The Common Good and Health Care Reform

BY FR. FRED KAMMER, SJ, M.DIV., J.D.

This is the text of a talk Fr. Kammer presented on Feb. 12, 2012, in Washington, D.C. during CHA’s Physician Leader Forum. It has been edited to conform to Health Progress style.

t isn’t easy to deal with the concept of the “common good,” and there are a variety of ways of applying it to the subject of health care and health care reform. I am not promising to I make the underlying concept clearer, in the sense of offering a better definition than the classical ones. But I am going to try to frame its underpinnings — look at its “innards,” we might say — and suggest some lines of their application to health care and health care reform.

Fr. Charles Bouchard has explained that the olic social thought that both help to explain the roots of the common good lie in Greek and Roman common good and that give muscle and sinew philosophy — common good as the goal of politi- to the overall skeletal concept. Later, I will enlist cal life, the good of the city and the task entrusted Pope Benedict XVI and his very recent discussion to civic leaders.1 In the medieval period, the com- of common good to spell out the implications of mon good was seen to be the good of any person, this understanding of common good. Then I will the good of any community and finally the good of try to offer three angles on the common good on God’s own self, to whom all creation tends. Lastly, health care and reform in terms of perspective, we arrive at the Catechism of the Catholic Church’s analysis, and commitment. The diagram [on page definition, which is taken from the Second Vatican 65] is an outline: Council and, ultimately, from Pope John XXIII in his encyclical, Mater et Magistra. According to its THE SANCTITY AND DIGNITY OF THE HUMAN PERSON primary and broadly accepted sense, the common Everything starts here with the creation of the good indicates the sum total of social conditions human person in the words of Genesis in the which allow people, either as groups or as indi- “image and likeness of God” — the foundational viduals, to reach their fulfillment more fully and concept that underlies all of Catholic social more easily. thought. It involves the dignity of the human per- Again, deferring to the catechism, Fr. Bouchard son that might be found in various secular phi- notes the three essential elements of the common losophies or political theories but raised to an good: Respect for the individual; the social well- incredible level in the belief that the human per- being and development of the group; and peace son is capable of intimate relationship with God which results from the stability of a just society. and made holy by the grace won by the salvation Nevertheless, Fr. Bouchard and several other of Jesus Christ. The Compendium of the Social authors note that the concept of the common Doctrine of the Church puts it this way: good “often remains an abstraction” or lacks real- ism,2 or is used by the church “as a mantra rather A just society can become a reality only than as a strong analytic tool.”3 when it is based on respect of the tran- scendent dignity of the human person. … SEVEN FOUNDATIONAL IDEAS “Hence, the social order and its develop- To make matters more confusing, I would like to ment must invariably work to the benefit of enumerate seven foundational ideas from Cath- the human person, since the order of things

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2012 55 Andy Hayes

54 JULY - AUGUST 2012 www.chausa.org HEALTH PROGRESS is to be subordinate to the order of persons, ment,” Catholic social theory has stressed through not the other way around.”4 subsidiarity that larger political entities should not absorb the effective functions of smaller and more This dignity and transcendence does not local ones. This was in part a reaction against the depend on any accomplishment, any level of edu- centralizing tendencies of socialism and fascism. cation or wealth or membership in any group, race At the same time, if smaller and more localized or nation. Likewise, it is not taken away by any entities were not able to cope adequately with a problem or need, then larger enti- Subsidiarity implies something, ties — the state, for example — have a responsibility to act. Circumstances as well, about “small is beautiful,” then determine the appropriateness of “big” or “small” government. environments where persons matter. The U.S. bishops later related subsidiarity to “institutional pluralism,” birth defect, any disease, any crime or member- such as the role of Catholic health care in the ship in any suspect group. It simply is. larger world of health care. It provides space, they Growing out of the concept of human dignity say, “for freedom, initiative and creativity on the is an important principle which the tradition calls part of many social agents.”6 Subsidiarity insists “subsidiarity,” first articulated in 1931 by Pope Pius that all parties work in ways that build up soci- XI in Quadragesimo Anno. It has implications for ety, and that each one does so in ways expressive both the importance of participation and for plu- of their distinctive capacities. This underscores ralism. The Compendium puts it this way: the importance of families, neighborhood groups, small businesses, professional associations, com- The principle of subsidiarity protects munity organizations and local, state, and national people from abuses by higher-level social government. It also underscores the importance authority and calls on these same authori- of international organizations to respond to needs ties to help individuals and intermediate and concerns of international scope. groups [families, cultural, recreational and Ultimately, the principle of subsidiarity is professional associations, unions, politi- rooted in human dignity, in the sense that we are cal bodies, neighborhood groups] to fulfill most human and expressive of our humanity in their duties. This principle is imperative making decisions and solving problems as close because every person, family and interme- to those affected by them as possible. Subsidiarity diate group has something original to offer implies something, as well, about “small is beau- to the community.5 tiful,” environments where persons matter, and participative decision-making.7 As Pope Benedict Pope Benedict XVI said in Caritas in Veritate: has made clear in Caritas in Veritate:

Subsidiarity is first and foremost a form … subsidiarity must remain closely of assistance to the human person via the linked to the principle of solidarity and vice autonomy of intermediate bodies. Such versa, since the former without the latter assistance is offered when individuals or gives way to social privatism … . groups are unable to accomplish something on their own, and it is always designed to SACRED AND SOCIAL achieve their emancipation, because it fos- Repeatedly the church has emphasized that, in ters freedom and participation through addition to the dignity and transcendence of the assumption of responsibility. Subsidiarity human person, that individual person is essen- respects personal dignity by recognizing in tially social in nature. Vatican II put it this way: the person a subject who is always capable of giving something to others. By consider- Man’s social nature makes it evident ing reciprocity as the heart of what it is to that the progress of the human person and be a human being, subsidiarity is the most the advance of society itself hinge on each effective antidote against any form of all- other. For the beginning, the subject, and the encompassing welfare state. goal of all social institutions is and must be the human person, which for its part and by Instead of being for or against “big govern- its very nature stands completely in need of

