'The place of religious and comprehensive world views in legislating, ethical decision making, and good medical practice informed by prudential resource allocation' — Remarks by Fr Frank Brennan to first year medical students at the University of Notre Dame Australia, 30 January 2018.
For some years, I gave the opening lecture to first year law students at the Australian Catholic University. I would usually make some remarks about the High Court of Australia's decision in the Mabo case. As medical students, you are not expected to have any detailed knowledge of any High Court decision. But as educated, engaged Australian citizens you will at least have seen the movie The Castle, and you will know that Mabo expresses the vibe of the Australian Constitution.
I used to invoke the Mabo decision as an example of a bold new development in Australian law. But then I realised one year that most, if not all, of the students listening to me had been born after the Mabo decision was delivered in 1992. What was a welcome new development in the law for me was an unremarkable piece of the nation's legal architecture for them. They had never thought of a world without Mabo.
On reflection, I have come to realise that my addressing you today is the equivalent of my being addressed as a first year law student in 1971 by someone who commenced their legal studies in 1924. My parents were not even born then. My grandfather who I never knew was not yet a judge. Most lawyers never even went to university back in 1924.
So I do not come amongst you to tell you what to do, what to think, or what to profess as future doctors. The world you will inhabit as doctors has not yet been invented, described or even imagined.
I know that you are likely to be less religious than your parents' generation. You are less likely to be committed to an institutional church than your grandparents' generation. Like all previous generations, many of you still have religious sensibilities, and most of you will have some comprehensive, though developing, world view which helps you to make sense of your world and to chart a coherent course for your future. Like all previous generations, each of us will have to face the mystery of suffering and death. Each of us will suffer in some way. Each of us will die. And every one of your patients will die at some stage, whether on your watch or on the watch of one of your colleagues. You are not here studying medicine by accident. You have come for a reason. Or you are acting on an informed hunch or on an abiding passion. These reasons, hunches and passions vary – but they go to make up who you are and why you are here.
You are also likely to be less trusting than your parents' generation were of tradition, authority and institutions. Australia has just emerged from a five-year royal commission investigating the failure of institutions to protect children from sexual abuse. This has been a particularly harrowing commission for the Catholic Church and those previous members of the church who were children abused by clergy and others in authority. The Catholic Church would not have been so derelict, and the consequences would not have been so dire, had other institutions like police forces and state child protection authorities been more attentive to the needs and cries of vulnerable children. Things would have been very different back then if the Church's own professional advisers (like lawyers and psychologists) had thought differently about the issues. Part the problem was that those advising the church leaders were engaged in the same thought patterns as most other members of their professions. The Church operated in a society, in a culture, in a pond of community group-think where most everyone failed to notice or to ask the right questions or to suspect possible wrongdoing. Even psychologists in the past advised that child sex offenders were deserving of a second, third or tenth chance. Even lawyers in the past advised that victims were unreliable and likely to be motivated by financial concerns.
In 30 or 40 years' time, there will be issues on which you will look back and wonder, 'How did we as the medical profession allow that to happen? Why didn't we notice?' I am not here to predict or name what THAT is. I have no idea. But I do want to urge upon you that the holding of some religious or other comprehensive world view will be an aid to your contributing to your profession's early detection systems. Phenomena like President Trump and BREXIT highlight that mistrust of traditions, authority and institutions are pervasive.
Even those of you who maintain a religious world view will find that it does not provide you with a guaranteed shortcut to the right answer on any particular controversy of the day. There is a difference between the theology which guides a religious grouping and the relevant principles which should inform law and public policy in a diverse community where the majority do not subscribe to the theology of one particular religious grouping. Last least year 62 per cent of those who expressed a view voted in favour of same sex marriage. I have no reason to think that the percentage was significantly different amongst Christians generally or even amongst Catholics. I am one Catholic priest who was prepared to say during the conduct of the survey that I would be voting 'Yes', in part because I thought that the outcome was inevitable. Full civil recognition of such relationships was an idea whose time had come. What was needed was an outcome which helped to maintain respect for freedom of religion, the standing of the Churches, and the pastoral care and concern of everyone affected by such relationships including the increasing number of children being brought up in households headed by same sex couples committed to each other and their children. I thought it appropriate that at least a handful of clergy should come out and, when asked, express their intention to vote 'yes'. Even within faith communities and amongst those with similar comprehensive world views, there must be space and time for respectful disagreement and rational engagement about how best to apply the insights from those world views to the immediate political and legal questions at hand.
