More or Less Than Business
Dr. Maddox is a ruling elder at Faith Presbyterian Church (PCA) and a family physician in Florence, S.C.
The outcry against viewing medicine as a business is subsiding in many circles. Most people have chosen one side or the other, learning to accept those of the opposite opinion. Now we are beginning to reap some of the effects of these decisions, in advertising, billing procedures, use of credit cards, third-party "reimbursement," views of charity, and attitudes toward the profession.
The basic issue has not been resolved, especially from a Scriptural standpoint. A recent article in JBEM warned Christians not to think of medicine as a business. Christians are once again asking what position they should take on this question. And so it should be: To the Law and to the Testimony. It is, in Scripture that we find how we ought to operate. Economics and related endeavors can only describe the operations. Only Scripture can teach us how the operations should run.
Before searching the Scriptures, we must define our terms. In order to limit the scope of this article, the term "medicine" will refer to the institution built by the majority of allopathic providers. It thus incorporates the modem concept of the (currently licensed) traditional physician in his office or hospital practice.
"Business" is more difficult to define. The title assumes that medicine at least has some business aspects. Few would disagree with this statement, but many have differing alternatives to business as the core or heart of medicine. Some see medicine as art, practiced for its own sake, with contributions made to the artist so he can continue in art. Others are thinking of the altruistic alternative, a selfless service to those in need, sacrificing as the Good Samaritan did. Perhaps others simply want to keep medicine warm and caring, avoiding the cold, impersonal connotations of business. Nor does it have to be one or the other, but is possibly all of the above, as well as business. Each of these alternatives assumes some definition or concept of business.
A return to first principles is necessary. Our first priority in life (or death) is to glorify God and to enjoy Him. Jesus Christ stated this as the summary of the Law and Prophets, to love the Lord our God with all our being. Flowing from this and consistent with it, we are to love our neighbor as ourselves. We are also taught that the greatest among us must be the servant of all. At issue is not whether to serve, but how to serve. As will be shown from the Scriptures, business is our stewardship in the service of others.
A survey of the Scriptures reveals many passages about our work, and still more about finances in general. Nowhere are we given a definition of business. As with so many other topics, the Scriptures seem to assume a working understanding and acceptance of the topic, with the Scripture correcting and advancing our concepts. This understanding does perhaps beg the question when defining business. So although the concept of business is assumed, the particular view of business given in Scripture may be far from our view. The process of sanctification and conforming to Christ demands that we remake our concept in terms of Scriptural teaching. It is possible that there is only minimal similarity between the current concept of business and the Scriptural concept of work. A man's work or calling, was not something separate from him, a person created by the state, licensed and granted limited liability. It was instead a man's service before God, intimate to him, owned or controlled by .him and by which he lived or died. This was as true of the laborer as of the field owner, since both had control over their own actions (Mt. 20:1-16). So perhaps business is not supposed to be cold and impersonal at all.
From the very beginning, man had work to do. Adam was given the job of dressing the garden. His sons had different, perhaps more specific occupations: one kept animals and the other tilled the earth. Cain's sons became proficient at other tasks: bronze work, making and playing musical instruments. Noah, being a man of the soil, became a vinedresser (maybe the first) (Gen. 9:20). Exodus 35:30ff, as well as other passages such as I Kings 5, demonstrate that God gifts certain individuals in particular crafts.
Deuteronomy 8:18 teaches us that it is God who gives us the ability to make wealth. It is of course God who gives us our abilities in general and it is with these that He enables us to make wealth. Further, skill in our work leads to greater service (Pr. 22:29). It is our lot to find satisfaction in this work God has given us to do, rather than chasing fantasies (Pr. 12:11, Eccl. 2:24; 5:18). Paul's example, which we are commanded to follow, was to work in the occupation in which he was skilled (Acts 18:3; 20:34).