56 JULY - AUGUST 2012 www.chausa.org HEALTH PROGRESS social life. This social life is not something The right of private property, added on to man. Hence, through his deal- ings with others, through reciprocal duties, however, remains intact, and through fraternal dialogue he develops especially seen as a way all his gifts and is able to rise to his destiny.8 for the poor themselves We all have heard of the need of babies and to acquire and exercise small children to be held and fondled, that, without such personal attention, touching and care, economic rights, freedoms even the provision of food, shelter, clothing and other essentials still will leave a child severely and human dignity. impaired. The New York Times columnist David Brooks, after extensive time spent with doctors, becomes illegitimate, however, when it is scientists and others, commented last year on not utilized or when it serves to impede the their findings about the human person in these work of others in an effort to gain a profit words: “Finally, we are not individuals who form which is not the result of the overall expan- relationships. We are social animals, deeply inter- sion of work and the wealth of society, but penetrated with one another, who emerge out of rather is the result of curbing them or of relationships.”9 illicit exploitation, speculation or the break- In this way, the more recent work of scientists ing of solidarity among working people. and doctors is deeply consistent with the faith tra- Ownership of this kind has no justification dition found in the Scriptures. and represents an abuse in the sight of God and man. UNIVERSAL DESTINATION OF PRIVATE PROPERTY10 The church’s stance toward private property and, Pope John Paul further explains that “owner- importantly, its concept of the nature of property ship morally justifies itself in the creation ... of evolves across the modern tradition. Initially, the opportunities for work and human growth for all.” popes were strong in their support for the right The pope also notes an important development of private property, though they call upon own- in the nature of property — the “what” — in Cath- ers to exercise their own social responsibility in olic social teaching, shifting over the past century sharing especially surplus property with those in from land to capital to know-how, technology and need around them. Gradually, the church stresses skill. This insight into the nature of property in a a social mortgage on private property. Individ- highly technical and organized economic society ual property rights are then conceptualized and prompts Pope John Paul to a deeper insight into affirmed in a socialized context where property the nature of poverty and marginalization within must serve the common good and where the state this same national or international society. has a duty to insist that it does, even to appropriate it to its common purposes. The right of private The fact is that many people, perhaps property, however, remains intact, especially seen the majority today, do not have the means as a way for the poor themselves to acquire and which would enable them to take their place exercise economic rights, freedoms and human in an effective and humanly dignified way dignity. within a productive system in which work In keeping with the tradition, Pope John Paul is truly central. They have no possibility of II in Centesimus Annus affirms the importance of acquiring the basic knowledge which would the right to private property and the understand- enable them to express their creativity and ing that these rights were not absolute, modified develop their potential. They have no way by complementary principles such as the univer- of entering the network of knowledge and sal destination of all goods. In his own treatment, intercommunication which would enable he roots the common destination of goods in cre- them to see their qualities appreciated and ation and in the Gospel of Jesus and clarifies its utilized. Thus, if not actually exploited, meaning: they are to a great extent marginalized; economic development takes place over their Ownership of the means of production, heads, so to speak, when it does not actually whether in industry or agriculture, is just reduce the already narrow scope of their old and legitimate if it serves useful work. It subsistence economies.

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2012 57 These people are thus unable to compete effec- for the worker and family to live dignified lives, tively or to meet needs formerly satisfied by tra- and private property, even a share of productive ditional means of production. Intensification of goods. Pope John’s related treatment of the right their poverty, powerlessness and marginalization to life specifically included adequate food, cloth- then results. In his words, “In fact, for the poor, to ing, shelter, rest, medical care, necessary social the lack of material goods has been added a lack of services and, in the case of sickness, inability to knowledge and training which prevents them from work, widowhood, or unemployment, some form escaping their state of humiliating subjection.” of “security.” This economic rights concept was carried RIGHTS AND DUTIES forward by Pope John Paul II in his 1981 encyc- In 1891, in Rerum Novarum, Pope Leo XIII built lical, Laborem Exercens and by the U.S. bishops upon the foundational concept of human dig- in their 1986 pastoral letter, “Economic Justice for nity and the related belief that work is not just a All.” It was also contained in the United Nations’ commodity to be bought and sold. From these he 1948 “Universal Declaration of Human Rights.” It developed specific rights belonging to workers: implied, as Pope John XXVIII indicated, duties freedom to receive and spend wages as they see of the state, not just to promote economic well- fit; to integrity of family life, including provision being, but to engage in positive steps such as pro- of necessities to children; a wage sufficient to sup- viding essential services and insurance systems to port a worker who is “thrifty and upright” and, guarantee these rights. by implication, his or her family. This concept of In Laborem Exercens, Pope John Paul developed or strengthened a wide range of Trade and professional unions are specific rights drawn from Catholic social teaching. The first was “suitable needed, and the workers retain the employment for all who are capable of it,” and, when unavailable, the pro- right to organize, act politically and vision of unemployment benefits by to strike “within just limits.” employers or, upon their failure, by the state. Just remuneration for work by a head of family must “suffice for estab- a family wage was clarified and grew across the lishing and properly maintaining a family and 120-year tradition, but its roots are clearly here in for providing security for its future.” This would Pope Leo’s writing and, before him, in centuries of mean a family wage or other social measures such Catholic philosophy and theology. as family allowances for child-raising mothers. In a new industrial age, Pope Leo upheld Pope John Paul taught that there must also be rights to reasonable hours, rest periods, health provision of social benefits such as health care, safeguards and working conditions and special coverage of work accidents, inexpensive or free provisions for women and children, including medical assistance for workers and families, old minimum age requirements; freedom to attend to age pensions and insurance and appropriate vaca- religious obligations; no work on Sundays or holy tions and holidays. Trade and professional unions days; and the right to form workers’ associations. are needed, and the workers retain the right to Workers also were bound to work well and con- organize, act politically and to strike “within just scientiously, not to injure the property or person limits.” The pope affirmed the dignity of agricul- of employers, to refrain from violence or rioting, tural labor, rights of disabled persons to appropri- and to be thrifty and prudent. ate training and work and the right to emigrate to Pacem in Terris, written by Pope John XXIII find work. in 1963, was considered to be a kind of human The tradition has always combined its asser- rights manifesto.11 Pope John used reason and nat- tion of human rights with a correlative set of ural law to set out rights and duties of persons, duties to exercise and/or protect those rights. The public authorities and the world community. He Second Vatican Council put it well in its discus- included economic, political and religious rights, sion of religious freedom: immigration rights and the mutual responsibilities of citizens. Pope John introduced the concept In the use of all freedoms, the moral of economic rights, drawn from a logical analysis principle of personal and social responsibil- of human dignity. He included the opportunity to ity is to be observed. In the exercise of their work and to do so without coercion, a just wage rights, individual men and social groups are

