General Information Programme and texts of the Congress Conclusions

Website: http://www.fiamc.org TEXTS OF THE CONGRESS THE ETHICAL CHALLENGES FOR CATHOLIC DOCTORS IN THE JUST DISTRIBUTION OF HEALTHCARE Rev. Dr. Stephen FERNANDES St. Pius College, Aarey Road, Goregaon East, Mumbai 400 063, INDIA AGENDA 1. Introduction 2. The Meaning of Health 3. The Foundation of the Right to Health Care 4. The Problem of Rationing Health Care 5. Ethical Challenges of a Just Health Care System 6. Conclusion 1. INTRODUCTION The foundation of the right to health care - the person's right to life - the duty of the state to save lives by earmarking funds for health care and - the Roman Catholic tradition of distributive justice being applied to health care In this paper, the meaning of health and the three bases on which health care can be acquired as a right, will be first presented. Thus, the foundation of the right to health care is shown to be i) the person's right to life, ii) the duty of the State to save lives by earmarking funds for health care and iii) the Roman Catholic tradition of distributive justice being applied to health care. Now assuming that health care has to rationed, the various problems encountered in determining a just rationing policy are discussed. Seven ethical challenges for Catholic Doctors are then exposed. The discussion concludes with the appeal to every Catholic Doctor to show compassion and love to all those in need of health care. 2. THE MEANING OF HEALTH - Question of Justice in Health - Official Catholic Teaching - Definition of "Health" - Fundamental Human Rights The question of justice in health care has become one of the most crucial issues in the area of biomedical ethics. There has been a longstanding tradition of understanding and concern for justice within the Catholic moral community, which has in recent times been given an impetus by the Second Vatican Ecumenical Council and the Encyclicals of the Popes. Official Catholic teaching recognizes the right to medical care. In Pacem in Terris, Pope John XXIII affirmed "that every person has the right to life, to bodily integrity, and to the means which are necessary and suitable for the proper development of life; these are primarily food, clothing, shelter, rest, medical care and finally the necessary social services".[1] In Populorum Progressio, Pope Paul VI reaffirmed this teaching.[2] However, the question that many ask is whether a person can have a right to health care. It appears obvious that one cannot have a right to health, since another person's action cannot provide one with health or produce health.[3] However, one could have the right to health care, that is, actions done by another person to me which have the capacity to foster or restore my health. There are many definitions of health, none of which are completely satisfactory. The World Health Organization (WHO) defines health as no less than "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity". The WHO further asserts that governments are responsible for providing "adequate and social measures". The definition of WHO on health is too broad since it makes all or nearly all problems health problems.[4] We need a clear concept of health in order to specify the various claims which persons have in society as support for their health. According to Boyle, a person is unhealthy if "he cannot perform or can perform only with difficulty, his bodily functions".[5] However, what kinds of bodily functions are to be taken as a criteria for health needs to be specified. For centuries, health was chiefly a private matter, and each person took personal responsibility for it. There was no collective understanding of the need to have a general interest in the health of everyone, and so the poor were left to suffer in agony. In the last two centuries, with the growing awareness of the concept of human rights, the right to health care slowly established itself among the fundamental human rights. It is from this time onwards that health care was linked to the dignity of the person and his/her quality of life, irrespective of economic considerations. [1] John XXIII, Encyclical Letter, Pacem in Terris, (Peace on Earth), 11 April 1963; AAS 55 (20 April 1963): 257-304. See no. 11. [2] Paul VI, Encyclical Letter, Populorum Progressio, (On the Development of Peoples), 26 March 1967; AAS 59 (15 April 1967): 257-299. See nos. 6,18, 22-23, 33. [3] Larry Churchill, Rationing Health Care in America. Perceptions and Principles of Justice. (Notre Dame, IN: University of Notre Dame Press, 1987), 96. See also Louis Kass, "Regarding the End of Medicine and the Pursuit of Health" in The Public Interest 40 (1975): 39. [4] Joseph Boyle, "The Concept of Health and the Right to Health Care" in Social Thought 3 (Summer 1977): 644. [5] Boyle, "The Concept of Health and the Right to Health Care", 645. 