Thursday, 08 December 2011

Charitable Healthcare: Taking Healthcare Backward to Move It Forward

Written by  Fr. James Thornton

Christmas time approaches, the season for giving, the season when people’s inclination toward charitable acts and other good works reaches its apogee. Preparations for the holiday are well under way, and at shopping centers and street corners everywhere, one sees those red kettles, a veritable symbol of the season, almost as ubiquitous as Christmas trees, holly, and colored lights. Christmas engenders a unique spirit in our hearts. As the great American author and essayist Washington Irving said, “Christmas is a season for kindling the fire for hospitality in the hall, the genial flame of charity in the heart.”

Americans are renown for their charitable giving. They support a vast network of charitable organizations, having given $290.89 billion in 2010. Additionally, 63.4 million Americans have practiced another form of charity by volunteering 8.1 billion hours of their time to help fellow Americans in need or improve their communities. It is estimated that the dollar value of that volunteer work is $169 billion. Americans are indeed a generous people. Moreover, Americans have been generous to those in need since the first settlers arrived on these shores.

Those English men and women who first arrived in the New World were confronted by difficulties few of them could have imagined when they left the country of their birth. In those early years, harshness of weather, crop failures, and outbreaks of disease often decimated the colonists, huddled in their tiny beachheads on the east coast of the strange new continent. They endured these rigors through extreme hard work and through close fellowship. There were no “safety nets,” save their own courage, tenacity, and solidarity. It was one for all and all for one. Colonists nursed sick neighbors back to health, provided sustenance to one another in times of dearth, and built houses and barns for neighbors in need. Their motto, so to speak, came straight from Holy Scripture: “Bear ye one another’s burdens and so fulfill the law of Christ.” By that injunction did these early settlements in New England and Virginia suffer those first years and live on to prosper. “Love thy neighbor” was the rule and remained the basis for charitable acts throughout those colonial times.

After the American Revolution and the establishment of the independent United States, the tradition of American generosity continued. During the 19th century, Alexis de Tocqueville commented on the propensity of Americans to form voluntary associations to promote many things, among them numerous charitable enterprises:

Americans of all ages, all conditions, and all dispositions constantly form associations. They have not only commercial and manufacturing companies, in which all take part, but associations of a thousand other kinds, religious, moral, serious, futile, general or restricted, enormous or diminutive. The Americans make associations to give entertainments, to found seminaries, to build inns, to construct churches, to diffuse books, to send missionaries to the antipodes; in this manner they found hospitals, prisons, and schools. If it is proposed to inculcate some truth or to foster some feeling by the encouragement of a great example, they form a society. Wherever at the head of some new undertaking you see the government in France, or a man of rank in England, in the United States you will be sure to find an association.

Thus it was that, in the early 19th century, societies to assist the poor and needy sprang up in the major cities of America. Marvin Olasky describes in his superb volume, The Tragedy of American Compassion, the successes achieved by private charities. The Boston Provident Association, for example, gave food, shelter, and other necessities to the poor. In Manhattan, medical help was given through free dispensaries and infirmaries, which were, again, charitable facilities that rapidly spread to most cities of the United States. A spokesman for a New York-based organization known as the Association for Improving the Conditions of the Poor explained the difficulties of its mission: “The work is vast, complex, and difficult. To visit from time to time all the abodes of want in a population of 650,000 souls — to discriminate between honest poverty and imposture — to elevate and not debase by relief — to arrest the vagrant — reclaim the intemperate — sympathize with the suffering — counsel the erring — stimulate the indolent — give work to the idle — … is an undertaking of all others, one of the most arduous and difficult.”