58 JULY - AUGUST 2012 www.chausa.org HEALTH PROGRESS Universal Rights Three Kinds Destination of and Duties of Justice Private Property

Social Anthropology: Preferential Person is Sacred Option for and Social the Poor

Sanctity and Dignity Institutions of Human Person MM and Systems CO ON L A Individuals G B O

D L

Groups Structures G

Perspective Analysis Commitment

HEALTH CARE

bound by the moral law to have respect both THREE KINDS OF JUSTICE for the rights of others and for their own Out of our medieval philosophical and theological duties towards others and for the common tradition, the U.S. bishops noted in their 1986 pas- welfare of all.12 toral letter on economic justice the development of three dimensions of basic justice which state For example, I have the right to have a family — “the minimum levels of mutual care and respect then I have a duty to care for them. I have a right to that all persons owe to each other in an imperfect vote — then I have a duty to do it. I have a right to world”: work for a family wage — I then have a duty to do so. I have a right to health care and a duty to care Commutative justice calls for funda- for my health and to make the effort to provide mental fairness in all agreements and health care for myself and my family, and so forth. exchanges between individuals or pri- And I have a duty to respect and promote those vate social groups. It demands respect for rights that all others have as well. the equal dignity of all persons in economic

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2012 59 transactions, contracts or promises ... For some people, the option for the poor is a Distributive justice requires that strong phrase “which has become a powerful sum- the allocation of income, wealth and mary and symbol of the new approach”17 of the power in society be evaluated in light church to the social question. The option for the of its effects on persons whose basic poor actually reflects Pope John’s emphasis one material needs are unmet. The Second month before the Vatican Council that the church Vatican Council stated: “The right to have present herself to the underdeveloped world as it a share of earthly goods sufficient for one- is, “the Church of all, and especially the Church self and one’s family belongs to everyone. of the poor.”18 The fathers and doctors of the church held His point has been emphasized again and again this view, teaching that we are obliged to by Pope Paul VI, Pope John Paul, and now Pope come to the relief of the poor and to do so Benedict. Pope John Paul also used an apparent not merely out of our superfluous goods.” alternative “a preferential love of the poor.” Pope Minimum material resources are an abso- John Paul further restated it as, “preferential yet lute necessity for human life ... not exclusive love of the poor,” apparently to cor- Justice also has implications for the way rect whatever he thought was misleading about the larger social, economic and political the uses of the phrase. Even in doing so, however, institutions of society are organized. Social Pope John Paul took pains to make it clear that he justice implies that persons have an did not retreat from the point of the preference.19 obligation to be active and productive He himself preached most strongly on this in participants in the life of society and his travels, including frequent use of Pope John that society has a duty to enable them to XXIII’s phrase “the Church of the poor.” In Eccle- participate in this way. This form of jus- sia in Asia, Pope John Paul again affirmed this tice can also be called “contributive,” for it preference and explained it this way: stresses the duty of all who are able to help create the goods, services and other non- In seeking to promote human dignity, material or spiritual values necessary for the Church shows a preferential love of the the welfare of the whole community. 13, 14 poor and the voiceless, because the Lord has identified himself with them in a spe- Even these three dimensions of basic justice, cial way (Mt. 25:40). This love excludes no the bishops noted, fall short of the goal of bibli- one, but simply embodies a priority of ser- cal justice which portrays a society “marked by vice to which the whole Christian tradition the fullness of love, compassion, holiness and bears witness. peace.”15 These aspects of justice, however, are foundational to the common good of any society. The appropriateness and tenacity of this concept in Catholic social teaching in the past half- OPTION FOR THE POOR century invite us to understand more deeply the Our sixth foundational idea is what the church concept and its application. has called the option for the poor, the preferential Pope John Paul continued the reflection of the option for the poor and sometimes a preferential church community on the preferential option for love of the poor. It is a controversial phrase with its the poor, but with a decided emphasis on the inter- roots in the Medellin Conference of Latin Ameri- national dimensions of the concern, especially in can bishops in 1968.16 his 1989 letter, Sollicitudo Rei Socialis:

... the option or love of preference for the We as social beings poor. This is an option or a special form of structure our lives, usually primacy in the exercise of Christian charity to which the whole tradition of the for good purposes; then, Church bears witness. It affects the life of these structures take on each Christian inasmuch as he or she seeks to imitate the life of Christ, but it applies a force, power and equally to our social responsibilities and hence to our manner of living, and to the existence of their own. logical decisions to be made concerning the ownership and use of goods.

