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CATHOLIC HEALTHCARE AND THE COMMON GOOD

he notion of "common good" has re­ the group, and peace, which is the stability of a mained constant through centuries of An Ancient just order.' Catholic social teaching. Its roots lie in Today, because health is clearly a good and Greek and Roman philosophy, in which it healthcare is a need common to all, we frequently was seen as the goal of political life—the Concept invoke the common gcxxl in the debate about the Tgood of the city—and entrusted to civic leaders. future of healthcare. Yet despite the centrality of this St. Augustine acknowledged that our earthly Can Bring concept in our tradition it often remains an abstrac­ cities achieved a common good of a sort, but he tion that is difficult to apply to the organization or stressed that only the heavenly city, the City of management of healthcare. In addition, the rich God, was truly worthy of that name. Later the Trans­ spiritual and theological meaning of the common thinkers in the tradition of St. Thomas Aquinas g(xxi is seldom seen as a resource in our attempts to saw the common good in three ways: as the good redefine Catholic identity in healthcare. of any being, as the good of a political communi­ forming ty, and, finally, as God's own self, to whom all CULTURAL CHALLENGES TO THE NOTION OF THE creation tends.1 Writing in light of the totalitarian COMMON GOOD horrors which preceded the Second World War, Power of Individualism and Pluralism Robert Bellah, following Thomist scholar Jacques Maritain emphasized Alexis de Toqueville's observations about the that the common good could never violate basic American character, has shown how Americans human dignity: "It is the good human life of the Grace into have clung to the same individualistic notion of multitude . . . their communion in good living. It citizenship that animated their revolutionary is therefore common to the whole and to the 4 the Public ancestors. This view emphasizes personal free­ parts. It flows back on the parts, and the parts dom and self-determination, low taxes, and pri­ must benefit from it."' vate initiative over government control. It has The Catechism of the Catholic Church sum­ Healthcare proved to be inhospitable ground for the notion marized this tradition by describing the common of common good. This is particularly true in good as "the sum total of social conditions which Debate healthcare, which is rooted in a whole array of allow people, either as groups or as individuals, to private goods: reach their fulfillment more fully and more easi­ ly." The catechism notes that the common good BY REV. CHARLES E. Physicians want to retain or restore autono­ involves three essential elements: respect for the BOUCHARD, OP, STD my of practice. Hospitals want market person, the social well-being and development of choices but protection from market disci­ pline. Suppliers of medical devices and pharmaceuticals want the widest range of proprietary control in the development and marketing of products and drugs. Insurers want release from cost shifting and mandat­ ed benefits and freedom to exclude high- Ft\ Bouchard is president, risk individuals. Patients and consumers of Aquinas Institute of Theology, health insurance want the greatest range of St. Louis. coverage at the lowest cost and access to

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the highest quality of medical care—with­ whether there would have been political life in par­ out gatekeepers, waiting lists, or rationing adise, before the Fall. If government were a pun­ of care. American taxpayers do not want to ishment for sin, we would expect him to reply in sacrifice the freedom represented by their the negative, but he docs not: "Someone has disposable incomes, and many are reluctant dominion [that is, exercises political power] over to abandon unhealthy habits. In short . . . another . . . when he is directing him to his own American health care is dominated by an good or to the common good. As such, domina­ individualism that asserts self- or group tion . . . would have existed in the state of inno­ interest over the common good/ cence . . . because we are naturally social, and [even] in innocence we would have lived in social In addition to all these incompatible needs, groups. The social life of many is not possible today we are rapidly adding high investor return unless someone presides who can direct the to the equation. Achievement of the common group toward the common jjood."