The Bioethical Principle of Distributive Justice and the State

Feature Article

The Bioethical Principle of Distributive Justice and the State

Merrill A. Cohen, MD

The four principles that guide current bioethical decision-making are beneficence, non-maleficence, autonomy, and distributive justice. Of these, the first three have been thoroughly discussed in the medical and ethical literature over the past two decades. The many issues that relate to these first three principles, such as consent, abortion, termination of treatment and end-of-life decisions, euthanasia, in-vitro fertilization and cloning, etc., likewise have been well scrutinized. The principle of distributive justice is currently the subject of discussion in the medical literature, and it increasingly is being incorporated into physician thinking. Is distributive justice a principle physicians should adopt?

This essay explores the meaning and use of the bioethical principle of distributive justice and its role in transforming medicine to a corporate/socialist ethic.

Observations

The medical literature increasingly contains articles dealing with distributive justice or social justice. A Medline search of articles bearing the term "social justice" revealed 330 entries for the period 1987 to 1992, but 790 entries for the period 1993 to 2000. The Journal of the American Medical Association (JAMA) in recent years has repeatedly editorialized for a new social ethic for medicine. A commentary printed in JAMA in 1997 calls for universal (nationalized) health insurance in the name of egalitarian social justice.(1) Other prestigious medical journals have published articles expressing similar views. In the Annals of Internal Medicine, for example, one reads the opinion, "physicians should think in terms of the best use of resources for the group of patients they are responsible for, rather than the traditional myopic focus on the absolute best for each individual."(2) Bodenheimer, who openly advocates nationalized health insurance,(3) approvingly parrots the view that "physicians must broaden their perspective to balance the needs of individual patients directly under their care with the overall needs of the population served by the heath care system, whether the system is an HMO or the nation's health care system as a whole."(4)

Recent medical school graduates are conscious of the need to contain health care costs. Indeed, many current interns and residents are reluctant to order tests to the extent that their ability to diagnose injury or illness is hindered. This parsimony in test ordering must often be over-ruled by alert supervising attendings. The explanation physicians in training offer for not ordering tests, although claiming that tests are "not indicated," is "to save society money."(5) But much experience, too often without guidance by controlled prospective studies, usually is needed to make test ordering decisions. Young physicians, imbued at medical school with the ideal of "saving society money," may short shrift patients who hope for a timely diagnosis and treatment.

Older physicians, too, are off balance. Some have come to believe that foremost saving society money is the appropriate thing to do. Disillusionment and cynicism are common. For example, it has been observed that physicians who earn most of their income from HMOs provide less unreimbursed or charity care than other physicians.(6)

The Clinton administration purportedly based its proposed health care system of 1994 on the principles of social justice, equality, "liberty," and community.(7) The proposal was a sweeping change, intended not only to reform medicine but to affect America in a profound way. The principle of justice was articulated to mean that benefits and burdens would be distributed equally and that health care would not exhaust resources needed for other government functions such as education, housing, etc. The principle of equality required equal access to health care and equal benefits, but costs were to be distributed on ability to pay. As far as liberty is concerned, it was recognized that people's liberty sometimes has to be limited to carry out social objectives, such as controlling health care costs. The commonness of a national health care system, it was claimed, would help bind America together into a tighter national community. "Wise allocation of resources" required the recognition of pursuits other than health care and therefore budget caps would be needed on expenditures; not all health services would be able to be provided, only those needs and services that were deemed to have priority.(8)

The World Health Organization (WHO) recently released its report on the health of the nations of the world.(9) WHO ranked the overall performance of the United States' system 37th out of 191 nations. Even Canada was ranked higher than the U.S. WHO made it plain that the U.S. did poorly in its evaluation. Why? According to WHO, a health system includes not only doctors, nurses and hospitals, but also government oversight function, health care financing methods, and equal provision of care regardless of social standing or the patients' ability to pay. In these latter areas, the U.S. was found deficient. WHO criticized the fact that 56 percent of health care in America is funded privately! The report advocated both centralized control of health care and explicit rationing, saying, "Rather than all possible care...it may be necessary and efficient to ration services..." and "If services are to be provided for all, then not all services can be provided." Health care rationing should be enforced by government bureaucracies exercising "stewardship." WHO discourages both individual physicians treating individual patients and private funding by individuals. The report also recommends sanctioning physicians who provide care that is regarded as unnecessary or impermissible. The principle guiding WHO is distributive justice. The objective appears to be central control of money and people.

