The Economics of Medicine: A Wholistic Approach
Dr. Payne is Associate Professor in the Department of Family Medicine at The Medical College of Georgia and is an elder in the First Presbyterian Church in Augusta, Ga.
The economics of medical care is headline news. Should the deductible be increased for the elderly on Medicare? How much should be given to the treatment for patients with AIDS and the research of the disease? What portion of the cost of hospital and other insurance should be paid by employers? What portion of the Gross National Product should be given to medical care?
These questions could be asked in a hundred different areas. The basic questions are, "Who should pay and how much should they pay?"
As a Christian concerned with medical ethics, I have encountered a distressing phenomenon: Christians almost totally ignore these basic questions of the cost of medical care. For example, an ethical issue that Christians have begun to address in increasing numbers is food and water for the debilitated, comatose and terminally ill. This concern rises out of the great pro-life movement that has opposed abortion for the past 15 years. It is definitely an issue that Christians need to address. Abuses are certain and we must do all we can to prevent them. As Christians, however, we are also called to a wholistic approach. As God and His Word are a unity, so must we strive for unity in our ethics.'
Hospital care averages over $600 per day with intensive care units (ICUs) twice that amount. Nursing homes range from $20-30,000 per year excluding intermittent hospitalizations and other costs (physicians, lab tests, special equipment and other items). Medical insurance will usually pay most of the hospital and ICU costs. Almost none will pay for nursing home care. Neither will Medicare (except for the first few days).
When I mention these costs, as part of the whole issue of the technical supply of food and water, and ask, "Who pays for them," I usually get vague answers, if any at all. Sometimes, I get an answer such as, "The Lord will provide." I am not being overly simplistic. I have done this many times. No one has yet answered with any practical or specific approach. Do we not require concrete plans for payment for all other areas of life? We work at jobs to provide shelter, clothing, food, recreation, education and other things for our families. Churches have budgets. When receipts fall during a year, we must cut back the next year (or eventually go bankrupt). Businesses must also have detailed plans for income and expenses or they go bankrupt.
Why is it so strange to ask for accountability concerning medical costs? Why should medical care not require the same detailed planning as other expenses? Obviously, it should, but I challenge you to show me articles or books or lectures where Christians have addressed the cost of medical care. It is as though the problem did not exist. Why?
Possible Reasons for Avoidance of the Problem
While I cannot be certain, I would like to suggest some reasons that this situation may exist. The Bible is clear in its call for Christians to care for the less fortunate, the ill and the injured (Matt. 25:31-46; Luke 10:25-3?). Historically, it also seems clear that the concept of hospitals grew out of this "call to care. 112 So, God's claim upon the Christian is clear and compelling, both Biblically and historically.
Further, the general tenet is often expressed by both Christians and non-Christians that a price cannot be placed upon health and human lives. In other words, cost should not be a factor when we speak of measures that affect these areas. This tenet has been incorporated into the civil rights emphasis of the past three decades to become the "right to medical care." That is, the best that medicine has to offer is a right of all people.
Finally, Christians believe that "God will supply all your needs according to His riches in Christ Jesus" (Phil. 4:19, NASV). The implication is that medical care should be provided before consideration of cost because "God will supply" as He has promised.
Certainly, these explanations have some validity. Nevertheless, they are only a part of the whole that needs to be considered. Other Biblical principles apply.
Few Christians would dispute the Bible's emphasis on stewardship of our financial resources. Someone has counted over 2000 verses that concern economics. First, we should consider who is responsible to pay for basic needs. It seems clear that the primary responsibility falls to the family to provide for its own (I Tim. 5:3-16). "...if anyone does not provide for his own, especially for those of his household, he has denied the faith, and is worse than an unbeliever" (v. 8). Strong words! We could go to other verses, but few argue that the family is far and away the primary provider.
If the family is unable to provide for its own, the church has some responsibility. The above passage was written to instruct Timothy's church (and all others, as well) in its responsibility for widows: "Honor widows who are widows indeed..." (v. 3). Elsewhere, Paul places special emphasis on doing good to "those who are of the household of faith" (Gal. 6:10). We could say then, that the church is the "back-up" provider for its members.
Beyond the church Christians are called to be generous with their charity. Gal. 6:10 also instructs us to "do good to all men." The Parable of the Good Samaritan (Luke 10:25-37) and Jesus' command concerning enemies (Matt. 5:43-48) considerably broadens our charitable efforts.