Whether or not our comprehensive worldview is shaped by religious influences, it informs the development of values which the individual expresses and lives out in their own specific cultural context. From those values, one is able to articulate principles which underpin informed and considered decision making about laws, public policies and public deliberation on contested social questions.
We can practise politics, that art of compromise in the public square where laws and policies are determined in relation to the allocation of scarce resources or in relation to conflicts where there is no clear resolution either in principle or by the exercise of legitimate authority. Public policy can include the allocation of preferences by the State extended to individuals who can avail themselves of state benefits while avoiding state burdens. Laws can include the dictates of the State enforceable against individuals who fail to comply voluntarily. Any civilised society will always maintain a special care to protect the consciences of those who cannot subscribe to the prevailing state mindset on contested moral issues.
At the moment, I daresay that many of you are thinking that you will be able to get by simply by honouring the individual autonomy of your patients and by ensuring that you always act in a non-discriminatory way — at least in relation to the key characteristics of race, gender, religion, and sexual orientation. You already know that there is a lot of politics involved in the running of major health systems and hospitals and in the allocation of scarce government and private resources. Many of you will think, 'None of that is for me. I will just get on and look after my patients as best I can.' Some of you will do so with a mixture of motives, including the desire for significant, deserved material gain which might assist with the flourishing of yourselves and loved ones. Some of you will selflessly dedicate yourselves to delivering the best possible health care to a cohort of patients, including the poor, marginalised and disadvantaged who cannot afford to remunerate you satisfactorily for your services. But all of you will come to appreciate that you cannot do it on your own. You need health professionals, some of whom will be drawn from your ranks, who can assist with setting the parameters and making the decisions about resource allocation so that individual doctors might then care appropriately for their patients within the constraints of resource allocation.
This morning's Sydney Morning Herald carries a story entitled: 'Australia could be world's healthiest nation, says innovation plan'. Strangely the story links developments in health with the expansion of Australia's capacity to export military hardware. The journalists introduce their story with these two paras:
Australians could be the healthiest nation on earth, with the longest life expectancy, if the government pursues a 'national mission' that harnesses genetic and precision medicine innovations, according to a new 2030 innovation blueprint.
Innovation and Science Australia chair Bill Ferris, who will release the blueprint alongside Innovation Minister Michaelia Cash on Tuesday, has also backed the Turnbull government's ambitious new Defence Exports Strategy, which aims to catapult Australia into the top 10 of global arms exporting nations.
Daniel Callahan is known in the USA as 'the Dean of bioethics'. He helped invent the science art or discipline of bioethics. After 40 years in the field, having been the founder of the world leading Hastings Center, he published a book of essays in 2012 entitled The Roots of Bioethics: Health Progress, Technology, Death. Writing about end of life care in 2011, Callahan posed the question: 'A Philosophical or Management problem?' He answered:
Modern medicine has on offer what I call the great trade-off: if you put your life in our hands, we will (for the most part) save you from a quick death by a heart attack or infectious disease thus allowing you to contract later in life a number of chronic diseases that will allow (or force) you to die much more slowly ... With chronic disease you will most likely have a much longer life, but spend a significant portion of your old age in poor health, inexorably declining.
Is that a good bargain? Most of us seem to think so.
Callahan points out that it is a 'costly bargain, economically, socially, and for many of us, personally as well.' He quotes the usual statistics which vary somewhat from country to country and from decade to decade. But for example, 'Some 25 per cent of Medicare costs go to 6 per cent of beneficiaries in the last year of life.'
Having spent a lifetime writing and reflecting about these issues, Callahan is very matter of fact. He writes:
In sum, medicine can offer no cures for chronic diseases, only the capacity to keep us alive longer with one or more of them. It is possible to save a person's life from cancer at 65, putting them on drugs and monitoring them thereafter, to save them from heart disease at 75 (with still more drugs to keep them going), and then to draw out such a life at 85 with Alzheimer's Disease.
The Congressional Budget Office pointed out in 2008 that the 'examples of new treatments for which long term savings have been demonstrated are few' and that improvement in mortality that decreases mortality 'paradoxically increases overall spending on health care'.
As doctors here in Australia you will be part of a health system which is really three systems in one: the public system, the private for-profit system, and the private not for profit system. As I am speaking at a Catholic medical school over the road from the iconic St Vincent's campus might I boast that the Catholic health system is well placed to make its distinctive contribution with a commitment to the inherent human dignity of all persons rather than an acquired human dignity enjoyed only by those who emulate a sufficient number of characteristics of the decision makers, with a commitment to respect for that dignity throughout the life cycle from the womb to the tomb, and with a commitment to the poor, marginalised and disadvantaged, some of whom will be able to enjoy the best of medical care usually reserved only to those able to pay.