One man, Charles Brace, was so sickened by the huge numbers of abandoned and orphaned children, who roamed the streets of New York, begging, stealing, and sinking into various forms of vice, that he organized the New York Children’s Aid Society in 1853, which set up six lodging houses for homeless children. The largest of these took in 91,000 children from 1854 to 1872. The society took in the children and then placed them into suitable homes, especially homes in rural farming communities, where the youngsters would not be exposed to the temptations inherent in the crowded conditions of big city life and where the atmosphere was wholesome. As Dr. Olasky explains, the society “placed close to one thousand children per year during the mid- and late-1850s, two thousand per year by the late 1860s, and close to four thousand per year by the late 1870s. The total between 1853 and 1893 was 91,536 youngsters.” By 1929, that total reached more than 200,000. The organization still exists, assisting 150,000 children each year.

I have mentioned only a handful of examples of the vitality of charitable activities in America before the intrusion of the federal government into this realm. It is abundantly evident that, from the time the first settlers arrived in America, through the 18th and 19th centuries, and on into the first half of the 20th century, the motivation behind all of these efforts was primarily religious, for the influence of religion in America was extremely powerful in our country during those years. As Alexis de Tocqueville wrote, “The religious atmosphere of the country was the first thing that struck me on arrival in the United States.”

Christian Care

Many historians declare that hospitals are an invention of Christianity. Although some dispute that, what is beyond dispute is that with the rise of Christianity, hospitals and clinics for the medical treatment of the poor became widespread, whereas, before that time, medical practitioners treated the sick at home and, for the most part, treated only those who could pay. Much venerated by Christians is the memory of Saints Cosmas and Damian, twin brothers and physicians, who lived in the third century and are known as “Unmercenaries” in that they treated the sick and refused all payment for their services. Their example epitomizes the outlook and practices of the early Christians, even though that was a time of severe persecution (Cosmas and Damian themselves eventually died as martyrs). It is no wonder, then, that the pagan emperor Julian the Apostate bitterly complained that the Christians, whom he despised, not only took care of their own poor but that they helped the non-Christian poor as well.

Professor Dr. John H. Lienhard states, “Hospitals have formed slowly for 2000 years.... Hospitals were a very altruistic Christian invention.... By the 4th century AD, newly Christianized Romans began running homes for the sick and needy. By the 8th century, the functions of Christian hospitals, or hospices, were highly specialized. Some served the sick, some the needy, lepers, the insane, and orphans.”

In the Greek Christian East, the first hospital noted by historians was established in the fourth century by St. Basil the Great, Bishop of Caesarea in Asia Minor. All forms of illness were treated there, insofar as the medical science of that time allowed, even including leprosy. St. Basil was unceasing in his appeals to his flock to help him to support these charitable medical activities. Historians of that era write that such institutions rapidly spread throughout the Eastern Empire. St. John Chrysostom built several hospitals in Constantinople. A large hospital was established in Ephesus with accommodations for 80 people, and similar institutions came into being throughout the cities of the Christian East.

Ecclesiastical historian the Rev. Dr. Demetrios Constantelos, in his Byzantine Philanthropy and Social Welfare, discusses the hospitals of ancient Byzantium: “The hospitals which existed in the Byzantine [Eastern Christian] Empire were general hospitals, leprosaria, maternity clinics, ophthalmological dispensaries, and foundling institutions. A modern historian of medicine writes that ‘they were in every respect perfect and nearly similar to present day institutions of this kind.... They were the first fully equipped European hospitals.’” Of course, as the writer quoted here points out, that perfection and similarity to modern hospitals must be understood within the context of the scientific knowledge of that time.