Before making application of these principles to modern medicine, however, we should note the limitations of church involvement. Paul has qualified his directives. He limits responsibility to those who are "widows indeed" (I Tim. 5:3). Then, he becomes quite specific about who these are. Widows with grandchildren (v. 4) or other close relatives (v. 16) should be provided for by them. Widows must be godly (v. 5, 10). Further, some widows should not be a responsibility of the church: those involved in "wanton pleasure" (v. 6), less than 60 years of age (v. 9), who have had more than one husband (v. 9), and who are "younger" (v. 11-15). We cannot deal with all the "ins and outs" of these particulars, but we do note that the general admonition has some of the most specific limitations of any passage of Scripture.
But what of the responsibilities of non-Christians? They are called to the same priority. Non-Christians may not know or give heed to God's standards as He has spelled them out in Scripture, but they are nevertheless called to and measured by those standards (Rom. 2:11-16).
Thus, in a general manner but quite accurately, we can say that these principles form the basis for the provision of medical care as a basic need of individuals and families.
With this foundation established, we encounter some problems relative to modern medicine. Individuals and families directly pay for less than one-half of medical costs, while private insurance and the government pays for the rest (see below). The question that Bible-believing Christians ought to ask, then, is, "What is the Biblical basis for this extensive involvement of these two agencies?" This situation is an excellent example of common and pervasive practices within modern society that are so common and have existed for so long that an initial challenge of them seems irreverent, if not ludicrous. If we believe that the Bible is our ultimate authority and that it is totally comprehensive over ethics (I Tim. 3:16-17; II Pet. 1:3), then we cannot accept anything that cannot be validated or permitted by Scripture.
Terrell has presented a sound Biblical basis for medical insurance.' He has also presented many unbiblical and practical problems associated with medical insurance and he has given practical instructions for their correction. With this foundation it is necessary only to say that medical insurance can be Biblical, but that its practices must be corrected by Biblical principles.
The presence of the government in the payment for medical care is more problematic. Indeed, it is quite complex. The unwillingness or the ignorance of Christians to ponder the role of government in any aspect of medicine is likely one of the two most pivotal issues here (the other is the efficacy of medicine, see following).
The first issue is whether there is any Biblical basis for any level of government to be involved in the payment of medical care.4 The burden of proof is on those who would say that government does have such a role, because no Biblical text speaks explicitly to this issue. One hermeneutic (principle of interpretation) is that "the implicit is to be interpreted by the explicit.",
What does the Bible does say, then, about the roles of government? Gary DeMar has found six Biblically legitimate roles of government: civil justice (Rom. 13:3-4), the maintenance of just weights and measures (Deut. 25:13,14), the defense of Christianity from public attack (I Tim. 2:2), national defense (Deut. 20), quarantine (Lev. 13:33-53),6 and the protection of private property (Ex. 20:15).7 He sees possible roles to build and keep up roads (Deut. 19:3) and enforce local use contracts (Nu. 35:1-8).
Let us not pass on too quickly here. If someone disagrees with my analysis, please cite Biblical texts as a basis for your argument. Is that not what we are about in this Journal? Some vague notion of "social responsibility" is just not sufficient for Bible-believing Christians. The example of Ananias and Sapphira (Acts 5:1-11) does not apply because they were giving to the church, not the government. I have no problem with individuals' gifts to provide for the medical care of others. I have no problem with large organizations devoted entirely to this provision. I have no problem with missions that provide medical care to undeserved people. I have no problem as long as these actions are voluntary. I do have a Biblical problem with the government's responsibility to provide medical care for anyone through an involuntary program (taxation).
Someone might argue that the government's provision of medical services for those who are unable to afford medical care or insurance is as legitimate as charity. That argument is totally without basis. Charity is by definition voluntary. Try not paying taxes if you think that this role of government is voluntary! Further, there is no reference anywhere in the Bible that it is the government's responsibility to provide for the basic needs of its people. What the Bible does clearly command is that Christians and nonChristian-, provide for the needs of their own family and through charity to others, but the Bible never commands the government to make such provision.
Let me add one qualifier. I do not recommend that government medical payments be stopped overnight. An orderly, but definitive withdrawal, would allow systems and people to adjust to the change. As this change occurs, Christians will have to give more emphasis to medical care as one of their charitable efforts.
A Humanist Agenda
May I suggest, even, that our current emphasis on the right to medical care is almost entirely an agenda of the humanists and that Christians have "bought in" because we are strongly exhorted to care? I cannot offer a complete argument here, but consider these thoughts. First, notice the emphasis on "rights". There is no question that the civil rights wave of the 1960s (that has continued to the present) was a liberal (humanist) agenda. It was at this time that Medicare and Medicaid came into being.8 Second, medical care is placed into a special category of "need." Biblical teaching emphasizes contentment with adequate food, shelter and clothing (Matt. 6.25-34;1 Tim. 6:8). It never mentions medical care as a need.9 By contrast, today medical care is promoted as a need above all others.
