Health Care Proposals Pending Before Congress:
Ethical Questions A Catholic Should Ask

Helen Alvare
and by E. Christian Brugger
©Culture of Life Foundation 2009
Reproduced with Permission
Culture of Life Foundation

We think that significant moral questions are raised by the universal health debate and would like to formulate several for you. Our purpose is not to draw a one-size-fits-all conclusion about the merits of all current health care bills. These raise complex questions and there are reasons to support and/or oppose various pieces of different bills.

The Catholic Church has affirmed for some time a right to a minimum of decent, humane and accessible health care.1 This does not imply that a nationalized health care system is a good idea, nor its establishment a fundamental right. But it does imply that Catholics should work for some kind of improvement or reform in the current system on behalf of those who cannot afford adequate care.

We pose the following twelve questions for your consideration. Not all are of equal moral 'weight'. Those questions pertaining to whether the plan deliberately mandates coverage for intrinsically evil acts (e.g., abortion, infanticide, euthanasia and contraceptive acts) or encourages the commission of such acts (e.g., requires end of life counseling encouraging the removal of food and water for patients for whom such care is necessary and effective for sustaining life) have the highest priority. This is not to say that questions which involve reasonable calculating of long term consequences are unimportant (e.g., will the costs of implementing and running a universalized or other new plan put undue stress on the economy in the long run resulting in rebound financial problems for everyone?). They are very important; but they rarely can be answered with the certitude of the former questions; and they often cannot be answered without special skills or knowledge. No one needs special knowledge to answer the question: should tax payer coverage for abortion be mandated by law?

Finally, we urge all our friends: avoid simplistic conclusions both in opposition or support of the issue. This debate requires serious practical reasoning on behalf of a morally conscientious citizenry.

Twelve Questions

1. Does the legislation sanction wrongful cooperation in the destruction of human life:

Note: The House bill, H.R. 3200, as currently drafted, authorizes the President to appoint the committee of experts ("Health Benefits Advisory Committee") who will propose the "essential benefits package" that must be included in any public health plan. The ultimate decision to adopt the benefits proposed by the Committee rests with the Secretary of Health and Human Services (pro-choice) Kathleen Sebelius. Unless abortion is explicitly excluded from the range of benefits covered under the government plan, it is almost certain that the Advisory Committee and the pro-choice HHS Secretary will include it in the package of essential services. Abortion will then be a mandated part of the government option of national health care. Every hospital and practitioner involved in pregnancy care and who participates in the government plan (which will include every full service hospital and most all economically viable ObGyn practices) will be required to offer abortion services. Opponents in both the House and Senate have offered amendments that would have explicitly prohibited the use of taxpayer dollars to fund abortions. To date, all such amendments have been defeated in both the House and the Senate.

Action item: press your public representatives - especially PRO-LIFE DEMOCRATS - to vote to explicitly exclude abortion from any national health care plan.

2. Does the legislation encourage certain populations - the elderly, chronically ill or disabled - to forego ordinary care? Or even to consider euthanasia or assisted suicide?

Note: The removal of food and water from a patient who needs them to survive and for whom their administration would not constitute an excessive burden is passive euthanasia (i.e., their removal is done in order to bring about the patient's death). This scenario - tragically illustrated in the life and death of Terri Shiavo - has become a routine alternative for end of life decisions in U.S. health care. It is not presented as euthanasia but rather under the guise of the otherwise legitimate removal of burdensome or futile forms of treatment. Such provisions are not presently included in H.R. 3200 and are unlikely (because of the strong outcry of seniors) to find themselves in any current bill. Christians should ask themselves however whether it is likely that a government administrated plan will in the long run begin to include such provisions; or more likely, whether through such a plan a culture increasingly impatient with the weaknesses of the elderly will increase pressure on the elderly, the infirmed, and their families to opt for choices intended to bring about death in end-of-life planning.

3. Does the legislation protect the rights of health care providers (doctors, nurses, etc.), workers, institution, and patients to conscientiously object on moral or religious grounds to services they believe or suspect are wrong? Does it protect employers whose consciences prevent them from paying for employee insurance coverage for abortion or other morally objectionable procedures or services?

