- D. Brendan Johnson
New Frontiers in Medical Justice:
Human Fraternity, Human Rights, and Neoliberalism among Fratelli Tutti Lord, Father of our human family, you created all human beings equal in dignity: pour forth into our hearts a fraternal spirit and inspire in us a dream of renewed encounter, dialogue, justice and peace. Move us to create healthier societies and a more dignified world, a world without hunger, poverty, violence and war.
With this prayer, Pope Francis (Jorge Mario Bergoglio) ends his latest encyclical, signed at the tomb of St. Francis in the saint’s hometown of Assisi. Addressed to “all brothers and sisters” and people of good will, Fratelli Tutti weaves a beautiful vision of human fraternity; the garment of gospel love springs forth from the heart of the Christian tradition but is meant to converse with and bless all human and creaturely life. As a student of medicine and theology, I find that Fratelli Tutti has much to say about the deeply Christian vision of justice and flourishing we should be pursuing through the healing vocations, especially in reference to the lively questions of human rights and neoliberalism.
Even for all the beauty of his encyclical, Francis is no stranger to the challenges facing the human family today: he acknowledges increased division, fearmongering, the superficial discourse of the internet, inequality, greed, calloused hearts, ecological devastation, injustice, and fake news – let alone the COVID-19 pandemic which began its deadly spread during the course of his writing. Yet despite these “dark clouds,” he voices the Christian love and Franciscan openness which has undergirds his pontificate. As we begin by affirming the dignity of each human person, Let us dream, then, as a single human family, as fellow travelers sharing the same flesh, as children of the same earth which is our common home, … brothers and sisters all. (8)
After describing the important yet familiar elements of the witness of Fratelli Tutti on questions related to medical justice, I will explore two frontiers of ethical questioning which this rich document raises for the healing professions.
Christian Ethics and Humanity in Fratelli Tutti
Fratelli Tutti reaffirms a number of Christian ethical themes that are relevant to justice and medicine, including the Good Samaritan story, the unity of truth, human dignity, a commitment to the ‘least of these’, reconciliation, and peace.
Francis reflects upon the parable of the Good Samaritan at length, and readers are encouraged towards love, compassion, care for the stranger, and towards encounter with the ‘other’ – the one who is not like ‘us’, who is sick, who is the stranger, or who is even just another human being. Just like the road to Emmaus, the ‘other’ is also a site for discovering truth, for discovering God at work, and for building community – after all, we deny our deep fraternity and common destiny only to our peril.
Another traditional emphasis Francis reinforces is the deep and indispensable Christian commitment to the poor and dispossessed, those of us and those among us who are preferentially to be shown friendship, charity, and the unflinching justice and action required to rectify the indignity endured. The indignity of exclusion is a form of moral violence, and inclusion is a sign of true fraternity. Because we love peace, we must consider how “inequality and lack of integral human development make peace impossible.” As we begin to think of systems anew, this “must always be from the least of our brothers and sisters” (235). The elachistoi, the ‘least of these’ – by which we will be judged (Matthew 25:40) – must continue to occupy the center of Christian ethical politics and social action, including medical care. Because the world makes a preferential option for the rich, what Archbishop Romero has called the ‘civilization of love’ expresses the love of God through the ‘preferential option for the poor’ (cf. 187).
In relation to broader questions of justice and oppression, while Christians are those to be marked by reconciliation and forgiveness, Francis says this does not mean allowing oppression to continue.
