Healthcare and the State

During the recent controversy about the plans for the National Maternity Hospital (NMH) on the St Vincent’s campus. Irish TDs and journalists  lined up to advocate State monopoly and control and to attack the record of the Religious Sisters of Charity in Irish healthcare. 

In the barrage of criticism of the Sisters and of the NMH deal, the specious arguments used have not always been fully articulated so it is perhaps useful to spell them out: abortion is good, abortion is healthcare and indeed a key element of “reproductive healthcare” and will be a central “service” in the new NMH. Or: Religious sisters don’t care about quality healthcare, or at least not about quality women’s healthcare, or certainly not about quality women’s “reproductive healthcare”. Or: State monopoly and control necessarily produce highly effective healthcare.

I am not an expert on the law and can’t offer informed comments on the new legal structures that have been set up in the St Vincent’s group but it is clear that the Religious Sisters of Charity are leaving acute hospital care in Ireland and that many ordinary Catholics are disconcerted that formerly religious-owned property will be used in the future to carry out abortions. My focus here, however, is not on the NMH deal but on wider arguments about State control and monopoly in healthcare.

Various systems of State provision and control have existed over the years. When I studied health policy many years ago, one of my textbooks presented the Soviet healthcare system as a model for the world. It was, apparently, a beacon of equality, comprehensiveness and effective healthcare delivery. The American author appeared to believe that a totalitarian political system could – mysteriously – produce a deeply impressive health service. Other sources pointed to huge problems of quality and delivery in Soviet healthcare, great contrasts between standards for the elite and the masses and major issues of unreliability of statistics in a Communist dictatorship. This is before one considers huge abortion rates from the earliest years of the USSR or the abuse of psychiatry in the ill-treatment of political prisoners.

A much more benign example of State-centred provision is the British NHS. Leaving aside deeply important questions of medical ethics, the NHS has many strengths and has enjoyed significant public support but it also suffers from historic weaknesses, for example, the political difficulty of raising taxes and thus of increasing funding in a tax-funded system. One might also mention “top-down” problems: excessive bureaucracy and constant organisational re-structuring, the amount of time available for consultations, for example, in general practice, and lengthy waiting times, for example, in Northern Ireland today. The Conservative reforms from the late 1980s aroused much debate but recognised that there was a problem of lack of responsiveness in the NHS and constituted a genuine attempt to make a highly centralised service more responsive to its users.

In my understanding, Catholic social thought highlights the important role of the State in social services but doesn’t see it as having a monopoly role. Catholic thinkers stress the importance of a plurality of social groups, including the State, with distinct rights but maintain that the State is not the sole legitimate entity in society. In contrast with liberalism, which focuses on the individual, and with socialism, which highlights the State, Catholic social thought, through the principle of subsidiarity, lays emphasis on the multiplicity of bodies that lie between the individual and the State. In a healthy society, such bodies are able to flourish and to make their distinctive contribution to society.

Pope Francis has emphasised the importance of the subsidiarity principle, which means, he suggests, respecting everyone’s autonomy and capacity to take initiative, especially that of the least. Speaking at a General Audience in September 2020 in in the context of the pandemic, he maintained that the State needed to provide the resources necessary for everyone to progress but that “intermediary bodies” with their own resources also revitalise and reinforce society.

In the NMH and other controversies, more debate on the role of the State in healthcare in Ireland would be helpful. The Italian economist, Stefano Zamagni, has argued the State has a number of potential roles in healthcare but has cautioned against an over-reliance on the State in the direct provision of services, maintaining that this may lead to poor service targeting and wasteful provision.

He has argued that the State’s intervention in social services, including healthcare, ought to have three main components: a definition of a universally available set of social services and the establishment of related quality standards; the fixing of rules of access for those services and for the redistribution necessary to ensure such access; and policies to ensure effective service allocation.  He has argued that “the greater the state’s role as manager, the lesser its capacity to regulate, and thus the lesser its capacity to ensure those objectives of equity and efficiency that are the hallmarks of any social security system”. 

The US scholar, Russell Hittinger, has argued that the capacity to make a social contribution is not just individual but also organisational – non-profit bodies, for example – have a unique and unsubstitutable “gift” to give or contribution to make, or capacity to respond to need, from which society benefits.

In a post-pandemic world, where all shoulders will need to be put to the wheel, an implication of “involving everyone” in healthcare, as Pope Francis has recommended, might be to re-discover the contribution of non-profit bodies, including faith-based providers, to healthcare. Such providers have faced many recent challenges, including the decline in vocations and resultant difficulty in managing services as in the past and the reputational damage caused by historical scandals, notably in institutional childcare. A certain era in religious non-profit provision in Irish healthcare has undoubtedly ended but this does not mean that there is no role for such bodies in future, under primarily lay leadership.

As an Irish Catholic editorial pointed out in May, the NMH debate in Ireland has been characterised by a lack of gratitude to the Religious Sisters of Charity for their enormous contribution to Irish healthcare in areas such as acute hospital services, care of the elderly and hospice care. In the nineteenth century, Catholic Emancipation opened the way for congregations of religious sisters and brothers to make their indispensable contribution to the health and welfare of the Irish population. Important research has been done recently by historians like Jacinta Prunty on the development and contribution of those congregations over time. When – hopefully soon! – we arrive at a less ideological public space in Ireland, that contribution will surely get much more recognition than it does at present.