In the Latin Christian West, one finds similar efforts on the part of churchmen. The situation in the West in the early Christian era was very unlike that in the East. The collapse of the Western Roman Empire and the invasions by barbarian tribes brought about a decline in the populations of the cities, a rapid deterioration of the communications infrastructure, and a breakdown in law and order. Professor Guenter Risse of the University of California, in his book Mending Bodies, Saving Souls: A History of Hospitals, notes that “providing hospitality and healing the sick became key responsibilities of European monasteries, reflective of both the inward and worldly missions they had assumed.” He goes on to say: “Thus, following the fall of the Roman Empire [in the West], monasteries gradually became the providers of organized medical care not available elsewhere in Europe for several centuries. Given their organization and location, these institutions were virtual oases of order, piety, and stability in which healing could flourish. To provide these caregiving practices, monasteries also became sites of medical learning between the fifth and sixth centuries, the classic period of so-called monastic medicine. During the Carolingian revival of the 800s, monasteries also emerged as the principal centers for the study and transmission of ancient medical texts.” Funding for these institutions came from the revenues of the monasteries and from the local diocese. Professor Risse explains, “As early as Merovingian times [approximately mid-fifth to mid-eighth century], local bishops had been charged with assigning one-fourth of their revenues for the needs of the poor.” With the rise of the empire of Charlemagne, although “Bishops remained responsible for administering the funds earmarked for the care of the poor and sick,” it was the “Monasteries rather than the decaying Episcopal cities [that] assumed the greater role in dispensing welfare.” And so religious institutions were the source and the guiding light for the creation and expansion of organized medical care from the time of the rise of Christianity in Late Antiquity and continuing through the Middle Ages.

Beginning in the 16th century, with the dissolution of the monasteries in much of Europe, hospitals and clinics were secularized. And while they remained ostensibly free to the poor, from that point onward they were government institutions, financed through taxation. Their staffs, from top management on down to the lowliest custodians, became government employees. As a result, inefficiencies and abuses multiplied, the reasons for which are not difficult to comprehend: The religious administrators and staffs of the old medical institutions were unpaid and so were motivated by love of God and love of neighbor, while the motivation of government-run and government-paid administrators and staffs was simply to collect their stipends with a minimum of effort.

The distinguished medical doctor and author of the early 20th century James J. Walsh M.D., Ph.D. points out that the “eighteenth century had much better hospitals than the nineteenth; and the sixteenth better than the eighteenth; and strange as it may sound to some ears, some of the finest hospitals that the world knows were erected in the later Middle Ages. Jacobsohn, the German historian of care for the sick, calls attention to the fact … that ‘devotion to the well-being of the sick, improvements in hospitals and institutions generally and to details of nursing, had a period of complete and lasting stagnation after the middle of the seventeenth century.... ’ The older hospitals had been finely organized, and so their organ-izations carried them on for a time but in an ever-descending curve, until about the middle of the 19th century they had reached a stage of decadence.” Dr. Walsh states that the mortality rate for inpatients in these secularized hospitals in the 19th century was one in 10, and in some places one in five, and that typhus and cholera were commonplace in large city hospitals. Only with the increased knowledge of the importance of sterile conditions and proper sanitation that came after the mid-19th century did things begin to improve.

Curiously, Dr. Walsh mentions that medical books from the late Middle Ages show that surgeons of that time, though unaware of the existence of microorganisms, nevertheless learned from experience and observation the importance of antisepsis and therefore employed wine with a high alcohol content to wash wounds and thereby avoid infection. One must assume that by the early 19th century such knowledge had been forgotten.

As evidence of the excellence of medicine in the Middle Ages, the doctor also points out, “The greatest triumph both for scientific medicine itself and for the health of the people during the Middle Ages was the eradication of leprosy — which in the course of time had become an epidemic folk disease — by the method of isolation practiced with the approval and by the instigation of the Church authorities. As Professor Sudhoff, the greatest of living historians of medicine, declared in his Essays in the History of Medicine: ‘The leaders of the Church derived from the instructions given to the Jewish priesthood of the old dispensation, the impulse and even the obligation to carry out similar procedures.... As a result, the idea of contagion now gradually became the motive power in the development of an entire system of preventive measures.’”

Doctor Walsh concludes by saying that “secular hospitals reached a low watermark of intolerable decay shortly after the middle of the nineteenth century. I know almost nothing in history that is so suggestive for profitable thought, and which should cause the enthusiastic advocate of the secularization of hospitals and government control of charities to pause and hesitate.”