The call that we hear from so many quarters is equal access to medical care for all. In other words everyone should have the best that medicine has to offer. Have you wondered why that standard is not applied to housing? To food? To clothes? Certainly, these needs are more basic than medical care. Why is there no campaign to provide modern apartments, even suburban homes for everyone? To provide the best in nutrition for everyone?'° To provide the best clothing for work and protection from the weather? Do you see the contrast? Do you see the distortion of this commodity that the Bible never directs us to provide?
The argument may be made that we cannot afford these things. This argument is inconsistent. A definitive case can be made that adequate food, shelter and clothing will contribute more to the health of a people than medical care ever could." Thus, we could simply transfer the money currently being spent for medical care to these more basic areas. If we are interested in the "most bang (health) for the buck," then medical care is not the best approach. But, reality is that we cannot afford comprehensive medical care for everyone anyway.
The Market Crash .. The Medical Crash
On October 19, 1987 stock exchanges around the world crashed. (They didn't burn, but they came close.) I believe that we are headed for a similar collapse in the medical care system, if current practices are continued.
In 1965 the total amount spent for medical care in the United States was $42 billion or 6.0% of the Gross National Product." In 1984 the total was $387 billion or 10.6% of the GNP. In 1983 dollars (to remove the inflation factor) $116 billion was spent in 1965 and $371 billion in 1984, an increase of 320%.
Also, a large shift took place in the source of payment. In 1950 12%, 5% and 83% of the total spent for medical care came from government, private (mostly insurance) and direct (personal payment by the individual or family) sources respectively. In 1980 the percentages were 35, 27 and 38 respectively."
Finally, we should note the contribution of medical care to the federal debt.14 From 1970 to 1983 federal spending for national defense increased 10% and for Medicare 236% (both figures on the basis of 1983 dollars). Other federal programs, such as medical research, medical benefits for military servicemen and their families, Medicaid, and veterans hospitals, are other large federal expenditures. All these have contributed a large percentage of the federal deficit, especially in recent years.
A recent article in the "American Medical News" stated:
The nation's health care system is fast approaching critical condition ... (a study) was released in Washington earlier this month that indicated that health care ass and delivery is worsening- threatened by fiscal constraints on every level.
Among their conclusions were:
Currently, there is legislation in both houses of Congress to provide cc catastrophic" health care insurance. On the one hand, such legislation seems desirable. Who wants to face bankruptcy because of a major, prolonged illness or injury? On the other hand, virtually every medical legislation has cost far more than its projections. This one is no exception. Five states have already enacted similar legislation.16 Three are no longer in operation because of their high costs. The two that remain have had to cut their programs drastically in order to control costs. Can you imagine the economic disaster if we get such legislation at the national level?
The system is crumbling. It may not experience the dramatic one-day fall of the stock markets, but the impact will be extensive." If other economic disasters occur, the medical system may crash suddenly as well. The focus here is that a severe restriction of medical services is beginning and is inevitable. The only question is whether it will be orderly or chaotic.
How Much to Pay for Medical Care?
Some people have debated how much of the GNP should go toward health care. At least one prominent Christian physician has suggested that we can pay much more. But ... he and others have not answered the more basic questions of who should pay and how should the limits be determined?
If we eliminate the government from payment for medical services, then the answer is more simple. Families make choices everyday according to the limits of their income. We choose a certain priced house to live in. We choose the quality and prices of food that we are willing to pay. We choose the price and quality of clothes that we buy. With every purchase the family decides what it is willing to spend. Why should medical care be any different? Does not the family know what is best for its own? Is not only the family able to make this decision? Most importantly, does not the Bible clearly give this responsibility to the family, as we have seen?
Thus, each family decides what they are willing to pay according to their other financial obligations, just as we decide daily on all the other purchases and plans that we make. The unexpected illnesses and injuries that exceed the family budget can be covered by insurance. Again, Dr. Terrell has described the need and the practical aspects of insurance. You can be sure that insurance companies within the free market will limit payments and control costs while covering clients according to their contracts.
As with widows, the church is a "back-up" agency for families. It is not, however, an unconditional back-up, as we have seen.18 Gary North calls for the church to require insurance coverage to avoid a catastrophic illness that would threaten the financial solvency of the church and its programs. 19 If one agrees that the church should provide for its own in this way, he has presented an argument that is difficult to refute. Whatever the plan, however, the local church will make its decision according to its priorities and budget.