Socio-political Perspective

It is generally believed that America faces the double economic problem of controlling rising health care costs and efficiently allocating resources to satisfy needs. The ethical issue this creates is how to structure a system that addresses these problems fairly. The role, if any, of government is at the center of all such discussions. The issue is typically framed as one of social justice.

Justice involves fairness of treatment. Similar cases ought to be treated in similar ways. Social theorists identify four principles of justice: equality, need, contribution, and effort.(10) Disagreements about distribution of health care generally result from the different importance people ascribe to these four principles. Marxist theories, for example, emphasize the principle of need. Libertarian theories, in contrast, put greatest weight on contribution. Some theorists attempt to combine principles. Utilitarian theorists, for example, combine those principles that maximize private and public interests. Those who write laws and develop policies to govern a just society necessarily adopt one or more of these principles to guide decision-making.

Theoretical disagreement notwithstanding, justice is an extremely important ideal. "The claim that society is failing to meet some basic need of all of its citizens and that this is unfair or unjust is a powerful charge. It can be a call to action in the service of justice. If the claim can be demonstrated, it has more than rhetorical power. It imposes upon us all an obligation to eliminate the source of the injustice."(11) Those who can establish that justice is on their side of an issue, as President Clinton attempted to do, have harnessed a very forceful argument.

On the ground of justice, many claim that a right to health care exists.(12) A compassionate society, it is argued, should provide health care to its members when it has the financial resources to do so, especially because most people are not responsible for the diseases they get and health care is often a necessity of life. This would mean, though, that the basis of medicine no longer would be compassion and benevolence, but rather state force (to satisfy the entitlement).

It also is claimed that Americans tend to be too individualistic and that there needs to be a greater concern for the common good of society. Therefore some believe that it would be proper to build into the structures of health care a focus on that which is best for society as a whole. The ethical principle of distributive justice, it is argued, requires this radical re-orientation of values.(13,14) Government agencies (that is, whoever controlled those agencies) ultimately would determine what is in the nation's best interest.

The bioethical principle of distributive justice, one of the four principles developed by Beauchamp and Childress(15) of the Kennedy Institute of Ethics, concerns the common good. It concerns the just or fair distribution of health benefits within the society. Distributive justice is the idea that physicians should broaden their perspective to include the needs of the entire group of patients if in an HMO and the needs of society as a whole, instead of caring only for their individual patients. The greatest good should be done for the greatest number of patients within the allotted budget; no individual patient has a right to maximal care. Distributive justice seeks to substitute a group ethic for medicine's traditional patient-centered ethic. It justifies a minimalist standard and it justifies reduced costs of care for whoever is paying.

"Allocation of scarce resources" is a recurring refrain in this discussion. Indeed distributive justice only becomes an issue when there is scarcity. What resources are scarce? Cost containment, also termed "resource allocation," is a euphemism for rationing. Rationing health care involves denying some potential benefit to certain people against their wishes; it is an abuse of power.(16) But it has not been demonstrated that there is yet a need for rationing. Americans yearly spend $586.5 billion on gambling!(17) As long as the debate stays focused on how to ration, no one will ever ask why we need to do it. Professor of philosophy Dan Wikler writes, "A growing number of health policy observers, as well as government officials, are endorsing the call for rationing. With the sense of breaking a great taboo, they ask us to accept a world of limits, both physiological and financial, and to cease reacting with moral indignation at the idea of a life deliberately not saved or a handicap intentionally not remedied. Their arguments, moreover, use the terminology of medical ethics. Whether voluntarily and wittingly or not, however, they are participating in an exercise which serves a particular ideological functionthe public is being prepared to accept responsibility for choices it should not have to make."(18)

Medicine is still practiced for the most part in the tradition of Hippocrates, the chief elements of which include the physician's over-riding duty to his or her patient to help and not to harm, an accountability to colleagues, protection of confidentiality, and an eschewing of physician-assisted death and abortion.(19) In spite of the prodigious technologic achievements of medicine during the 20th century, physicians have tenaciously adhered to Hippocrates' tradition of loyalty to their patients. This ideal is currently being challenged by the commercialization of medicine with its array of financial incentives to provide minimal care.(20) Physicians find themselves serving as agents for large corporations in the business of marketing health services. At issue is profit as well as health. Cost containment appears to have as its ultimate objective maximization of corporate profits.