3. THE FOUNDATION OF THE RIGHT TO HEALTH CARE • The Ultimate Needs of the Person viz., the Right to Life • State Duty to Save Lives by Allocating Sufficient Funds for Health Care • The Roman Catholic Tradition Founds the Right to Health Care on Distributive Justice - The Classical Notion of St Thomas Aquinas - The Standard Notion of Distributive Justice . Health Care Considers The Common Good . The Task of Rationing Health Care Today, our conception of health gives rise to numerous demanding issues of justice. But first let us examine on what basis can health care be considered as a basic human right. 3.1. The Ultimate Needs of the Person viz., the Right to Life One can certainly support the view that at least in certain cases, there would be a just distribution of resources. On the one hand we have the resources of those persons and groups who provide the funds and the needs (which is done through government taxation, etc.). On the other hand we have the claims and rights of those who are going to receive them. In the case of an ultimate need such as kidney dialysis or transplant, without which the person will die, the right to live weighs more heavily on the scales of justice than other rights. Hence, it would seem that one ought to pay whatever is necessary to save the life of the one who needs the kidney transplant. The argument is not so easy when one considers that the funding is provided for all those suffering from kidney disease to such an extent that funds are not distributed to other urgent needs, where other people would also die.[1] Though it is not clear as to how one can weigh life against life, when there are various ultimate needs, what is evident is that the right to health care is founded on the ultimate needs of the person, namely, the right to life. 3.2. State Duty to Save Lives by Allocating Sufficient Funds for Health Care Thousands of people spend money on alcohol, tobacco, cosmetics, advertising, illicit drugs, gambling and various types of luxuries. If a nation could cut back its consumption on these unreasonable expenses and contribute what is saved to pay for the health care of all those suffering from a killer disease e.g. kidney disease, it would save so many lives. Thus, Dr. Edmund Pellegrino argues that the State should pay huge amounts for health care to save lives.[2] So, there is a duty of beneficence or charity to make such a sacrifice to save the lives of others. Accordingly, the State needs to create the right to health care by law in order to provide financially for those whose lives are threatened, by taxing those who can afford. However, the liberalists argue that it is unclear why those whose lives are threatened by death have a claim on justice on those few citizens who have the money to spend on their own wants. 3.3. The Roman Catholic Tradition Founds the Right to Health Care on Distributive Justice The Roman Catholic foundation for one's right to health care is distributive justice, which considers the persons in society to be social persons who have bonds with one another and the whole community. Let us examine both the notions of the Church's understanding of distributive justice 3.3.1. The Classical Notion of St Thomas Aquinas In the view of Aquinas[3], any person who has charge of some item belonging to the common inventory, has duties in distributive justice. In his doctrine on private property he held that since the goods of the earth are ultimately to be used for the good of all, all the goods ultimately belong to the common inventory. This means that any property which an individual person legitimately possesses has a kind of social mortgage which he or she may have a duty in distributive justice of giving it to another in serious need. Similarly, there is no absolute right to health care and one cannot claim that the State is simply appropriating what belongs to me to pay for the health care of others. One may have duties in justice to distribute what I have to those in need. This classical theory of distributive justice is a valuable contribution to our understanding of justice. 3.3.2. The Standard Notion of Distributive Justice Distributive justice is concerned with the relationship of the community to its members. In the standard account of distributive justice, the duties of justice are thought of to belong only to the State or the community as a whole. It orders that the benefits and burdens which are common to society be distributed to the members according to proportional equality. This means that where a form of distribution is unequal, those who propose the unequal distribution must demonstrate that this is proportional to needs, contributions and basic welfare. For example, if the State allocates 85% of its health resources to retirement homes for its State employees and only 15% to maternal and prenatal care, one could without hesitation say that such a manner of distribution is wrong and