I Peter 4:10 teaches us how to live, how to spend the time we are given. We are to be clear-minded and self-controlled so that we can pray. We must love one another, and be hospitable. We must serve others with whatever gift we have received, all to God's glory and the edification of His people. This passage is usually seen only in relation to the Church, since that is the context in which we are accustomed to speaking about the gifts. It is inconceivable that Peter could be so narrow in his focus. At the narrowest, he may mean that we are to serve fellow Christians, though not just within the worshipping body, or in the government or institution of the church. Elsewhere Paul tells us that we are not to leave the world, that we are to continue associating with the people of the world who are sinners (I Cor. 5). But are we to serve them? This is apparently his meaning. in Gal. 6:10, where we are instructed to continue doing good to all people (serving them), especially the household of faith.
God's people are to relate to each other by serving others. Yet Paul tells us that even the teaching elders deserve to be paid for their service, as Paul himself deserved to be paid. In support of this teaching, Paul quotes the law, which instructs us in what we ought to do, and he also tells us by example that men who work expect to be paid. The soldier, the vinedresser, the shepherd, the plowman, and the thresher all work with the expectation of sharing in the profits. Whether these are laborers or entrepreneurs does not change the conclusion. If laborers, they expect a wage, and the law demands they be paid. If entrepreneurs, owning their own fields, vineyards or flocks, they still have the legitimate expectation of sharing in the harvest. Even the one sowing a spiritual seed should reap a material harvest, as Paul says (I Cor. 9:7-12; 1 Tim. 5:1718).
Paul also tells us that work is doing something useful with our own hands (Eph. 4:28). This is a recurrent theme, though the meaning is not entirely clear (I Thes. 4:11; Pr. 10:4).
Whether this use of "hands" refers only to hard labor, or only applies to those in an agrarian society, or simply is a metonymy for our own labor, be it mental, physical, or some other, it is clear that our own work must be useful and productive. We must produce in order to share with those in need. Producing to share is the necessary response for one who has been stealing, but it is the righteous way for all.
Scripture leads us to conclude that business is the application of our calling before God in the service of others. Business is the vocational stewardship of the resources or talents granted by God, employed to His glory, in the service of our fellow-man. In a more general sense, business is an economic transaction, economic being used in a most general sense to mean any interaction involving exchange of value, whether "financial" or not. In either sense, we are commanded to be law-abiding in all our ways.
If our definition holds, then not only is all business vocational stewardship but all vocational stewardship is business. This points to the weakness in the definition. Could not one employ these resources without remuneration? One could promiscuously dispense resources as favors. Would this qualify as business? Not by its ordinary use. But neither would this ordinarily qualify as stewardship. Generous, perhaps. Commanded, perhaps. But good stewardship it is not. The steward manages affairs well. But the resources are not the steward's to dispense.
The parable of the shrewd steward confirms this, because although the steward was commended for his shrewdness in making friends using the resources that would not last, he was being fired for mismanagement.
The steward is expected to manage well. This means he manages in the owner's interest. Christ tells us a parable teaching -that this means investing for a return. We are to use the resources He has given us to reap more for Him. A profit then is not evil or unchristian, but rather necessary to being a steward. However, profit is not the prime motive, or the only or final criterion by which we are judged. The good manager manages according to the desires of the owner. (This means that Adam Smith's formulation of each man acting from self-interest as the ideal is mistaken.) This normally means to make a profit, but also requires generosity to those to whom the owner wishes to be generous. A profit or remuneration is not necessarily financial. The benefits and returns gained from proper management may be in terms of kingdom-building rather than money. God will judge our work by its conformity to his revealed will, the Law.
We are taught in the law not to muzzle the ox that treads. Paul puts this together with Christ's command that the worker is worthy of his hire. One should not be made to work for nothing. This is obvious also from the command to work in order to eat. This command would be meaningless if we are not paid for our work. So we must not be afraid of a return on our services, as if profit is unspiritual. There may be some difference in the common use of the words income and profit. If the latter implies unjust gain, then we are judged by the Law. But income is gain and gain is profit. From Christ's original command, one might only expect a reimbursement of expenses, with no gain over that. But Paul's use of this in terms of a material harvest imply again over and above expenses.
