2. Christians, Health Care Policies and the Dangers of False Equivalencies
PJR Vol. 8, Issue 3, Article 2 2018, A Way Forward: Christian Principles for Health Care Policy
Dr. Ruth Groenhout is Distinguished Professor of Healthcare Ethics at the University of North Carolina Charlotte.
Michelle Kirtley’s thoughtful comments on health care policy are wonderful. Her proposed principles are ones I largely agree with and support, and she offers positions that thoughtful Christians across the religious spectrum would do well to consider adopting. And the description she offers of the clinic she works with in Durham makes it clear how much good it is doing for the people who live near it. So, in what follows I will not be disagreeing with the general principles Michelle offers, but I will raise some concerns about the over-all position she offers, concerns that I think need to be taken seriously by all Christians, but especially seriously by white Evangelicals in the American world.
I’m going to begin my remarks about Michelle’s comments with an anecdote that will sound a bit off- topic. I was recently in Ireland for a conference, in the days prior to the run up on the vote to repeal the 8th amendment to the Irish constitution, an amendment that banned abortion under practically all situations. Prior to the actual vote, no one really knew what the outcome would be, but the issue was tremendously galvanizing. Both sides advertised widely, with multiple posters on every possible light post.
In an NPR analysis of the referendum, prior to the vote, it was noted that the anti-abortion side of the debate wanted to emphasize the moral nature of the issue (and their signs certainly did that.) The analysis continued with the comment that the anti-abortion supporters requested that the Catholic church remain largely out of the debate on the issue. It was felt that the church had no moral standing with which to speak in the public sphere on this issue. Let me say that again: in Ireland, once one of the most Catholic nations on the face of the earth, the Catholic church is no longer seen as having a moral voice.
It’s a rather shocking anecdote for anyone who knows Irish history, but what does it have to do with Michelle’s discussion? I begin with this anecdote because what the Irish experience should remind us
of is a very real danger that faces the American evangelical church today, and more specifically the white Evangelical church. As Michelle’s remarks imply, we Christians are called to resist absolute identification with any partisan agenda, and this is one of the real strengths of a Kuyperian approach to public engagement. Unfortunately, the way that this resistance manifests itself, too often, is to fall into a false equivalence: to insist, regardless of what issue is under consideration, that both parties in contemporary American politics are equally wrong (and equally right) when it comes to policy matters. But that false equivalence is false in ways that may leave the American Evangelical church with as damaged a reputation as the Catholic church in Ireland. What I believe must be said is that the American political scene is not one in which Christians find themselves equally at home with the health care policies offered by both political parties.
We have one party that has attempted to respond to a real crisis in American health care, not a perfect solution, sometimes not without creating its own new problems, but an attempt made all the same. On the other side we have a political party that has sometimes misrepresented those policies. Who can remember the claim that the ACA would result in death panels? It made Politifact’s lie of the year in 2009. It is worth remembering that what was characterized, at the time, as ‘death panels’ was, in fact, a proviso in the legislation that required insurers to pay for physicians who spent time with their patients discussing end of life decisions. That provision was removed from the ACA. The same party has spent a good portion of the last year trying to repeal the Affordable Care Act with no plans for its replacement or for policies that would address the lack of access to health care that millions of Americans still face.
Evangelical support for gutting the ACA has not gone unnoticed in the public sphere. It is one piece of a much larger willingness among Evangelicals to harness the name of Christ to policies that harm the most vulnerable (think of current policies separating immigrant children from their parents, for example). And this has not gone unnoticed by the next generation—as study after study demonstrates, Millennials are leaving the church in large numbers. The Evangelical witness on key social issues, health care fore among them, must certainly play a role in this exit.
And this forces me to be just a bit critical of the vision of shalom that Michelle offers. It is true, and undeniably true, that for the people who live near the clinic she describes in Durham, its presence is truly a blessing. And it is true that those who work in these clinics are doing their best to provide health care and support in ways that reflect their Christian faith. Nothing I say in what follows denies either of these two points.
My point, instead, is that holding up charity clinics as a clear image of shalom, under current conditions, is deeply problematic. Providing health care through clinics run by volunteer power and supported by charity is not a substitute for true reform of the health care system. For one thing, there simply aren’t enough clinics to meet the extensive need for health care in North Carolina, which has rural communities with continually diminishing access to health care and increasing poverty levels, inner city communities with appalling living conditions, and working poor facing bankruptcies due to health conditions. And the lack of access to health care is not simply a matter of arbitrary fate. The decision made by North Carolina’s legislature to oppose the Medicaid expansion was supported by white Evangelicals in North Carolina.
Michelle cites Neil Plantinga’s definition of shalom as a situation where things are the way they ought to be, but it is worth digging a bit deeper into that notion of how things ought to be. As Nick Wolterstorff noted years ago in Until Justice and Peace Embrace, a Kuyperian, Reformed understanding of shalom requires that justice be done and people’s basic rights protected. It is never a situation of shalom when these are not present. Among the rights that must be protected are sustenance rights, rights that ensure that we will be, in Wolterstorff’s words, “adequately sustained in existence (p. 81).” One way of imagining sustenance rights in the contemporary world is by basic minimum health care, ensured – as with other political rights – by the state. Denial of this right is unjust. In other words, the State of North Carolina, by choosing not to expand Medicare, denied a basic right to many of its own citizens.