unjust. This is because expectant mothers who have significant needs as well as substantial contribution to society, have been given too little weight and there is no reason to justify this inequality. However, since some health care needs can never be satisfied, one cannot make need alone to be the criteria of distributing health. If there is no limit set to the claims based on need, society would empty all its resources into the care of the 'most needy' and neglect all the other important needs. Therefore, it is necessary to include a general criterion such as 'human welfare', so that a limit can be set. Consequently, health care is distributed in such a way that all the members in society would be able to have a "decent minimum" living standard. Naturally, this decent minimum is relative to the condition of the society in which the people live. To sum up, under Roman Catholic Tradition, distributive justice is exercised by the community, either through the State or by any individual who has control over the 'common inventory' so as to bring about a proportional equality in the distribution of the common good of the society to the members of the society. This notion of distributive justice leads us to study the meaning of common good and to the rationing of resources for health care services. i) Health Care Considers The Common Good: In viewing the common good, one needs to consider the good of the community over the maximum fulfillment of the individual. It is that good which is brought about by the joint collaboration of the members of society in order to advance the good of the society. Health care, which is an important common good meant to overcome the limitations of illness, can only be produced by intense collaboration of people. ii) The Task of Rationing Health Care: Today, there is a debate on whether health care should be rationed. Most are in favor of rationing health care. Obstacles that one definitely incurs in rationing are now discussed below. [1] Ruchlin, "The Public Cost", 8. [2] Edmundo Pellegrino, "Rationing Health Care: The Ethics of Medical Gatekeeping" in The Journal of Contemporary Health Law and Policy, Vol. 2 (Spring 1986), 37. [3] Thomas Aquinas, Summa Theologiae, II-II, Vol. XXXVII, ed. Thomas Gilby (London: Blackfriars, 1974), q. 61, a.1, resp., ad 1m, ad 2m, ad 3m, and ad 4m. 4. THE PROBLEM OF RATIONING HEALTH CARE - Ascertaining the GNP Percentage for Health Care - Excluding Certain People from Quality Health Care - Cost Cutting Policies - Positive Gatekeeping for Personal or Corporate Profit - Large Amounts of Money Benefiting Only a Few - Age as a Criterion to Limit Health Care - Limited Resources Leading to Microallocation Decisions - Penalties for Illnesses Arising from Neglect - A Two-tiered or Multi-tiered System of Health Care Daniel Callahan has forcefully argued that universal health care is neither feasible nor plausible without health care rationing. For our discussion here, rationing[1] would mean "the intentional withholding of needed diagnostic services or effective medical therapy by the patient's individual physician on the perception by the physician of scarce resources".[2] No society has been able to avoid rationing its health care services. The only question is how to do it justly. 4.1. Ascertaining the GNP Percentage for Health Care Are there any ethical criteria to decide whether a certain percentage of a country's Gross National Product (GNP) is adequate or not for its expenditure on health care? Some argue that the amount of expenditure set aside for health care should be sufficient enough to assure the basic minimum for a dignified human existence. Though cost-containment may not be taken as the fundamental and dominant norm to decide upon society's expenditure on health care,[3] some form of cost-containment policy, would morally justifiable under certain carefully defined conditions of economic necessity.[4] Thus, the social justice considerations of the wider community and the moral considerations of providing quality care are to be taken into account by the fiscal authorities in making a budget for health care services. In other words, the decision of restricting financial support for health care should not be taken solely for political motives or be the result of the market-driven forces. 4.2. Excluding Certain People from Quality Health Care A government policy which excludes persons or provides less than quality care cannot be morally justified. Sometimes physicians in concealing the economic and political motives of the government, either conceal the availability of the treatment or simply state that the patient is not suitable for it. In doing this, a physician violates justice. 