Ronald Pies, MD

SUNY Upstate Medical University, Syracuse, New York, and Tufts University School of Medicine, Boston, Massachusetts, United States

Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.
Rev. Dr. Martin Luther King

Introduction

In this paper, I examine the question of whether healthcare is regarded as a “basic human right” in the three Abrahamic faiths: Judaism, Christianity, and Islam. Though there are significant theological differences among these three religions, each is a monotheistic faith that traces its origins to the Biblical figure of Abraham.1 Non-Abrahamic religious traditions, such as Hinduism and Buddhism, do embody values regarding the provision of healthcare; however, an exploration of these faiths is beyond the scope of the present paper.

What constitutes a “human right” is an important and controversial ethical issue. There is, in fact, little agreement on the nature and definition of these terms. Furthermore, the religious foundation of human rights differs from secular or political formulations, as developed by philosophers such as John Locke or Jean-Jacques Rousseau. Notwithstanding these complexities, we can orient ourselves to the general concept of human rights through this definition from philosopher James W. Nickel:

Human rights are international norms that help to protect all people everywhere from severe political, legal, and social abuses. Examples of human rights are the right to freedom of religion, the right to a fair trial when charged with a crime, the right not to be tortured, and the right to engage in political activity. These rights exist in morality and in law at the national and international levels.2

The Judaic-Rabbinical perspective

Rabbi Elliot Dorff, a pre-eminent authority on Jewish medical ethics, has noted that Jewish sources on distributing and paying for healthcare are “sparse.”3 In general, rabbinical texts regarding communal services usually deal with the communal-ethical duty to provide for the needy or to rescue someone from captivity. However, Dorff notes that such “moral problems and their suggested solutions are often similar to those associated with scarcity and cost in modern medical care.”3 Of special importance is the Talmudic requirement that every city fit for a Jewish scholar must have a physician available. Since every Jewish community needed a rabbi, Dorff concludes that the requirement to have a local physician “effectively makes it every Jewish community’s responsibility to provide medical services.”3

But who will pay for such services? The Jewish tradition divides responsibility among the physician, the individual, family members, and the community. The physician is permitted to charge a fee for medical services, while at the same time being admonished to ensure that the poor have access to medical care. This need was traditionally met through the physician’s personal acts of charity when faced with sick and indigent patients. However, Dorff notes one 19th-century rabbinical ruling requiring that the communal court “should force physicians to give free services to the poor if they did not do so voluntarily.”3 Arguably, one can find in this ruling the implicit assertion of a “right” to receive healthcare. Indeed, while rabbinical sources are clear that those who can afford to pay for their medical care are expected to do so, Dorff concludes that “with donations from, or taxes on, its members, the community as a whole has the duty to pay for the healthcare of those who cannot afford it themselves . . . . Even the synagogue’s needs must give way to the requirements of the indigent sick.”3

In 1993 the Commission on Social Action and Public Policy of the United Synagogue of Conservative Judaism expressed similar views:

Jewish values demand that we work to create a society where no one is denied proper medical care. We are all created b'tzelem Elohim—in the image of God—health is not a luxury, and it should not be the sole possession of a privileged few. Elderly people should not be required to impoverish themselves in order to receive medical coverage.4

The Reform tradition takes a similar stance. Thus, the Religious Action Center of Reform Judaism states:

Providing healthcare is not just an obligation for the patient and the doctor, but for society as well. It is for this reason that Maimonides, a revered Jewish scholar, listed healthcare first on his list of the ten most important communal services that a city had to offer to its residents. Almost all self-governing Jewish communities throughout history set up systems to ensure that all their citizens had access to healthcare. Doctors were required to reduce their rates for poor patients, and when that was not sufficient, communal subsidies were established.5

How would such a comprehensive insurance program be funded? There is little question that taxation for the purpose of providing healthcare services to the indigent is fully consistent with Judaic and rabbinical tradition. This was abundantly clear from a survey of rabbis from various Jewish denominations, published recently in Moment Magazine. As Reform rabbi Laura Novak Winer, put the matter:

In the Babylonian Talmud, we are taught, ‘The law of the state is law.’ . . . Taxes are also a moral duty. . . . From the Torah, we learn that we are each responsible for giving one-tenth of our earnings toward helping those in need. . . . Our taxes go toward social services, education, healthcare and other services. . . . We have a civic responsibility to pay them.6

This last point is important, since libertarian critiques of universal healthcare sometimes assume that a “right” to healthcare will inevitably devastate the economy. This would happen only if the putative right to healthcare were not carefully balanced against other recognized rights, goods, and services. No “right” need be conceived as absolute, or unfettered by practical constraints.

The Christian perspective

There is certainly a spectrum of views within the many Christian denominations, ranging from the view that healthcare reform is a betrayal of “God’s plan” to the stance that healthcare is a basic human right. The preponderance of Christian statements on healthcare tends to support the latter position, though not always explicitly.

Indeed, several teachings from the New Testament may gesture toward a personal and societal responsibility to care for the health of others, though this is not clearly propounded as a specific responsibility of government. On the other hand, governmental responsibility for healthcare is sometimes explicitly asserted, based on scriptural sources. For example, the United Methodist Church draws upon the parable of the “Good Samaritan” in its support for healthcare as a basic human right:

The provision of healthcare for all without regard to status or ability to pay is portrayed in the parable of the Good Samaritan (Luke 10:24-35) as the duty of every neighbor and thus of every person. In a conversation that began with the question of how one might obtain eternal life, Jesus asserted that one must love God and one’s neighbor. In response to the next question as to who one’s neighbor is, Jesus portrayed a Samaritan, an outsider, who coming upon a wounded traveler, provided him with healthcare. Jesus portrayed the duty to provide healthcare as 1) one that is owed regardless of the merit or ethnicity of the person in need; 2) one that is owed to the limit of one’s economic capacity—the Samaritan told the innkeeper, “Take care of him; and when I come back, I will repay you whatever more you spend” (Luke 10:35); and 3) a duty that one neglects at the peril of one’s eternal life. In a democracy, our duty to our neighbor merges with the duties that the Hebrew scriptures assign to government: the prophet Ezekiel denounced the leaders of ancient Israel whose failure of responsible government included failure to provide healthcare: “you have not strengthened the weak, you have not healed the sick, you have not bound up the injured, you have not brought back the strayed, you have not sought the lost, but with force and harshness you have ruled them” (Ezekiel 34:4, NRSV). The United Methodist Church therefore affirms . . . healthcare as a basic human right.7

Catholic views

The Catholic Church has been unequivocal in its support of healthcare as a basic human right. Cited in the National Catholic Reporter, Bishop William Murphy, chair of the US Bishops’ Committee on Domestic Justice and Human Development, writes, “Reform efforts must begin with the principle that decent healthcare is not a privilege, but a right and a requirement to protect the life and dignity of every person. . . . The bishops' conference believes healthcare reform should be truly universal and it should be genuinely affordable.8

Indeed, the teaching that healthcare is a right rather than a privilege was articulated by Pope John XXIII in his encyclical, Pacem in Terris (Peace on Earth), published in June, 1963. Recently, at an international papal conference on healthcare (November 18, 2010), Pope Benedict XVI and other Catholic church leaders affirmed that it is the “moral responsibility of nations to guarantee access to healthcare for all of their citizens, regardless of social and economic status or their ability to pay.”9

In a separate statement, Vatican Secretary of State Cardinal Tarcisio Bertone stated, “Justice requires guaranteed universal access to healthcare,” adding that minimal levels of medical care are “a fundamental human right.”8 Cardinal Bertone went on to say that “Governments are obligated, therefore, to adopt the proper legislative, administrative, and financial measures to provide such care . . . . The governments of richer nations with good healthcare available should practice more solidarity with their own disadvantaged citizens.”9