Finally, charity is a Biblical source of financial help. It may be administered from one family to another, by the church or by an independent agency. Each source determines the amount that it is willing and able to pay according to its income and other plans.
A practical example was related to me recently, although it may sting a bit for us physicians. A physician had been to a county medical society meeting of some 200 physicians. The meeting's agenda had included discussion of the problem of indigent care, "street people" who fall into the cracks of current welfare schemes. No one had answers. As he was leaving, he noticed dozens of the physicians' expensive automobiles. He did some rough calculations. If these cars were sold and others bought that were worth approximately half as much, the interest alone on the remaining money would be enough to open a full-time indigent clinic!
Each source will not pay the same amount for medical care, just as each source does not pay the same amount for all other purchases. Each source has fiscal accountability that cannot be extended as a "deficit" (at least for more than a short period of time).
Thus, we have an answer to the question, "Can you place a price upon medical care?" (The question is usually asked rhetorically to stop all debate because it supposedly cannot be refuted.) Each fiscal unit makes that decision daily in areas more important than medical care. As with those decisions, a price that each is willing to pay is determined within the total context of all obligations!
Is Medical Care a Reason to Assume Debt?
We have seen that medical care has contributed a large share to the federal deficit. We have dealt with the issue of payment for medical care by the government, but is medical care a reason for families to assume debt? Perhaps, more accurately, is medical care of such importance that debt is justified to obtain it? Surely, if anything, health is that important!
In general, God warns us about debt (Deut. 15:6,28:43-44; Pro. 22:7,26-27; Rom. 13:8). It is not to be entered lightly. Further, if debt cannot be repaid, it becomes theft (Psa. 37:21). Surely, no Christian would challenge the fact that theft is always wrong, a violation of the Eighth Commandment (Ex. 20:15). A related example would be stealing food or money from a neighbor in order to feed one's starving family. Such a means with a noble and responsible end (especially for a parent) is still a violation of this commandment. Many of us when faced with this situation might succumb and steal anyway, but the action would still be sinful and a punishable crime.
So, the issue is whether the debt can be realistically re-paid or not. In most situations it would seem that medical debt could not be repaid. While minor problems that are handled in a physician's office could be repaid, the more common situation is the patient who needs hospitalization, surgery or a nursing home. In these instances the costs will be tens of thousands of dollars. If not covered by insurance (nursing homes almost never are), then a huge debt will be incurred that most families are not likely to be able to repay. Perhaps, a high wage earner could face these costs and be able to repay them. More likely, however, this person will have sufficient insurance to pay for most of these costs (except the nursing home).
So, ethically the issue is not complex. The inability to pay should preclude debt because it will later become theft. Subjectively, the issue is heart-wrenching. Some might wonder how I can be so callous. Nevertheless, as Bible-believing Christians we claim that principle must rule over situations. (That is, situational ethics are wrong.) But, let me quickly add, there is not so much lost as one might suppose.
The Hype Concerning Medical Care
Even in this day of supposed medical marvels, the issue of what is and is not quality medical care has never been determined. In other words no standard exists by which medical care can be fudged! Further, there is a serious question whether medical care actually contributes to overall health or whether it causes more problems than it helps. This issue is indeed a complex one. I have written extensively on it in one chapter of my book.20
One example must suffice here. The war that was declared on cancer in the 1960s has been lost. When all cancers are taken together, there has been no decrease in mortality over the past 20 years.21 In few other areas, if any, has a greater effort in research and treatment been made by so many to one category of medical problems. Yet, little, if any, progress has been made. Certainly, nothing has been gained relative to the effort made.
So, when I say that there is not as much lost as one might suppose, there is a great body of evidence to support that contention. The unwillingness of Christians to examine the efficacy of modern medicine is the second of the two most pivotal issues here. We would likely not work so hard to justify full medical benefits for everyone if they were not beneficial, and we would be more willing to eliminate those that clearly were not beneficial.
We Can Care When Medical Care Cannot Be Provided
We are blinded by the supposed marvels of medical care. One false assumption (.note often implied than actually stated) is that we cannot "care" unless we provide "medical care". That is, unless we can provide all that modern medicine has to offer, we have not really cared. I suggest that caring is infinitely more important than medical care. I will give one graphic example.
