For the past 40+ years I have been a chaplain at varying times in a city hospital, a community mental health center, an academic medical center, a community not for profit hospital setting. I have seen patients from all places on the economic spectrum, gender, disease modalities, injuries, emotional difficulties and reactions and more. I have seen the staffs that work with these people – some of whom are bright, curious, well educated and highly motivated; and some who are simply putting in their hours of the job, dull in mind and spirit, and uncaring.

Why is it important to talk about health care at a rally for freedom?

Well, about 100 years ago, the government said it would ensure high-quality doctors. What they did was take away our freedom to get low-cost routine care from nurses and other clinicians, as well as our freedom to choose different types of health systems. In place of that freedom, they gave us higher health care costs, and lower quality medical care.

Then the government said it would ensure high-quality health insurance. What they did was take away our freedom to purchase health insurance from outside our own state. In place of that freedom, they allowed special interests to drive up the cost of health insurance with hidden taxes and coverage that we don’t want or need.

In a previous post, I used Paul Menzel’s provocative contribution to the Hastings Center’s Values and Health Reform Connection as a touchstone for getting clearer on what implication the values of fairness and equality of opportunity might have for health care reform. Since that post was mostly critical in nature (I argued that they do not have the implication Menzel describes), I wanted to offer a constructive suggestion that, while not novel, might provide some reason to think that seemingly conflicting strands in contemporary political philosophy can provide mutually supportive grounds for a government guarantee of affordable access to adequate health insurance.

In “Justice and Fairness: Mandating Universal Participation,” Paul Menzel grounds his endorsement of government-assured universal access to basic health care in a ideal of “just sharing” between fellow citizens. At the same time, Menzel calls unfair the current arrangement that shifts the costs of unpaid emergency care provided to “those who cannot afford to pay” onto “patients who can pay, almost all of whom are insured.” According to the figures cited by Menzel, such cost-shifting raises average family premiums by roughly $1,000 per year, and amounts to “unfair free-riding.”

There is some dissonance between these two planks of Menzel’s overall view.

As Americans, we value a health care system where people are treated fairly. We expect that if we work hard and pay our taxes, we’ll have access to that most basic human right — getting care when we need it. But for millions of people in this country who work hard and pay their fair share of taxes, that’s not the reality…

Assume, for the moment, that you support the adoption of universal, single-payer coverage in the United States. Let us say that you believe that everyone has a right to a decent and equitable minimum of health care, and that we as a society have a moral duty to ensure that everyone has financial and other access to such services. Under these circumstances, to what extent, if at all, can you reasonably support the current major congressional efforts to reform health coverage, and at what point if at all – and why – ought one to withdraw support?

So often the political debate in America revolves around two seemingly conflicting values: solidarity and subsidiarity. William Sage touched on the former. Opponents of health care reform often talk about the latter. But it is the intersection of these two values that matters most to American politics, and nowhere more so than in the health care debate…

The health reform debate, like so many debates in ethics and policy related to health care, tends to assume that the representative “health care professional” is a physician. For many months, American have heard how the various reform proposals would affect physician’s autonomy, practice, income, terms of employment, and so on. No one would argue that the interests of physicians are not integral to this debate.

But let’s look at the numbers…

The president emeritus of the Hastings Center opens his insightful essay with the observation that the American people’s faith in medical progress is boundless. In this short comment, I want to expand on his thoughts by reexamining the cardinal tenets of that faith, since they embody a set of values that distract us from building a society that promotes good health, an infinitely more difficult task than building a better sick care system.

Let’s get even more pragmatic about our values and talk about accountability.

It is a business truism that if you can’t measure it, you can’t manage it. Our healthcare system is incredibly adept at measuring revenue, procedures performed, and patients moved out the door. In our current system, physicians and facilities get tangible rewards for managing these measures efficiently. However, research such as the Dartmouth Atlas illustrates that more of these things—payments, procedures, and patient throughput—aren’t yielding better health outcomes…

The American health reform initiative of 2009 has provoked the debate that couldn’t shoot straight. The issues and subjects have been wildly misdirected. In so many ways, these past few months of health reform controversy have shown the immaturity and ignorance of American politics. And I don’t just mean the “death squads.”…

Let me start with Bruce Jennings’ fascinating opening essay on liberty. Given reform opponents’ frequent appeals to personal freedom both in specific cases–fears about government intrusion into end of life care, most notably–and in broader “the government is controlling your body” terms, establishing that health care reform is part and parcel of American ideals of freedom is absolutely essential, and so arguments like Jennings’ are absolutely critical to winning the debate…

Liberty. Justice, Responsibility, Solidarity.

These are some of the American Values highlighted in the Hasting Centers report on “Connecting American Values with Health Reform”.

Watching health reform unfold here in Washington, however, that “Connection” is painfully elusive. The debate is not a careful calibration of competing rights, values and obligations. It’s a political moshpit. Instead of values, we have vitriol…

While many speak of healthcare as an individual “right,” I prefer to think of universal coverage as something that we, as a civilized nation, desire for all members of our society because we recognize each other as equally human, vulnerable, and in need of care.

As a society, we have a moral obligation to provide access to medical care for all of our citizens. When we frame healthcare as a “right,” we shift responsibility from society to the individual. It is up to him to demand his due. At that point, the word “entitlement” comes to mind, along with the conservative image (so artfully drawn by President Reagan), of an aggrieved, resentful mob of freeloaders dunning the rest of us for having the simple good luck of being relatively healthy and relatively wealthy…

I’m going to do something “radical” here in the spirit of Dr. Sabin’s opening quote – and speak from my gut on the topic of responsibility.