60 JULY - AUGUST 2012 www.chausa.org HEALTH PROGRESS Today, furthermore, given the world- gospel love; and action for justice as a part of our wide dimension which the social question preaching.22 has assumed, this love of preference for the Now here, we encounter another understand- poor, and the decisions which it inspires in ing of justice, distinguished from the three kinds us, cannot but embrace the immense mul- of justice that came out of the medieval synthe- titudes of the hungry, the needy, the home- sis and discussed earlier. Justice, however, as used less, those without medical care and, above since the 1960s in contemporary church teach- all, those without hope of a better future. ing, focuses primarily on economic, social, cul- It is impossible not to take account of the tural and political structures. Justice, or the lack existence of these realities. To ignore them of it, manifests itself in the ways in which soci- would mean becoming like the “rich man” eties have patterned themselves in institutions, who pretended not to know the beggar power arrangements, systems of finance and mar- Lazarus lying at his gate (Luke 16:19-31). ... keting, relationships between classes, ownership The motivating concern for the poor — of goods and technology and the distribution of who are, in the very meaningful term, “the costs and benefits among groups of persons. Sys- Lord’s poor” — must be translated at all temic or structural justice is about those arrange- levels into concrete actions, until it deci- ments, patterns, systems and the “ways we do sively attains a series of necessary reforms. things here.” Each local situation will show what reforms Not only are these structures real, but in a pro- are most urgent and how they can be found number of powerful ways they shape who achieved. But those demanded by the situ- we are — shape our living, our loving and our ation of international imbalance, as already faith. In their pastoral on economic justice, the described, must not be forgotten. U.S. bishops stated quite simply: “People shape Pope John Paul makes it clear that the prefer- the economy and in turn are shaped by it.”23 Sim- ential love of the poor has worldwide dimensions ply stated, this insight reveals that social struc- and yet touches our most personal decisions. It tures interact with individuals in at least three is rooted deeply in the tradition of the Church, ways: First, we as social beings structure our lives, and yet demands contemporary political and eco- usually for good purposes; then, these structures nomic action. take on a force, power and existence of their own, An interesting formulation of the preferential comparable to ours in many senses; and finally, we option was made by the U.S. Bishops in their 1986 are shaped by their existence and power. pastoral on economic justice: “The fundamental Theologians now speak of graced social moral criterion for all economic decisions, poli- structures as those which promote life, enhance cies, and institutions is this: They must be at the human dignity, encourage the development of service of all people, especially the poor.”20 community and reinforce caring behavior. Such entities structure or institutionalize goodness in INSTITUTIONS AND SYSTEMS a way analogous to the good deeds of individu- The seventh foundational theme around which als. Sinful social structures destroy life, violate revolves the church’s reflection in the late 20th human dignity, facilitate selfishness and greed, century is captured in the following, frequently perpetuate inequality and fragment the human quoted declaration of the 1971 Synod of Bishops: community. As such they embody evil in the way sinful deeds do.24 Action for justice and participation in What does this mean? In simple form: the transformation of the world fully appear We have schools that do not teach to us as a constitutive dimension of the Prisons that do not rehabilitate preaching of the Gospel, or, in other words, Cities that do not work of the Church’s mission for the redemption Governments and political parties that are of the human race and its liberation from unresponsive to people’s real needs every oppressive situation.21 A food and agriculture system that pays Action for justice, then, constitutes part of the farmers not to grow while many people go hungry preaching of the Gospel. Preaching of the Gospel A health care system that leaves 45-50 mil- must give rise to action for justice, or it is sim- lion people out, makes some people very rich and ply not a credible Christian gospel. There are two often is out of focus in its approaches to human elements here: justice as a part, an expression, of life, happiness, health and dying