* good falls far down the line of priorities in the This means that, theologically, we do not view development and delivery of healthcare. government, nor presumably a common good Affluence and Political Apathy Affluence and the false toward which it can direct us, as necessary evils nor security it provides are further obstacles to the as infringements on human freedom. As persons common good. They can lull most of us into feel­ with a communal, transcendental end, this drive ing that the rest of us will be just tine, and that toward union is inherent, and the political means government and political life are more intrusive to achieve it are a blessing rather than a curse. than helpful. Harper's editor Lewis Lapham has Government and political life exist not to limit noted with dismay the growing disenchantment Affluence human freedom, but to help facilitate distribution with politics in America. The general ineffective­ of goods, with a view to creating a peaceful, inter­ ness of our political system today, coupled with dependent society. In our own day, Aquinas might unprecedented economic prosperity, has led and the well have asked whether, in a state of innocence, many to believe that government and political life there would have been managed care! are not really necessary any longer. He cites security it Moral Agnosticism Philosophically, the biggest remarks by New York Post columnist James K. obstacle to a theory of the common good is epis- Glassman, who noted that Americans are "really provides are temological: Is there "a good" to be known, and, happy," and probably do not need to be interest­ even if there is, who can know it: There is a ed in politics. Mr. Glassman elaborated: "We further strong strain of moral agnosticism which denies have reached an era ... in which we can turn our that we can know what our own good is. Michael attention from politics and war and toward art, in Novak notes: the broadest sense of the word, which includes obstacles to not just porcelain, but philanthropy, aesthetics, It is not so easy, either, to come to know religion and family. As the century draws to a the common the common good of free persons. There close, we seem to be witnessing the death of poli­ are three reasons for this. First, even in try- tics and the rise of something else. Call it the art good. ing to determine one's own economic of living." good, in the full context of one's own Lapham says this affluence and the correspond­ political, moral and cultural goals—one ing indifference to politics have appeared before. often feels confusion and uncertainty. They caused "an oligarchy that might once have Should one buy this house? Take this posi­ aspired to an ideal of wisdom or virtue'"' to acquire tion? Accept this contract? All such deci­ instead what Aristotle called 'the mentality of the sions are made in ignorance of the future. prosperous fool'—a man or class so bewildered by Not all the relevant contingencies can be their faith in money that they therefore imagine known. ... It follows that it is no easier to that there is nothing that it cannot buy."" This know the economic good even of one's view of government and political life contrasts best friends and nearest neighbors. . . . sharply with the descriptions of the common good Second, each of us is necessarily ignorant taken from the Catholic tradition. about the economic good of those in This idea that the best government is the least trades . . . and circumstances of which we government is rooted in a view of the human per­ have no experience. Third, the economic son that stresses freedom and autonomy above all good Of at! entire nation, on a high level of else. Theologically, this view depends on seeing abstraction from particular persons or government as a result of the tall and as a punish­ groups, may be easy enough to sketch in a ment for sin. If that is true, then indeed, the less of "wish list": low inflation, low unemploy­ it the better.7 However, the Catholic view is more ment, steady growth, [etc.]. Yet the schol­ sanguine. In a rather arcane question, Aquinas asks arly discipline designed to investigate the

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tradeoffs among these . . . goods has won Healthcare Management and Participation Not very long the historical sobriquet of the "dismal sci­ ago the healthcare relationship was a private one ence". . . . The phrase "common good" between the physician and the patient. Today, sounds simple and neat. But upon inspec­ medical care "has moved from being a privately tion this good turns out to consist of main paid, individual good of marginal value to the sta­ goods. . . not only not in natural harmony, tus of a largely public-supported individual and but often in direct conflict. . . . Thus, even social good of great benefit."" The patient MK\ if we were to accept the ideal of the com­ physician are just two players in a whole panoply mon good, we would still be operating in of providers and support personnel whose inter­ considerable darkness and uncertainty. ests are not always complementary. Managers must learn not only to maintain a strong bottom Novak goes on to say that even though, line, but to create healthcare facilities and systems because of this ignorance, it is impossible to "in­ that operate as organic units and maximize tend the common good," or "take it by frontal employee participation in achievement of the common good