The Orthodox Church

It appears that there have been no official statements issuing from the organs of the Orthodox Church, regarding a “right” to healthcare. However, according to Orthodox Church theologian Father John Breck OCA, “[in] the statements on bioethics put out by Greek, Russian and other churches, that right seems to be assumed.”10

The Episcopal Church

The Episcopal Church, the American branch of the Anglican Communion, has generally supported the concept of universal healthcare.The 76th General Convention recently passed several healthcare–related resolutions in support of universal access to quality, affordable healthcare. Also, the members of the Bioethics Commission of the Episcopal Diocese of East Tennessee recently affirmed that the “provision of basic healthcare for all is a duty of a nation of Judaic-Christian values.”11

Protestant and Evangelical views

As a general matter, most moderate and liberal Protestant denominations support some form of “universal access” to healthcare, and strongly imply that the government has a key role to play in providing such care—notwithstanding the claim by some ultra-conservative Christian organizations that government involvement in healthcare is contrary to God’s “design” for government.

For example, the Minnesota Family Council (MFC) describes itself as “a non-partisan, grassroots, Christian organization dedicated to strengthening the family.”12 The President of MFC has argued against “government-run healthcare” and has asked, rhetorically, “Who do we trust, God or government?”13 Arguably, however, this is primarily a political, not a theological, position. In any case, the MFC position is in distinct contrast to the stated views of most mainline Protestant denominations. The United Methodist Church, in its Social Principles, regards healthcare as:

a basic human right, as well as a responsibility both public and private. As the position of the Church elaborates: “We encourage individuals to pursue a healthy lifestyle and . . . also recognize the role of governments in ensuring the each individual has access to those elements necessary to good health.”14

Within the Methodist tradition, we find general support for the provision of universal healthcare, particularly to indigent and other vulnerable populations. Thus, the Social Creed of the Christian Methodist Episcopal Church—historically a predominantly black denomination within Methodism—states as follows:

We stand for the provision of adequate medical care for all people, with special attention to the aging, the young and low-income individuals and groups. We support our government, individuals and foundations in required public health research, and we support legislation to meet these needs. We believe that adequate facilities with a professionally trained staff must be made available for the emotionally ill and the mentally retarded of every community.15

Similarly, the group Protestants for the Common Good (PCG), which describes itself as the “voice of progressive Protestant Christianity,” also promotes policies consistent with the concept of healthcare as a basic right. PCG notes:

[PCG] works, through education and advocacy, to enact public policies that assure quality and comprehensive healthcare is accessible and affordable to all people; achieve financial, administrative, and regulatory efficiencies so resources will be directed to patient care; and provide health services justly and with compassion.16

The Evangelical Lutheran Church in America—often considered the most liberal Lutheran denomination—clearly supports the general concept of a right to healthcare. One of their official social statements asserts:

healthcare as a shared endeavor entails a comprehensive and coherent set of services of good quality care throughout one’s life span. At a minimum, each person should have ready access to basic healthcare services that include preventive, acute, and chronic physical and mental healthcare at an affordable cost.17

As a rule, evangelical Protestant denominations do not explicitly articulate a “basic human right to healthcare,” but many of their official statements have increasingly pointed clearly in that direction. Thus the National Association of Evangelicals affirms that “the right of people with disabilities to adequate medical care must be safeguarded.”18

Islam

In classical Islamic medical ethics, “being a doctor is in the first place an act of charity; medicine is a gift that all must enjoy: rich and poor, sinners and virtuous alike.”19 Indeed, according to the Islamic Code of Medical Professional Ethics, “[t]he humanitarian aspect of the medical profession must never be neglected. The physician must render the needed help regardless of the financial ability . . . of the patient”20; for “health is . . . an essential condition for the preservation of life, which is why Islam has prized it so highly . . . . Islam has honored health as a fundamental right of every human being.”21 Indeed, it is worth noting that the first public hospitals arose in Islamic cultures, and “there was generally a moral imperative to treat all the ill regardless of their financial status.”22 This tradition has carried through to the present day. Thus, the Ethics Committee of the Islamic Medical Association of North America (IMANA) says simply, “Islam considers health as a basic human right.”23

