famous article that recommended that inhabitants of Ireland might increase their food supply by eating their children. In the same spirit, Warwick suggests that “accident watching clubs” should be formed to supply helicopters able to reach scenes of accidents quickly to secure organs of the victims of the accident. Such clubs also ought to lobby to prohibit the use of seatbelts and other safety devises. If anyone objects that such a policy is designed deliberately to kill people, let them reflect how American know-how can respond by mastering the logistics of using several of the organs of a single victim for the good of five or six needing the resulting organs. Such a procedure can be justified by basic utilitarian calculus.
Ramsey reports that Warwick argues that not only do we need a new definition of death to harvest organs more efficiently, but a new philosophy of the body: “Society should have the right to tax a man’s body by claiming its organs, since social resources have maintained his health—just as we tax his estate on the grounds that the common prosperity had something to do with the wealth a man earns.”5 If necessary, this understanding of the body might be extended to encourage, for example, women seeking abortions to allow the fetus to develop to the stage they could be used to supply organs.
Ramsey reports that Warwick concludes his article with the plea, that since clearly organ transplantation has won the hearts of the American people, physicians must not back “proved losers,” such as the archaic notion that preventive medicine is better than later treatment. Funds to learn more about how we should live to prevent heart and kidney disease are not going to be forthcoming, but research funding for transplanting those organs will be supported by the American people. Medical students should learn quickly that the action is not in preventive care but crisis intervention.
Ramsey acknowledges he could not refrain from calling attention to Warwick’s article for the “sheer fun of it,” but he thinks the article raises the central issues. For the article rightly raises the question of how the ordering of our medical priorities might be subject to some rational scheme. Ramsey asks, “who shall say or how do we go about deciding what sorts of medical services should be given priority over others, and how much of a nation’s resources should be spent on medical care in comparison to other claims and needs?”6
Ramsey argues that once such questions are raised, there are no good reasons to avoid them by indecision, but that is the way it seems we have chosen to proceed. That is, we choose to order our priorities by not ordering them—or perhaps more accurately, we do not make explicit or acknowledge the forces that are ordering our priorities. We tell ourselves that we want nothing other than the best medical care for every patient—“you cannot put a dollar value on human life”—but in fact we know we participate in as well as support social institutions that put a dollar amount on human life. Physicians learn to organize their practice in a manner they do not have to acknowledge that certain patient populations are hidden from them—you cannot neglect patients you never see.
Of course there is a conception of justice that determines the distribution of health care in America. It is assumed that justice is achieved by satisfying the needs and wants of individuals in an open market of supply and demand. Justice is determined by our ability to pay. Accordingly, there is no general right to health care. The professional skill that physicians possess is property they can sell to whom they please. Attempts to respond to the inequities this system creates only reinforce its character because they are, in fact, public subsidies for private markets.
Yet many argue that market justice is inappropriate to determine the distribution of medical care. For when we are ill, we are in no position to bargain. The market assumes, if it is to work fairly, that everyone is a free and rational agentable to barter and choose intelligently the service offered. But when we are sick, our capacity to judge is compromised and our choices are severely limited. Moreover, in matters of medical care, assumptions about supply and demand presupposed on the market model simply do not apply. This is partly the result that physicians generate their own business—thus, the creation of wellness centers. That physicians are thought to be experts who decide what constitutes an illness needing intervention as well as the recipients of the rewards for such an intervention means there is no incentive for control of costs.
That market justice results in inequity for those needing care is, I think, beyond dispute. But I think the problem is deeper, involving how such an account of justice may distort the very character of medicine itself. For as I suggested above, such a view encourages physicians to look on their skills as their property, but physicians do not own their craft; they are their craft. To be a physician is not to have a job, but to be engaged in a practice that constitutes the common good of a community. The trust a physician enjoys is based on the presumption that the physician is in service to the public good.
The good that is at the moral heart of medicine, the good that shapes all a physician is and does, I take to be the commitment of a physician to care for a patient in a manner that any judgments about the patient are moot other than what needs to be done to restore the patient to health. A patient may be someone that mistreats children, but if he or she has a bad gall bladder he or she is to be cared for. A person who has a heart attack because he or she is seriously overweight is still to receive medical care. I call attention to these common practices because when we fail to name them, we can miss their significance for how we think about justice and health care.
That we treat those who we may well think do not deserve to be treated is why issues of distribution of health care, in Ramsey’s terms, are so intractable. The commitment of those in medical care to care for the patient without attending to their individual worth creates an almost interminable need. For in an attempt to help one individual patient, for example, with leukemia, modalities of care are discovered to help a wide range of patients who in the past could not have been helped or even recognized as needing to be helped. In other words, the commitment to the care of the individual patient creates possibilities that encourage us to have needs that we otherwise would not have. As a result, medicine creates the bizarre world in which some will receive heart transplants while others die of pneumonia.
Thus the argument that need should determine the character of justice in regard to the distribution of health care. Ill health is distributed unevenly and we can exercise only moderate control over what makes us healthy or ill. Illness is not just one burden among others, but rather to be ill is a condition of compromised human agency. The sick live on the dark side of the human condition and to deny them medical care is to write off their existence. That is why medical care is foundational if we are to recognize the goods we share in common.