through mission education. assault," it could be achieved by persons with Managers must freedom and dignity, "by an indirect, less pater­ This education should be rooted in the notion nalistic route."" of subsidiarity, where authority and competence This kind of liberalism stresses human freedom learn to create to act are not merely delegated from above, but and independent choice of individual goods. It are elicited from employees' talents and commit­ creates, at best, a "thin theory of the good" that healthcare ment at a level appropriate to their skills. We are values noninterference and privacy rights over tlying to make our employees part of something cooperation in a common project. However, as organizations bigger than themselves. Ezekiel Emmanuel calls Daniel Callahan notes, it is important to remem­ this "something" a "higher level of freedom ber that this approach can also limit freedom by that operate as [where they] develop the capacity to understand creating its own culture: the views of others and to make decisions not organic units against them, but with them . . . [enabling them] If we think of medical developments as to transcend contingent, individual existence by 13 simply putting difficult but discrete moral becoming part of an enduring community." choices before us—how best to use this or and maximize This participation is at the heart of the notion of that technology, whether to turn off this the common good. The catechism stresses the respirator—we have already failed to see the employee importance of participation by "each according to presence of a still deeper question, [e.g.]: his position and role, in the promotion of the com­ first, to what extent has the culture engen­ participation in mon good" and notes that responsibility extends dered by medicine already constrained our not only to personal and family life but to public choice (forcing us, for instance, to consider achievement of life, and even to "a continually renewed conversion the use of a respirator whether we want of the social partners" (nn. 1913-1916). Kenneth such a choice or not); and second, what the common Himes summarizes this tradition by noting that kind of a culture will we be engendering by "the common good is the term used by the the pattern of private decisions that eventu­ Catholic tradition to convey this sense that human ally emerges from the need to make deci­ good through well-being is achieved through experiences of soli­ sions. Those individual decisions, in short, darity, a life lived with and for others."13 sooner or later create a culture.1" mission Corporate Management and the Common Good Originally, "business ethics" meant codes of conduct that CAN WE RETRIEVE THE COMMON GOOD AS AN education. reflected usual business practices. More recently it OPERATIVE PRINCIPLE IN CATHOLIC HEALTHCARE? has come to mean thoughtful deliberation about Despite these cultural and theoretical difficulties, how corporations ought to conduct themselves, the public nature of healthcare demands that we especially internally. But the definition is expand­ find ways to make it more than a private good or ing even further to include ways in which a corpo­ a series of individual choices. Since the notion of ration might conduct itself responsibly and effec­ tively as a public moral agent that has a major role the common good is also a spiritual concept root­ 14 ed in the belief that our common good is God's in shaping the society around it. The emerging own self, Catholic healthcare providers must find field of organizational ethics asks what it means to new ways to link the social and human good of consider corporations as moral agents, and this healthcare with its spiritual and sacramental question becomes even more pressing if political goods. This involves development of new, partic­ life is diminished or dysfunctional, as it is in the ipatory management styles, redefinition of patient United States in 1999. Corporations have un­ and physician autonomy, and increased awareness precedented economic and cultural power in our of the sacramental nature of healthcare. society. Healthcare corporations arguably have

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even more. Not only do they collect and disburse of something larger than his or her own medical hundreds of millions of dollars per dav, but their • needs: product, healthcare, is at the very heart of what it means to be human. David Hollenbach notes: The moral, social and communitarian side of citizenship emphasizes common purposes Managers must be careful to recognize when and shared vulnerabilities. This latter under­ they are functioning in their traditional roles standing of citizenship identifies the self as arid when they are functioning as representa­ essentially social, as constituted by civic rela­ tives or stewards for a tionships. . . . Our group of economic reliance on the con­ and human assets that cept of citizenship is are part of the na­ intended to evoke