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Monday, July 13, 2015

Subsidiarity, Socialization, Solidarity: Heathcare, Patients and Doctors

Subsidiarity, socialization and solidarity are the trinity of principles that form Catholic social teaching. To be sure, Catholic social teaching is as old as the Gospel itself, but it takes the form of official teachings at the end of the 19th century with Leo XIII's Rerum Novarum. The latest encyclical dealing with Catholic social teaching, Laudato Si', recently made a splash in global media, but has gone cold and will soon be forgotten. Quite simply,  the principle of subsidiarity insists that, in the social order, whatever can be accomplished at the lowest level, for example the level of the individual or small community, must be accomplished there, and larger social structures such as higher levels of government should yield to the greater efficacy of the lower levels. Socialization, on the other hand, insists that what the lower levels have failed to do, or have accomplished ineffectively, or have ignored, must be enacted upon by higher levels of the social order. 'Human dignity' and the 'common good' drive the choices that locate where that good is best accomplished. Solidarity, has two meanings: first, it means that all humans at the various levels of community are in irrevocable relationships, and the common good is exercised at all levels of such relationships. The second meaning, more cynical, is simply to offer a less threatening term for socialization, as so many people hear in that latter term 'socialism,' a nasty word for liberal democracies seeking to balance political power.

Leo's encyclical reacted against the rise of socialism in response to the problems of labor by embracing subsidiarity; John XXIII's Mater et Magistra flowed in the other direction in response to laissez faire attitudes but also back again to socialization regarding healthcare and housing. Francis' Laudato Si' embraced an 'ontoecological' solidarity in response to the rape of the natural world and the further degradation of the poor. All three encyclicals are rewarding reads, and I highly recommend them as my brief summaries hardly do them justice.

The clearest validation of Catholic social teaching can be seen in the issues of American healthcare. The absolutely dismal failure of the American system gave rise to Medicare and similar programs, managed care, and the latest program, the Affordable Care Act (ACA). The failures are largely at the lowest levels, where people seek care through too few doctors and over-crowded hospital emergency departments. What we have here, as Strother Martin once noted, is a failure to communicate.

While Medicare is arguably the best idea that emerged in the American system, managed care, and its chimeric monstrosity, the ACA, while having the best of intentions, have taken Americans down the road to hell, as Samuel Johnson might have observed. The problem of course is the corporate greed that transformed the practice of medicine into a generator of wealth. This wealth generator has no objection if somewhere along the generation of mega-dollars a few people actually get the healthcare they need, but the system is designed to garner wealth for the few. America pays more than any other country per capita for its health system, but does not approach other countries' effectiveness and good outcomes: the 'common good.' Sadly, human dignity plays no role in the American system.

The failures at the points of service underscore a failure of subsidiarity, and mandates socialization. The American game of feigning commitment to free enterprise has left too much money in the hands of the few and too little, if any, improvements in healthcare delivery to actual Americans. Solidarity remains elusive in American healthcare because it is inconvenient to business interests that have usurped the very nature of medicine and healthcare and transformed it into another 'free enterprise'-government collusion to concentrate wealth in the hands of power structures.

This result was not the intent of the presidency and legislative bodies that shepherded ACA into being, but good intentions are often short-sighted and don't see the beast of unsatiable and unquenchable desire (capitalist-government entanglements) until it's too late. And the beast's brood ain't walking any of it back anytime soon. No, I'm afraid the disingenuous game of 'free enterprise' must yield to the common good and the dignity of the human person sooner or later. A single, single payer system will go a long way in removing the interlopers in the delivery of healthcare. A doctor and a patient must be free to operate without having to answer to stockholders and the wealth-generating machine that places obstacles to the delivery of care so that costs can be channeled into profits.

One way we can conceive the 'common good' is 'human dignity' writ large, and nowhere is the dignity of the human person more present than it the doctor-patient relationship. What happens at the bedside must be reflected at the larger order of social commerce, but, in fact, the flow is in the reverse direction. The commodification of healthcare and its transposition into transactions of goods and services has injected suspicion and hoodwinkery into the sacred space of disclosure and foreclosure, what was once a space of trust. The injection of distrust and malice infects both sides of the relationship. Defensive medicine confronts consumerism and both pound thunderously as the white elephants in the exam room. Doctors have forgotten how to speak to patients empathetically and effectively and patients feel cheated and injured when things don't go as well as Madison Avenue and the marketplace had promised.

The problem has become acute and the medical profession has decided to address it head-on in remediation of physicians' communication skills. Either under the aegis of hospice and palliative medicine, or medical ethics, or malpractice education, physicians hone their skills in role-play, scripted dialogue and general education in empathetic communication. Yet empathy itself cannot be learned, and patients' suspicions are not allayed by canned speech. Only time will tell if essential conversations between patients and doctors are becoming more effective and trusting.

The dignity of the human person as microcosm or macrocosm should begin in the relationship between a doctor and her patient. Human dignity and the common good root deeply in an "I" and an "other." The potential for intersubjectivity is always present in such relationships, if given the tools and skills that can facilitate meaningful communication. Subsidiarity and socialization go hand in hand in healthcare; and only in solidarity, as individuals and as smaller and larger communities, can the problems in healthcare become truly manageable. The human element in the sacred relationship between a patient and her physician is always poised to engender an authentic morality and ethic that goes all the way up and down.

Other equally authentic Catholic (or even strictly secular) viewpoints on the issue of healthcare abound; but unless the discussions become political or fall into the trap of ideology, other viewpoints must identify and stress the successes of our current system, of the situation at the bedside, of the current communication skills of physicians, and of the trust level of patients. Interpretations of the status quo will be judged by how well they ring true in the ear of the beholder.

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