Note: H.R. 3200 currently contains two conscience clauses which would prohibit discrimination against physicians, other health care professionals, hospitals, provider-sponsored organizations, health maintenance organizations, and health insurance plans for refusing to provide, refer for, pay for or provide coverage for abortions. The Senate HELP bill, while it provides some protection to health care providers or entities in connection with participating in "the Gateway" (the HELP bill's health care exchange framework), is limited to refusals to perform abortions, but does not protect providers who refuse to pay for or refer patients for abortion services. This conscience provision also has an "emergency" exception which is undefined, and therefore subject to abuse2.

4. Does the plan discriminate in the provision of health care services on the basis of categories which are unacceptable? For example, will large families be discriminated against on the basis of 'environmental' criteria? Will the disabled or chronically ill be discriminated against on the basis of "quality of life" criteria? Will a patient's genetic information be used to unfairly discriminate? Etc.

Note: We can expect that a nationalized health care plan will involve rationing of health care as a mechanism used by government to control how much government spends on health care. That rationing can take many different forms including long waits to receive care, refusal to pay for certain types of care or treatment, and limitations in the dollar amount that government will reimburse a provider leading some providers to cease providing certain health care services. Knowing that any nationalized plan will necessarily include some rationing, we need to ask whether decisions for the rationing of resources are based on objective criteria central to the purposes of health care (i.e., the genuine medical needs of patients and probability of success), not based upon morally problematic categories, such as disability or perceived quality of life?

5. Does the plan assure/try to assure that all members of society have reasonable access to the health care they require in order to live in a manner befitting the dignity of the human person? In particular, does it extend access to health care to those who cannot, despite the good stewardship of their resources, afford decent and ongoing care for themselves or their families?

Note: Health care entitlements need not and indeed should not be extended to those who for reasons unrelated to factual need choose not to have health care coverage. The question of whether every citizen should be required to possess health insurance is difficult. At very least we agree that all dependent citizens should have minimum health care coverage and therefore those competent adults upon whom they depend should be required to secure it on their behalf, even if not for themselves.

6. Does the legislation respect the moral "principle of subsidiarity," which requires that larger social entities (e.g., the federal government) should leave to smaller groupings (i.e., those intermediate associations within the local community) those functions and responsibilities which the smaller communities can reasonably fulfill (and often fulfill much better) on their own? Or will particular decisions about health care be made by persons or groups of persons or bureaucracies far removed from knowledge of the particular person and his or her situation?

Note: It is reasonable to doubt whether federally administrated oversight will be able to adequately attend to the particular needs of patients. We are all familiar with HMO bureaucrats denying treatments or altering treatment decisions for patients whom the bureaucrats have never seen or examined, even contrary to the judgment of the physicians who have. Is a federalized plan likely to re-personalize health care or will economics unreasonably drive treatment decisions? One provision of the Senate and House health-care bills appears to allow an existing government entity within the Department of Health and Human Services - The Agency for Healthcare Research and Quality - to carry out comparative effectiveness research (that is, it would determine the most cost-effective treatment for a specific medical condition which could effectively override a particular doctor's decision for a particular patient). There's no problem in principle with an agency of experts assigned to carryout effectiveness research and to establish policies regarding resource allocation based on unbiased "best use" criteria; in fact, such an agency undoubtedly will be necessary within any nationalized health care system. A problem more likely arises if at a distance far removed from the particular needs of patients, it gets involved in individual diagnostic and treatment decisions. Again, this raises fears of the selection of inappropriate or ineffective treatments for patients, whose health could unfairly suffer as a result.

7. Is there sufficient accountability upon the persons or groups authorized to make crucial decisions about any of the above matters? Are these persons or groups likely to be unreasonably influenced by ideological factors or by those with profit motives in mind (insurance companies, health care provider groups?) rather than by the citizens whose health care is determined by the legislation?

Note: As stated above, the legislation presently calls for a new health-benefits advisory committee that has the authority to define benefits for all health plans in the United States. It is an unelected committee named by the Secretary of HHS; there will be no accountability to the citizenry for what the committee determines will be the necessary components of health coverage. Moreover, in the bill approved by Democrats on the Senate Health, Education, Labor and Pensions (HELP) Committee, States would have the authority to limit the number of insurance offerings provided to consumers in "exchanges." Exchanges, which might be State or regional, are groups of health insurance providers, which may or may not include a "public option," which could be offered either to everyone, or to more restricted groups of traditionally more marginalized consumers of health care. Government-run agencies will oversee consumer enrollment in insurance plans. Qualified insurers seeking to offer coverage to "exchange" participants may or may not get to do so. It would be up to government bureaucrats, who could deny market entry to an insurer for apparently any reason. It's possible that this broad authority will be abused to benefit politically connected providers - at the expense of consumers.