In my opinion, it’s human nature to shirk responsibility, and our current society is a great facilitator of that natural urge. The more wealthy and technologically comfortable we become, the fewer responsibilities we have (in terms of securing basic needs), and the more empowered we are to indulge our inner narcissism. Until we accept that we all have this selfish tendency, we’ll continue to point at others and engage in a blame game that keeps us all very much in the dark about what’s really going on….

To exercise stewardship, or not—that is the question. Why put the point that way? Because one path leads to an abundant life, and the other is a dishonest, if elaborate, form of suicide.


Stewards distinguish themselves first by accepting responsibility, and then by acting on that responsibility to preserve, protect, and nurture something precious, through recurrent threats, for the purpose of delivering that precious thing to future generations.

Few dispute the need for health care reform in America. Two problems—access and cost—attract the most commentary, and for good reasons. The ranks of uninsured Americans, which have increased annually for the last six years, are likely to reach 50 million in this economic downturn, and health care expenditures are predicted to top $2.5 trillion in 2009. Both problems are unsustainable features of American health care. But these problems share company with a third that has gone largely overlooked. Our health system, if it can be so called, is not designed to produce health. Indeed, health care is but one determinant of health, and by some measures it is a relatively minor one. Despite the trillions spent on medical services, the United States ranks poorly on key measures of health. For example, according to 2004 World Health Association data, the United States ranks forty-sixth in average life expectancy out of 192 nations.

Some major fault lines in the current health reform debate arise out of conflicting notions about the definition and goals of efficiency. There is, however, a simple and intuitively appealing concept of efficiency that I believe should be a central virtue of any health reform effort: To be efficient means to use our resources in the best possible way to achieve our ends. This makes “efficiency” an instrumental ideal—a goal whose meaning depends on whatever substantive ends we embrace.

A movement has emerged within health care over the past several decades that sees quality as the combined and unceasing efforts of everyone involved in health care—professionals, patients and their families, researchers, payers, planners, and educators—to make the changes that will lead to better outcomes, better system performance, and better professional development; in other words, better health, better care, and better learning. This sweeping view recognizes that the pursuit of quality and safety is a dynamic process, not a static and narrowly focused endpoint. People associated with the quality movement accept this pursuit as both a moral responsibility and a serious applied science. They also believe unequivocally that everyone in health care has two jobs when they go to work every day: to provide care, and to make it better—a view that is entirely congruent with the idea that “unceasing movement toward new levels of performance” lies at the very heart of professionalism.

To deem itself civilized, a society must protect the personal integrity of its citizens. Without such protection, the integrity of the society itself unravels as more and more effort goes into protecting individuals against the chicanery of their fellow citizens. Perhaps this is why Plato called integrity “the goodness of the ordinary citizen.”

Above all values, Americans prize freedom—the right of individuals to control all aspects of their lives, including the personal and the economic. In many ways, both major political parties embrace individual freedom, with Democrats stressing personal freedom and Republicans economic liberty. What is often absent in political discourse around freedom, however, is the common good and an appreciation of when rigid adherence to individualism is inimical to collective welfare.

Writing in 1780 to his friend Joseph Priestly, the British scientist, Benjamin Franklin said that with an increase in the “power of man over matter, . . . All diseases may be prevented or cured, not excepting that of old age.” The great American Revolutionary War physician, Benjamin Rush, was no less utopian in prophesying that there will someday be a “knowledge of antidotes to those diseases that are thought to be incurable.” …

Illness, we are often told, is a private matter. Accordingly, none must interfere in the medical decisions that emerge from the confidential relationship between physician and patient. Yet evidence of interdependence is ubiquitous in health care. One person’s malady can harm families, workplaces, clubs, churches, and sometimes entire communities. Similarly, a suffering patient must rely on many individuals, associational groups, corporate entities, and government agencies for support and assistance. It is, therefore, unsurprising that various social units claim an interest and a voice in maintaining health and treating disease…

We in the United States are deeply committed to “responsibility” as a core American value. Being responsible and taking responsibility are good. Being irresponsible is bad. But “responsibility” means very different things to different people. As a result, calling for “responsibility” in U.S. public discourse is like waving a red flag at a convention of bulls — it elicits passion, rancor, and disorderly conflict…

Convictions about justice are a deep and persistent force in health care. It seems distinctly unjust and unfair, for example, that one victim of a disease dies or is permanently impaired and financially devastated, while another with the same disease is readily cured and lives financially unscarred…

The atmosphere was tense. Representatives of the insurance industry were huddled in one corner. The other members of the Task Force on Genetic Information and Insurance, mostly academics and consumer representatives, were bunched across the room. As chair of the task force, I was in the middle, trying to make sense of the disagreement, which was growing more intense by the minute.

America is the child of John Locke, the great philosopher of liberalism and natural rights. This commonplace observation holds a key to understanding the politics of health reform in the United States. The tradition of liberalism (in the philosophical sense of the term) is still the context of our political morality, our constitutional law, and much of our public policy. Liberty is the fundamental value of American politics; not the only one, to be sure, but the fundamental one nonetheless. Liberty has been central to the ethical justification for health reform in the past, and it will continue to be in the future.