But even if this argument for a need-based account of justice is right, it does not settle or resolve the incorrigible questions raised by Ramsey. We still do not know if we spend so much of our resources rightly on those who are in their last year of life. Of course, often we do not know they are in their last year of life. Indeed, one of the problems with the celebration of the power of modern medicine is that patients are encouraged to believe they have the right to any procedure that may help keep them alive. As a result, we corrupt ourselves as well as the character of medicine by trying to make it do more than it is capable.
So I suspect that questions of how medical care should be distributed cannot be settled by developing different accounts of justice. Indeed, I suspect one of the problems with such accounts is that justice is separated from other virtues that are crucial for recognizing what is and is not just. In particular, justice must draw on the virtue of courage if we are to know how we are to face our deaths. The ill distribution of our health care resources, I think, reflects the general inability of our society to come to terms with death. For if we share anything as a people, it is that death ought to be avoided in the hope we can finally get out of life alive. As a result, those with the economic and social power are able to command resources to keep their deaths at bay to the detriment of those who are not facing death.
For example, Ramsey points out that when the first heart transplant was done in Britain, a dozen operations had to be postponed due to the limited facilities at the National Heart Hospital. We may well think that that is England and we are America, not subject to such limits. Ramsey, however, argues that this example is a prism through which we can comprehend that, measured against the human need of any nation, we possess sparse medical resources at best. Moreover the truth is that this is the human condition made worse in modern times when the fear of death appears to have become ubiquitous with secularism.7
Ramsey argues, therefore, that before we get to questions involving who will live and who will die, there are more fundamental questions to be raised about the medical priority to be given to the development of increasingly exotic medical procedures. Behind these questions, moreover, is the even more challenging question of how the medical profession and society in general decide such questions and the probable immorality of letting them be decided by professional and social indecision.
But I suspect such “professional and social indecision” will rule the day as the inequity that results will appear to be no one’s fault. That those who are poor fail to get even minimal medical care can be interpreted as a matter of bad luck, not social policy. Moreover such “indecision” works to the advantage of those that have the economic and social power to serve their feverish desire to get out of life alive. Perhaps the poor’s only consolation is the biblical insight that often those who would command the powers to do their will end up subject to those very powers. That is, it may well be that sinners no longer fear falling into the hands of an angry god. Now they fall into the hands of a seemingly benevolent medical establishment whose self-interest is underwritten by our fear of death.
But surely such a perspective is not all that can be said. Those who argue that the development of modern medicine may be a danger for our moral health maybe right, but that does little to help children who need basic medical care. What can be done to insure adequate medical care for the poor? I have no concrete proposals, but I hope calling attention to Ramsey’s analysis at least may suggest where we might begin. For if he is right, our problems are theological. The problem is quite simply that medicine has been put at the service of cheating death by a people who no longer believe our deaths have any meaning.
I do not make this point in order to suggest that a recovery of belief in God is necessary to secure a more nearly just distribution of medical care. One should only believe in God if he or she thinks such a belief is true. Moreover, I do not believe, even if there were some robust return to belief in God in our society, our problems would be over. That is especially not the case given the expectations that are now in place.
However, I do not think this means that nothing can be done, particularly by people who call themselves Christians. For I assume that they are a community of people who have learned that their deaths are not an unmitigated disaster. Even more important, they are or should be a people who have learned that service to one another is more important than life itself. As a result, they can envision form of care in which the poor are not excluded. We need to remember that the great imaginative invention we now call the hospital was the result of a people who thought that even amidst the injustices of the world, you could take time to be with the dying. They cared with presence even when they could not cure. This is a reminder that medicine is not justified by the power to heal, but by the refusal to abandon those who are sick.
If I am right about this, then I think that hospitals that are sponsored by as well as serve the people called Christian may well be called on to take a more distinctive stand than they currently can imagine. The attempt to get more resources to serve the poor is to be welcomed. But more important is the possibility that Christians may have to learn to deny themselves forms of extraordinary care that medicine seems determined to develop. In other words, I suspect that we may well have to imagine as Christians that there may actually be something like a Christian practice of medicine.
I am well aware that such a suggestion may seem outrageous. For if unbelief is our problem, then it seems we face an intractable problem. Christians have long pursued social strategies, not only in medical care, that assume that belief in God makes or should make no difference for how we think about justice. In the name of charity or justice we seek social policies that we hope will be good for the poor. In no way do I mean to disparage the good that has resulted from these endeavors, but I worry that such strategies are no longer sufficient for the care we offer one another through the good office of medicine.
For the problem with abstract conceptions of justice, whether they be market, merit, social worth, or need, is they are just that—abstractions. No account of justice can be intelligible without drawing on the profoundest convictions and practices of a community and its traditions. Indeed, the very attempt to develop conceptions of justice abstracted from such communities but manifest conceptions of community that assume we are individuals free of such traditions. In contrast, I am suggesting that Christians must recover our sense of care and concern for one another as a resource for helping us better understand why everything we can do to prevent our own death may not be done if such a project makes it impossible for the weakest member of our community to be cared for. Only when we recover that sense of ourselves will we know what we are about when we call for a society to employ the scarce resources of medical care in service to one another.