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2012 61 An economic system in the United States accumulation and concentration of many and worldwide that is making some people very, personal sins. It is a case of (1) the very per- very rich and billions of other people poorer and sonal sins of those who cause or support poorer evil or who exploit it; (2) of those who are Not only are the macro-systems not working in a position to avoid, eliminate or at least well, but they are creating extensive injustice, limit certain social evils but who fail to do poverty and human suffering across the world. so out of laziness, fear or the conspiracy of In addition, the repeated and more insistent mes- silence, through secret complicity or indif- sage of the bishops and popes in modern times ference; (3) of those who take refuge in the supposed impossibility of chang- If the systems are not working, then ing the world and (4) also of those who sidestep the effort and sacri- our faith response has to be systemic fice required, producing specious reasons of a higher order. The real and structural as well as personal. responsibility, then, lies with individuals. A situation — or likewise is that the situation is getting worse, not better. an institution, a structure, society itself — is In fact, the social, economic and political systems not in itself the subject of moral acts. Hence are working so badly in many areas that church a situation cannot in itself be good or bad.” leaders, such as the bishops gathered at Medellin, have felt compelled to speak of “institutionalized Human responsibility is thus retained in violence” as the end-product of the status quo.25 Pope John Paul’s analysis of social structures. In Sollicitudo Rei Socialis, Pope John Paul We human persons are still related to all institu- seems at first to accept the analysis of sinful social tions and systems as: (1) creators, supporters, or structures which I have sketched out. His term is exploiters; (2) accessories through complicity or the “structures of sin,” but his analysis ties these indifference; (3) accessories through fatalistic structures much more acutely to the acts of indi- avoidance; and (4) accessories through consecra- viduals. tion of the status quo. If the systems are not working, then our faith ...it is not out of place to speak of “struc- response has to be systemic and structural as well tures of sin” which, as I stated in my apos- as personal. We must do justice as well as char- tolic exhortation “Reconciliatio et Paeni- ity. It is not enough just to engage in a commend- tentia,” are rooted in personal sin and thus able service that reaches out to help individuals always linked to the concrete acts of indi- whose lives touch our own, not in the face of mas- viduals who introduce these structures, sive structural evil that makes these people needy. consolidate them and make them difficult The faith of those who follow Christ must deal to remove. And thus they grow stronger, with social, economic, cultural and political struc- spread and become the source of other sins, tures as well. We must love persons so much that and so influence people’s behavior. we change the structures that affect their dignity. Looking at the broader economic scene in Eco- In footnote no. 65, the Pope lays out four ways in nomic Justice for All, for example, the U.S. bishops which individuals are responsible for sinful social put it this way: structures, quoting his earlier apostolic exhortation. (I have inserted the numbers in parentheses Whether the problem is preventing war for clarity): and building peace or addressing the needs of the poor, Catholic teaching emphasizes Whenever the church speaks of situa- not only the individual conscience, but also tions of sin or when she condemns as social the political, legal and economic structures sins certain situations or the collective through which policy is determined and behavior of certain social groups, big or issues are adjudicated.26 small, or even of whole nations and blocs of nations, she knows and she proclaims that Pope John Paul underscores the urgency of such cases of social sin are the result of the connecting action for justice to faith in a term

62 JULY - AUGUST 2012 www.chausa.org HEALTH PROGRESS clearly reflecting his Polish background, the duty [a] Besides the good of the individual, there is of solidarity. While not originating with Pope John a good that is linked to living in society: the com- Paul,27 solidarity includes the structural response mon good. It is the good of “all of us,” made up demanded by Gospel love. Solidarity involves of individuals, families and intermediate groups fundamental economic and social changes.28 In an who together constitute society. It is a good that is almost shocking assertion in Sollicitudo Rei Socia- sought not for its own sake, but for the people who lis, he says, “Solidarity is undoubtedly a Christian belong to the social community and who can only virtue.” really and effectively pursue their good within Solidarity therefore must play its part it. [Here Pope Benedict is making the link between in the realization of this divine plan, both individuals, groups and the larger society — which on the level of individuals and on the level I try to reflect in the diagram in the interconnection of national and international society. The of individuals, groups, and structures or systems, “evil mechanisms” and “structures of sin” my position being that a clearer picture of reality is of which we have spoken can be overcome to see individuals, groups, and larger systems and only through the exercise of the human and structures of society.] Christian solidarity to which the Church [b] To desire the common good and strive calls us and which she tirelessly promotes. towards it is a requirement of justice and charity. Only in this way can such positive energies [These two foundational virtues lead us to desire be fully released for the benefit of develop- the common good.] ment and peace. [c] To take a stand for the common good is on the one hand to be solicitous for, and on the other This solidarity takes concrete form, the pon- hand to avail oneself of, that complex of institu- tiff says, in personal decisions, in “decisions of tions that give structure to the life of society, jurid- government”, in economic decisions, in public ically, civilly, politically and culturally, making it demonstrations by the poor themselves, in sacri- the pólis, or “city”. [Here Pope Benedict is clearly fice of all forms of economic, military or politi- emphasizing the importance of institutions and sys- cal imperialism, and in a variety of other concrete tems of various kinds in working for the common actions, both personal and structural. Solidarity, good.] we are told by the Vatican, will require developing [d] The more we strive to secure a common new forms of collaboration among the poor them- good corresponding to the real needs of our selves, between the poor and the rich, among and neighbours, the more effectively we love them. between groups of workers and between private Every Christian is called to practise this charity, and public institutions.29 in a manner corresponding to his vocation and according to the degree of influence he wields in GLOBAL COMMON GOOD the pólis. [Here again, Pope Benedict emphasizes This then brings me — “at last,” you might say — the roots in charity and also, as in the sentence back to the common good. Only now I want to call it above, our role as “citizen” — going back to clas- the global common good, in the sense that the com- sical thought.] mon good spans societies from local communities [e] This is the institutional path — we might to the so-called “community of nations.” I want also call it the political path — of charity, no less to start this part with the most recent authorita- excellent and effective than the kind of charity tive church statement on the common good, from which encounters the neighbour directly, out- Pope Benedict XVI in 2009 in the encyclical Cari- side the institutional mediation of the pólis. [The tas in Veritate. As I do so, I want to highlight what I pope’s reference to institutions here underscores think are themes or elements of the common good the three dimensions indicated above.] explicit or implied in his text. I have inserted let- [f] When animated by charity, commitment to tered sub-paragraphs in the text for ease of analy- the common good has greater worth than a merely sis. Otherwise, the text in the original is a continu- secular and political stand would have. Like all ous paragraph, no. 7. My own explanatory com- commitment to justice, it has a place within the ments are in brackets and italics. testimony of divine charity that paves the way for 7. Another important consideration is the com- eternity through temporal action. Man’s earthly mon good. To love someone is to desire that per- activity, when inspired and sustained by charity, son’s good and to take effective steps to secure it. contributes to the building of the universal city of