The Government Moves In

Let us now consider the situation in healthcare today. Government intrusion into healthcare in the 1960s has dramatically changed the face of our medical system, one of its most significant effects being on the cost of healthcare. While consumer prices as measured by the Consumer Price Index are now five times what they were in 1970, healthcare spending is now approximately 20 times what it was in 1970. Healthcare spending now consumes approximately 16 percent of the U.S. Gross Domestic Product, while in 1960, before massive government intrusion, it consumed only 5.2 percent. With costs so high, hospitals owned by religious organizations have done what all other hospitals have done: They have aligned themselves with the various government programs so that, insofar as free healthcare is concerned, they are no different than other large medical facilities — they seek government reimbursement by encouraging the uninsured poor to sign up for Medicaid or, failing that, seek direct or indirect government reimbursement through what are called “Charity Care” programs. Thanks to government mandates and government-generated costs, it is either that, or extinction. Nevertheless, in spite of these trends, a recent study has shown that, even now, church-run hospitals provide higher quality care and are more efficient than secular for-profit and non-profit hospitals.

Liberal politicians tout government intervention in healthcare as a matter of compassion, saying that without massive government programs, the poor would be left to suffer needless pain or even die without hospital and clinic care. Are they correct? Is government-run healthcare more compassionate?

We begin to answer those questions by examining the case of our northern neighbor, Canada, and its socialized healthcare system. According to an article published by the Cato Institute in 2005, at any given time 900,000 people are on waiting lists in Canada, awaiting medical treatment. In New Brunswick, Canada, the waiting time between seeing a general practitioner and getting treatment is 25.2 weeks. In Saskatchewan it is even longer, 27.2 weeks, while in Ontario (the best among the Canadian provinces) it is 15.0 weeks. The median wait to get an MRI in Canada is 10.1 weeks. British and Canadian doctors see 50 percent more patients than do doctors in America, which simply means that with such a heavy workload they have little time to spend with each patient. Among women diagnosed with breast cancer in the United States, about one-fifth die. In France and Germany, with their government-run health systems, a third die after diagnosis, while in the United Kingdom and New Zealand, also with government-run systems, the death rate is nearly half.

In an article published by the Free Market Cure, an organization opposed to collectivized medicine, Stuart Browning writes of “the sad story of Janice Fraser who, unable to urinate, needed to have a pacemaker-type device implanted to control her bladder. Unfortunately, the [Canadian] hospital arbitrarily rationed the operation by doing only one per month. Janice was number 32 on the list — nearly a three year wait. She ended up waiting so long that she developed life-threatening infections, had to have her bladder removed in an emergency procedure, and will now wear a urine bag for the rest of her life.” The same author also tells of “an Ontario man with a fist-sized hole in his head — due to a car accident — who had to wait one year for surgery to close it.” Rationing is the norm for all elective procedures in Canada, cancer surgeries and heart-bypass surgeries being classified as elective, unless perhaps one is at the very brink of death.

Speaking of death, a 2007 study by medical doctors in Scotland showed that 462,000 deaths were caused by the Scottish National Health System over the last 30 years because of a lack of “timely and effective treatment.” Of these, 250,000 were heart attack or stroke patients, another 7,300 had cancer, and slightly more than 2,000 suffered from pneumonia. Scotland thus has one of the highest rates of avoidable death in Western Europe. So much for the claims of “compassion” by spokesmen for government-run healthcare systems, systems that always tend to treat individual human beings and human lives as mere statistics and where inefficiency and unconscionable delays are the norm.

Cost is another important factor when considering the subject of government-run healthcare. James Rolph Edwards, in his study “The Costs of Public Income Redistribution and Private Charity,” writes that government welfare agencies (including those involved in healthcare) “are estimated to absorb about two-thirds of each dollar budgeted to them in overhead costs, and in some cases as much as three-quarters of each dollar.” By way of contrast private charities “absorb, on average, only one-third or less of each dollar donated, leaving the other two-thirds (or more) to be delivered to recipients.”