But because of the power of ideas and values, it is the increasing emphasis on distributive justice rather than the business aspects that has the potential to lever physicians away from the patient-centered tradition of Hippocrates. The ethic of distributive justice even falsely resolves the contradictions of modern commercialized medical practice. The ethical requirement of distributive justice assumes rationing will be needed; this means coercion by the government, which promotes authoritarian rule. Distributive justice threatens to transform both medicine and society.

The state seeks always to aggrandize itself.(21) The history of man can be viewed as the history of the ascendancy and tyranny of the state. American history this century chronicles attempts by the state to overcome the restrictions and limitations wisely placed on it by the Founders. We see a now burgeoning federal government, huge and nearly out of control.(22) Men lust for power and control. Socialism claims distributive justice as one of its key principles because, as illustrated in the WHO report, in its outworking, distributive justice aggrandizes the authority of the state.

Biblical Perspective

The Scriptures and theology illuminate this discussion, even for someone who may distrust biblical justifications. Although the Bible does not say a great deal about either medicine or economic systems, a biblical perspective on both emerges from the text because both connect deeply with life and society and how we treat fellow humans. The Bible provides the moral context in which the current attempt to transform medicine can best be understood. Besides, it is alleged that the biblical tradition of a focus on the common good of society (as opposed to self-interest) necessitates transforming our health care system.(23) Is that true?

Consolidation vs Dispersal of Power

St. Augustine (A.D. 354-430) pointed out that government was established by God to restrain evil. It is because of man's sinful nature that government is necessary. God delegated to man the authority to punish murderers (Genesis 9:5-6); this implies institution of structures within society to effect this, in order to preserve the worth and dignity of man. The Romans 13:1-7 passages on government ("sword-bearing" and tax-paying) similarly views the role of the state as restraining sin by punishing crime. The paucity of particulars suggests that the functions of government are limited. Although 1 Peter 2:13, adds that a function of government also is "to commend those who do right," it is doubtful that that role can be re-defined to include the provision of education, housing, health care, etc., without limit.

"Bearing the sword" and demanding payment of taxes means coercion. The problem this creates is that the men who are in positions of government are also sinful, so government can be itself an evil, in need of restraint. John Cotton, Puritan clergyman, wrote "it is necessary therefore that all power that is on earth be limited...It's counted a matter of danger to the state to limit prerogatives; but it is a further danger not to have them limited; they will be like a tempest if they be not limited..."(24) Sin involves the rulers of the state as well as its citizens.

The Tower of Babel incident (Genesis 11:1-9) occurred because, contrary to God's command, men wanted to remain in the land of Shinar, build a city, and build a tower. They would be proud of their unity and strength. But exactly because of that unity there would be the potential for great evil. The dispersal and division of men was necessary to prevent the dimension of sin that would be possible if men were united and if power were concentrated centrally.(25) Limited central government such as America's Founders created intentionally prevents the concentration of power that could be maliciously used.

Corporality and Individuality

In the Old Testament, God related to the nation of Israel as a corporate body. Yet that national body consisted of individuals who were each the object of God's attention and concern. The principle implicit in distributive justice, that a person should so identify with the group that what might be due him or her instead transfers to the community, does not derive from the Bible. Universal principles of justice that recur in the Pentateuch include maintenance of human dignity, protection of life, property rights, protection of the weak and vulnerable, the necessity of truth, mercy and generosity, sanctity of marriage and holiness regarding sexuality, and the maintenance of social order. The principle of "corporate solidarity" emerges only vaguely or indirectly in such passages as Deut. 21:1-9, dealing with the guilt of a murder even though no murderer is identified.(26) Collectivist subordination of individuals for the welfare of the group or for social ends is foreign to the Mosaic justice legislation. As Henry states, "[L]ove, or compassion, is a relationship between persons, not between institutions or between institutions and persons[I]n community relationships, justice is the course that neighbor love takes[L]ove gives itself voluntarily, not because the giving is legally due another."(27)

In the New Testament, God relates also to a local assembly of Christians, but not in the sense that individuals lose their self-identity and assume the identity of the body. The church is a conglomeration of unique persons, not a swarm.