4.3. Cost Cutting Policies A government policy which provides incentives for certain forms of treatment (e.g. home care instead of hospitalization) only because they are less expensive, and without considering the medical needs and proper preferences of the patients, are considered to be morally objectionable. Since hospitalization is one of the most expensive components of health care, as part of the cost-cutting strategy, patients are ejected from the hospital when they are on ventilators or unable to walk, when they have fever, urinary catheters, and draining wounds. As a result of this, should the Catholic Doctor succumb to the pressure of discharging the patients more quickly? 4.4. Positive Gatekeeping for Personal or Corporate Profit When a physician induces a patient to undertake a form of health service (e.g. dialysis) when another form of treatment would be in the patient's best interest (e.g. home dialysis), from motives of personal or business profit, it is not morally justified. Pellegrino calls this an indefensible form of gatekeeping.[5] 4.5. Large Amounts of Money Benefiting Only a Few Can expenditure of very huge amounts of money on procedures which benefit only a few people be justified when a minimum amount of care is not provided for others in society? In Illinois, Amy Hardin's family and friends raised $ 265,000 from private resources to pay for her liver transplant.[6] In Florida, Billy Bostick received half a million dollars through the largesse of a Saudi Arabian prince to pay for a new heart and lungs.[7] Other people whom we cannot name, suffer from similar problems and die, away from our attention. Such inequalities in the distribution of health care resources goes against the principle of distributive justice. 4.6. Age as a Criterion to Limit Health Care Daniel Callahan argues that there should be limits on providing health care to the aged. He says that "…medicine should be used not for the further extension of the life of the aged, but only for the full achievement of a natural and fitting life span and thereafter for the relief of suffering".[8] He is not saying that society should stop providing health care to the aged because it costs too much or because the aged are of no use to society, but he claims that technology has led the care for the aged to concentrate on extending life as far as possible rather than accepting the limits of life and concentrating on the meaning and quality of life. Callahan cautions that this approach could lead to making age as the basis of a kind of penalty which reduces or removes the full right to health care of persons. In the United Kingdom, elderly victims of end-stage kidney failure have been excluded from dialysis and transplantation because they were considered too old.[9] The use of age as a criterion may reflect unjust discrimination against the elderly by an ageing society. 4.7. Limited Resources Leading to Microallocation Decisions When there are limited resources for the number of patients who require them, how should the selection be made? Could the criteria of age, contribution to society or merit be used as the basis for selecting some and rejecting others? A just procedure would be to i) Decide on medical grounds as to those most likely to benefit from the procedure and ii) Select from this group, randomly or by lot, those who are to be treated. 4.8. Penalties for Illnesses Arising from Neglect According to Joseph Boyle, "The need for health care is thus not sufficient by itself to generate the right to health care. For those who are moral agents, a personal commitment to the good of health is also required".[10] This means that to have a right to health care, one should exercise personal responsibility within that community. If one neglects personal responsibility for one's health, one cannot in the name of justice, ask society to pay for one's care. Rather, those who do not take care of their health are to pay more than others in compensation for the extra burden they have placed on society. Insurance companies would thus be justified to include penalties for those illnesses arising out of neglect.[11] However, some argue that such a policy would be impossible to implement.[12] They ask as to what criteria is to be used to establish the fact of neglect. For example, would there be special tribunals to determine whether a person contracted AIDS from sexual activity or blood transfusion? And if it ascertained that it is due to the person's own neglect, should the person be penalized? 