An Issue of Justice

Posted on January 1, 2009

I once had a nationally recognized minister tell me, “I have no interest in making the world a better place from which to go to hell.” He told me this during a tour of the Church Health Center, our clinic and preventive medicine ministry that serves over 55,000 uninsured workers and their families. We do not rely on government funding to keep our doors open. Rather we rely on the generosity of our faith community.

Advocating for justice too often creates controversy and divisiveness among Christians. Thankfully, the famous pastor’s comment about “going to hell” is one I have rarely heard. Rather, in my 25 years in medical ministry, I have found that the issue of justice in healthcare actually unifies Christians. Jesus’ call to discipleship is always to preach, to teach, and to heal. Being engaged in a healing ministry is not optional. No matter what theological differences may exist, most Christians I have met agree that quality health care for all people is integral to Christian ministry.

Differences emerge when the details of what such ministry looks like are discussed.

In my own practice as a family practitioner at the Church Health Center in Memphis, Tennessee, I recently encountered a mother and her four children whose plight strikes at the heart of the issue of justice. Margaret was recently promoted as the manager of a sandwich shop. She got a small raise and her health insurance. But the increase in pay and added benefit meant she lost her Medicaid coverage for her two sons.

Without health insurance, when her twelve-year-old, Joseph, complained of an earache, she decided to give him an antibiotic she had in her bathroom cabinet rather than take him to the physician. Unfortunately, Joseph had an allergic reaction to the medicine and began having respiratory distress. Margaret took him to the closest hospital which then transferred him to the children’s hospital. He responded quickly to treatment, but she is now facing two hospital bills she cannot afford to pay. In addition, her ten-year-old, Jason, is autistic.

Because of the loss of Medicaid coverage, she can no longer afford the medicine that has kept him functioning at a fairly high level. When I first saw him, he had significantly decompensated.

How is it that the American health care system has come to the point where a work promotion for a single mother leads to her inability to provide health care for one child and the treatment for autism for another? To my mind, advocating for health reform that prevents this scenario is part of a Christian call for justice.

What such a health care system would look like, of course, leaves room for debate among Christians. During the coming year, there will be much opportunity for people to express their opinions about the direction health care reform in America should take. Relentlessly looking for a way to care for Joseph and Jason, I hope, is a matter of justice on which we can all agree.

Justice in health care for Christians is, however, not only about universal health care. The issues of justice go far deeper than affordable access. They include issues which deal with the end of life, prevention, tort reform, quality of care, mental health, dental and eye care, cultural issues, and (here comes the controversial biggie) the right to life/choice. Each of these topics has a deep and wide reach that touches every Christian physician and health care provider at some point in time.

Looking just at two of these topics illustrates how we become divided—prevention and end–of–life.

Prevention seems sensible. It should not be controversial nor should it relate to justice. Preventive medicine, however, has been stymied because of our health care system’s reliance on technology. The demand for more technology to treat acute and existing disease absorbs the majority of the resources in our hospitals and in our research facilities—resources that could be working on preventing disease.

Instead, our reliance on technology continues to swell, in spite of the fact that health care outcomes are not pervasively improved by technology. In fact it rarely justifies the enormous cost of this new technology.

So how does this effect preventive health care? Technology absorbs the time, talent, and resources we need for keeping us healthy (rather than waiting until we are broken). An example is the childhood obesity epidemic. We are raising an entire generation of kids who go home from school, sit on the couch, play X–Box and eat junk food. These obese children will be adults who have hypertension, diabetes, and trouble getting a job - a very expensive outcome on many levels.

Were we willing to dedicate our resources to combating obesity, instead of focusing on developing pharmaceuticals to treat high cholesterol, erectile dysfunction, or the next generation of MRI, we would have a significantly healthier community in short order and for years to come. Yet the fact that everyone bemoans the problem while little is done slows even the church from addressing healthy living in a serious way. Think about it. The least healthy meal we eat is at a church supper. The fact that we do not see this as an issue of justice as it relates to caring for God’s children is simply wrong. The failure to give children hope for their future is at the core of what the New Testament regards as justice.