The Sermon on the Mount appeals to individual self-interest. Decisions in the Bible are for the most part an individual matter. Persons are allowed a measure of freedom to choose among options, and individuals bear the responsibility for their choices. Self-sacrifice may be a feature of the Christian life, but it is voluntary and is motivated by love.

The Bible does not teach or affirm totalitarian collectivism. The Spenglerian notion that society is an organism, and that each man is only a corpuscle to be sacrificed for the good of society if necessary, existing only to support and preserve the body, is defiantly anti-biblical.(28) Any appeal to "justice" in the Bible to promote societal transformation is either ill-considered or an exploitation of a potent biblical ideal for political benefit.

Physicians' Personal Moral Responsibility

The parable of the Good Samaritan in Luke 10:30-37 also is instructive. The parable establishes the principle of beneficence, but it does more. The Good Samaritan had a model virtuous character. The good that he did flowed from his self-effacing, compassionate character. God is concerned about our personal character. In every encounter with someone ill or injured, someone who has fallen victim of necessity, who is dependent, vulnerable and weak, it is the character of the physician (himself fallible) that is on display. In an ultimate sense, the essential feature of the medical encounter may be the demonstration of a sensitive, caring character. Medicine, in other words, may be not so much what is done as the character of the one doing it. Distributive justice has the potential to erode this essential aspect of medicine.

Correlation

Justice can mean fairness, holding lawbreakers accountable, compensation for wrongs, equal opportunities and equal punishment, as well as just distribution of goods. Not everyone understands justice in the same way. Aspects of justice can be informed by philosophy, but it is from the Bible that we derive our basic understanding of justice. Rules of justice are explicitly presented in the Pentateuch and later rehearsed in the writings of the prophets. And examples of injustice in the Bible abound for our moral instruction. But justice in the Bible concerns individuals and relationships between individuals, not the common good. Indeed, it is impossible to advance the common good ("social justice") without someone suffering loss, and that would be an injustice. The very concept of justice requires the assumption of the equal worth of all persons. To argue that some persons in need of some benefit may be denied that benefit (rationing) for the supposed benefit of an abstract impersonal group repudiates justice. Justice is always personal. The only impersonal justice is the writing of law.

Distributive justice is joined to the principle of utility. Utilitarian thinking means that the welfare of society takes precedence over that of an individual. The prime consideration of policy makers is what is expedient for the government and for the economy. Utilitarian thinking, for example, using methods such as cost-benefit analyses and quality of life equations invariably discriminates against the elderly and the weak and vulnerable, the very ones for whom the Bible commands special concern. A result of utilitarianism could be the development of a harsh societal attitude toward the elderly and those with chronic conditions, those who are viewed as a "drain on resources."

The ethical need for "a greater concern for the common good of society," requiring "that individualism be tempered," is unmistakably collectivist in the Plato-Kant-Hegel-Dewey tradition. By this tradition, it is "society" which needs always to be improved. Hopefully, the improvements will filter down to the individual, but it is not the individual who is primarily in view to benefit, it is the society. To view man only corporately is demeaning and demoralizing to the individual. Unless a public health specialist, the physician's duty is not to an abstract group, society, nor to shareholders of the MCO, but to the sufferer in need.

By minimizing the worth and power of individuals, the state arrogates immense power to itself. But unrestrained government is dangerous. It is conceivable that in the name of "saving money for society," non-productive persons or those with a diminished value ("quality of life") could be disposed of, and even individuals with only potentially costly illness or conditions could be disposed of. The evil a collectivist-authoritarian state is capable of was hideously made manifest in Nazi Germany, when the state co-opted medicine to do its will.(29,30) Harold Brown writes, "When a culture loses its awareness of and sense of responsibility toward God or the divine order...it becomes increasingly difficult to respect individual human beings as such. They become ciphers in the calculus of societal utility, like the animals in a veterinarian's care, treated and healed when it is possible and economically feasible, but painlessly disposed of when it is not."(31) Ethical "principles" and political schemes that promote the "common good of society" should be viewed with alarm.

Physicians hold immense power over their patients. The chief control on that power is the physician's commitment always to help, and not to hurt. If this intrinsic control is eroded, the physician could be dangerous. As the state (or those who control the state) with time accumulates power, not accountable to anyone, it becomes increasingly dangerous, too. The creation of a medical-political complex poses a threat to Americans. Any supposed ethical principle that increases governmental control of medicine, therefore, ought to be resisted.