4.9. A Two-tiered or Multi-tiered System of Health Care Today, many ethicists argue for a basic equality of health care facilities since it is not merely a commodity, but rather gives the possibilities of fulfillment of persons and the community. However, there are others who propose a two-tiered or multi-tiered system of distribution. According to Rawls, one should ignore what people already own since according to his Theory of Justice,[13] it is the distribution of the health care that should produce equality. And if there are inequalities, they should be justified by the benefit they bring to the least advantages. Thus, this system is justified, when those who benefited from the first tier, would because of better opportunities for health received, lead to the benefit of those who are at the bottom of the second tier. [1] The word rationing is packed with many meanings. To some it means cost containment. To others it means that some individuals are not insured. To still others, it is understood as a waiting period for medical service. See John Collins Harvey, "Should Health Care be Rationed? The Physician's Viewpoint" in Linacre Quarterly 61, no. 1 (February 1994): 66, 67. [2] Edward Pellegrino, "Is Health Care Rationing Ethically Defensible in our Country Today? in The 1991 Distinguished Visiting Professorship Lectures, ed. J.E. Hamner (Memphis, Tennessee: University of Tennessee), 97-118. [3] See Victor Fuchs, The Health Economy (Cambridge: Harvard University Press, 1986), 356. [4] Pellegrino, Rationing Health Care, 44. [5] Pellegrino, Rationing Health Care, 44. [6] David Wessel, "Transplants Increase and So Do Disputes Over Who Pays Bills" in The Wall Street Journal, Vol. 73 (12 April 1984), 1, 24. [7] Raleigh News and Observer, 13 June 1985. [8] Daniel Callahan, Setting Limits: Medical Goals in an Aging Society (New York: Simon and Schuster, 1987), 53, 137. [9] See A.J. Wing, "Why Don't the British Treat More Patients with Kidney Failure?" in British Medical Journal 287 (1983): 1157; V. Parsons and P. Lock, "Triage and the Patient with Renal Failure" in Journal of Medical Ethics 6 (1980): 173-176. [10] Joseph Boyle, "The Concept of Health Care and the Right to Health Care" in Social Thought 3 (Summer 1977): 5-17. Reprinted in On Moral Medicine, eds. Stephen Lammers and Allen Verhey (Grand Rapids, MI: William B. Eerdmans Publising Co., 1987), 647. [11] See Robert Veatch and Peter Steinfels, "Who Should Pay for Smokers' Medical Care?" in The Hastings Report 4 (1994): 8-10. [12] Charles Curran, "The Right to Health Care and Distributive Justice" in Charles Curran, Directions in Catholic Social Ethics (Notre Dame: University of Notre Dame Press, 1985), 278. [13] John Rawls, A Theory of Justice (Oxford: Oxford University Press, 1972). 5. ETHICAL CHALLENGES OF A JUST HEALTH CARE SYSTEM - The First Challenge: Individual vs. Community Aspect of Health Care - The Second Challenge: Option for the Poor or for Profit - The Third Challenge: Treating Patients with Respect or as a Commodity - The Fourth Challenge: Cooperating with Institutions having Moral Principles - The Fifth Challenge: Being Compassionate or Indifferent - The Sixth Challenge: Influencing the Government/ Drug Manufacturers to Reduce the High Costs of Medications - The Seventh Challenge: Organizing Medical Education Programmes - An Alternative Model of Health Care &endash; Primary Health Services: A Challenge for Developing Countries In this section, we will focus on the burning ethical issues of health care that are likely to preoccupy biomedical ethics for the next decade. There is need to take note of the fact that health care as it has developed in the First World today is not even conceivable in Third World countries like India and Bangladesh. In these Third World countries the government does not have any funds reserved for health care. What is does have are primary health services which have their own problems and moral issues. Thus, the challenges to health care have to be understood from the perspective of both the First and Third World. Accordingly, a special mention and thrust of the Third World concerns will be taken up here below. 5.1. The First Challenge: Individual vs. Community Aspect of Health Care In order to know how to distribute health care resources, we need to understand what we hope to achieve in doing so. As Michael Walzer has observed, "If we understand what [a good] is, what it means to those for whom it is good, we understand how, by whom, and for what reasons it ought to be distributed".[1] For a long time, health care meant care for the afflicted, as seen in James Burtchaell's description of Dutch Physicians, responding to Nazi policies: "They knew their job was not to produce a healthy, working population, nor to eliminate the stunted; it was their profession to heal whom they could, alleviate the affliction of those they could not and stand by all whom they served".[2] This is an individualistic approach to health care. But emerging in this paper is another view of health care, as an instrument to improve our collective physical well-being. Oregon governor John Kitzhaber notes: "Health care is but a means to an end &endash; not an end in itself. And thus it is important only to the extent that it furthers the end of maintaining, restoring or improving (national) health".