POLICY ARGUMENTS IN A PUBLIC CHURCH: CATHOLIC SOCIAL ETHICS AND BIOETHICS

Transcription

1 J. BRYAN HEHIR POLICY ARGUMENTS IN A PUBLIC CHURCH: CATHOLIC SOCIAL ETHICS AND BIOETHICS ABSTRACT. This paper is an analysis of the relationship of social ethics and bioethics in Roman Catholic theology. The argument of the paper is that the character of both Catholic moral theology and ecclesiology shape the broadly defined interest of the church in bioethics. The paper examines the common elements of social ethics and bioethics in Catholic teaching, describes how ecclesiology shapes Catholic public policy and uses the examples of abortion and health care to illustrate the relationship of Catholic social thought and bioethics. In developing the relationship of these two dimensions of Catholic moral argument the article highlights how the appeal to natural law categories differs in social ethics and bioethics and how the two topics are received differently in the theological community. It also seeks to illustrate how the premises of Catholic social ethics remain central to public positions taken on bioethics. Key Words: ecclesiology, moral theology, natural law, social ethics The nature and objectives of Catholic moral theology encompass the full range of human activity, personal and social, public and private, national and international. The purpose of this article is to address two dimensions of Catholic teaching: the relationship of social ethics to bioethics and health care issues. The focus of the article is to illustrate how Catholic public policy positions on biomedical and health care issues are rooted in the character of the Catholic theological, social and ecclesiological vision. The argument will have three parts: first, an assessment of the structure of Catholic social teaching; second, an examination of how ecclesiology complements this social vision; and third, examples of biomedical and health care issues which illustrate the relationship of Catholic positions on public policy to both social ethics and ecclesiology. /. Bryan Hehir, Th.D., Joseph Kennedy Professor of Christian Ethics, Kennedy Institute of Ethics, Georgetown University, Washington, D.C , USA. The Journal of Medicine and Philosophy 17: , Kluwer Academic Publishers. Printed in the Netherlands.

2 348 /. Bryan Hehir I. SOCIAL ETHICS: ITS PLACE IN CATHOLIC MORAL THEOLOGY Both social ethics and bioethics in Catholic teaching are part of a broader moral framework. Although each has had a distinct history, there are certain characteristics which they share. Both social ethics and bioethics reflect the basic character of Catholic moral theology: the conviction that two sources of moral wisdom exist, one rooted in the revelation of the scriptures and the other rooted in human nature as understood through philosophical reflection. While religious presuppositions and themes permeate Catholic moral theology, both social ethics and bioethics have been developed primarily in terms of a natural law position. 1 The natural law ethic, as found in Catholic thought, is based upon a dyadic conception of the moral order. The natural law philosophy is rooted in a personalist conception of society, but it develops a structured view of social existence. At the center of Catholic social ethics is the human person, endowed with transcendent dignity. The theological designation of this dignity is the Imago Dei, while the philosophical statement is based on the spiritual character of human existence, expressed through the capacities for knowledge and self-determination. The dignity of the person, protected by rights and duties rooted in human nature, is the standard in light of which every social system is judged. This focus on the person pervades Catholic social ethics, but it is complemented by the conviction that personal dignity can be realized only in a social setting. The natural law ethic is personalist but not individualistic; the person is essentially a social being. The dynamism of human nature finds expression in a series of communities which are not optional but are necessary for the achievement of full human development. Much of Catholic social teaching is focused on a structural evaluation of three basic communities: the family, civil society (the nation) and the human community (international relations). In light of this basic design of an ethic which is personalist in its foundations and social in its scope, Catholic social teaching develops three themes which also set a context for biomedical issues in Catholic moral theology. The three themes are: (1) an organic conception of society; (2) a positive conception of the state; and (3) an expansive view of the relationship of law and morality. The organic conception of society is a product of the social