a tion's economic and sense of belonging to social potential. Ex­ something larger than ecutives must develop self, or particular in­ a broad view of the dividual relationships. national interest and Citizens are persons then be sure that their who perceive alle­ companies' positions giances as extending are consistent. An bevond self-interest. international view and . . . The citizen is not an educated perspec­ only a patient with tive on major national rights, but a citizen issues are important with duties. . . . The to their effectiveness right to make health­ in their new role.15 care decisions should not be seen as an ab­ solute without a con­ Redefining Autonomy: The text, but as bounded Patient as Citizen We have by the limited re­ made great strides in sources of society and patient autonomy in the the competing rights past 20 years. The of others.1" notion of informed con­ sent has evolved to include living wills, This reminds us that durable powers of attor­ any valid theory of ney, and the Patient Self-Determination Act. The rights presupposes a corresponding obligation or downside of this evolution is that it sometimes responsibility on someone else's part. "The idea reinforces patients' view of themselves as totally of patient as citizen," Danis and Churchill con­ autonomous agents, consumers who have a wide tinue, "can help to bring these responsibilities to variety of healthcare products to choose from. the foreground. . . . The patient as citizen has But, as Daniel Callahan notes, we must be aware rights, but also duties to make judicious and pro­ of the social nature of medicine and the con­ portionate choices." straints it places on our demands: "The social One of the most important areas where these constraint on the self means that its demand for duties come into play is the duty to rethink what health and its desire to avoid death do not impose appropriate medical care is as we age. Callahan ruinous burdens on others, whether family mem­ has urged us to think about age as a factor in bers or the public. The provision of healthcare is decisions about medical care, and has advanced increasingly a communal task. We are medically the notion of "biographical age," a point at and economically interdependent. We need, which our natural lives, while not over, nor even therefore, a picture of the self that is compatible 16 threatened, have largely drawn to a close, at least with that mutual dependence." in terms of what we will accomplish in the future. A number of other authors have highlighted This is the point when the quality of care should this communal duty as well. Marion Danis and shift from acute intervention to preparation for Larry Churchill have proposed that by returning death. He writes: to the ancient, political roots of the notion of the common good, we can see the patient as "citi­ There are large and growing numbers of zen" rather than as consumer, and hence as part elderly who are not imminently dying but

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who arc feeble and declining, for whom healthcare reform as merely a serial distribution of curative medicine has little to offer. For things, but rather as "education in virtue [so many, old age is a reason in itself to think that] human individuals are not primarily con­ about medical care in a different way, sumers or private appropriators of things that whether in forgoing its life-saving powers have instrumental value; they are interdependent when death is clearly imminent, or in for­ beings who arc in need of mutual assistance and going its use even when death may be dis­ who, if properly motivated, possess the power to tant, but life has become a blight rather offer it to others in turn?"21 than a blessing.Is THEOLOGY, SPIRITUALITY, AND CATHOLIC IDENTITY This view need not be morbid nor harshly utili­ The common good is, as I have shown, a secular tarian. It is really rooted in an eschatological view idea used originally to describe the role of secular of the person in which physical life, marvelous government. But, at least since Augustine, it has though it is, is not the final purpose for which God also been a theological concept that must shape created us. Our common good is ultimately to be the Church and its institutions. For much of the one with God in whom we have our beginning. past 20 years, discussions about Catholic identity Another way of seeing this is to understand have focused on proscribed procedures, so that healthcare as a "•commons," much like large fields Catholic healthcare facilities are often defined in the middle of colonial towns that were main­ We might view more by what they do not do than by their posi­ tained and utilized by all the citizenry. Nancy tive goals and values. This has caused us to Jeckcr and Albert Jonsen propose that, like the healthcare as a neglect the theological roots of what "Catholic" commons, healthcare (1) depends on contribu­ means. If Catholic healthcare wants to root its