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2012 63 God, which is the goal of the history of the human would be important in this regard; so would family. [This picks up the concept that working for professional development programs. the common good contributes to building what our Looking at patients or residents from the theology traditionally has called the city of God.] perspective of the common good might lead [g] In an increasingly globalized society, the me to ascertain that all interactions with common good and the effort to obtain it cannot them respect their dignity, that they receive fail to assume the dimensions of the whole human high-quality care and that they are treated family, that is to say, the community of peoples and not as isolated individuals but as members nations, in such a way as to shape the earthly city of families and other communities. This in unity and peace, rendering it to some degree an perspective might also generate concerns anticipation and a prefiguration of the undivided regarding an individualistic approach to city of God. [Here, Pope Benedict makes the point advance directives, to treatment decisions of the importance of the universal or global com- and to the use of resources. mon good.] Finally, a common good outlook would also sensitize me to the local community IMPLICATIONS OF THE COMMON GOOD and its members, to how well their basic FOR HEALTH CARE AND REFORM needs are being met, to the community Understanding common good and the seven fun- and/or societal structures responsible for damental themes from Catholic social thought, meeting or not meeting those needs, to how then, gives more specific content to common good members of the community participate in which manifests itself in three “modalities”: per- its goods and life and to how my organiza- spective, analysis and commitment. tion might contribute to the enhancement of the community and its members.31 Perspective: I was very taken with the approach of Ron Hamel, Ph.D., in his article enti- What Hamel has done in this important inter- tled, “Of What Good is the ‘Common Good’?” pretation is to alert us to what we might call the There, he took the approach of treating common instinctual reactions or perceptions of a person good as a “lens through which we look at our vari- who has imbibed the sense of the common good ous worlds.” If we do so, he argued, “the concept and made it part of their total world view. shapes our worlds, ultimately affecting how and what we see.” Hamel called this a perspective, Analysis: I want to suggest now that such “part of the fabric of our being. Having been inter- a person, under the influence of this ancient and nalized, it is simply part of the way we see and contemporary set of common good values and approach things.”30 Using this approach, Hamel insights, would want to ask a series of analytic raised several of what he termed “suggestive, not questions that really arise out of the seven foun- exhaustive” points that such a perspective would dational insights that have given shape to our have on health care and reform: understanding of the common good. Using the seven foundational insights, we then might ask Were I a leader in Catholic health care, a the following types of questions about health care concern for the common good would likely and reform: direct my attention to the wages and ben- Re: Sanctity and Dignity: Are the dignity of the efits of the organization’s employees, to the people involved — patients, family members, staff, environment in which and the conditions doctors, etc. — respected in the shape and deliv- under which they carry out their responsi- ery of health care services and care? In keeping bilities, and to the degree to which they are with subsidiarity, is individual decision-making able to participate in the decision making respected and encouraged? Are individuals and and successes of the organization. I might families educated to deal with their own health wonder how well my organization not only needs and growth? respects basic rights, but also how well its Re: Social Anthropology: Are the relationships practices and policies foster an environ- of people with one another — in families, work ment in which all employees are respected, units, laboratories, unions, etc. — respected and valued and affirmed and, ultimately, are able encouraged? As Hamel indicated, what is the to flourish. Personnel practices and policies impact of health care delivery systems and ser-

64 JULY - AUGUST 2012 www.chausa.org HEALTH PROGRESS vices on the health and well-being of local com- COMMITMENT munities? Here, I want to return to the concept of solidarity Re: Universal destination: To what extent do which we discussed under the heading of insti- the health care system and reform plans recog- tutions and systems. What are the implications nize that the common destination of all goods — of that concept, that virtue, in terms of human including medical care and services, technology, reaction to injustices of various kinds? Pope John natural resources, the ability to pay and even the Paul, the foremost exponent of solidarity, ties human body and its parts — takes precedence that theme to action for justice in Sollicitudo Rei over any private claim to ownership? Socialis: Re: Rights and duties: Are the individual rights of all those involved respected in the context of It is above all a question of interdepen- their responsibilities for their own care, for oth- dence, sensed as a system determining rela- ers and for the larger common good? Are the tionships in the contemporary world in its rights of employees in health care encouraged, economic, cultural, political and religious especially the right of participation? Is there a elements, and accepted as a moral category. duty of the larger citizenry to sacrifice to insure When interdependence becomes recog- that everyone can exercise their right to health nized in this way, the correlative response care? as a moral and social attitude, as a “virtue,” is solidarity. This then is not a As we look at the often heated context of feeling of vague compassion or shallow distress at the misfor- the health care reform issues, it is good tunes of so many people, both to be rooted in the virtue of hope. near and far. On the contrary, it is a firm and persevering determination to commit oneself to Re: Three Kinds of Justice: Is there commuta- the common good, that is to say, to the good tive justice in the agreements between payer and of all and of each individual because we are payee, workers and management and in the qual- all really responsible for all. ity of care provided to those seeking medical services? Is there distributive justice in the service In the very next sentences, Pope John Paul of all people, regardless of income and ability to underscores the power of sinful social structures pay? … Is there social justice in the contribution as the reason he gives for juxtaposing the power- of the entire populace to the health care system ful virtue of solidarity: and in the respect for the scarcity of health care resources locally and globally? This determination is based on the Re: Preferential Option: Are the poor, the chron- solid conviction that what is hindering full ically ill, those with disabilities, the frail elderly, development is that desire for profit and those with mental and emotional ills and mem- that thirst for power already mentioned. bers of racial and ethnic minorities given special These attitudes and “structures of sin” are attention in individual care and in the design of only conquered — presupposing the help of the health care system and reform plans? divine grace — by a diametrically opposed Re: Institutions, Structures and Solidarity: Do attitude: a commitment to the good of one’s we challenge the systemic aspects of current and neighbor with the readiness, in the Gos- planned health systems in ways that speak truth pel sense, to “lose oneself” for the sake of and compassion to entrenched power and greed? the other instead of exploiting him, and to Can we contribute to major paradigm shifts in “serve him” instead of oppressing him for health care services that will encourage preven- one’s own advantage (Matt. 10:40-42; 20:25; tive health progress, community health benefit, Mark 10:42-45; Luke 22:25-27). cost restraint, improved quality and access for all? Does the overall design of the health system When we look at health care in this country protect and enhance all seven themes and do so (and around the world), as I said earlier, we see consistent with the global dimension of the com- a system that now leaves 45-50 million people mon good? out, makes some people and organizations very