When it has been determined that resuscitation will only prolong imminent death, "Do Not Resuscitate" orders are sometimes written (appropriately). Several studies, however, have shown that after these orders are written the patient is virtually ignored by the medical staff and the family! To me, the logical conclusion can only be that the discontinuation of full medical care is equivalent with a patient's death. Prior to the order, there was likely a beehive of activity around the patient with all the tests and consultations that are possible. Now that medicine has "given up" (as it sometimes should), the patient is treated as though he or she were already dead.
My contention is that the greater role of health care workers and the family is still present. That is, our role to provide the personal and nursing needs of this patient. Indeed, one of the greatest fears patients have is being abandoned. Thus, we fail them at their most vulnerable level, blinded by the "busy-ness" of modern medicine. Surely, this need to care is more valid at any level of medical care than technology!
What About Nursing Homes?
The expense of nursing homes is one of the major expenses
of modern medicine that "falls
My contention is that many nursing home patients could be cared for in the home. I am not saying that all such patients could avoid nursing home care. Most of these patients' medical conditions, however, are stable and require the same procedures on a repetitive basis. These procedures are usually simple and could be learned easily by family members. Back-up could be provided by other health care professionals. Churches could (and should) design programs to assist families.
Practically, this approach would be difficult. We are so accustomed to the freedom that comes from our turning such difficult situations over to others. For most, this provision would require a drastic change in their lifestyle. Some may have to quit their jobs. (If they make less than $20,000 per year they will come out ahead.) All will face unpleasant daily tasks that are routine for nursing care.
There are, however, many advantages of home care. Patients would far prefer to be with their families. Families would not have to schedule visits or feel guilty that they do not go more often. Patients will not be susceptible to "antibiotic resistant" bacteria and other contagious diseases from other patients.
I have only presented some basics here. Other issues and more detail are needed. For example, to what extent are we responsible for the care of others, especially when their medical problems are caused by their chronic sin? What is the answer to the malpractice crisis? Will churches and charity provide sufficient care if the government does withdraw from the payment of medical services? If we cannot afford all medical procedures for everyone, how do we decide which ones to omit and which ones to continue?
My two goals have been to prod other Christians to at least face the economic issues with some concrete answers and to provide some answers that seem Biblical. If I achieve the first, we can work together toward the second. If I cannot achieve the first, then the second will continue to be dealt with piecemeal by only a few of us. We will fail to achieve the mind of Christ on an important subject that affects us all.
1. Payne, Franklin E., "Biblical Ethics in Medicine," Journal of Biblical Ethics in Medicine, 1:1 1-4, 1987.
2. Woods, John E., "Hospitals," in Carl F. H. Henry, Baker's Dictionary of Christian Ethics, Grand Rapids: Baker Book House, 1973, pp. 299-300.
3 .Terrell, Hilton P., "Ethical Issues in Medical Insurance," Journal of Biblical Ethics in Medicine, 1:75-82, 1987.
4. Indeed any role of government in medical care is questionable. See the article on medical licensing in this issue.
5. Sproul, R.C., Knowing Scripture, Wheaton, Illinois: InterVarsity Press, 1977, pp. 75-79.
6. The Biblical concept of quarantine would be an excellent topic for an article in this Journal.
7. Gary DeMar, Ruler of the Nations: Biblical Principles of Government, Ft. Worth: Dominion Press, 1987, pp. 76-81.
8. Payne, Ed, "The Right to Medical Care: A Biblical Construction," Christian Medical Society Journal, 18(3):13-15, 1987.
9. Here, I am not saying that medical care is not a Biblically legitimate need. It is, but its defense as such is more complex than other needs named in Scripture.
10. It is fascinating that our government gives food stamps, but does not care whether they are used for nutritious food or not!
11. Sewage systems and other waste disposal, screens over windows, refrigerators and other improvements in housing and living conditions have contributed more to health than the work of physicians.
12. Carr, Albert, "An Attack on Physician Services," Journal of the Medical Association of Georgia, 74:142-151, 1985. This article is a comprehensive resource for statistics relative to the costs of medical care.
13. This shift of payment, as one dimension of medical care, also represents a shift in the direct relationship of the physician and patient.
14. Some may not consider the federal debt a problem, but I believe that it will eventually cause an economic catastrophic in this country.
15. February 19, 1988, p.11.
16.Chris Warden, Washington Report, February 1988, pp. 7-8.
17. A description of what changes will occur and how to prepare for them would also make a good article for a future issue.
18.This subject would also be a good article for someone to tackle.
19. North, Gary, "Dependence on Private Insurance Covenants," The Journal of Pastoral Practice, 6(2): 3-12, 1983.
20. Payne, Franklin E., Biblical/Medical Ethics, Milford, Michigan: Mott Media, 1985, pp-3350.
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