tions from society; (2) benefits society; (3) has a "commons," mission in this theological notion of the common finite carrying capacity; and (4) is a vital and good, it must be clear about its theological basis. important good to members of society.19 like those large There are three primary theological elements to Principles of Catholic social justice can help us the notion of the common good: that we are cre­ educate patients, start", and sponsors about ways ated "into the image of God"; that our human in which healthcare is a public good that is held in fields in community, and the common good itself, have trust and stewarded responsibly. an eschatological and supernatural dimension; Physicians, too, need to see themselves as citi­ colonial towns and that healthcare is sacramental. zen-participants in achieving the common good. It Creation "into the image of God" In his Summa Tluo- has not been customary, but is it possible for us to that were lojjiae, Aquinas talks about humans being created imagine that physicians can begin to make deci­ not in the image of God, as though we were sions about patient care based not just on benefits maintained reflections in a mirror, but "into the image of and burdens for this particular patient, but for the God" (ad imajjinem Dei). This implies that the patient citizenry as a whole? As Danis and and utilized moral life, far from being just conformity to a Churchill note, referring to the code of the more or less arbitrary moral law, is really a dynam­ American Medical Association, "the idea of citi­ ic movement into the image of a God who has zenship as a source of medical obligations is not by all the revealed himself through scripture and human new. What is new is our contention that citizen­ experience. Aquinas suggests clearly that God's ship should play a different and a larger role than in citizenry. plan for us is planted deeply within us, and that the past. . . . If resources are acknowledged to be we can come to know this plan which God has for scarce, both physicians and patients have a respon­ us and take intelligent steps to achieve it. This sibility for helping to shape policies for fair alloca­ could blend well with liberal theories of morality, tion at the societal level and for participating self­ since it suggests that God has endowed each of us consciously in enacting those policies humanelv at with an exquisite, unfettered freedom. However, the level of individual patient care."20 we must also remember that we are called to achieve our goal and purpose with one another Underneath it all, this requires that we help since "persons tend by nature to communion."" our patients and staff cultivate what Bruce This natural tendency is not just accidental but is Jennings calls "the virtue of solidarity." "Framing essential to what it means to be human. As Himcs health reform as a problem of distributive justice notes: inevitably leads to conceptualizing healthcare itself as a 'commodity' [and] obscures the tradi­ tion . . . where physicians are not simply pro­ To perfect oneself requires participation in viders and patients are not simply consumers. . . . community, for, in Catholic teaching, It also leads us to think about health and illness as communal life provides the opportunity to conditions that happen to individuals one at a gives oneself away to another and it is by time." Can Catholic healthcare move from seeing so doing that a person becomes more fully

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realized. . . . "Justice as participation" is a Gospel in all aspects of human existence. way of summarizing the foundational the­ No realm of our life is removed from the ory which serves as the warrant for rights redemptive work of Christ. [To divide up] language in Catholic social teaching.23 human existence into compartments, some labeled sacred and others profane, is funda­ The Eschatological Nature of the Common Good Wendy mentally a misunderstanding of the power Manner notes two reasons why Americans refuse of religious belief to integrate and bind to accept rationing: the absence of any limitation together the range of human experience. on healthcare, and the belief in vitalism, that Catholic teaching affirms the divine pres­ "everyone is entitled to unlimited longevity and ence in all reality', but maintains that such good health."24 However, if we believe that per­ presence must be manifestly expressed.2S sons have a supernatural destiny, and that we were created, as the Baltimore catechism used to Thomas O'Meara takes this even further and say, "To know God, love God and serve God in emphasizes the importance of human instrumen­ this world, and to be happy with him forever in tality when he says that we can actually "cause the next,'" then we must be willing to move away grace": from a vitalistic position and to acknowledge, happily, that there are limits to healthcare. We have seen that Aquinas so prized the If Catholic healthcare can be animated by