3 Policy Arguments in a Public Church 349 nature of the person. If persons are social by nature and not by choice, then the organic model presumes a bond of solidarity existing among all members of civil society. 2 This ontological bond is to be expressed in society through relationships shaped by justice and charity. These norms are defined in light of an order of rights and duties rooted in human nature, recognizable by reason and morally binding on members of society. The pervasive influence of the organic theory of society shapes Catholic moral teaching on the role of the state, on the role of civil of law and on the relationship of public and private morality. On all three topics there is a significant difference of perspective and emphasis in Catholic teaching from a liberal model of society rooted in the social contract. The differences have been evident in the last decade in the United States on issues as diverse as economic policy and abortion. Catholic teaching on both topics reflected its organic character, and in both instances the teaching ran counter to dominant ideas in American public opinion. An organic view of society yields a positive view of the role of state in society. A natural law conception of the role of the state involves a broader conception of public authority than a liberal or social contract view. Both society and state are understood as a complement to the person. Both are necessary for personal development, and there is not an immediate presumption of an adversarial relationship between the citizen and the state. In the natural law view of the state as found in Catholic thought, there are limits placed on the scope and nature of the power of the state. The two principal restraints (found more clearly in Catholic teaching since Pacem In Terris) are the rights of the person and the role of voluntary organizations in society. Respect for both requires a pluralist structure of power in society, lest the state overwhelm other agents. But even when these two limits on the role of the state are in place, the natural law argument endows public authority with a broad social mandate. The specific responsibility of the state is the protection and promotion of public order. Public order is part of the common good; it guarantees the goods of public peace, basic requirements of justice and public morality (Murray, 1964, pp ). These values do not exhaust the meaning of the common good, but they are the precondition in civil society to the achievement of the common good. Responsibility for the common good in all its aspects rests with civil society taken as a whole,

4 350 /. Bryan Hehir including citizens, voluntary associations and the state. The tatter's principal role is to guarantee public order and to facilitate the response of others in pursuit of the common good. Both the organic view of society and the positive conception of the state shape a natural law understanding of the relationship of moral law and civil law. At the foundation of a natural law jurisprudence is the conception of 'the higher law', the perennial need to test positive law by a conception of the moral law. The testing has two purposes: first, the civil law should reflect and be rooted in the moral law; second the two should overlap but not be identical. Incorporating large areas of the moral law in the civil law would extend the coercive power of the state into personal, familial and social life without sufficient cause. The determination of the degree to which the civil law should explicitly include prescriptions and prohibitions of the moral law is set by the requirements of public order. Unless it can be shown that a specific positive law is needed to guarantee one of the elements of public order, the presumption should be against adding legislation. If public order concerns are at stake, three further tests need to be passed by proposed legislation: will the law merit consent? is the law enforceable? will the enforcement cause more harm than achieve good? (Murray 1960, pp ). The jurisprudential view of an activist state using the civil law to protect basic moral concerns can find expression in social ethics in terms of workers' rights, preventing discrimination, and protecting vulnerable citizens like children or the elderly; in biomedical issues the law can be invoked on issues of abortion, informed consent, experimentation and care of the terminally ill. Each of the major components of a natural law ethic - its theory of society, the state, civil law - has shaped social ethics directly and bioethics indirectly in the Catholic tradition. But the dominant role which natural law has had in Catholic thought has been qualified in two ways since the Second Vatican Council ( ). First, beginning with Gaudium et Spes, and especially in the writing of John Paul n, there has been a growing tendency to use explicitly biblical and theological themes in both the social teaching and in biomedical ethics (Vatican II, 1965, in Gremillion, pp ; John Paul II, 1981, 1987). This turn to the scriptures reflects broader patterns of development in Catholic theology, and it has provoked substantial debate about the content and method

5 Polio/ Arguments in a Public Church 351 of moral theology. 3 In social ethics one example of its influence has been the call, first in the Theology of liberation, and then in the official teaching of the church, for an 'option for the poor'. While the natural law ideas sketched above recognized a particular obligation to address the needs of the poor, the option for the poor discussion has been grounded in the soil of biblical theology. In the social teaching (e.g., in On Social Concern or Economic Justice for All) the option for the poor has been woven into the more philosophical themes of rights, duties and principles of distributive justice (John Paul II, 1987, pp. 84r-86; National Conference, 1986, p. 28). But it is not clear that in addressing dvil society as a whole the meaning of 'option for the poor 7 can simply be translated into the natural law categories of the social teaching. The second qualification about the role of natural law in Catholic teaching is a more complex but by now well told story. In the post-conciliar period it has been necessary to distinguish between the reception given natural law categories in the social teaching and that given them in bioethics and sexual ethics. For the social teaching, the status of the natural law categories and the reception of the teaching in the theological and ecclesial communities has remained strong. Conclusions have certainly been disputed and some theological commentary has called for a more definitive shift to biblical categories, but the precision and social utility of natural law analysis continues to command respect. The reception has not been the same for biomedical and sexual issues in the last twenty years. Since the publication of Humanae Vitae, which was framed exclusively in natural law terms, a vigorous critique of the encyclical and other teaching depending on it has developed in the theological community (Shannon, 1988, pp ; Curran, 1988, pp ). The critique is systemic in character; it objects to several conclusions drawn on sexual and medical issues, and to the conception of 'the natural' which stands behind the reasoning of the magisterial teaching. An examination of the critique would run from Humanae Vitae through Donum Vitae and would include the arguments made against a 'physicalisf use of natural law, as well as a review of the extensive debate on 'fundamental moral norms' which has been carried on in Europe and the United States. In the social teaching natural law has conveyed a sense of an order of relationships in light of which structural and institutional evaluations could be made about law, social policy and the protection of human rights at every level of