On the contrary, true love for an oppressor means seeking ways to make him cease his oppression; it means stripping him of a power that he does not know how to use, and that diminishes his own humanity and that of others (241)
Further, Francis reiterates the longstanding Catholic prohibition against capital punishment because it denies the “inalienable dignity” of human beings, and strengthens his position against war. Here, perhaps, we are nearing the sustaining drumbeat of Fratelli Tutti: Francis’ insistence upon the fundamental dignity of the human person, a nonnegotiable element of Christian witness. The human person is stamped with the imago Dei; because God is the source and unity of all truth and love, humanity – and the indispensable web of life we are created to be a part of – is profoundly valuable. This is true for the individual as well as the community, and the index of our care for the dignity of all is seen in the hospitality and gentleness with which we treat the most vulnerable through our actions and institutions, “especially when they are poor and disabled, ‘not yet useful’ – like the unborn, or ‘no longer needed’ – like the elderly” (18). Attentive, personal, and dignified care is a cornerstone of Christian care for the sick or disabled. Christians have developed institutions and practices of care which joyfully practice care, even when cure is impossible.
Each of these emphases above, traditional for Francis and the Catholic Church, have clear connections to medical ethics – the centrality of human dignity, for example, prohibiting medical participation in capital punishment. Yet, perhaps the most novel element of Fratelli Tutti’s connection to justice in medicine comes through several perhaps surprising topics: a vision of human rights based in God-given human dignity, the threat of neoliberalism to health and flourishing, and predatory debt in the international economic system.
New Horizons and Emerging Questions
Perhaps surprising to American ears, the Bishop of Rome hardly mentions the centrality of human dignity without mentioning the sociopolitical consequences which follow: human rights. Quoting Pope John Paul II, Francis affirms human beings as the “visible image of the invisible God, [and] therefore by [their] very nature the subject of rights that no one may violate” (273). Human rights are thus a fundamental category to be considered in Christian ethics. Francis affirms the 1948 Universal Declaration of Human Rights, which affirms the human right to an adequate standard of living, including healthcare. Health(care) is a human right. Yet, his notion of rights is not simply that of persons as individualistic and self-sufficient “monads” (111). Because humans are fundamentally relational creatures, rights take on a communal dimension. Socioeconomic “development must not aim at the amassing of wealth by a few, but must ensure human rights – personal and social, economic and political, including the rights of nations and of peoples” (122). Thus while individual rights are not unlimited (111), nor do the existence of rights imply unlimited power for the state (175), human rights can and must be protected.
We are still far from a globalization of the most basic of human rights. … Hunger is criminal; food is an inalienable right. Often, as we carry on our semantic or ideological disputes, we allow our brothers and sisters to die of hunger and thirst, without shelter or access to health care. (189)
The human rights which are rooted in the Biblical dignity of humanity are affirmed to supersede the absolute national borders (121), the ‘secondary right’ of private property (120), or even individual wealth, which, if others are poor, Francis claims is essentially theft (119). Shocking as it may be to our ears, Francis’ strong notion of Christian justice and Biblical human equality is rooted in the imago Dei and love for God in Christ. Interestingly, many Protestant theologians like Stanley Hauerwas, and many secular left thinkers like Michael Hardt, do not emphasize human rights, or critique it as merely a product of philosophical modernity. Francis, however, joins with thinkers like physician-anthropologist Paul Farmer and conservative scholar Robbie George who affirm human rights as a genuine and useful category for ethics and action. Francis affirms a grounded and robust version of human rights which is not based on a limited philosophical movement, but rather on the boundless love of God and the imago Dei present even in the most dispossessed, scorned, and excluded. Furthermore, rights are not simply a ‘blank check’ to be cashed at will to one’s government, though governments certainly must uphold human rights. There is a call upon each of our lives – a duty – to build a society which honors the rights of all. With Grand Imam Ahmad Al-Tayyeb, Francis declares that “God has created all human beings equal in rights, duties and dignity, and has called them to live together as brothers and sisters” (5). The language of human rights, for Francis, is a bridge linking the rich theological reflection upon the human person with its secular and even interreligious sociopolitical consequences.
Francis’ rich and multivalent notion of human rights presses us in medicine to firmly commit to the moral call for medical care for all, acknowledging that medicine is one piece of a larger project of the movement towards what the martyred archbishop Óscar Romero called the “Civilization of Love.” Enabled by the Holy Spirit who first plants the dream, human work towards the Civilization of Love is possible. Human rights are the indispensable guardrails in pursuing God’s shalom.