In Islam, the right to health is essentially an extension of the broader concept of a “right to life.” As Dr. M. H. Al-Khayat observes, “when we talk of the right to life as a basic human right, we simply mean the right to preserve life, literally and morally. This right is not completely assured unless man is able to enjoy good health and live in a healthy environment. Both are integral parts of the right to life.”21

Dr. Al-Khayat notes that these principles have been part of the Islamic state since the time of Mohammed. In particular, zakat (alms-giving) is one of the “Five Pillars” of Islam:

Sick people had the right to medical care provided by the state. An example is the following report: ‘As he passed through Al-Jabiyah in Damascus, Umar [a companion and adviser to Mohammed] passed by a group of Christians suffering from leprosy. He ordered that they be given a portion of zakat and a food allowance . . . .’ [moreover] incapacitated, handicapped and elderly people were also entitled to state care, as outlined in the peace treaty concluded by Khalid ibn Al-Walid and the people of Al-Heerah, which states: ‘I have also agreed the following condition: Any old person who is too weak to work, or any person who falls victim to a disease, or a rich person who suffers a loss of his means so that his co-religionists would give him part of their charity shall be 1) exempt from the jizya tax [imposed on non-Muslims], and 2) provided for, with his dependents, from the Islamic state treasury as long as he lives in the Islamic state.’21

Al-Khayat concludes by stating:

It is clear from all these examples that the Islamic state considers the right to health a human right applicable to all human beings with no discrimination on the basis of color, race, or religion. Moreover, care is provided by the Islamic state from birth, ensuring that every child is breast-fed, and continues into old age, making sure that each elderly person receives an allowance ensuring healthy living. In between birth and old age, government care is available to everyone who is ill, incapacitated, handicapped, or sustaining a serious injury.

All human beings, whatever their status or affiliation, were, in the Islamic state, entitled to equal healthcare, preventive or curative. This is indeed the essence of the goal advocated fourteen centuries later by the World Health Organization, defined as 'Health for All.'21

Conclusion

In this review, I have emphasized the concept of healthcare as a basic right within the ethical framework of the three Abrahamic faiths: Judaism, Christianity, and Islam. Several secular institutions have also taken the position that healthcare is a human right, and several such declarations have emerged within the past 50 years; e.g., in 1948, the General Assembly of the United Nations adopted The Universal Declaration of Human Rights, article 25 of which states:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control.24

Of course, a broad moral assertion of this sort is not the same as a well-designed economically feasible healthcare system. Nevertheless, as early as 1978, theologian Robert L. Shelton had concluded the following:

Can we, then, speak responsibly of a right to healthcare? Yes, we can. We have a growing community of understanding that human beings do have a proper moral claim to a basic, ‘decent’ level of healthcare. This is a right, not in a strict legal sense, certainly not politically codified into the economic structure, but a condition of public policy emerging with increasing force and clarity.25

Indeed, in the final analysis, a “basic right to healthcare” is not a proposition that can be proved scientifically. Rather, the assertion of a right to healthcare amounts to a statement of moral purpose. As physician and ethicist Paul Farmer, MD, has put it, “I can't show you how, exactly, healthcare is a basic human right. But what I can argue is that no one should have to die of a disease that is treatable.”26

Acknowledgments

The author wishes to thank Cynthia M. A. Geppert, MD, PhD; Nassir Ghaemi, MD; Rabbi David Lerner; Father John Matusiak, OCA; Father John Breck, OCA; and Professor Susan Pace Hamill for their valuable teachings and/or comments on this manuscript. However, the conclusions reached herein are the author’s alone. I also wish to thank Ms. Chantelle Marshall for her assistance in preparing the manuscript.

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RONALD PIES, MD, is professor of psychiatry and lecturer on bioethics at SUNY Upstate Medical University, Syracuse, New York, and clinical professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He is the author of several textbooks, a short story collection, a collection of poems, and books on philosophy and ethics. His most recent work is Becoming a Mensch: Timeless Talmudic Ethics for Everyone.