[3] We sincerely hope that health care will serve both these purposes. However, in a world of scarce resources and rising health costs, where the welfare of the weak is likely to compete against the 'wellness' of the majority,[4] the task of the Catholic Doctor becomes even more challenging. 5.2. The Second Challenge: Option for the Poor or for Profit A health care system which neglects the poor, impoverishes the social order of which we are constituted. Sixty four years ago Henry Sigerist claimed that "the chief cause of disease is poverty".[5] Research on the relationship between race, class, poverty, and health consistently shows the same pattern.[6] Unfortunately many physicians are lured by the greed for profit and show no consideration to those who cannot afford to pay. Providing medical treatment to the poor is at the heart of the Catholic mission in health care. Health care that reaches out to the marginalized is an expression of social solidarity. The question of social justice in health care is: Are Catholic Doctors willing to care for the needs of the downtrodden of society. Financial access to medical care is becoming a benefit only to the healthy and the economically advantaged. Many middle-class and all poor families are not in a position to afford health insurance. Thus, the challenge today is to make health care available to all those socially disadvantaged who need it. 5.3. The Third Challenge: Treating Patients with Respect or as a Commodity The Revised Ethical and Religious Directives[7] for Catholic Health Care Services replace an earlier "best interests" model with a "responsible patient's wishes" model. Though it is written by the United States National Conference of Catholic Bishops, its principles hold good for all Catholic Health Care institutions. Here, the directives not only require a patient's consent but also ask the patient to provide "all reasonable information" so that the patient's consent becomes free and informed. The document insists repeatedly that the patient's wishes must be respected so long as they do not violate Catholic moral principles. Unfortunately, many times doctors decide for patients without even consulting them. Further, the Catholic Doctor, in representing the best interests of the patient, as expressed in the Hippocratic Oath, is obliged to give to the patient necessary and effective treatment, in so far as he/she (viz. the Catholic Doctor) can judge its effectiveness, no matter how scarce are the resources. The phenomenon of illness makes an unequal partnership between the Catholic Doctor and the patient, a partnership which is based upon mutual trust and respect. The patient who is weak, frightened, exploitable and suffering from a loss of freedom, turns in trust to the Doctor with the hope that his or her superior knowledge would give the right solution. And the doctor, if he withholds an effective treatment from an individual, on the grounds of protecting scarce resources, or by sheer habit of treating the patient as a tool, is violating a fundamental ethical principle in medicine, namely, beneficence in the best interest of the patient.[8] However, we need not forget that there is also danger in overstressing the value of physical life. This could lead to a refusal of death by using technologies that postpone death indefinitely.[9] A patient is not obliged to oppose the natural deterioration of the body. Thus, one is not obligated to submit oneself to a disproportionate treatment to conserve one's life.[10] Families are regularly making inappropriate requests for aggressive treatment, also called therapeutic obstinacy[11], at the end of life. More often than not, physicians accommodate these requests out of fear of being sued or to avoid the tension of dealing with the family. The result is that resources are unnecessarily spent at the end of life on futile or burdensome treatments where the cost is extremely high and the benefit is minimal. On the grounds of having a proper stewardship of scarce resources, hospitals can say "no" to these requests. It would be virtuous for the patient and his family members to refuse such treatment because another person could use the same resources.[12] 5.4. The Fourth Challenge: Cooperating with Institutions having Moral Principles When a Catholic Health Care institution enters into partnership with a secular institution whose activities are judged morally wrong by the Church, the Catholic institution "should limit its involvement in accordance with the moral principles governing cooperation", always bearing in mind that cooperation "may be refused because of the scandal that would be caused in the circumstances".[13] For example, no amount of duress will justify the practice of abortion within a Catholic Health Care institution. The greed for profit sometimes entices health care personnel to enter into allegiance with money making medical institutions that regrettably violate Catholic moral principles. 