If people have a right to something—in this case, health care—then proposing that their needs should be met by charity does them an injustice. It is an injustice whether there are adequate charitable resources or not, but it is especially deep when charity does not meet their needs. Because it is an injustice, substituting charity for respecting rights can never be held up as an example of shalom.
The recognition that substituting charity for the rights one is due is an injustice is one that has deep roots in Reformed thought. I’ll discuss three broad reasons why the Kuyperian tradition might argue this:
First, a point that was noted by the early members of the Reformation: the substitution of charity for what someone is owed by right is contrary to the basic equality and dignity of all humans. Charity creates debts of gratitude on one side, and a sense of superiority on the other, and particularly in the case of important rights, this undermines basic respect and dignity. Rights need to be secured for all by proper political authorities, not handed out by the fortunate to the unfortunate. For precisely this reason, early Reformation leaders such as Zwingli rejected the notion that the poor should be supported economically by way of charity, and instead advocated that provision for the poor must be provided from institutionalized systems of communal tithing, His reasoning for this was specifically that the poor and the rich ought to not stand in the unequal relationship to each other that charity creates. This has obvious implications for health care policy. If people have a right to basic care but can only receive that health care as a matter of charity, not of right, then their basic dignity is not respected.
My second point concerns another difference between justice and charity. Nick Wolterstorff argues in his book Justice, that the recognition that the denial of rights is unjust is morally different from an evaluation of whether some individual has done something wrong. Many times, when we ask questions about whether an action was right or wrong, we look to the individual who performed the action to see what his or her intentions were. So, in a case such as this, perhaps we want to decide whether the legislators who voted not to expand Medicaid were doing something wrong. It is quite probable that the bulk of these legislators had good intentions. But if we are concerned with justice, simply knowing their intentions is not enough.
Justice is done only when people’s rights are respected. When an individual’s (or a group’s) rights are violated, they are wronged regardless of what was intended by those who created the situation. The injustice done to those individuals or that group needs to be acknowledged and rectified. When we are concerned about justice, we need to ensure that people’s rights are protected and, in this case, a case in which the right of citizens of North Carolina to have access to basic health care is denied, an injustice is occurring.
If justice requires providing health care as a right, people deprived of that right are treated unjustly even if some of them have access to charity clinics. It is not the intentions of those who set up and administer such clinics that determines whether the situation is just, though they are certainly doing something good. The key question is whether people’s rights, and hence their dignity, is protected. Providing health care by way of charity clinics is better than leaving people with no access at all, but it is certainly no substitute for ensuring that people have access to health care as a basic human right guaranteed by the state.
The third reason why charity is no substitute for providing access to health care as a right is that charity leaves people vulnerable to the loss of care without redress. Clinics can lose funding, volunteers grow scarce, and the provision of care ceases. Now, it is certainly true that state provided health care can also be withdrawn, but in that case those who need care have the right to demand that their needs be met. Not so with charity. By definition, those dependent on charity have no right to claim that they are owed any care—an act of charity is precisely something one is not owed and cannot demand. Rights recognize human dignity by enabling those who bear them to claim what is theirs by right; charity offers help but can withdraw it at any time.
True shalom requires that policies protect human rights. While I fervently agree with Michelle in placing shalom at the heart of the health care policy debates, I must respectfully disagree with her example of what that would look like. Shalom requires that health care be provided as a matter of right, not as a matter of charity for those fortunate enough to live in proximity to clinics. Christians, I would argue, have a duty to work to make universal health care a reality for precisely that reason. And the stakes are high.
The world pays attention to what Christians do, and when Christians are identified as the group that works to deny health care to the poorest and most vulnerable, we lose moral authority. But imagine, instead, that white Evangelicals took seriously their responsibility to make sure that justice was done in the contemporary world by working to ensure that every state in the union provided adequate health care for all its residents. Imagine that they held legislators of both parties responsible for producing legislation that would make this a reality. My sense is that this would be a true reflection of shalom, and one that we all should work to make a reality.
To respond to the author of this article please email PJR@cpjustice.org. The articles in the Public Justice Review do not represent a consensus of positions on questions of public policy. We do not expect our readers will agree with all the arguments they find here, but we believe that within the broad tradition of what we call public justice we can do more by providing a forum for the debate and exchange of Christians, within those bounds, to work out public policy faithful to
God and in service of our neighbors. We do not necessarily share the views expressed, but we do accept responsibility for giving them a chance to appear.
To respond to the author of this article please email PJR@cpjustice.org. The articles in the Public Justice Review do not represent a consensus of positions on questions of public policy. We do not expect our readers will agree with all the arguments they find here, but we believe that within the broad tradition of what we call public justice we can do more by providing a forum for the debate and exchange of Christians, within those bounds, to work out public policy faithful to God and in service of our neighbors. We do not necessarily share the views expressed, but we do accept responsibility for giving them a chance to appear.
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Read the Full Series
1. Biblical Shalom and the Health Care Debate
2. Christians, Health Care, and the Dangers of False of Equivalencies