Government should not be in the role of providing medical care. The individual with his own wallet should decide what is or is not done. The individual would quickly become educated in health matters, which is surely a desirable end, and costs would be contained not by government force but by a patient and his physician reasoning together about options. Responsibility and stewardship thus would be encouraged.

Individualism and self-interest are not unethical. Self-interest is a legitimate motive for a person's actions. Too, what about the enormous self-interest of those elites who seek to plan and manage a self-interest-less society? It also is in one's best self-interest to want to be free of tyranny! An ethical requirement should be to limit government simply to maintaining order "so that free individuals could arrange their personal, social, business and religious affairs as they see fit" (Gordon H. Clark). It cannot be stated apart from demagoguery that increased concern for the common good and less individualism is an ethical requirement for any social policy.

What can be done? Cameron writes inspiringly, "[W]e must nurture the communities of dissident medicine. A dissident medicine will keep alive the vision of Christian Hippocratism for those who share that medical visionit will constantly disturb the new, post-Hippocratic mainline by calling it back to its own better self in its original Hippocratic identity"(32)

Conclusion

The present day use of the principle of distributive justice seems to be maximization of corporate profits and concentration of governmental power centrally. Distributive justice is the supposedly moral and rational justification to change the ethic of medicine so as to strengthen the structure of corporate socialized medicine. Distributive justice thus is a "point of departure" because it has transforming consequences. The present reluctance of physicians to fully adopt the principle into their practice is preventing the realization of all that it portends.

Cameron believes that we "find in medicine a bellwether of our understanding of human nature."(33) If medicine is reduced to a power play of interested parties and the exercise of mere technique, and if persons in need are first evaluated on some utilitarian basis before helping them, we deny the sacredness of human life that emerges so clearly and powerfully from the Bible. Any so-called bioethical principle that diverts physicians' focus from caring for the sick or injured in front of them to concerns for an abstract, nameless group must be challenged.