6 352 /. Bryan Hehir society. In the sexual and biomedical teaching natural law quickly becomes a casuistry focused on specific actions, using a contested method of moral analysis. An example of how these two appeals, the social and the biomedical, are made to natural law and how they are received is found in Donum Vitae, the Instruction of the Congregation of the Doctrine of the Faith issued from the Vatican in 1987 (Congregation, 1987). The text is the most extensive Vatican statement on bioethics issued since Pius XII (d. 1958). It is a natural law assessment of recent technological developments affecting conception and birth. The Vatican document not only addresses a series of specific issues, it also is based upon a view of society permeated by natural law themes: the responsibility of society and state to respect life, the role of civil law in protecting moral values and the obligations of professional responsibility in science and medicine. In the view of Donum Vitae, society provides moral direction for biomedical issues through civil law. The case made is for an expansive conception of the role of civil law. The new technologies "require the intervention of the political authorities and of the legislator" (Congregation, 1987, p. 35). The existing civil law in many countries is judged to be "incapable of generating that morality which is in conformity with the natural exigencies of the human person" (Congregation, 1987, pp ) as these are known through natural law. In light of this picture, the Instruction urges legislators to shape a public consensus to prevent abuse of human dignity by the new medical technologies. Two comments can be made about the natural law case offered by the Vatican in both its social and biomedical dimensions. First, it is difficult to accept its expansive claims for civil law and the role of the state apart from the organic conception of society which is presumed by the text. The strong social sense which shapes this perspective affirms a close tie and causal connection between personal choices and patterns of social life. Hence the line between 'public and private' morality is not as sharply drawn (or as often invoked) as it is in a liberal conception of state and society. Specifically, issues of sexual morality are always understood in a social context. While it is understood that these are intensely personal and private in one dimension, such choices about procreation, abortion, sterilization and insemination are regarded as having profound social implications. Because of their

7 Policy Arguments in a Public Church 353 possible social consequences, the issues addressed in Donum Vitae (from IVF to AIH and AID to abortion) are presumed to be legitimate concerns of civil law and public authority. This presumption is held with such conviction in the Instruction that its call to shape civil law and public opinion is made without consideration of how difficult this task is in a pluralist society, based on a much more constrained notion of the role of civil law. Second, even if the social vision of the Instruction is accepted in its presumptions and its premises about law and authority, a different set of problems arises when the moral analysis of specific biomedical issues is made in the document. At this level of analysis the still conflicted questions of the Humanae Vitae era are resurfaced. The theological commentary from within the Catholic community shows a much greater agreement on some issues (abortion, experimentation on the embryo, surrogacy) than upon homologous artificial insemination. The moral pluralism on the biomedical issues is not between church and civil society; it begins inside the church. Donum Vitae, therefore, highlights the strengths and vulnerabilities of the intersection of Catholic teaching on social and biomedical issues. The convictions about social philosophy are both well received and badly needed in the highly technological and profoundly individualistic culture of Western societies. Relating the social vision to the casuistry supporting specific moral choices involves the double challenge of forging a new consensus within the church and articulating it in civil society. These are two unfinished tasks for the public church. II. THE STYLE OF A PUBLIC CHURCH The Catholic church's deep engagement with biomedical and health care issues is not simply the result of its social and moral teaching. It is also the product of its ecclesiology. Professor Martin Marty has coined the term "the public church" to describe a style of ministry which cuts across several ecclesial communities (Marty, 1981). This entirely accurate designation is not devalued by recognizing that Catholicism has long been described as the ideal-type of a public church. The locus classicus is the work of Ernst Troeltsch, (Troeltsch, 1960) but the validity of Troeltsch's characterization is reflected in a document as contemporary as Vatican II's Pastoral Constitution on the Church in the Modern World

