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Health, Education—and Welfare?

Medicine and school are both in crisis after being given from the Church to the marketplace.
Georgetown University Hospital

Often discussed in different sections of the newspaper or the blogosphere, the twin crises of health care and higher education are extraordinary in their similarities. Both are regarded as necessary goods for human flourishing whose costs are spiraling out of control. Both rely on a professional class that is becoming more specialized, losing the generalist who once cared for the “whole person.” Both have seen expanding intervention by the central government which has sought to provide access to the lower and middle classes. Both are believed by many conservatives to be properly reformed by means of market-based solutions. Both are the subject of intense contemporary political debate.

And both were once almost exclusively the province of the Church, and, indeed, can trace their institutional origins—hospitals and universities—as part of the Church’s charitable ministry.

This latter fact, it seems to me, sheds bright light on the common roots of the contemporary crisis of each area. The dominant voices in the debate in both areas—health and education—cleave closely to the contemporary party lines.  On the Right, the case is made that a competitive market model will solve the ills of both health care and education. By allowing prices to be driven by supply and demand, and the motivations of the primary actors—doctors and professoriate, on the one hand, patients and students, on the other—to be largely self-interested, the market will resolve how best to allocate the relatively limited access to the best health care and the best institutions of higher education. On the Left, it is believed that the State should rest a heavy hand on the scales of the market, enforcing widespread access, suppressing costs (or providing subsidies), and forcing providers to conform to state-mandated expectations and standards.

Yet there is something fundamentally amiss with making provision of health and higher education contingent on market models and profit calculus, as both seem to be goods that are not subject to the same kind of calculus as automobiles and bubble gum. The very idea that doctors and teachers are or ought to act out of the motivations of self-interest, and provide services to their “consumers,” seems fundamentally contradictory to the kind of work and social role performed by each. The decline of the “generalist” in each sphere is indicative of a deeper crisis of the willingness to act on behalf of a broader conception of the good intrinsic to each profession and on behalf of the person being served, in favor of the specialization encouraged by modern canons of efficiency, productivity, profit, and rationalization.

At the same time, the State is rightly suspected of being unable to fundamentally improve or even maintain the quality of either sphere. It is doubtless the case that it can assure access by the heavy hand of threats, but many rightly worry that, as a consequence, the quality of care and education will deteriorate as a result. The State takes on the ersatz role of “generalist,” seemingly concerned for the good of the whole. It can only pursue that good by seeking to control pricing and access while influencing the ways “care” is provided, but it fails necessarily in caring for the vision of the whole that the actors of the professions are no longer willing or able to perform.

The debate as currently constituted represents a pincer movement aimed ultimately at the re-definition of each area—as we have seen in so many areas of contemporary life. While superficially opposites, proponents of each position in fact share a fundamental hostility to the original presuppositions that had informed the foundation of both institutions—the corporal works of charity central to the Church’s earthly mission.

In fact, it seems increasingly evident that practices such as health care and education are likely to fail when wholly uninformed by their original motivation of religious charity. Neither functions especially well based on the profit-motive or guided by large-scale national welfare policies. As the failure of the market model in each area becomes evident, the demands for the second—government intervention and control—have quickly followed. That both are reaching crises at the same time is hardly coincidental: both benefitted for a long time from the “social capital” accumulated as Church institutions, a legacy of cultures and practices that persisted for a long time even after the practitioners had ceased to embrace them. However, in both cases, the social capital is now depleted, and each now operates on a nonsensical combination of self-interested market motivations and taxation and threat-based national welfare policy. Neither is a fitting motivation or model for either sphere.

Even more deeply still, it is not untoward to speculate that part of the modern project is eventually to drive the Church from the dominant, and even residual, place of trustee in all areas of life where it once reigned.  The market and State have infiltrated all areas where once the Church was the main actor, transforming institutions ranging from schools to land-stewardship to charity to marriage simultaneously in the image of market-based individual choice and nationalized demands for equalized homogeneity.

The motivation of charity is deeply suspect by both the Right and the Left. The Right—the heirs of the early modern liberal tradition—regard the only legitimate motivation to be self-interest and the profit motive. They favor a profit-based health-care system (one explored to devastating effect in this recent article on health care in the New Yorker), and a utilitarian university (the “polytechnic utiliversity” ably explored by Reinhard Huetter in the most recent issue of First Things).

The Left—while seemingly friends of charity and “social justice”—are deeply suspicious of motivations based on personal choice and religious belief. They desire rather the simulacrum of charity in the form of enforced standardization, homogeneity, and equality, based on the motivation of abstract and depersonalized national devotions and personal fear of government punishment. They insist on the appearance of “social justice” without any actual commitment to this end on the part of the citizenry. As a result, enforced equality gives rise to resentment and ill-will throughout the citizenry, turning commitments to goods that ought to be widely shared—health and education—into hot-button political issues.

In both spheres, health and education only “work” when those working in those areas are motivated most deeply by care for the people they serve—especially those who are less powerful, less mature, less accomplished than the professions that should rightly be considered “vocations,” not merely jobs. Both spheres require care for the whole person in all of their complete and individual integrity, not treatment of people as “parts” whom we serve mainly for the advancement of one’s own career or profit. In both spheres, increasingly, those who purportedly serve others—doctors and professors, who purportedly serve persons as patients and students—know little to nothing about either. They have become good workers on an assembly line, putting heads on pins, ignorant of the “product” they make—its history, its current state, its ultimate end.

Both spheres also require a concomitant shared commitment to commonweal on the part of those who benefit from the contributions of the professions. Doctors and teachers are not simply to be viewed as providing a service for pay, subject to the demands of “consumers.” Viewed through this market-based lens, the “buyers” make the demands on the providers. However, this understanding undermines the proper relationship between trustee and beneficiary—the doctor or teacher is actually in a relationship of responsible authority with the recipient, and ought rightly to make demands and even render judgments upon the one who is paying for the service. The trustee has a duty and a responsibility to enlarge the vision of the recipient—in matters of health (how certain behaviors might have led to a state of illness, in what ways the person ought to change their lives outside the doctor’s office), and formation (thus, a student should be challenged by the teacher not only to do well in the subject at hand, but to become a person of character in all spheres of life). Both the market and the State, however, increasingly regard the recipients simply as “consumers,” a view that is increasingly shared by every member and part of society.

Both practices are most appropriately animated by a more encompassing conception of human flourishing, which both integrally serve. Both are increasingly reduced to a utilitarian logic that internally destroys the integrity of each sphere, and, in that destruction, requires the increased intervention and control by the State.

For much of Western history, there was an understanding that there were two spheres of legitimate authority and competence—the Church and State, religious and civil. As part of the modern project, the Church was stripped of all claims to competence other than purely private belief.  Arguably, one result of the increasing separation of the Church from these practices has been a bounty of benefits deriving from an increasingly scientistic and utilitarian pursuit of each, both premised on the human ability to master and control nature. These achievements are constantly celebrated as the rewards of the modern settlement (though the long-term benefits from this “mastery” seem tenuous to me).

But almost altogether unnoticed are the attendant costs of this transformation, costs that, ironically, make both health and education increasingly the province of the strong and wealthy. The appearance of crisis in each sphere at the same time is not coincidental—it is a consequence of a conscious set of decisions to banish motivations of Christian charity from almost every institution of human life. In their place, we have two deficient motivations and attendant practices—self-interest and depersonalized State-mandated social justice. It becomes clearer with every passing day that neither suffices, even as both grow stronger at the expense of the only motivation that might save us—the love of God to the point of contempt of self.



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