References/Notes

1. Reinhardt UE. Wanted: A clearly articulated social ethic for American health care. JAMA 278:1446-1447,1997.
2. Hall MA, Berenson RA. Letter to Editor, Ann Int Med 129:674,1998.
3. Bodenheimer T. Letter to editor. N Engl J Med 1998;338:396.
4. Grumbach K, Bodenheimer T. Painful vs painless cost control. JAMA 1994;272:1458-1464. See also Hiatt HH. Protecting the medical commons: Who is responsible? N Engl J Med 1975;293:235-41; Eddy DM. The individual vs society: Is there a conflict? JAMA 1991;265:1446-50; and Greenlick MR. Educating physicians for population-based clinical practice. JAMA 1992; 267:1645-48.
5. Some tests (such as the blood leukocyte count), of course, lack sensitivity and specificity and need to be interpreted in light of clinical findings and can be dispensed with in the presence of other strong clinical indicators.
6. Cunningham PJ, et al. Managed care and physicians' provision of charity care. JAMA 1999;281:1087-1092.
7. Brock DW, Daniels N. Ethical foundations of the Clinton administration's proposed health care system. JAMA 1994;271:1189-1194.
8. Although this proposal was rejected by Congress and the American people, President Clinton boasted on September 15, 1997 in a speech to the Service Employees International Union, "If what I tried before won't work, maybe we can do it another way. That's what we have tried to do, a step at a time, until we finally finish this." Hence the incremental changes in medicine that were enacted through the Kennedy-Kassebaum bill of 1996 and the Balanced Budget Act of 1997.
9. World Health Organization, "The World Health Report 2000," June 21, 2000.
10. Munson R. Intervention and Reflection: Basic Issues in Medical Ethics, 4th ed. Belmont, California, Wadsworth Publishing Co., 1992, pp. 37-40.
11. Ibid., p. 39.
12. Nielsen, for example, argues for this right. Since everyone's life matters equally, he writes, justice requires that medical care must be publicly funded and made available to everyone, so that an equality of condition within society results. "Modern societies need systems of socialized medicine," he says, and "petty entrepreneurship should be taken from the medical profession" (Nielsen K. Autonomy, equality and just health care system. Int'l J Appl Philosophy 1989;4:39-44). Daniels, too, claims that health care, because it is special, should be a basic right - but only those services for which resources are adequate. Beneficial care could be denied so as to "be better used elsewhere in the system" (Daniels N. The ideal advocate and limited resources. In Beauchamp TL, Walters L. Contemporary Issues in Bioethics, 5th ed. Belmont, California, Wadsworth Publishing Co., 1999, pp. 63-69). Callahan and co-authors state in an article entitled, "Toward Justice in Health Care," that because medical care, unlike other commodities, is a basic social good, it should be viewed as a social responsibility. Thus these authors believe that we have a "collective responsibility" to guarantee a "decent level of health care" to all (Bayer R, Callahan D, Caplan A, Jennings B. Toward justice in health care. Am J Public Health 1988;78:583-588).
13. To assist in this re-orientation process, some have redefined health. Rather than health being the absence of disease, it is increasingly being viewed as "a state of physical and mental well-being that facilitates the achievement of individual and societal goals." The traditional definition from the medical dictionary is focused on individuals. The new one includes societal objectives, thus the ethical requirement takes a decided political slant. It would not be hyperbole to say the result could be disastrous.
14. The term distributive justice is used by ethicists to refer to a fair distribution in society, according to norms that the society adopts, of economic goods (such as welfare, research grants, etc.) and fundamental political rights and burdens (such as paying taxes, military draft, etc.).
15. Beauchamp TL and Childress JF. Principles of Biomedical Ethics, 4th edition. New York, Oxford University Press, 1994. Tom Beauchamp and James Childress developed their four principles to provide bioethicists and clinicians with a methodology that would be in line with accepted moral philosophy. The 4-Ps chosen are prima facie principles (i.e., they are principles that can be accepted at face value without first having to develop more fundamental matters such as the nature of the good or an epistemology of ethics, nor having to ground the principles in any moral tradition). Two of the principles, beneficence and non-maleficence derive from the tradition of Hippocrates. The principle of autonomy was novel and contrary to the tradition of authoritarianism and paternalism, but it was in the spirit of the civil rights movement, consistent with the American ideal of individualism, and it was central to the idea of informed consent. According to Pellegrino, the principle of justice is foreign to the tradition of Hippocrates, which held as its sole focus the patient - not society (Pellegrino, ED. The metamorphosis of medical ethics: a 30-year retrospective. JAMA 1993;269:1158-1162). Wesley Smith, in his Culture of Death (Encounter Books, 2000), and Gerald McKenny, in To Relieve the Human Condition (Albany, State University of New York Press, 1997), write critically of bioethics.
16. If a person wants to forgo an expensive treatment for the sake of saving money for his family to use for other purposes, that is voluntary and praiseworthy self-sacrifice. Rationing can be criticized for many reasons: (a) A common mistake in thinking about rationing is to confuse a costly treatment for a scarce treatment. An MRI scan is costly, but it is not scarce. The issue is really willingness to pay for something, not availability. (b) The army of cost-containment managers themselves cost more than they contain. More overhead is simply added to the cost of medicine, and money is not saved. (c) Money saved by denying care to one person is not and cannot be spent instead to help another specific individual. The fragmentation of programs makes that impossible. (d) The ethical reasoning why the person in need is denied some beneficial treatment so as to save money for "society" is vague. Who is "society" if not that patient? (e) Rationing requires physicians to be deceptive in withholding information from the patient regarding possible benefits not being extended. Physicians serve in the capacity of "double agency" which is unethical unless the patient is so informed. (f) Rationing health care is not like rationing gasoline during war-time because so much is placed at risk. (g) It has not been demonstrated that there is yet a need for it.
