Eco-Justice Ministries  

Eco-Justice Notes
The E-mail Commentary from Eco-Justice Ministries

Eco-Justice and Health Care
distributed 8/21/09 - ©2009

Health care reform is the explosive issue in the United States this August. While I admit that I am not well-versed in the policy details of that issue, I hope that I can add to the debate by offering some relevant thoughts from my somewhat distant area of expertise.

Most of the work of Eco-Justice Ministries deals with topics and perspectives that have a clearly "environmental" component. But the very large umbrella of eco-justice covers more than bunnies and trees, toxic waste and climate change. The basic ethical principles that inform us environmentally should also be appropriate guiding norms for all other parts of our community life. The same broad moral rules should apply whether we're dealing with health care or the impacts of global warming.

Wise leaders in the eco-justice movement have defined four foundational ethical norms. Let's see how those principles can inform our thinking on the topic of health care.

Solidarity: We're all in this together.
There is a difference between setting social goals and creating a personal wish list. It is not always true that maximizing the good for each individual is the same as meeting the common good. Health care policy, like environmental policy, needs to be focused on what is best overall for our community and our nation.

Providing a basic level of health care to all people is compassionate, but it is also in our collective self-interest. When all people are provided access to health services, diseases don't spread as widely, school kids are more able to learn, the workforce is more reliable, and the high costs of acute care are reduced. If families are less likely to be driven into bankruptcy by medical bills (both because of preventative care, and better financial coverage), then our communities and our overall economy are strengthened.

It is to be expected that each individual will ask about gains or losses in their own coverage. But the social policy of health care reform -- which is mostly about changes in health care financing -- needs to be guided by what will best serve our nation as a whole.

Sustainability: Plan for the long haul.
Health care funding is on the nation's political agenda primarily because of financial sustainability. Can we afford health care in the future? Can we sustain our commitments?

In 2009, health spending is expected to be 17.6% of the US gross domestic product, and those costs continue to rise. Eventually, if overall spending for this one sector of our society gets too large, it simply crowds out other important parts of the economic pie -- like food, housing and education. Whether the maximum realistic slice is 20 or 50% (or perhaps we already passed it at 15%), there comes a point when we have to admit that it is not possible to spend that much on doctors, hospitals, pills and other health costs without creating enormous problems. The advocates of reform point to a very real need to reduce the share of our collective wealth that goes to health care -- by cutting overhead and inefficiency, and by reducing costs.

Some of those who argue against reform raise legitimate questions about the size of direct governmental payments under some of the current proposals. Is the US government taking on too large an obligation, or subjecting itself to too much debt, to be sustainable in the long term? That question about the appropriate scale of government spending is different from the overall question of total health costs. If new federal programs provided coverage for all people, for example, the price of private insurance might fall because emergency room services (the last resort for those without coverage) would not be subsidized by other health plans. The size of government spending is a valid concern, but it must be addressed within the context of overall social costs.

Sufficiency: Enough.
Eco-justice says that social justice is found by minimizing the gap between those with much and those with little. It also affirms that the good life can be found when our basic needs are met. Sufficiency looks to quality of life as more important than quantity of life. Both individually, and as a society, we will need to make decisions about what is enough, and what is more than we need or can afford.

Sufficiency in the medical realm places the greatest emphasis on primary care and preventative care -- the stuff that is necessary to keep us generally well. Vaccinations, prenatal care and early treatment for diabetes should be services readily available to all. Organ transplants and other exceptional intervention may need to be considered "more than enough." And I do know that finding that dividing line is complex and controversial.

The surprisingly heated fights over counseling about end of life care (whether doctors may be reimbursed for talking with patients about their own choices) is clearly related to questions of sufficiency. Individuals and their families should be able to make informed and legally binding decisions about the form and extent of treatment that they desire, including hospice and "do not resuscitate" orders.

Participation: All the stakeholders are involved.
One aspect of this norm has to do with patients being able to make choices about the treatment that they will, or will not, receive. Within the range of available options, folk should be able to decide for or against surgery, family planning, types of cancer treatments, or hospice care. An ethical health care system will not dictate too many details, whether by government programs, private insurance, or a family's ability to pay.

The norm of participation is more often invoked at the level of policy decisions. All of the stakeholders need to be able to participate in deciding how the system will work. That has been an unusual aspect of this summer's political theater.

If insurance companies, pharmaceutical firms, hospitals and doctors are testifying before Congress, but the uninsured are not present, then full participation is not there. In the last several weeks, though, the discussion of health care has often moved into "town hall" settings. I have no idea if the voices that have been heard there are broadly representative of our communities, but "the public" is definitely speaking out. I am concerned, though, about the quality of that discussion. Genuine participation requires civility and some grounding in truthfulness. Emotions and moral values are legitimate topics of debate, but lies, distortions and shouting matches don't empower the community in making careful decisions.

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As I said, I am not an expert on health care. I've had more than enough to do this summer without getting involved in town hall meetings and advocacy beyond the environmental realm. It does seem to me, though, that the carefully developed ethical norms of eco-justice provide helpful guidance about living justly and compassionately in a world that is both limited and unequal. Those norms don't provide all the answers, but they can help to clarify the central questions.

As our society wrestles with how to provide health care, we will be blessed if we bear in mind the ethical principles of solidarity, sustainability, sufficiency and participation.


Peter Sawtell
Executive Director
Eco-Justice Ministries

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