Saturday, December 09, 2006

Toward An Episcopal Culture for Health Care: Justice

"Will you strive for justice and peace among all people, loving your neighbor as yourself?"

This is one of the promises in the Baptismal Covenant. I've written before here and here of the distinctive North American use of the Baptismal Covenant, and especially regular recitation by all present at baptisms, confirmations, and the Easter Vigil. Certainly, this would be important in developing an Episcopal culture for health care.

But, what comes under the category of justice? . Health care institutions are only involved in the justice system at the periphery. Some of us have cared for prisoners, and there are health care providers in that system; but for Episcopal health care institutions this is not a formative issue.

Moreover, in health care justice has a rather specific connotation. Justice is the fourth category in "the Georgetown Mantra," the categories of respecting personhood that currently pervade clinical ethics. In discussions of health care ethics, the question of justice is how the issue under discussion affects others beside patient and providers, including family, other patients, and society at large. Justice issues can be as large as national decisions of health care policy; or as intimate as which of two eligible patients gets access to the one available donor organ or mechanical ventilator. It can be both at the same time, as when a hospital decides how much care can be provided to patients who can't pay, and has to decide how this applies to the person who just walked into the ER.

Justice is also the category under which money issues are discussed. Almost inevitably, when a money issue is raised in an ethics discussion it is prefaced with an apology: " I hate to bring up money, but.... " We are appropriately wary of "putting a value on human life (or suffering or rights)." At the same time, care does cost something, and funds are not unlimited. Corporations have, in the past at least, practiced the notorious "Pinto planning" - calculating the cost of a safety-oriented engineering change against the probable liability and legal costs resulting from not making the change. Many now are making decisions regarding whether to reduce health benefits of employees. We do make such decisions, if indirectly. When we do, it is certainly an issue of justice.

So, how would an Episcopal culture for health care reflect justice among all people? Certainly, economic concerns would be one expression. In recent years, as so many Christians have wrestled with issues of human sexuality and family relationships, we have often been reminded that in the Bible there are many more references to economic issues than to issues of human sexuality. In most cases, those issues relate to economic behavior as an expression of justice and wholeness. The various laws related to the year of the Jubilee, and the restrictions on lending reflect that theme. The repeated calls for justice in Isaiah and Amos reflect behavior and class structures expressing significant economic differences. Micah tells us it is the first thing that God requires. Jesus’ proclamations of the Kingdom, whether in reading from Isaiah in Luke 4 or in the Last Judgment in Matthew 25, insist that the Kingdom serves the poor and the least. The promise that “the first will be last and the last, first,” seems to apply as much in financial status as in social status. I have already written about the poor in an Episcopal culture for health care. Caring for them is as much an expression of justice as of compassion.

Other aspects of justice would also seem to be important. For example, does the institution have policies to support a diverse leadership and staff? How many different expressions of diversity are recognized and celebrated? Issues of social justice respecting persons regardless of age, race, gender, creed, or sexual orientation may reflect contemporary political considerations, but they also reflect the Biblical tradition of welcoming the sojourner and the Christian tradition that all are equal before God.

Respecting patient rights in clinical and research ethics would also seem relevant to issues of justice. After all, justice is, as has been noted, one of the principles of “the Georgetown Mantra.” The intent in articulating those principles is to insure an approach to care based in respect for persons.

Related to that would be policies and practices in an institution built on obeying relevant laws and regulations. Federal, state, and municipal laws, and standards of various accrediting organizations are oriented directly or indirectly to protecting patients, families, and staff. And violation of laws would involve the institution with the justice system.

This is a preliminary reflection on how an Episcopal culture for health care would reflect this injunction from the Baptismal Covenant. Further reflection could center around our concepts of “peace” and “all people” and “neighbor.” However, justice is an appropriate place to start. It is where the injunction begins. It is a central theme of “walking humbly before God.” It would certainly be an identifiable dynamic of an Episcopal culture for health care.

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