Publication Year: 2014
Josh Daniel: What was your inspiration for this project?
David Craig: This book was inspired by conversation. It started with a chance conversation about Catholic hospitals and economic justice that sparked my interest in the mission and values of religious health care organizations. Then I took a leap into qualitative research interviews, conducting a moral ethnography that grew to 100 interviewees who were either employees of Catholic and Jewish hospital systems or activists in the Greater Boston Interfaith Organization. I asked how religious values inform their organizations’ delivery of health care and their assessments of the U.S. health care system.
For the most part, we ethicists have ignored these moral languages hidden in plain sight. Yet my interviewees’ answers revealed rich moral reflection on the importance of justice, stewardship, tzedakah, dignity, common good, and covenant in health care. They told me stories about how their values are served or frustrated by various health policies—Medicare, Medicaid, community benefits, high-deductible health plans, the individual mandate, and so forth. They recounted the difficult tradeoffs between accountability to a community’s health needs and economic efficiency in a competitive market. The interviews provided me with an inductive grasp of the complexity of U.S. health care, which is often obscured when formal theories of justice are applied to health care reform.
Time and again, my expectations were surprised, as when the human resources director of a Catholic hospital chain called physicians their “biggest customer.” But surely if a hospital has a customer, it is the patient. In reality, however, hospitals have to rely on admitting physicians even as competition grows between hospitals and physician-owned labs, imaging centers, and surgical hospitals. This comment helps explain the arms race for technology in U.S. health care and the construction boom in fancy suburban facilities, both of which must be factored into any reform effort aimed at controlling health care inflation while increasing services in poorer urban and rural communities.
This example is just one of the many stories I heard about health care delivery, finance, policy, and reform. My journey into U.S. health care was guided by these conversations with people who are working to put their values into action. They opened my eyes to the challenges of balancing moral and economic priorities. In the process I learned that many of my prior prescriptions for health care reform were untenable. The book shares these surprising stories and makes the health care system comprehensible not only in terms of its economic and policy dynamics, but also in light of Catholic, Jewish, and Protestant values. I hope this inductive, normative approach can help us push past the silver-bullet solutions to health care reform that dominate the U.S. debate. This book—inspired by conversation—seeks to contribute to a more informed public conversation about which values Americans want their health care system to serve.
Why should the general public be interested in this work?
This book argues that Americans think about health care the wrong way. Some people claim that health care should be private—a private benefit provided by employers or a private choice made by consumers. Others argue that it should be public—a public right insured through a single-payer government health plan. My interviews taught me that health care in the United States is neither private nor public. To a large extent, Americans have organized health care as a social good that they share and pay for together. The two pillars of this social good are public funding of nearly half of all health care costs and extensive reliance on nonprofit organizations to serve public interests.
Today’s health care reform debate boils down to a choice—either make health care a more complete social good, which is the aim of the Affordable Care Act, or to jump to a private market-based system, in which individuals largely pay for their own health plans and services, as conservatives propose. The book explains the public philosophies and health economics behind these two alternatives. It adds a normative history of U.S. health policy that catalogs some of the public values already invested in health care through public funding and nonprofit mission.
The book is a work of public ethics. As I understand it, public ethics involves taking seriously the ethics of the public and doing ethics in the public forum. My research interviews were an effort to take seriously the ethics of various publics. Although I focused on health care insiders and activists, their stories and examples illustrate ethical models and public norms with broad cultural resonance. I heard religious hospital leaders describe the nation’s public obligations to uninsured patients in terms of a secular social contract, a Jewish covenant, or a Catholic common good. The Greater Boston Interfaith Organization built solidarity for health care reform in Massachusetts through members’ actions, giving practical meaning to such values as social justice, dignity of the poor, the truth of personal responsibility, and the mercy of shared sacrifice. This work by religious health care organizations and interfaith activists makes religious values available as public norms that tap into, while appealing beyond, the moral energies of particular religious communities.
In writing this book for an audience of educated readers, I sought to increase the public’s sense of ownership over the health care system. My hope is that religious health care organizations, congregations, and interfaith coalitions will engage in moral dialogue and social activism that can help reorganize health care toward greater inclusion, fairness, efficiency, and affordability.
What is one question that you wish someone would ask you about your work, and how would you answer?
How can you be so naive to think that all sides in the debate are committed to health care justice?