5.5. The Fifth Challenge: Being Compassionate or Indifferent Catholic health care is rooted in a commitment to defend human dignity from the moment of conception until death. Every person enjoys an inherent dignity that must be respected and in no way violated. This dignity rests in the person being created in the image and likeness of God, and so any violation against a person is in some sense an act of doing violence to the image of God. Thus, in a particular way, the Church affirms the worth and dignity of every sick person and has called health care the sacrament of compassion. Caring is essential for human birth, growth, survival and for a peaceful death. To treat a person only as a diseased body to be repaired without caring is equivalent to psychological and spiritual abandonment. Caring is an ethic that links us together as members of the human community.[14] 5.6. The Sixth Challenge: Influencing the Government/ Drug Manufacturers to Reduce the High Costs of Medications The cost of prescription medications is rising more rapidly than all other health costs. This is mainly due to the large amounts of time and money that drug manufacturers spend in competitive research and development to produce new drugs or develop redundant drugs. Though some of the costs are recovered through Government grants, the rest of burden falls on the consumer. One also hears sad stories of how drug manufacturers cease to produce certain medication that are useful in poor countries where little profit can be made.[15] Also, the May 2000 decision of several major drug manufacturers was the reducing of the cost of AIDS medication to poor countries, especially Africa.[16] Could some action be taken to reduce the prices of drugs to the developing and poor countries? 5.7. The Seventh Challenge: Organizing Medical Education Programmes There is an increasing need today to provide social action programmes to provide health care for the poor. Medical schools are to be encouraged to establish programmes in their hospitals to focus both on caring for the poor and at the same time education the medical students. To keep all these programmes functional, the medical schools and hospitals could be aided by public funding from institutions such as Medicare and Mediaid. For example, the students of St. John's Medical College, Bangalore, India, are encouraged to work in needy rural areas after the completion of their training to be doctors. It has started a rural service system built into the admission of the medical students called the "rural bond". All the MBBS students execute a bond to serve in a medically underserved area for at least two years after they complete their training. Our Catholic doctors can be instruments of promoting the values of respect for life, medical ethics, effective communication, understanding the dynamics of rural family life, etc. 5.8. An Alternative Model of Health Care &endash; Primary Health Services: A Challenge for Developing Countries In developing countries such as India, where there is no system of health care but rather primary health services, the challenge to provide adequate health services to all is an almost impossible task. Any attempt to eradicate ill-health should be pursued side-by-side with three other mutually supportive objectives of eliminating hunger, poverty, inequality and ignorance, and against a backdrop of socio-economic transformation which will give effective power to the poor and underprivileged groups to demand for their basic rights. This model of providing primary health services is based or rooted in the community. It goes beyond the curative aspects of health and integrates promotive, preventive and curative aspects. It gives up the overemphasis which the present system places on large urban hospitals and creates small community hospitals or health centers in villages. Here, community participation in the community health programmes is encouraged. Further, home based domiciliary care where community health workers pick up early uncomplicated signs and symptoms, and treats them with basic essential drugs, is now gaining much acceptance. This reduces the need for rarely available doctors and nurses and also reduces hospitalization costs. The challenge lies to educate community health workers to run more of domiciliary based care. Today, in a situation of rising population and difficulty to control diseases, the only probable solution to improve the health scenario is to involve the community in providing health care. Here, the key is community participation where people work in partnership with those who are able to assist them, identify their problems and needs, and take responsibility for concrete action. [1] Michael Walzer, Spheres of Justice (New York, NY: Basic Books, 1983), 9. [2] James Burtchaell, "How much should a Child Cost? A Response to Paul Johnson" in On Moral Medicine, 508. [3] John Kitzhaber, "The Oregon Health Plan: Presentation to the Conference