Stewardship necessarily involves managing the assets, talents and resources for profit, under normal conditions. Vocational stewardship is the management of such properties in the specific area to which God has called us to labor. Profit is expected in this vocation, as is generosity. This is true no matter what the vocation.
It must also be established that medicine is vocational in nature. This would seem obvious, but a common objection is that medicine is a different type of vocation that others. Normally, a vocation is a legitimate calling by which one makes his living. But medicine as a vocation is seen differently from other vocations, as if it is wrong to make a living from others' misfortunes. However, many vocations are based on correcting misfortunes, whether the plumber unclogging pipes, or the body shop fixing bent bumpers. The objection is then raised that there is a difference between bumpers and bodies. This is true, both because people put more value on their bodies and because we think God does also. The latter will not be disputed, but there is no definite connection between health and medicine (as a profession or a treatment). There is a definite connection between food and life (or health). No one argues that a grocer must routinely give away food because of the priority of life.
It may be objected that the Good Samaritan was not paid for his care of it is clear that medicine is vocational stewardship, and is thus business. It is also clear that this is not license for gouging, overcharging, or otherwise taking advantage of a patient. If medicine is to be differentiated in any way from other business, perhaps it should start here. It is certainly easier to convince a sick or distraught person of his need for some unnecessary service. A person desperately needing his car may agree to services that would be obviously unnecessary were he in a better state of mind. The Law requires us not to take advantage of this situation. To do so would be stealing. Likewise, to do a procedure on a patient (that incidentally is $600 in the doctor's pocket) just because it can be done and has the slim possibility of helping, would not be proper. To set our fees by the maximum that will be reimbursed should also be questioned, since the service is not necessarily worth that amount to the patient. This actually requires that the whole third-party payment system be reevaluated, since the third party has no way of knowing what the service is worth to the patient.
The law requires that one love his neighbor as himself. This law applies in business as anywhere. To sell a product that I know is not what the other party wants or needs, misleading him, is lying and stealing. This would hardly be loving my neighbor as myself. The wages gained would not bring life or blessing but rather punishment (Pr. 10:16). An exchange which mutually benefits both parties is not precluded, nor even an exchange which is not to the benefit of one party, as long as he was not misled or coerced by the advice of the other party. The motives are important. There will certainly be the victim. This is true. As stated above, remuneration is not always financial. Nor was the Samaritan rescuing victims as a vocation. This parable obligates every man to love his neighbor, not only the doctor. To expect something for nothing is actually a violation of the Tenth Commandment (against coveting).
We are commanded by Scripture, all through the Law, and in Christ's Sermon on the Mount, to generously feed the needy. Giving water to the thirsty is a commendable action. But this does not command us never to sell grain or water, or that that these are commodities outside the normal market processes. We are commanded to be generous, whether in medicine or farming or any other vocation.
Understood in this way, many transactions where both parties are convinced the other is getting the bad end of the deal. Having duly warned, one may proceed with the transaction as long as it is lawful before God to provide that service or item. But honest scales are required, meaning that any deception about the product is unlawful (Pr 11:1).
The foregoing raises the whole question of value. What is the value of any particular service or product provided by a doctor? It is common now to hold to a subjective theory of value, each individual setting the value from within himself. This is a reaction to the former objective theories of ages past, and is conveniently developed in this post-Kantian age. The Biblical view would be an analogical value, with our valuation based on and consistent with God's. His valuation is prior and true; ours is derived and distorted by sin. This however, cannot be used to imply a Medieval "fair-price" theory, in which a certain price is assigned as the fair market price with the acceptance of more being sinful. A Biblical model would be tri-perspectival, ala Frame, with a normative situational and existential aspect to every valuation (refer to the review of his Medical Ethics elsewhere in this issue). This allows for the value to have some subjectivity, depending on the individual's desires and needs, as well as a component that varies with the situation. These are all of course within the parameters of God's Law (the norm).