A similar problem exists with our current approach to the end of life. An inordinate portion of a person’s life time health care dollars may be spent in the last six months of life. 1 We as Christians have let the medical profession convince us that death must be avoided at all costs. Surely another point of agreement among all Christians is that death is not the enemy. Still, we remove the chance for people to die with dignity and to experience death as the last stage of life. Treatment as death approaches is delivered just because it is possible to extend a person’s life span. We aren’t asking the serious questions about the essence of life as God calls us to live it. Only Christians and Christian doctors will be able to change our current practices by advancing a national discussion on these issues. To do so will serve Christian justice for all of us.

Historically, Christian physicians have been very generous with their time and willingness to care for the poor. Yet, in 1965, with the advent of Medicare and Medicaid, all physicians began placing signs in their offices that read, “Payment is expected at the time of service.” Caring for the poor in one’s own community was replaced by taking overseas mission trips on a periodic basis. Local health care for the poor fell to community-based and governmentfunded safety net hospitals that usually were tied to medical education. Before 1965, one-third of every doctor’s practice was expected to be charity care—today, that percentage is usually less than five percent.

This shift in care has become increasingly problematic as safety net institutions have struggled financially in the last several years. As a result, both the quality of and access to health care for the poor has suffered. These are, however, examples of how Christian physicians have led the way to address these issues motivated entirely by a desire for justice.

In Memphis, uninsured patients with simple fractures, until recently, were initially treated in community emergency departments, then referred to the public teaching hospital for follow-up care. Because of recent financial cut backs, the public teaching hospital is no longer able to provide the follow-up care. As a result, patients who can not afford a private orthopedist are left to have bones heal without being set.

When the extent of the problem was realized (431 fractures from one hospital ED in a two-month period), the orthopedists themselves agreed to see all cases in their offices in follow-up based on the Emergency Department’s call schedule without regard to the patient’s ability to pay. This is a simple solution based on the common practice before 1965, but one that would not have been implemented were it not for Christian physicians looking to act in a manner motivated by justice.

Similar solutions must be sought for equally troubling problems that we currently face. The immigrant population in America receives very poor health care. Regardless of a person’s immigration status, when someone is building our offices, caring for our children, cleaning our homes, and they or their children get sick, surely we have an obligation to care for them.

Currently, this is not the case. The Latino population in America receives poor health care because they are afraid of being asked for their green card, and because they are often not fluent in English. Jesus’ call for hospitality to strangers surely implores us to improve the quality of care for those who work and live among us.

A similar question of equity applies to matters of charges for care that are imposed on the uninsured versus those with health insurance. How is it just that having health insurance entitles a patient to a deep discount while being uninsured requires someone to pay the full price? The only persons asked to pay the full charge for health care these days are the people who can least afford it. While some efforts have been made to address this inequity, as a general rule, it is still only the poor who are expected to pay full price and to pay at the time of service.

Lastly, there continues to be certain areas of health care that are essentially not available to the poor. The most obvious of these is dentistry. There are very few dental practices that offer a quality service to people in low paying jobs. Yet, dentistry is extremely important to the poor. Most minimum wage jobs are working with the public, and if a person’s mouth is a mess, it can be hard to get a job or get a better job. The poor only see the dentist’s office as a place to go to have their teeth extracted. The long term benefits of dentistry, including prevention, are simply not available or realized. Dental care should not be a luxury and should be an issue of justice for all Christian dentists and health care professionals.

Many Christian physicians and dentists are very generous with their time when asked to take overseas medical mission trips or to care for an individual when someone who is a friend advocates on their behalf. But, justice and charity are not the same. The Bible does not call for charity to roll down like an ever flowing stream, but, rather, insists that justice is the duty of all who seek to follow God’s call. For many, health care has become nothing more than a business. I hope that for Christian physicians it continues to be a calling that is grounded in God’s justice.

ENDNOTES

1 Elliot S. Fisher, Julie P. Bynum, and Jonathan S. Skinner, “Health Care 2009: Slowing the Growth of Health Care Costs— Lessons from Regional Variation,” New England Journal of Medicine 360 (February 26, 2009) : 849-852.

Scott Morris, MD, is a family practice physician and an ordained minister in the United Methodist church. He is the founder of the Church Health Center in Memphis, TN where he continues to practice medicine and to help the church reclaim its Biblical commitment to care for our bodies and spirits.

Tags: H&D, Healthcare System

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