When talking about the health care reform debate, I sometimes open with two political cartoons. The first shows Rep. Paul Ryan (R-WI) unplugging an elderly Medicare patient’s ventilator. As a flat-lining monitor “Beeeeeeeeps” in the background, Ryan says, “Hear that America? That’s the sound of self-reliance.” The second cartoon features a donkey sitting at a desk in front of the sign, Democrats’ Health Care Reform. While ringing up costs on a calculator, he cheerfully announces to a pregnant woman pushing her elderly father in a wheelchair, “We don’t consider your father worth saving. But if it’s any consolation, we do consider your child worth aborting.” My point in showing these cartoons is that ascribing bad motives to opponents is commonplace in American politics. I want people to gauge their emotional and cognitive reactions to the cartoons to see if either perspective strikes them as reasonable. In fact, both cartoons depict political opponents as fundamentally heartless about human life, vitiating any other values they bring to the health care reform debate.
In assessing various arguments about health care reform—economic, political, moral, religious—I illustrate the values advocated by different groups. For example, conservatives are correct that economic efficiency is essential to reform. Even if the Affordable Care Act achieved universal coverage, it would be unsustainable without cost control. Instead of debating how to balance important values, the rhetoric of health care reform often boils down to two clashing rights: a right to life versus a right to universal health coverage. We can certainly imagine a health care system in which both rights are honored. But in American political discourse, rights frequently function like lightning strikes in a scorched-earth politics. Concentrating their moral force in a singular public obligation, they burn down all other ethical considerations. For example, religious conservatives invoke a right to life against expanded government guarantees of health coverage. Religious liberals advocate a right to universal coverage in response to the health care system’s disenfranchisement of the poor. In fact, the realities are more complex. Without the universal guarantees of Medicare funding, pro-life advocates would have many more concerns about care for the elderly. Poorer Americans still have some health care access, partly through expensive, inefficient, and burdensome care in emergency departments.
Acknowledging the legitimacy of competing visions of health care justice highlights a third rights claim in the national debate—namely, the personal property right to covered services. The clash between the right to life and the right to universal health care leaves this libertarian claim standing as the principal right in our health care system. For this reason, I contend that religious liberals should stop making a right to universal health coverage the center of their arguments. It would be better to focus on ideals of health as wholeness and neighborly care in communities, commitments shared with religious conservatives.
Much of your argument relies on an unspoken perspective, which I would call “institutional realism.” You insist that, in order to understand how health care works in the US vis-à-vis religious values and how we might make it work better, we need to attend to institutions. You focus on “stories of health policy” because these enable us to see how religious values are concretely enacted by organizations as they deliver health care or lobby for particular health policies. The upshot of this perspective and focus is the realization that, on the institutional level, health care already operates like a social good, despite the prevailing moral languages that identify health care as a private benefit, private choice, or social good. To the point, you pitch the first part of the book as a discussion of prevailing moral languages of health care, but the crux of your argument are the institutional realities that belie these languages and demand the articulation of a new language (health care as a social good).
Could you say more about the role of institutions in your argument, and what this might mean methodologically for religious ethics more broadly and for other social phenomena? To push this further, do you think that religious ethics focuses too much on discursive realities—narratives, languages, etc.—and thereby miss morally salient institutional realities?
This question asks me to clarify my methodology in helpful ways. I agree that religious ethics focuses too much on discursive realities, particularly the exchange of propositional claims in logical arguments. I strive to understand and represent the logic of different reform arguments, but I have become increasingly convinced that people’s ethical commitments are shaped by their group affiliations, practical activities, and symbolic visions of the good. That is why I think that changing the culture of health care in the United States depends on religious congregations, coalitions, and health care providers acting on their values to construct new outreach efforts and delivery structures that promote healthier communities.
I am also struck by your phrase “institutional realism.” The term is illuminating in two ways. First, the book analyzes medical research and training, public insurance programs, private health insurance, and the health care safety-net as institutional realities. I demonstrate how the history and financing behind these policies belie Americans’ assumptions about the private or public nature of our health care system. In addition, I argue that health care providers’ mission and values have little meaning unless they are built into organizational structures for delivering and financing care. In other words, mission must have institutional reality to matter. Both ways of accounting for structural values can be useful methodological tools for religious ethicists. Yet I hesitate to suggest that my qualitative interviews and my analysis of health policy capture the “reality” of these institutions. Mostly I am pressing these institutions to live up to their stated aims, not demonstrating their success. Perhaps my approach is better described as “institutional aspirationalism.”
I have come to understand my methodology in terms of John Dewey’s The Public and Its Problems. Dewey describes how different “publics” can take shape when the actions and interactions of private individuals affect distant people’s interests. For example, the high cost of health care affects most Americans, and tens of millions of people struggle to access affordable and timely services. Naturally, we might expect a new public to form in favor of developing lower-cost community-based strategies to raise health care outcomes in the U.S. According to Dewey, however, a public is not simply the product of shared interests. Publics must be unified by moral ideals and attachments, and the legitimacy of existing publics hinders new ones from gaining legitimacy.