8 354 /. Bryan Hehir (Gaudium et Spes) (Vatican n, 1965, in Gremillion, pp ). Troeltsch traced an historical pattern of Catholicism's relationship with society; Gaudium et Spes articulates the theological basis of that relationship, revising it to meet contemporary social conditions. Using both history and theology one can identify two basic themes within the ministry of a public church. The first is a conception of ecclesial responsibility; the second is a conviction about the possibilities of public moral discourse. Both of these themes are found in Donum Vitae. The ecclesiological premise of a public church is the conviction that its pastoral responsibility extends beyond the ecclesial community to the civil society, In light of this theological perspective, Catholic ecclesiology develops a broad conception of the church's responsibility in society. The responsibility is shaped by two principles: first, that institutions as well as individuals must be judged in light of the moral law; and second, that the long-term effect of social and cultural patterns on members of the church requires a continuing effort to harmonize the demands of personal conscience and the prevailing institutional mores of society. The goal of both principles is to avoid a situation in which citizens are regularly confronted with social policies which violate their consciences. This view of ecclesial responsibility leads directly to the issue of whether it is possible to shape a moral consensus beyond the community of faith. This question has consistently evoked, in a Catholic context, the response that a limited but significant degree of public consensus on moral questions is possible in the area of civil law and public policy. The response illustrates the traditional affinity of Catholic ecclesiology and a natural law ethic. The theological and moral arguments shape a distinctive style of ministry. It defines civil society as both an audience for its teaching and an object of its pastoral care. Its positive view of the state leads it to seek a structured collaborative relationship with the state based on clearly defined competencies and spheres of influence. Finally, it works to achieve coherence and complementarity between the civil and moral law. In pursuit of these multiple goals of ministry, the church's teaching role is framed by a double challenge: to guide choices of conscience in personal life and to shape public institutions. This twofold ministry to personal and public life in society requires different modes of discourse, one for the com-

9 Policy Arguments in a Public Church 355 munity of faith and the other to engage a more pluralistic public. This broadly defined, strategically complex understanding of ecclesial ministry is what supports the activity of a public church. Three major criticisms are lodged against such a view of ministry. They can be summarized as splitting the difference, losing the edge and imposing the faith. The first critique, splitting the difference, focuses on the fact that a church which tries to shape the culture as well as the church will always be involved (as Troeltsch understood) with compromise. For Troeltsch the idea was a positive one, involving creative adaptation to a changing social setting. For critics of compromise, its effect is the erosion of a dear religious-moral address to society. The church will be left with the continual problem of being a party to, and perhaps an exponent of, policies, laws and programs which do not conform to the fullness of its moral principles. The second critique, also arising from within the ecdesial community, builds on the first. Losing the edge is a criticism which focuses upon the church's style of teaching rather than its tactical choices. It asserts that the price of seeking to speak to the whole of civil sodety involves forfeiting the opportunity to use the richer, sharper, more demanding language and ideas of the prophets, the Sermon on the Mount and the haunting sodetal judgements found in Matthew 25. The church loses the edge of biblical imagery and inspiration, and it loses the moral appeal which the revealed word holds for the human heart and mind. The third critique originates outside the church and is quite different in its concern than the first two. Imposing the faith is the charge sometimes made against a public church in a pluralistic society. The critique is that the church does not really restrict its public objectives to those laws and polides whose validity can be demonstrated within the limits of an ethic of reason. In fact, runs the critique, there is an attempt to impose the terms and tenets of a religious vision on sodety as a whole. In the face of these recurring arguments, Roman Catholicism, from the papacy to the parish, has remained a public churdi. It has been willing to uphold the position that compromise in human affairs has its merits, that the search for dvil consensus is a valid and necessary ecclesial task, and that the churdi's case can be made at the bar of reason. While these general prindples have been sustained, it has also been necessary to adapt and shape the meaning of public ministry to different sodo-cultural settings. A