Though just commencing your medical studies, you should consider how you might make your distinctive contribution to one or other of these three systems and how you might make a real difference expanding the horizons of research or universal health cover.
When it comes to prudential resource allocation, Callahan in his 2011 essay on Rationing: Theory, Politics and Passion notes that the health system engages in three types of rationing of resources: direct and naked rationing, indirect and veiled rationing, and covert rationing. He warns that all three types of rationing are here to stay. Direct and naked rationing occurs when the public system determines that a service is not available and that those who seek it will need to buy it for themselves. Indirect and veiled rationing occurs when governments use copayments and deductibles 'particularly when they are set high enough to discourage but not to openly stop people from using expensive services'. Covert rationing is rationing by dilution, with health professionals deciding 'not to order an expensive diagnostic test, or to reduce ward staffing levels in order to be able to balance the budget'. Callahan says:
The rationing problem in the end is that we have a culture and politics that invite evasion of hard ethical dilemmas, outrage and shouting instead of deliberative democracy, and a bad case of what has been called the 'California disease' – a limit on taxation combined simultaneously with unlimited demands for evermore benefits. We want unbounded medical progress, an all-out war on death, lower taxes and no medical rationing.
Callahan is adamant that there is only one coherent ethical theory on rationing: 'only committee decisions with considerable public input ought to be acceptable'. Or to put it another way: there are no right answers to rationing; there are only right processes. Ahead of time and before any particular decision has to be made impacting on a patient, we need to be satisfied that all appropriate consultations have occurred with all sectors being able to own the outcomes. That this is fair. This is just. Mind you, notions of justice will continue to be contested.
The Nobel peace prize winner, economist and philosopher, Amatya Sen published a book The Idea of Justice. He gives the simple example of three children and a flute.
Bob is very poor and would like to have the flute because he has nothing else to play with. Carla made the flute and wants to keep it. Anne is the only one of the three children who knows how to play the flute and she plays it beautifully bringing pleasure to all who hear her.
Who has the best claim on the flute? Sen tells us that the economic egalitarian would give it to Bob. The libertarian would insist that Carla retain the fruits of her labour. Most Australians without a second thought would simply assert, 'Carla made it; it's hers; the rest should stop complaining; if they want a flute they should make their own!' The utilitarian hedonist would give it to Anne. Who would you give it to? And it is no answer to say that you would split it in three.
Being a Jesuit I cannot conclude without quoting just a little from Pope Francis. He was recently in Myanmar. He met with the Jesuits there. One of the Jesuits was an Indonesian, expert in Islamic-Christian dialogue living now in a country where there is a need for Buddhist-Christian dialogue. He asked: 'A serious problem here is fundamentalism. I come from a region where there are many tensions with Muslims. I wonder how you can take care of people who have this tendency toward fundamentalism. What do you feel about this, visiting our country?' Pope Francis answered:
Look, there are fundamentalisms everywhere. And we Catholics have 'the honour' of having fundamentalists among the baptised. I think it would be interesting if some of you who are preparing for graduation were to study the roots of fundamentalism. It is an attitude of the soul that stands as a judge of others and of those who share their religion. It is a going to the essential – a claim to be going to the essential – of religion, but to such an extent as to forget what is existential. It forgets the consequences. Fundamentalist attitudes take different forms, but they have the common background of underlining the essential so much that they deny the existential. The fundamentalist denies history, denies the person. And Christian fundamentalism denies the Incarnation.
The good doctor is the one who is humble, available, clear and compassionate, the one who embraces the mystery of suffering and death in their own lives and in the lives of their patients, and the one who goes to the essence of the medical problem for the patient, while holding respectfully the existential reality of the patient and the consequences for the community generally when deciding how best to honour the Hippocratic Oath.
I wish you well in your discerning the place of religious and comprehensive world views in contributing to lawmaking and policy setting, in ethical decision making, and in your good medical practice informed by prudential resource allocation. Please remain ever attentive to cultivating your comprehensive world view, whether it be religious or not, and always be open to respectful dialogue especially with those whose views differ from your own and from the prevailing group-think, and with those from diverse disciplines. Maintain your passion and commitment to making a difference to the lives of your patients, and every year, go and do something completely different (preferably in another country or culture) no matter how successful your practice and indispensable your professional services.
Frank Brennan SJ is the CEO of Catholic Social Services Australia.