the activity of creatures that even in the realm of belief that our common good is, finally, God's grace he permitted [us] within life, church own self, that to be one with God is the ultimate At least and liturgy to make grace present. The min­ reason for which we were created, then the cura­ istries of priests and bishops, parents tive powers of healthcare can be seen in a relative since Augustine instructing their children, husbands and sense. We will no longer need to grasp at even' wives living amid the joys and difficulties of technological intervention. Both healthcare the common married life—ordinary people could be real providers and patients will feel free to "let go" causes of grace. Strictly speaking of course, when the burden of a treatment has outweighed only God could cause grace. . . . Never­ its potential benefits, if these benefits are viewed good has been theless, in ways quite circumscribed, God not only in the perspective of physical life, but allows and encourages creatures to act.26 relative to eternal life and union with God, which a theological is our ultimate goal. Surely healthcare, which touches us at such a Healthcare and Sacramentality The single most charac­ concept profound level of life, is also a "cause of grace." teristic feature of Catholic thought is the notion Would Catholic healthcare be different if we—and of sacramentality, described succinctly in the shaping the our employees—really believed that? axiom "grace perfects nature." The Catholic Politics, Compromise and the Allocation of Healthcare This view—foreign to most Protestant theology, which Church and its sacramental understanding of reality affects how holds that grace and nature have been rendered the Church "stands in the world," as well. incompatible or even hostile to one another by Christians can, for example, adopt a separatist or original sin—insists that human nature, even institutions. sectarian approach in which they view the world weakened by original sin, is still "good enough" as essentially evil and, like the Amish, withdraw to mediate grace. Whatever is naturally good is from it into small communities to avoid contami­ open to fulfillment or perfection by grace. nation. They can also see religion as an essentially This is the source of our sacramental system, private matter that has no bearing in public life or which takes ordinary good things and makes public policy. Or they can try to replace public them "occasions of grace," and it is also the theo­ life with religion, creating a theocracy that aims at logical basis of healthcare. We undertake health­ total moral purity. care because it is an act of basic human compas­ The Catholic view, however, differs from all sion; but we also do it because we know that these. Rather than exhorting its members to human actions—and these include healing—arc withdraw from a sinful society, keep religion pri­ sacramental. They are goods in themselves, but vate, or replace civil government with a theocra­ they also mediate God's grace. Not all doctors or cy, the Catholic view urges us to seek common nurses or even administrators must be Catholic, ground with those who do not share our views, but, if they work in a Catholic hospital, they must while also trying to persuade them of the deeper be aware of our belief that healing touches us at values and goods which underlie our view of both a social and spiritual level and bears the pos­ human life. We might describe this view as "per­ sibility of redemption. As Himes notes: suasive collaboration." The Catholic understanding of the relative The Church must bear witness to the compatibility of grace and human experience

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leads us to look for the holy or to "name grace"2" Report, March-April 1992. pp. 52-55. in the world around us, and also to acknowledge 11. Marion Danis and Larry R. Churchill, "Autonomy and the need for compromise in a pluralistic society. the Common Weal." The Hastings Center Report, It is this view that provides the theoretical basis January-February 1991 p. 29. 12. Emmanuel, pp. 158-160. for joint ventures and mergers with non-Catholic 13. Kenneth Himes. "Catholic Health Care: The Common or non-faith-based healthcare institutions. We Good, Public Responsibility and the Culture of Profit," know that such cooperative arrangements may New Theology Review, November 1997. pp. 22-28. not fully express the truths and values of our 14. David Hollenbach, "The Common Good Revisited." faith, but we are willing to "tolerate" this com­ Theological Studies, March 1989. p. 73, quoting promise as a means toward the common good of Joseph Bower, notes that "corporate decision making high-quality healthcare. This view recognizes that not only influences the success of a company itself, but also bears on the well-being of larger, interdepen­ if the common good is ultimately God's own self, dent communities." it will never be fully realized here and now. Yet 15. Hollenbach, p. 