10 356 /. Bryan Hehir public ecclesial posture in Poland, Brazil, South Korea and the United States can have similar premises, but must take a different specific shape. The differences would become evident if the call of Donum Vitae to influence public opinion and civil law were tested in each of these countries. In the United States the public ministry must address three permanent realities: a secular state, a religiously pluralistic society, and a liberal philosophy of law. Each element poses its own challenge. The state is both secular in nature and limited in scope. Hence civil authority cannot legitimate its activity or extend its writ to any area of society by appeal to religiously grounded principles. The justification of the activity of the state must be made in terms accessible to all. The secular state must protect the religious liberty of all, but it cannot pass judgement on the religious truth of different communities of faith. The discourse of public policy should have a secular character, even if its inspiration and insight may lie in religious roots. Both the secularity test and the limited reach of the state would have to be addressed in responding to the call of Donum Vitae. While limitations on or prohibition of surrogacy could certainly be developed to meet these tests, Donum Vitae's positions on artificial insemination are likely to fall short. The secular state would be especially hard pressed to use as the basis for public policy the Humanae Vitae - Donum Vitae rationale for forbidding homologous artificial insemination; and the limited state has already accepted constraints on its activity affecting sexual matters within marriage through the Supreme Court's 1965 Griswold decision. The religiously pluralist society confronts the teaching of Donum Vitae with even more stringent tests. When the Vatican document urges that public opinion and law be influenced, a pertinent aspect of this task is what are the starting points for various groups in society. Since the secular state requires secular discourse as a rationale for policy, what are the possibilities for finding the formula for such ideas and language. On the social front, the civil rights struggles of the 1960s showed the possibilities of combining religious symbols and motivation (e.g., Martin Luther King's discourse) with a secular rationale (appeal to the natural rights tradition) to shape a public position. But developments in biomedical issues over the last twenty years have escaped the progress which has marked ecumenical discussions of both doctrinal issues and social ethics. Biomedical and sexual

11 Policy Arguments in a Public Church 357 issues have become increasingly intractable in the ecumenical dialogue. On most of the issues addressed in Donum Vitae, consensus on law and policy is unlikely even among the major Protestant churches and the Roman Catholic church. The secular state in the United States is shaped by the premises of a liberal philosophy of law. While such a position need not be identical with a positivist view of the civil law, a liberal state and society will not spontaneously be inclined toward the degree of coherence between the moral and civil law which Donum Vitae envisions. Nor will a liberal society easily extend the writ of civil law into the realm of personal choices about sexuality, marriage and conception as Donum Vitae believes necessary to protect the moral law. A public order argument could be shaped to meet some of the Instructions concerns, but the obstacles which are certain to be present in U.S. society are hardly envisioned in the Vatican text. The liberal, secular, pluralistic character of American society confronts the church in both its social and biomedical or health ministries. Earlier in this article the difference in the teaching style between the two aspects of Catholic thought was noted. The question to be addressed now is whether the style of public advocacy by the church differs in these two areas. In terms of a general approach to public advocacy, the church has used a similar style on both sets of issues. If the U.S. Catholic Conference, the civil agency of the bishops, can be used as a test case, one finds there a similar strategy at work on social and biomedical issues. Within a general philosophy and strategy, however, specific differences do exist in pursuing the social and biomedical issues. The first difference is an extension into the civil debate of the two uses of natural law discussed above. In both of the pastoral letters of the 1980s, the U.S. Bishops ultimately relied upon a mode of natural law discourse. Even though such a position is not well known or widely used in American academic or social policy debate, the positions of the bishops catalyzed a broad public discussion and found support beyond the boundaries of the Catholic community. The bishops' philosophical perspective often found more support than the specific policy conclusions they drew from it. On the biomedical issues, it has been very difficult to get a hearing for either the philosophical foundation or the conclusions espoused by the bishops. The reasons is partially due to in two characteristics which

12 358 /. Bryan Hehir marked the approach to economic and nuclear policy in the 1980s. First, the wide-ranging consultative process used in shaping these positions meant that the public debate was about the entire argument on a position and was not simply a response to a policy conclusion. Second, the teaching was proposed with a clear distinction made between the principles which were behind a position and the specific conclusions drawn on given issues. Readers of the texts were invited to distinguish between principles and conclusions with the latter carrying less moral authority in almost all cases. When the advocacy is about the biomedical agenda, these characteristics are less visible. The consultative process is likely to be more contentious because of the differences between much of the theological community and the magisterial positions. Hence, there is less inclination to use this method in developing a position. In addition, since the official teaching on biomedical and sexual issues often invokes the judgment of 'intrinsically evil acts', the style of ethical discourse leaves much less room for distinguishing between principles and policy conclusions. In summary, the public church style does extend in Catholicism across the social and biomedical agenda, but it admits of differences in the way natural law is used, in the degree of theological support which official teaching generates and in the way positions are formulated. III. ETHICS AND ADVOCACY: BIOMEDICAL AND HEALTH CARE ISSUES Both ecclesiology and moral theology drive the Catholic church into biomedical and health care issues. Two issues, abortion and access to health care, illustrate the way in which a public church seeks to relate bioethics and social ethics. The Catholic position on abortion dates from the first century. While it has always been a staple of Catholic moral theology, it took an entirely new significance in the United States after the 1973 Roe v. Wade decision of the Supreme Court. Since then no other institution in the country has been so consistently and visibly in opposition to the prevailing civil law and policy on abortion as the Catholic church. The opposition has manifested both the moral and ecclesiological characteristics of a public church. The U.S. abortion debate is a three-tiered question: moral, legal