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2012 65 rich and often is out of focus in its approaches Fr. FRED KAMMER, SJ, is director of the Jesuit to human life, happiness, health and dying. Tak- Social Research Institute at Loyola University ing the view of this health care world from those of New Orleans. An author and an attorney, Fr. least served and most in need, Christians, in John Kammer is the former president/CEO of Catholic Paul’s view, are then bound to commit themselves Charities USA and former provincial superior of to effective action to change the economic, social, the New Orleans Province of the Society of Jesus. cultural and political “ways of doing things” that create and enhance health care injustice. In their place, those who stand with the poor are to erect PAPAL ENCYCLICALS CITED IN THIS ARTICLE structures of social, economic and health care Pope Pius XI, Quadragesimo Anno (On Reconstruction justice. of the Social Order), 1931. One final word: As we look at the often heated Pope John XXIII, Mater et Magistra (On Christianity context of the health care reform issues, it is and Social Progress), 1961. good to be rooted in the virtue of hope — foun- Pope John XXIII, Pacem in Terris (On Establishing Uni- dational to our religious commitments and often versal Peace), 1963. underestimated and misunderstood. It is impor- Pope John Paul II, Laborem Exercens (On Human tant to remember the Gospel — that building Work), 1981. the Reign of God is about planting small seeds Pope John Paul II, Sollicitudo Rei Socialis (On Social from which great harvests grow and trusting the Concerns), 1987. power of God to turn crucifixion into Easter. My Pope John Paul II, Centesimus Annus (On the Hun- favorite description of such hope came from the dredth Anniversary of Rerum Novarem), 1991. Czech poet Vaclav Havel, hero in the struggle against communism in his homeland and later OTHER PAPAL DOCUMENTS CITED Czech president. In 1986, while his country was Pope John Paul II, “Ecclesia in Asia,” 1999, apostolic still in the grip of communism, he had this to exhortation. say about hope during a visit to Liberty Hall in Philadelphia: NOTES Either we have hope within us or we 1. Charles E. Bouchard, “Catholic Healthcare and the don’t; it is a dimension of the soul, and it’s Common Good,” Health Progress, May-June (1999): 34. not essentially dependent on some particu- 2. Lisa Sowle Cahill, “Good News and Bad: As a Source of lar observation of the world or estimate of Inspiration for Healthcare Reform, the Catholic Tradition the situation. Hope is not prognostication. Has Both Strengths and Weaknesses,” Health Progress, It is an orientation of the spirit, an orienta- July-August (1999): 18. tion of the heart … 3. Clarke E. Cochran, “The Common and Healthcare Hope, in this deep and powerful sense, Policy,” Health Progress, May-June (1999): 41. is not the same as joy that things are going 4. Pontifical Council for Justice and Peace, Compendium well, or willingness to invest in enterprises of Social Doctrine of the Church, (2005). that are obviously headed for early success, 5. Compendium of Social Doctrine. but rather, an ability to work for something 6. United States Catholic Bishops, “Economic Justice for because it is good, not just because it stands All,” (1986). a chance to succeed. 7. Philip S. Land, Shaping Welfare Consensus: U.S. Bish- Hope is definitely not the same thing as ops’ Contribution (Washington, D.C.: Center of Con- optimism. It is not the conviction that some- cern, 1988): 174-177, quoting and responding to Andrew thing will turn out well, but the certainty Greeley. that something makes sense, regardless of 8. Vatican Council II, Gaudium et Spes (1965). how it turns out … It is this hope, above all, 9. David Brooks, “The New Humanism,” Times Picayune which gives us the strength to live and con- (New Orleans), March 12, 2011, B-5. tinually try new things, even in conditions 10. Section adapted from Kammer, Doing Faithjustice: that seem as hopeless as ours do, here and An Introduction to Catholic Social Thought (Mahwah, NJ: now. Paulist Press, 1991, 2004), 131-134. — Vaclav Havel, 1986 11. “While it is true that human rights had been defended