73. we must continue to strive for it. As good citi­ 16. Daniel Callahan, The Troubled Dream of Life: In zens. Catholic healthcare systems must gently but Search of a Peaceful Death, Simon and Schuster, New persistently bring our belief in community, escha- York City, 1993, pp. 122-3. tology, and the ultimate transforming power of 17. Danis and Churchill, p. 27. See also Churchill, "The Ethical Issues of Futility from a Community grace into the public debate. a Perspective," North Carolina Medical Journal, September 1995, pp. 424-427: "We need to demon­ strate that it is possible to break free from the grip of medical utopianism—the idea that medicine is more NOTES important than other social goods, that medical Surely progress holds the key to human happiness." See also 1. See Thomas Aquinas, Summa Theologiae. I-II. quest. Leonard Weber, "The Patient as Citizen," Health 47. sect. 10:"... now the good of the whole universe Progress, June 1993, pp. 12-15. is that which is apprehended by God, who is the healthcare, maker and governor of all things: hence whatever he 18. Daniel Callahan, "Terminating Treatment: Age as a wills, he wills under the aspect of the common good. Standard," The Hastings Center Report, October- This is his own goodness, which is the good of the which touches November 1987, pp. 21-25. whole universe." I wish to thank Ann Garrido for her 19. Nancy Jecker and Albert Jonsen, "Healthcare as a research assistance on this topic. us at such a Commons," Cambridge Quarterly of Healthcare Ethics, 2. Jacques Maritain, "The Person and the Common 4,1995. pp. 207-216. Good," in Joseph Evans and Leo Ward, eds., The 20. Danis and Churchill, p. 29. For a negative appraisal of Social and Political Philosophy of Jacques Maritain, profound level this approach, see Jerome P. Kassirer, "Managing University of Notre Dame Press. Notre Dame. IN, Care: Should We Adopt a New Ethic?" New England 1955, p. 82. Journal of Medicine, August 6, 1998, pp. 397-398. 3. Catechism of the Catholic Church, nn. 1907-1909. of life, is a Kassirer notes with disapproval the fact that many 4. Robert Bellah, et al., Habits of the Heart: Individualism healthcare plans are forcing physicians to "make car­ and Commitment in American Life, University of "cause of ing for their entire group of patients a higher priority California Press, Berkeley, CA, 1996. than caring for each individual patient." 5. Charles J. Dougherty, "Ethical Values in Health Care 21. Bruce Jennings, "Beyond Distributive Justice in Health Reform," JAMA, vol. 268,1992, p. 241L grace." Care," The Hastings Center Report, November- 6. Lewis Lapham. "Coq au Vin," Harper's, March 1998, December 1996, pp. 14-15. pp. 8-10. 22. Maritain, La personne et le bien commun, Desclee de 7. Jeffrey Stout says, "The idea that liberal society lacks Brouwer, Paris, 1946, p. 47. Quoted by Hollenbach, any shared conception of the good is false, but this who notes two reasons for this statement: "First, it is doesn't mean that all is well. It could still be the case the result of the fact that the positive realization and that politics, as the social practice of self-governance fulfillment of personality is achieved only through directed toward the common good, has begun to give knowledge and love of other persons .... Second, way to merely bureaucratic management of competi­ human beings are social for a negative reason as well. tion for external goods." Ethics after Babel, Beacon As finite and limited persons they have needs and Press, Boston, 1988. p. 291. deficiencies as well as positive capacities for friend­ 8. Summa Theologiae, I, quest. 96, sec. 4, "Whether ship. They need other persons and the larger society man in the state of innocence would have held sway in order to strive or even to exist at all" (p. 86). [held dominion, governed] over other men?" 23. Himes, p. 24. 9. Michael Novak, Free Persons and the Common Good, 24. Wendy K. Mariner, "Rationing Health Care and the Madison Books, New York City, 1989, pp.87-89, p. 92. Need for Credible Scarcity: Why Americans Can't Say Ezekiel Emmanuel, MD, himself a communitarian No," American Journal of Public Health, October 1995, thinker, acknowledges this difficulty and describes at pp. 1439-1445. least six concepts of "the good life" operative in deci­ 25. Himes, p. 26. sions to terminate medical care for incompetent 26. Thomas O'Meara, Thomas Aquinas Theologian, patients. See The Ends of Human Life, Harvard University of Notre Dame Press, Notre Dame, IN. 1997. University Press, Cambridge, MA, 1991, pp. 78-82. p. 146. 10. Daniel Callahan, "Bioethics: Private Choice and 27. I am indebted to Mary Catherine Hilkert for this con­ Common Good," The Hastings Center Report, May- cept, found in her book, Naming Grace: Preaching and June 1994, p. 31. See also Callahan. "When Self- the Sacramental Imagination, Continuum Publishing, Determination Runs Amok," The Hastings Center New York City, 1997.

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