13 Policy Arguments in a Public Church 359 and political. The Catholic church uses a modified natural law argument at the moral level, a classical natural law case at the jurisprudential level and a public church strategy at the political level. While it is possible to construct a pure natural law argument against abortion, the Catholic moral position has combined religious and philosophical themes. John Noonan has shown how theological ideas and liturgical symbols have been woven through the argument opposing abortion from the time of conception (Noonan, 1970, p. 3). Within the ecclesial community, appealing to the conscience of Catholics, the joining of religious and moral themes is surely appropriate; anything short of the use of all these resources would be surprising. When the legal case is made, however, both the moral and legal aspects of the jurisprudential position must be restricted to categories which are accessible to and persuasive for citizens with no allegiance to Catholicism. The case made since Roe has been a prototype of a natural law argument, appealing above the existing law to moral arguments opposing the direct killing of the innocent. Such an appeal requires a prior argument about the moral status of the fetus; the Catholic position has used a mix of philosophical and empirical themes to argue that the fetus should be accorded the legal protection provided for all individuals in society. Without entering the substance of the debate about the personhood of the fetus, my purpose here is simply to note the character of the jurisprudential case. Its appeal to the higher moral law seeks to undermine the force of a civil law. It appeals directly to the conscience of the citizenry to withhold support or cooperation from existing law and policy. The appeal to conscience - the ultimate natural law argument - involves increasing levels of complexity. At times the distinctions among the levels are not always acknowledged within the church or in civil society. The simplest and most direct appeal is to each citizen to oppose abortion personally and in the realm of public opinion. A second level involves an appeal to professionals in health care, seeking both personal opposition to abortion and conscientious refusal to aid or abet the abortion decisions of others in society. A third level addresses public officials; here the complexity is greatest and the possibility of confusion escalates. The debate often moves between a call for perfect congruence between the moral and legal dimensions of the abortion case to the position which separates the two ('personally opposed, but not publically 7 ). The first

14 360 /. Bryan Hehir proposed is infeasible and the second fails to examine intermediate steps which could be taken in the realm of law and public opinion to limit the resort to abortion. Neither the moral nor the jurisprudential levels of the abortion debate have approached a satisfactory resolution. For this reason these two levels of the issue have been swept into the political process. Faced with this fact, the church's strategy has steadfastly followed a public church approach. This public position has been taken in the face of opposing advice. Both theologians and politicians have at times urged the church to retreat from direct public advocacy and to concentrate on shaping the mind and the life of the ecclesial community. The rationale for concentrating on the church varies, but the effect is the same: forsake the struggle to change the civil law. Such a position would be very different from the ecclesial policy discussed in part two of this article. That policy refuses to confine its activity to the ecclesial community and it refuses to concede the right or possibility of shaping public institutions solely to other agencies in society. The great disparity between existing constitutional law and public policy and the Catholic position on abortion makes a focus on the ecclesial community an appealing option. The consistent refusal of the church to adopt such a strategy testifies to the depth of conviction in Catholic theology that the church must accept a public vocation. The strategy may ultimately fail, but the failure will be that of a public church, rather than a decision by a once-public church to retreat within a purely ecclesial definition of its role. A different moral and ecclesial challenge for the public church is posed by the problem of access to health care in the United States. The dimensions of the problem are well known: in 1990 the United States spent 12% of GNP ($650 billion) on health care, yet 37 million people were without health insurance and the costs of insurance are skyrocketing for individuals and employers (Catholic Health, 1991, p. 3). Both the costs of health care and the increasing needs of those who are not served by the system place the problem of access to care at the center of federal and state budgetary debates, at the door of the health care professions and in the domain of a church with a social teaching on justice and a major institutional commitment to health care. Papal social teaching does not really address the issue of access to health care. But the church in the United States has done so at