on Health Care", unpublished lecture given at a conference on "The Oregon Solution", Portland, Oregon (09 August 1991), 5. [4] M. Carhleen Kaveny and James Keenan, "Ethical Issues in Health-Care Restructuring" in Theological Studies 56, no. 1 (March 1995): 139-140. [5] Henry Siegerist, "Social Medicine" in The Yale Review 27, no. 3 (Spring 1938): 462-481; reprinted in Moral Problems in Medicine, ed. Samuel Gorowitz, et al. (Engelwood Cliffs, NJ: Prentice Hall, 1976), 468. [6] Churchill, ibid., 85. [7] National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (ERD), (Washington D.C., 1995). [8] John Collins Harvey, "Should Health Care be Rationed? The Physician's Viewpoint" in Linacre Quarterly 61, no. 1 (February 1994): 66-71. [9] William Maestri, "Stewardship of Life" in Linacre Quarterly 47 (1980), 167, 169. "To seek to use all available means to preserve one's life or health is to ask for what is, at once, impossible, irrational, and even if possible, it may be contrary to the sacredness of man as God now makes him". [10] It is important to state here that there is a grave obligation to employ proportionate means of conserving life. [11] Therapeutic obstinacy means the use of intensive and exaggerated medical methods which do not respect the natural moment of death. [12] Scott Rae, "Money Matters in Health Care" in Cutting-Edge Bioethics. A Christian Exploration of Technologies and Trends. eds. John Kilner, C. Christopher Hook, and Diann Uustal. (Grand Rapids, MI: William Eerdmans Publishing Company, 2002), 113. [13] ERD, directives 69 and 70 respectively. [14] Diann Uustal, "The Ethic and Spirit of Care" in Cutting-Edge Bioethics. A Christian Exploration of Technologies and Trends. eds. John Kilner, C. Christopher Hook, and Diann Uustal (Grand Rapids, MI: William Eerdmans Publishing Company, 2002), 156. [15] An example is the drug melarsoprol, much needed in some African countries for the treatment of sleeping sickness, but out of production because it is not needed elsewhere and not profitable to the manufacturer. Cf. Donald G McNeil, "Drug Makers and the Third World: A Case Study in Neglect" in The New York Times, 21 May 2000. [16] Donald McNeil, "Companies to Cut Cost of AIDS Drugs for Poor Nations" in The New York Times, 12 May 2000. 6. CONCLUSION - Benedictine rule: "the care of the sick is to be placed above and before every other duty" - Health care persons very valuable service to life - Good Samaritan - Purpose of the health care ministry: Humanitarian St. Benedict, the father of Latin monasticism, wrote in his Benedictine rule that "the care of the sick is to be placed above and before every other duty". "The work of health care persons is a very valuable service to life. It expresses a profoundly human and Christian commitment, undertaken and carried out not only as a technical activity but also as one of dedication to and love of neighbour".[1] It is a form of Christian witness.[2] The parable of the Good Samaritan belongs to the Gospel of suffering. "For it indicates what the relationship of each of us involved in health care must be towards our suffering neighbour. We are not allowed to "pass by on the other side" indifferently; we must "stop" beside him. Everyone who stops beside the suffering of another person, whatever form it may take, is a Good Samaritan. The name "Good Samaritan" fits every individual who is sensitive to the sufferings of others, and who is moved by the suffering of others by bringing help in suffering. He puts his whole heart into it, nor does he spare material means. Here we touch upon one of the key-points of all Christian anthropology. Man cannot "fully find himself except through a sincere gift of himself". A Good Samaritan is the person capable of exactly such a gift of self".[3] As Catholic Doctors, who have an identity and mission of Catholic health care, it is the experience of faith and love for Christ that urges one to face the challenges of showing compassion and love to all those in need of health care. The whole purpose of the health care ministry is being humanitarian.[4] It is the Lord Himself whom we serve in others and it is His love that called to share when we do the serving. "When I was sick, naked and imprisoned you cared for my needs". We recall the words of St. Bonaventure who said, "the day you no longer burn with love, many others will die of the cold". [1] Pontifical Council for Pastoral Assistance to Health Care Workers, Charter for Health Care Workers. Vatican City: Polygot Press, 1994. [2] John Paul II, during his visit to Mercy Maternity Hospital in Melbourne, 28 November 1986, in Insegnamenti IX/2 (1986) 1734, no. 5. [3] John Paul II, Apostolic Letter, Salvifici Doloris, 11 February 1984; AAS 76 (1984): 201-250. See Nos. 25, 28. [4] Rev. Russell Smith, "Health Care Rationing: A Theologian's Perspective" in Linacre Quarterly 60, no. 3 (August 1993), 20-29.