For example, I may value a certain coin more highly than other people would because it was owned by my grandfather. But I would value the coin very little compared to water, if thirsting in the desert. It is not wrong for me to value the coin highly, but God sets certain absolute priorities of value. The kingdom is the pearl of great price, the field of treasure, to be valued above all else. That is, obedience to God is our highest priority. Our families are to be valued above our own lives. There is no greater love than for a man to lay down his life for his friends, especially those of the household of faith, and particularly those of our own households whom God has entrusted to us.
The value of medical care, like any other commodity, must first be viewed in terms of the value God sets on it, and then secondarily how we as his individual creatures value it, in reflection of God's values. This will necessarily vary from person to person and from situation to situation even for one person. Medical care is not to be valued too highly, ignoring the stewardship of the doctor's and patient's resources. One must remember, also, that medical care may not be equated with life or even health. Nor can life be made the highest value.
So medicine deals with products and services with high relative value, magnified by the distress and insecurity of the purchaser. These are, of course, related issues, since a patient is more distressed about his health because he values it highly. (For a lengthier treatment of modern man's search for security through medical care, see "The Frustration of Fallibility," JBEM, Vol. 1, No. 1, pp13-16.)
Medicine is also different from other businesses by the nature of the product. It is necessarily an ill-defined product, unlike groceries and car repairs. It is often difficult to evaluate the services rendered. It often involves unseen and un-testable products or services.
Medicine deals as much with the spirit as with the body. In this regard it is unique. Other vocations deal just with the physical (ie grocer, shoemaker) while others deal just with the spiritual (counselors, pastors). Admittedly, the physical and spiritual are never completely separable. The two are brought together in a unique way in medicine. This causes some of the difficulty in defining the proper scope of medicine. It also mandates a greater need for compassion in medicine than in other vocations. This is the reason that many see medicine as different. One can be a doctor without compassion but it is much more difficult than being a mechanic. Medicine must be concerned about causes, precipitating or exacerbating factors, prognosis, therapies, and course; and encouragement or reassurance. It is this very issue that makes the concept of the business of medicine difficult to grasp, because we do not know what we are selling and whether we ought to be selling this.
Medicine, the current allopathic institution and the less traditional forms, is business, the vocational stewardship of some men gifted by God for this service to others. As Christian doctors, we must not lose sight of the fact that we are stewards of God's possessions and must given an accounting for our use. We can no more be frivolous than we can be tightfisted. The implications are manifold. But very simply, we may charge reasonable fees that our patients are willing to pay. We must deal directly with the patient and family, not with a third party. We must not make claims for our services that are false or misleading. We must be honest and fair in our dealings. We must give generously to those in need, as the Lord blesses us. This may take any numbered of forms, but must not be coerced or done out of guilty feelings.
Additionally, medicine is an excellent tool to be used by the church to illustrate the blessings of the covenant. Not only is the nature of medicine conducive to this in that it deals with the relationship and interface of spirit and body, but Christ himself used the physical healing to illustrate, confirm and magnify the whole person healing that He brings. The church historically seems to have recognized this. Thus good stewardship by both the doctor and the church may be for the church to provide the money and the doctor the time to run a clinic which serves the needy and poor, thereby allowing the recipient a glimpse of the largesse of Christ in His covenant community. This would not be wasted time and resources, but rather a very potent form of witness, the return being the glory of the Name of Christ.
Medicine is a business, if business is understood properly. If this seems to make medicine into an impersonal, cold, or self-seeking enterprise, then we must change our concept of business to make it conform to Scripture. Our work in medicine is to use the skills and compassion with which we are gifted by God to serve our fellow-man and glorify our Father in Heaven. Medicine is indeed a wonderful and kingdom-building business.
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