15 Polio/ Arguments in a Public Church 361 different levels. In 1981 the Catholic bishops issued a pastoral letter, Health and Health Care; in 1986 the Catholic Health Association issued its report, No Room in the Marketplace: Health Care of the Poor; and in 1990 it also issued With Justice for All? The Ethics of Health Care Rationing. From these documents, particularly the first two, one can draw the elements of the Catholic response to the macro-level of the biomedical issues. Several elements of Catholic social ethics converge to shape the position on access to health care. The foundation of the argument is the recognition of a right to health care grounded in the dignity of the person. The right is affirmed in Peace on Earth (John XXIII, 1963, in Gremillion, p. 203), and it is the basis of the pastoral letter, Health and Health Care (U.S. Catholic Conference, 1981, pp ). Neither the affirmation of the right nor its content distinguishes Catholic teaching from several other arguments. Within the context of Catholic teaching, however, the designation of a right to health opens a line of analysis which yields a systemic logic for responding to the right. A right has as its object a good deemed essential to the dignity of the person; in Catholic thought, rights language is used sparingly. Unless one can demonstrate the link between the good specified and the dignity of the person, a right is not at stake. If a right is truly present, then the next step in the argument is to define its content and to specify those in society who have the duty to respond to the right. Neither Peace on Earth nor the American documents adequately define the content of the right to health care. The logic of Catholic teaching on rights points in the direction of determining a basic level of a good which is required to protect human dignity. But the meaning of a basic minimum of health care is much less clear than the content of other rights in Catholic teaching (e.g., just wage; religious liberty; the right to form unions). In spite of this gap, however, the broader structural framework for meeting the right to health care can be set forth. The provision of an adequate level of health care to members of society is part of the common good; hence the first responsible body for the right is society as a whole. The state has an obligation to participate in this societal response but it does not have either the sole responsibility or even the principal responsibility. The Catholic argument is systemic but not statist; there must be a coordinated systematic social response to the need for health care, but it does not necessarily have to be a state sponsored program. The logic of the

16 362 /. Bryan Hehir teaching specifies two roles for the state: it must be the final guarantor that a right will be fulfilled; and it should be available to cooperate with other agencies even if they are the principal means by which the right is being met. Since Catholic teaching allocates social responsibilities in light of the principle of subsidiarity, the presumption is that other social institutions than the state have a prior responsibility for meeting health care needs. In this instance the health care professions are the primary agents with the duty to meet the health care needs of society. The responsibility flows from the role they have as a profession, a specifically social role. This framework defines societal responsibility for health care in terms of the roles and resources of multiple actors. The presumption of the model is that fulfilling the right to health care is a task for law and policy not one to be left simply to market forces alone. This sketch of a Catholic response highlights three areas where development of the teaching is needed. First, unlike other areas in social ethics (e.g., just-war teaching; religious liberty) the position on health care is a structural framework not a developed policy position. Failure to move beyond a framework will leave a church with a solid structural vision at the margins of the public debate. A second area of development needed is to relate the public policy framework on health care to the policy and practice of Catholic institutions. This need has been recognized in the bishops' pastoral letter, and the two reports of the Catholic Health Association can be seen as a response to the need. Unlike some other areas of church teaching (e.g., on defense policy) in the health care field the church is an actor whose institutions strengthen or erode its teaching by the quality of their performance. Another area of institutional development is more theoretical. Catholic teaching on subsidiarity espouses a pluralistic structure of power in society, utilizing the resource of public and private agencies. In an era of rising social problems (with health care a central one) and declining public resources, the principle of subsidiarity takes on new meaning. But there has been little attention in the church to spelling out both the theoretical meaning and strategic implications of the principle for Catholic health, educational and social service institutions. There are today both public policy and institutional reasons for a renewed assessment of subsidiarity. Third, specific attention must be given to the areas where