Neoliberalism and Debt
A second theme related to justice in medicine is neoliberalism, which is a set of beliefs and approach to social life that Francis sees as a threat to integral well-being (168). Pastoral psychologist Bruce Rogers-Vaughn describes neoliberalism as a “global rationality that organizes all of life” along the principle of market competition: “In such a society, every individual becomes an entrepreneur” and “each person must depend on their own creativity and effort alone” in order to survive. While neoliberalism is primarily used as an economic, cultural, or political term, Pope Francis describes it in such a way to make clear its importance to justice and health. This way of thought is politically tied to a destruction of social safety programs, risk-sharing ventures, and even a loss of the idea of collective wellbeing. These are replaced by discourses of ‘personal responsibility’ and competitive individualism above all. Thus, neoliberal changes accompany decreased family stability and a decline in close relationships and local ties. More broadly, neoliberal policies include deregulation, privatization, and disinvestment in public services – all of which become commodities for purchase. All risk is unnecessarily placed upon the individual, and cooperation becomes suspect: Margaret Thatcher famously declared that “there is no such thing as society, only individual men and women.”
Pope Francis spares no ire for this idolatrous position. There are individual ‘persons,’ but no such thing as an autonomous ‘individual’: we are constituted and made human through the love of others. We are “members of one another” (Romans 12:5). We come into being through relationships and care. Thus, isolated individualism is a dangerously reductive vision of what it means to be human. Another issue is the dominance of the market as the primary form of human relationship: “The marketplace, by itself, cannot resolve every problem, however much we are asked to believe this dogma of neoliberal faith” (168). Neoliberal logic reduces the diverse bouquet of human relationships to the monochrome of competition, threat, and transactional relationships. Finally, many valuable human goods (sacraments, voting, justice, romantic relationships, bodies, family, nature, judicial decisions, etc.) quite simply should not or cannot come under market logic, even as Tinder, the global slave trade, and Citizens United vs FEC attempt to undermine this reality. Human rights, too, should not come under market logic, and thus it seems to be an extension of the Pope’s thought that healthcare provision – because we need it to survive and thrive – should not be bought and sold like a commodity.
Neoliberal policies have proven to be medically disastrous. This is especially so in the many poor countries which have received loans from financial institutions such as the World Bank or International Monetary Fund. Since the 1980s, these institutions have had ‘strings-attached’ policies which require neoliberal policy changes – for example, privatizing healthcare or cutting social service budgets in order to invest in manufacturing or trade – which accompany these loans. While these transnational loans themselves are often ethically problematic, the neoliberal policy changes they require are more so. The dominant idea is that the best way to improve health and well-being is for a nation to under-invest in social provision in order to grow the economy. Empirical research has shown this simply to be untrue; Kerala (India), Costa Rica, Sri Lanka, Vietnam, and Cuba which achieved the same mortality reductions through direct intervention in 20-30 years that indirectly took 200 years of economic growth in the United Kingdom: “income per head is unimportant relative to social policy in determining social welfare.” It is well known that the strongest determinants of health are structural and social, not personal, thus these decisions have enormous implications for health justice.
Even in wealthy countries, neoliberal austerity measures have caused reductions in health outcomes. Moreover, debtor countries become trapped under ever-increasing loan repayment burdens to the nations which often formerly colonized them. Francis joins this discussion in emphasizing how foreign debt can impinge upon individual and social rights (126). Extractive debt relationships lead to impoverishment, ultimately leading to underequipped healthcare systems. Medical organizations, popular movements, and even the World Council of Churches (WCC) have called for the cancellation of these neocolonial debts, and call us to more closely analyze the way in which these reinforce the pathogenic neoliberal order.