8. What effect will the cost of health care reform have on the public monies available for other important services (e.g., social services to the poor, education, job stimulation, crime prevention and criminal justice reform, environmental services, etc.)?

Note: Because answering this question involves extensive access to national budget information coupled with a specialized knowledge of economic dynamics, it's near impossible to answer for the layperson. The fact is, however, that questions like this are rarely answered well even by experts. As a pebble tossed into a still pond generates disturbances far beyond the place it landed, so too radical transformations of social systems as essential to a community's wellbeing as healthcare can have wide-ranging and unanticipated effects far from the specific areas being reformed. Concerned citizens need to press their elected leaders for answers to these questions, or at least for intelligent reflection upon them, before the stone is launched, since once it's released, much of the change it generates cannot be undone.

9. Would the proposed nurse-home-visit services impinge inappropriately on families' private decisions about parenting, intervals between pregnancies, or childbearing generally?

Note: General language in the House bill recommends home visits by nurses in order to counsel mothers and families about parenting practices and intervals between pregnancies. These have left many worried. Worries stem from past government policies - failures all - in the areas of explicit sex education, birth control, and abortion.

10. What effects will nationalizing our health care system have on the overall quality of healthcare in the United States and, in particular, on the doctor-patient relationship?

Note: We know that the rise of institutionalized managed care in the last twenty years has changed considerably the face of the doctor-patient relationship by forcing many physicians to turn their medical practice into an assembly line, making group medical clinics more profitable than single doctor practices (and hence eroding the personal relationship that patients develop with a single doctor), and threatening doctors' treatment decisions with an insurance company's veto. At the same time, wellness care has been introduced, the relatively simple "copay" has become a part of daily life for those with insurance, and costly services have become accessible to most persons with full coverage. Will those who secure coverage because of a nationalized plan have access to an ambient quality of care commensurate with those who presently possess insurance? Will the overall quality for everyone decrease - be 'dumbed down' to make room for all? Will the bureaucratic requirements that are introduced become so onerous that qualified candidates will be deterred from choosing the medical profession? Will government oversight function as a catalyst for or straightjacket upon innovation, creativity and bold R & D initiatives?

11. Can we afford it?

Note: In a time of unprecedented economic instability, and on the heels of the passage of the largest stimulus package in history, is now the time for the federal government to introduce a costly social reform? The President has vowed he will not sign a health care bill that is not "revenue neutral". And yet the Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) have estimated that enacting H.R. 3200 would result in a net increase in the federal budget deficit of $239 billion over the 2010-2019 period3. Given that the three states that have introduced publicly administrated healthcare options - Massachusetts, Maine and Tennessee - have all gone significantly over their initial budgets, is it reasonable to conclude that $239 billion is a gross underestimate?

12. Do we need it?

Note: This is really the central question. Most people agree that health care reform of some sort is needed to address the problem of the uninsured. But is nationalization the best solution? Multiple plans short of nationalization have been rejected over the years: small business pooling of candidates to make insurance bids more competitive; removing insurance from the employer based system and giving individuals a $7500.00 tax credit ($15,000 for couples) for purchasing personal plans; other federal deductions and tax credits for insurance and medical expenses; expanding Medicaid and SCHIP (State Children's Health Insurance Program) to include the uninsured; etc. Because of the all the potential harms discussed above, moral reasoning requires that nationalization be a "last resort" option for rectifying problems. Since no other federal reform option has been tried in recent times, are we not justified in concluding that the condition of last resort has not yet been met?


1 See Benedict XVI, Encyclical Letter Caritas in Veritate (2009), no. 43, John XXIII, Encyclical Letter, Pacem in Terris Sollicitudo Rei Socialis (1987), no. 42, par. 3, Pius XI, Encyclical Letter Quadragesimo Anno (1931), no. 28. [Back]

2 See Americans United for Life, Status of Conscience Protection in the Pending Health Reform Bills at (1963), no. 11; cf. John Paul II, Encyclical Letter [Back]

3 See [Back]