17. Constance H. (ed.) Gambling on the increase. Science 1998;279:485.
18. Wikler D. Ethics and rationing: "Whether, how, or how much?" J Amer Geriatrics Soc. 1992;40:398-403.
19. Brown shows the historical development of Hippocratic medicine was a contrast to Babylonian medicine: "The Hippocratic physician worked for the patient. Unlike the Babylonian physician a millennium earlier, he did not work for or report to the monarch but instead had to respect the patient's privacyHammurabi's physicians practiced government medicine; Hippocrates gave us human medicine." (Brown HOJ. The Sensate Culture. Dallas, Word Publishing, 1996, p. 196-7.)
20. Physicians have always been tempted to place self-interest above that of patients. Allegations of unnecessary surgery so as to boost physician income have been commonplace, for example, and are unavoidable given the fallibility of man. But in doing procedures that may on close scrutiny turn out to be unnecessary, the over-arching objective in the physician's mind is to offer something for his patient that he hopes will be beneficial. This contrasts with the current ideal of deliberately withholding something from the patient for reason of "the common good."
21. Foucault writes, for example, "[S]ince the state is its own finality, and since the governments must have for an exclusive aim not only the conservation but also the permanent reinforcement and development of the state's strengths, it is clear that the governments don't have to worry about individuals[O]f the relationships between the individual and the state, the individual becomes pertinent for the state insofar as he can do something for the strength of the stateAnd sometimes what he has to do for the state is to live, to work, to produce, to consume; and sometimes what he as to do is to die" (Foucault M. Power. New York, The New Press, 1994, p. 409).
22. Whereas Emerson's ideas predominated in America in the 19th century, towards the end of that century Hegelian philosophy began to dominate. Many American students at the time returned from a year of study in Germany and taught the collectivist ideas they had learned there. Laissez-faire capitalism furthermore brought guilt, and the call to self-sacrifice for the sake of the nation sounded superior to self-interest. The 20th century brought the pragmatism of William James and John Dewey. Dewey held that men can always will to try new social models, and he believed that there are no autonomous individuals, rather it is society which has to be reconstructed. Dewey held too that the ideas of the Founding Fathers may have been relevant for their day, but that they are not fixed for all generations and need to be abandoned, along with ideas of personal liberties, capitalism and private profit, individual initiative, and enterprise conducted for private gain. He called for "some kind of socialism." Dewey was not alone. Franz Boas, Ruth Benedict, Thorstein Veblen, Harold Lasswell, and Lester Frank Ward ("the individual has reigned long enough") are just a few who at the start of this century also tried to set America in pursuit of a new political and social order. The history of this century chronicles the incremental outworking of this new collectivist ethic.
23. Dougherty CJ. Ethical values at stake in health care reform. JAMA 1992;268:2409-12.
24. Cotton J. An exposition upon the thirteenth chapter of the Revelation. London, Hand and Bible in the Old-Bayly, 1656, p. 72. Quoted in Miller P. The New England Mind: The Seventeenth Century. Cambridge, MA, Harvard University Press, 1963, p. 409.
25. Economic power too needs to be dispersed, for similar reasons. Control of the economy as in socialism places immense economic power into the hands of a few. Economic controls are really people controls. When the government controls the economy, it controls people, and that always in some way diminishes freedom. The free market, on the other hand, disperses economic power uniformly within the entire society. Instead of immense power in the hands of a few, tiny power resides in the hands of everyone, and everyone benefits.
26. This passage and several other instances in the Old Testament of corporate punishment (Joshua 7, 2 Samuel 21:1-14, and 2 Samuel 24) are problems of retributive justice rather than examples of distributive justice. Walt Kaiser critically discusses the idea of corporate or group solidarity in Toward Old Testament Ethics (Grand Rapids, Michigan, Academic Books, 1983, pp. 67-72).
27. Henry CFH. Linking the Bible to Public Policy. In Demy TJ, Stewart GP (eds.). Politics and Public Policy. Grand Rapids, Michigan, Krebel Publications, 2000, pp. 66-67.
28. See Gordon Clark's, A Christian View of Men and Things (2nd ed. Jefferson, Maryland, The Trinity Foundation, 1991) for a critical appraisal of Oswald Spengler's, The Decline of the West.
29. Alexander L. Medical science under dictatorship. N Engl J Med 1949;241:39-47.
30. Lifton RJ. The Nazi Doctors. New York, Basic Books, Inc., 1986.
31. Brown HOJ. The Sensate Culture. Dallas, Word Publishing, 1996, p. 197.
32. Cameron NMdeS. The Christian stake in bioethics: the state of the question. In Kilner JF, Cameron NMdeS, Schiedermayer DL (eds.). Bioethics and the Future of Medicine. Carlisle, U.K., Paternoster Press, 1995, p. 12.
33. Cameron NMdeS. Soundings in a theology of medicine. Trinity Journal 1993;14:123-141.

Dr. Cohen is an emergency medicine physician in York, Pennsylvania. His e-mail is: [email protected].