The book details the institutional realities of U.S. health care to highlight the system’s economic interests and social costs and their moral justification by well-established publics. Today the main publics served by U.S. health care are (1) working Americans with private health benefits, (2) Medicare recipients who treat their public insurance as private benefits, and (3) the specialist-heavy, acute-care physician workforce in whom Americans place their trust. In addition to studying institutions, we need to examine ongoing cooperative efforts to reshape our institutions and culture. Lisa Cahill coined the term “participatory discourse” to describe the moral languages that emerge in practices where people jointly pursue social change. My book illustrates how this practical idealism can draw people together through values-driven compromise and shake up established norms through the renewal of moral encounter. So I would say that my methodology oscillates between institutional realism and practical idealism.
Now, I have referred to your perspective as “institutional realism.” I don’t know if you will accept this description, but if so, it makes me wonder: How you would position your argument vis-à-vis Reinhold Niebuhr’s disagreement with the Social Gospel movement regarding what we can expect morally from institutions. On the one hand, your argument seems very Niebuhrian in terms of demanding that a value like cost control be taken account of and balanced along with more overtly religious values like mercy and solidarity. On the other hand, you seem convinced that institutions are moral actors, sites of moral responsibility and enactors of specific values. How do you place your argument in the legacy of American social ethics, and what direction do you hope such ethics takes?
I place considerable trust in participatory democracy, and I see religious health care institutions as important sites of shared purpose in American public life. Both commitments place me in the lineage of the Social Gospel movement and, even more so, Deweyan pragmatism. Reinhold Niebuhr famously and powerfully challenged the Social Gospel movement’s faith in redeemed institutions. For Social Gospelers, the clashing interests and competitive rewards produced by some institutional forms could be replaced by others that fostered mutuality and cooperation. Dewey’s analysis is not so sanguine. He starts from the recognition that people’s private interests inevitability produce new conflicts, as do the competing aims of various established publics. He also astutely observes how corporate and government bureaucracies hijack these publics’ moral ideals and language to maintain their power. At the same time, however, Dewey hypothesized the emergence of a broader, more inclusive public, which he dubbed the “Great Community.” As I state in the book’s conclusion, “Health care works only if everyone is in it together.” This sentiment rings with Dewey’s optimism that Americans can forge a new public, where, for example, the goal of securing better health and more affordable care for everyone takes hold as a commitment to social solidarity.
One of my hopes with the Affordable Care Act is that Americans will get angry, not at the law, but at the high costs of care that we collectively bear. This anger could yield new political will for changing our public research funding and reimbursement structures that currently prioritize high-tech, niche medicine delivered in expensive acute care settings over the integrated primary care and chronic disease management that might keep people healthier at a lower cost. Niebuhr would dismiss my optimistic hope as naive or shallow. On the one hand, reconfiguring health care incentives will simply trade one group’s interests for another group’s interests. On the other hand, my support for this change would persist only so long as either I or my loved ones did not find ourselves in need of aggressive new therapies.
Niebuhr supported early efforts to create a national health insurance plan to help achieve a best-possible justice through political efforts to balance opposing group interests. Given American political culture and its exceptionalist emphasis on personal liberty, I do not see a single-payer plan as politically viable. In fact, reading Niebuhr in historical context suggests that his distrust of groups and institutions may have less to do with human beings’ inherently sinful tendencies to magnify self-interest into group domination than it does with the American love of liberty that frees corporate entities from contributing to and abiding by social guarantees for all citizens.
In college I decided not to major in economics because I found the intellectual premise of homo economicus, the rational utility-maximizer, implausible. My scholarship has mostly walked the line between ethics and economics. I now appreciate economists’ recognition of the importance of personal preferences and market incentives along with their skeptical agnosticism about notions of the public good. As a virtue theorist, however, I view social practices as key sites of character formation and heartfelt cooperation on behalf of shared purposes that help us envision a broader social justice and commit to policy structures for achieving it. In these practical encounters and the institutional structures that support or thwart them, we can hear the fuller moral languages that give rise to the sound-bites of contemporary politics. I would like to see a social ethics more attuned to ethnographic engagement with the practices, institutions, and moral languages by which people live and struggle. The new trend toward moral ethnography entails pragmatic limits. Grand theories give way to contingent efforts at social change, and scholarship slides toward activism. I view moral ethnography as vital to tackling the public ethics of food, housing, immigration, inequality, prisons, sustainability, and more.