66 JULY - AUGUST 2012 www.chausa.org HEALTH PROGRESS in previous documents, they had never received such a that the Church intends to maintain its preferential love systemic and thorough treatment. The encyclical was for the poor and encourages the engagement of those heralded, not for its continuity, but as a breakthrough.” who, faithful to the directives of the hierarchy, devote Philip S. Land, S.J., Catholic Social Teaching (Chicago: themselves selflessly to those most in need. That is an Loyola Press, 1995), 106. integral part of their mission.’ 12. Gaudium et Spes. “A few weeks earlier still the Holy Father had affirmed 13. Excerpted from Doing Faithjustice: An Introduction to a similar position to the bishops of Paraguay: ‘It is true Catholic Social Thought, Fred Kammer, SJ (Paulist Press, that the precept to love all men and women admits no 1991, 1992, 2004), 78. exclusion, but it does admit a privileged engagement in 14. Economic Justice for All. favor of the poorest.’” 15. Economic Justice for All. Jean-Yves Calvez, “The Preferential Option for the 16. “Though the precise expression cannot be found in Poor: Where Does It Come for Us?” in Studies in the the documents of the 1968 Medellin Conference, there is Spirituality of Jesuits, vol. 21, no. 2, (March 1989): 23-24. no doubt that — as the Latin American Bishops stated 10 19. Calvez, citing a 1980 address of Pope John Paul to years later at Puebla — it adopted a clear and prophetic the dwellers in the favela of Vidigal in Rio de Janeiro. option expressing preference for and solidarity with the 20. Economic Justice for All. poor,” Henry Volken, “Preferential Option for the Poor,” 21. Synod of Bishops, “Introduction,“ Justice in the Promotio Justitiae, 29 (January 1984): 15. World, (Rome 1971). This widely quoted section of the 17. “For those in favour of the term its main value is document has stirred a lively debate focusing on the that it expresses succinctly and uncompromisingly the word “constitutive.” Those not happy with the essen- practical implication for the Church of committing itself tial and central nature of justice being asserted for the firmly to the promotion of social justice,” Donal Dorr, church have argued that the word “integral” should Option for the Poor: A Hundred Years of Vatican Social replace “constitutive” and thus action for justice could Teaching (Maryknoll, N.Y.: Orbis Books, 1983), 209. take a second place in the church’s evangelizing mission 18. “ ... the pope, in a whole series of addresses in 1984- to more spiritual or religious matters. See Dorr, Option 85, was rather chagrined that he could have given the for the Poor, 187-189 and later. The statement has also impression of not believing in the preferential option for been played down by those who hold that the Synods of the poor, or of not believing in it very strongly. To a group Bishops are merely advisory to the Pope. Its widespread of cardinals in Rome, Dec. 21, 1984, he protested: usage however evokes a power and credence among ‘This option which is emphasized today with particu- contemporary Catholic Christians reflecting a kind of lar force by the episcopacy of Latin America, I have consensus fideliumbuilding among both laity and clergy. firmed repeatedly ... I gladly seize this occasion to repeat 22. This emphasis is akin to that contained in liberation that engagement with the poor constitutes a dominant theology as presented by Gustavo Gutierrez: motif of my pastoral activity, a concern which is daily “Much more could be said about the theology of and ceaselessly part of my service of the people of God. liberation as presented by Gutierrez, but it should be I have made and I do make this option. I identify myself clear by now that this is a theology directed toward with it. I feel it could not be otherwise, since it is the action in the political, economic, and social spheres. eternal message of the Gospel. This is the option Christ Gutierrez says in his concluding remarks: ‘if theological made, the option made by the apostles, the option of the reflection does not vitalize the action of the Christian Church throughout its two thousand years of history.’ community in the world by making its commitment “On October 4 of the same year, he had said to the to charity fuller and more radical ..., then this theo- Peruvian bishops: logical reflection will have been of little value,’ and ‘Without doubt, you and your priests know, at first ‘... all the political theologies, the theologies of hope, hand, the tragedy of the citizen of the countryside and of revolution, and of liberation, are not worth one act of the towns of Peru: his very life threatened every day, of genuine solidarity with exploited social classes.’” crushed by wretchedness, hunger, sickness, unemploy- 23. Economic Justice for All. ment; that unhappy citizen who, so often, merely sur- 24. Wesley Theological Seminary professor of biblical vives rather than lives, in conditions which are subhu- theology Joseph Weber describes this reality in these man. Certainly such situations respect neither justice terms: nor the minimum dignity corresponding to the rights of “The demonic is not an abstract force that can be man. Reassure fully the members of your dioceses who separated from human existence or from the social and work for the poor in an ecclesial and evangelical spirit, political structures of the world. The demonic forces

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2012 67 exist in and through structures. They enter human in the thinking of John Paul II. His 1981 On Human Work existence in such a way as to be inherent in human used the word frequently enough to cause comment existence.” Weber argues that, while a variety of names about his explicit support for the Polish workers’ move- are used for the demonic forces — principalities, lords, ment. But the theme if not always the word is also not gods, angels, demons, spirits, elements, Satan, and new in the previous social teaching of the Church. John the devil — the terminology all expresses the power of XXIII in his 1963 Pacem in Terris spoke of the ‘active Satan. solidarity’ which benefits relations between states, pro- 25. The Latin American bishops: “He [the Christian] rec- moting the ‘common good of the entire human family.’” ognizes that in many instances Latin America finds itself Peter J. Henriot, “The Politics of Solidarity: John Paul II’s faced with a situation of injustice that can be called Analysis and Response,” in Promotio Justitiae, no. 39, institutionalized violence, when, because of a struc- (October 1988): 6. tural deficiency of industry and agriculture, of national 28. Economic Justice for All: “The principle of social and international economy, of cultural and political life, solidarity suggests that alleviating poverty will require ‘whole towns lack necessities, live in such dependence fundamental changes in social and economic structures as hinders all initiative and responsibility as well as that perpetuate glaring inequalities and cut off millions every possibility for cultural promotion and participation of citizens from full participation in the economic and in social and political life,’ thus violating fundamental social life of the nation. The process of change should rights.” Second General Conference of Latin American be one that draws together all citizens, whatever their Bishops, The Church in the Present-Day Transformation economic status, into one community.” of Latin America in the Light of the Council (Washington, 29. Congregation for the Doctrine of the Faith, Instruc- D.C.: United States Catholic Conference, 1973), section tion on Christian Freedom and Liberation (1986). 2.16, 61. 30. Ron Hamel, “Of What Good is the ‘Common Good?’” 26. Economic Justice for All. in Health Progress, (May-June, 1999): 45. 27. About solidarity: “Solidarity, of course, is not new 31. Hamel, 46-47.

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