In addition to the immense and tragic deficiencies just mentioned, government-run healthcare systems always strive to impose, by force of law, their own political and moral agenda. Currently, that involves attempting to require all medical facilities, even those that are religiously based, to perform abortions. This writer believes that the time will come, in the not-too-distant future, when physician-assisted suicide (so-called euthanasia), now legal in parts of Europe, will come to our own country. If “inconvenient” babies can be murdered, why not the old, the chronically ill, and the disabled? Even if that horrifying possibility is never accomplished by direct government mandate, the truth is that it can also be accomplished by bureaucrats who, under government-run systems, decide who will receive treatment, when they will receive it, how much they will receive, and for how long they will receive it.

Where To From Here?

What is the alternative to government-sponsored and government-run healthcare? How do we avoid the nightmare confronting us? How do we untangle this Gordian Knot of modern healthcare? To discover the solution we must rely on the lessons of history, both recent and distant.

We have shown that Christianity invented and developed the idea of the hospital, that hospitals and healing clinics were supported by the church and by monastic institutions, that this led to improvements over the centuries in the science of medicine, and that the secularization of medical care in the 16th century led to a sharp decline in quality of care, a decline that continued for several centuries. In the Middle Ages, and in certain instances until quite recently, churches had large numbers of nursing sisters selflessly devoting their lives to the care of the sick as part of their Christian calling or their religious vocation. And so cost was less a serious issue at that time than it is today. Finally, we have seen that government-sponsored and -run health systems lead inevitably to vastly increased costs and, at the same time, to poor or mediocre service, sometimes so poor that it costs tens of thousands of lives.

In studying this issue, three things strike this author as immensely important. The first is the principle of subsidiarity, which holds that nothing should be done by a larger more complex organization that can be done as well by a smaller, simpler organization. According to that tenet, when a problem arises, the entity closest to the problem should try to solve it before going higher. The immediate family is the entity closest to an individual person, the extended family comes next, one’s circle of close friends comes next, then the church, the local community, the county, the state, and finally the federal government. Problems should be referred to a higher entity only as a last resort, when the lower-level entity has failed. That principle was understood by the Framers of our United States Constitution and was set down in the 10th Amendment, which says: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.” Under that principle with regard to healthcare, the federal government should not be the solution to the problem and, in fact, violates the Constitution in attempting to be the solution.

The second factor is that a large part of problems in the medical care field might be solved through the market place, unfettered by Washington, by removing government from its role in healthcare and removing all of its unnecessary regulations and bureaucratic red tape. That role, in any case, the government is neither suited nor constitutionally authorized to play, and a government withdrawal from healthcare would, by itself, dramatically reduce the pressure that is spiraling costs upward. To be sure, given the circumstances of today and the complications involved in climbing out of the near-bottomless quagmire that self-serving politicians have created, a retreat by government from this field would have to be undertaken in stages, over time.

The third factor is that there is a huge, untapped reservoir of volunteers (including medical doctors and nurses) and charitable institutions that could answer the question of care for the poor and needy, as it has done in the distant and the relatively recent past. There are already many free clinics in cities across the country staffed by volunteers. Wealth is vastly greater today than it was in the Middle Ages or even in the 19th or early 20th century. Wealth is so great today that even the poor in America are known to give generously to charity. Consequently, healthcare, even hospitals, provided through charitable organizations is not at all a utopian notion. That is especially true since taxes could be substantially reduced, and in many cases eliminated, were the federal government restricted to its constitutional role; consequently, charitable giving could be much, much greater.

Churches would naturally play a central part in this task of healthcare revitalization. Religion in America is far stronger than in Europe, yet church attendance, even here, is falling. Perhaps such a worthy cause as an expanded commitment to charity could reverse that trend and help, at least in part, to revitalize religion by demonstrating the beauty of faith in action — faith with the power to transfigure men and nations. St. Basil the Great, who, as we pointed out earlier, founded one of the first great hospitals in the fourth century, said, “I have learned from Jesus Christ Himself what charity is, and how we ought to practice it; for He says: ‘By this shall all men know that ye are My disciples, if ye love one another.’ Never can I, therefore, please myself in the hope that I may obtain the name of a servant of Christ if I possess not a true and unfeigned charity within me.”

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