Thus, while philanthropic and non-profit approaches are often indispensable in emergencies, and encouraged out of a spirit of Christian charity, Francis’ message encourages the medical community to not allow these benevolent efforts to preclude the clearsighted analysis of the causes of health and disease – and the political economy with which they are intimately bound. As St. Augustine once quipped, “charity is no substitute for justice withheld.” Christians should support strong and sustainable institutions based in fundamental human rights, and Francis helps to call medicine’s attention to these concerns.
While Fratelli Tutti does not take up medicine as a major theme, its meditations on human fraternity, dignity, and solidarity opens conversation about important theological questions for justice in medicine. While rightly affirming and carrying forward the tradition of Christian attention to the vulnerable, the dignity of all humans beyond their ‘usefulness’, and the story of the Good Samaritan – with all the personal, theological, and institutional implications therein – Pope Francis pushes the conversation forward by identifying the importance of human rights and the threat of neoliberalism. These certainly do not exhaust the implications for medicine in this encyclical. Yet, by grounding human rights in the indelible and God-given dignity of humankind, Francis enables reflection about all that is necessary to survive and thrive as limited creatures. This includes the human right to health(care), thereby calling Christians in medicine to the radical reform of the political economy of healthcare and institutional practice wherever this right is not affirmed. Similarly, Francis’ reflections on neoliberalism and debt are based in a robust theological anthropology, social critique, and the acknowledgement of the spiritual and material dangers of debt. Because a neoliberal worldview enforces a diminished conception of human life and a denial of human rights, it must be resisted if we are to pursue healthcare and justice. Francis’ vision of solidarity, human rights, and human fraternity in Fratelli Tutti serves as a practical inspiration towards the just and flourishing vision medicine must orient itself towards, especially as it fulfills its call by attending to the vulnerable, poor, and ill. Let us end with Francis’ own words:
[I]f we accept the great principle that there are rights born of our inalienable human dignity, we can rise to the challenge of envisaging a new humanity. … For a real and lasting peace will only be possible on the basis of a global ethic of solidarity and cooperation (127)
Notes: 1. Francis, Fratelli Tutti (Vatican City: Vatican Press, 2020), sec. 8; hereafter, all citations from Fratelli Tutti will be denoted by the section number in parentheses.
2. For more on this point, see Gutierrez, G., and Paul Farmer, eds. Michael Griffin and Jennie Weiss Block, In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutierrez, (Maryknoll, NY: Orbis, 2013) and Hannah Murphy, “At Global Public Health Conference, Farmer Calls for Equal Care for the Vulnerable,” The Heights (blog), September 24, 2019, https://www.bcheights.com/2019/09/23/at-global-public-health-conference-farmer-calls-for-equal-care-for-vulnerable/.
3. Paul Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor, (Berkeley: University of California Press, 2003). International (secular) human rights language has strong roots in traditional Christian theology (cf. Jacques Maritain).
4. Colón-Emeric, Edgardo, Óscar Romero's Theological Vision: Liberation and the Transfiguration of the Poor, (South Bend, IN: University of Notre Dame Press, 2018), 105.
5. Rogers-Vaugh, Bruce, Caring for Souls in a Neoliberal Age, (New York: Palgrave Macmillan, 2016), 44.
6. Quoted in Rogers-Vaugh, Caring for Souls in a Neoliberal Age, 77. 7. Sam A. Okuonzi. Dying for economic growth? Evidence of a flawed economic policy in Uganda. Lancet 2004; 364: 1632–37, Salmaan Keshavjee, The Blind Spot: How Neoliberalism Infiltrated Global Health (Berkeley: University of California Press, 2014), and Rogers-Vaughn, Caring for Souls in a Neoliberal Age. 8. For an example, see Arundhati Roy’s essay The Greater Common Good, (Bombay: India Book Distributor, 1999), also easily available online. 9. Okuonzi, “Dying for Growth,” 1636. 10. For further reading on the relationship between human rights, health and development, and neoliberalism, see Audrey Chapman, Global Health, Human Rights, and the Challenge of Neoliberal Policies, (Cambridge: Cambridge UP, 2016).