17 Policy Arguments in a Public Church 363 Catholic social teaching and Catholic bioethics may have conflicting objectives. The possibilities are multiple, but the hard case which could easily arise would be a major federally sponsored initiative extending access to health care which would not exclude funding for abortion. The logic of Catholic social teaching leads to support for the health care initiative but the content of the bioethical principles counsels steadfast opposition to abortion. Indeed both of these positions have already been advocated by the church in the United States. How to respond to a legislative initiative which combines the issues? Resolving the issue involves an argument about material and formal cooperation at a legislative policy level, as well as a determination of the limits and possibilities of civil law and a final consideration of what the symbolic and substantive consequences would be for the church if any "compromise" was openly supported regarding the abortion issue. More than one strategy could be constructed from these elements, but not in the closing paragraphs of an already lengthy article. The specific problem, however, simply reiterates the broader theme of the article; both social ethics and bioethics share a common foundation in Catholic teaching, but shaping a coherent public strategy for the two is a yet unfinished agenda in Roman Catholicism. NOTES 1 The natural law argument is found in the patristic authors, in Aquinas and most extensively in papal social teaching of the last century (cf., Calvez, 1961; Gremillion, 1967). 2 The organic philosophy is evident both in Catholic ecclesiology's frequent appeal to the Pauline 'body' metaphor and in its social philosophy. 3 The shift toward a more biblical - theological approach began with Vatican II's Gaudium et Spes and has been carried forward by John Paul II's On Human Work, On Social Concern and On the Hundredth Anniversary. For the theological debate surrounding a philosophical vs. a theological emphasis in moral theology (cf., Mac Namara, 1985). REFERENCES Catholic Health Association: 1986, No Room in the Marketplace, The Catholic Health Association of the United States, St. Louis, Mo. Catholic Health Association: 1991, With Justice For All? The Ethics of Healthcare

18 364 /. Bryan Hehir Rationing, The Catholic Health Association of the United States, St. Louis, Mo. Calvez, J.Y. and Perrin, J.: 1961, The Church and Social Justice, Regnery, Chicago, IL. Congregation for the Doctrine of the Faith: 1987, Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation: Replies to Certain Questions of the Day (Donum Vitae), U.S. Catholic Conference, Washington, D.C. Curran, C: 1988, Tensions in Moral Theology, University of Notre Dame Press, Notre Dame, IN. Gremillion, J. (ed.): 1976, The Gospel of Peace and Justice: Catholic Social Teaching Since Pope John, Orbis Books, Maryknoll, N.Y. John XXIII: Encyclical Letter Peace on Earth (Pacem in Terris) in Gremillion. John Paul II: 1979, 'Address to the U.N. General Assembly', Origins, 9, John Paul II: 1981, Encyclical Letter On Human Work (Laborem Exercens), U.S. Catholic Conference, Washington, D.C. John Paul II: 1987, Encyclical Letter On Social Concerns (Sollicitudo Rei Socialis), U.S. Catholic Conference, Washington, D.C. John Paul II: 1991, Encyclical Letter On The Hundredth Anniversary of Rerum Novarum (Centesimus Annus), U.S. Catholic Conference, Washington, D.C. MacNamara, V.: 1985, Faith and Ethics, Georgetown University Press, Washington, D.C. Marty, M.: 1981, The Public Church: Mainline, Evangelical, Catholic, The Crossroad Publishing Co., New York, N.Y. Murray, J.C.: 1960, We Hold These Truths: Catholic Reflections on the American Proposition, Sheed and Ward, New York, N.Y. Murray, J.C.: 1964, The Problem of Religious Freedom', Theological Studies 25, National Conference of Catholic Bishops: 1976, Documentation on Abortion and the Right to Life, vol. II, U.S. Catholic Conference Washington, D.C. National Conferene of Catholic Bishops: Economic Justice for All: Pastoral Letter on Catholic Social Teaching and the U.S. Economy, U.S. Catholic Conference, Washington, D.C. Noonan, J.T. (Ed.): 1970, The Morality of Abortion: Legal and Historical Perspectives, Harvard University Press, Cambridge, MA. Shannon, T.A. and Cahill, L.S. (Eds.): 1988, Religion and Artificial Reproduction: An Inquiry into the Vatican Instruction on Respect for Life, The Crossroad Publishing Company, New York, N.Y. Troeltsch, E.: 1960, The Social Teaching of the Christian Church, Vols. I and n, Harper and Row, New York, N.Y. U.S. Catholic Conference: 1981, Health and Health Care: A Pastoral Letter of the American Catholic Bishops, U.S. Catholic Conference, Washington, D.C. Vatican II, The Pastoral Constitution on the Church in the Modern World (Gaudium et Spes) in Gremillion.