Justice and Long-Term Care: A Theological Ethical Perspective

Abstract

The relevance of justice for the current debate on long-term care is explored on the basis of demographic and economic data, especially in the U.S. and Germany. There is a justice question concerning the quality and availability of long-term care for different groups within society. Mapping the justice debate by discussing the two main opponents, John Rawls and Robert Nozick, the article identifies fundamental assumptions in both theories. An exploration of the biblical concept of the “option for the poor” and its influence on a new “ecumenical social teaching from below” leads to the conclusion that a Christian ethical account of long-term care will argue for a system that guarantees decent care to every citizen. The German model of Soziale Pflegeversicherung is presented as one possible option for putting this ethical guideline into political practice. In a final reflection, the role of religious affiliation for long-term care is discussed by looking at empirical data and by naming seven dimensions of faith-driven long-term care.

Keywords:

• biblical ethics
• long-term care
• Lutheran theology
• religious affiliation
• social justice

I. INTRODUCTION

… the health care financing and delivery system has increasingly focused upon reducing costs and providing cost-efficient care. Many hospitals have closed; those that remain in operation have downsized in order to enter into affiliations with other facilities that reduce duplication of services in a given area and achieve economics of sale. Managed care has increased emphasis on the need to provide medical services in the least intensive setting possible, including, if possible, discharge to home care.

(Kaveny, 2002, p. 177)

If one didn't know the context to which this description of the situation refers, a possible guess could include many countries of the Western world. What Cathleen Kaveny identifies as the situation of the healthcare system in the U.S. certainly also applies to the present situation in Germany, both concerning healthcare in general and long-term care in particular.

In times of scarcity, justice issues become especially important. If, due to a lack of resources, not everyone can get the optimum medical treatment or care, who, then, deserves to get what? To be sure, the actual existence of scarcity in the medical field might be doubted if one considers the immense private material wealth to be found in countries like Germany or the United States. Perhaps, therefore, the apparent scarcity problem is nothing but a problem of distribution. Still, it is hardly disputable that there is an issue of scarcity, especially in the field of time-intensive long-term care, in which not all the care time desirable can be paid. For we do indeed face the question of distributive justice: Is the amount of attention somebody gets dependent on the need that his or her condition reveals? Or does that attention depend on his or her private material resources? Or is that attention based on the insurance policy that he or she has wisely or unwisely chosen in times when things were still fine? Or is it the obligation of the state as a true “commonwealth” to provide an optimum of attention and care for all citizens, no matter how they have prepared for it?

Apparently, the future of our systems of healthcare in general and long-term care in particular cannot be politically and ethically discussed with the necessary depth unless special attention is given to the underlying concepts of justice. Considering the rootedness of our concepts of justice in religious traditions, there is good reason to expect that religious thought can make a viable contribution to this debate.

In seeking to offer such a contribution, I shall first describe the specific problems of the future of long-term care in many Western societies by including sample data from the United States and Germany. I shall then discuss different concepts of justice, as these are commonly, implicitly or explicitly, presupposed in the controversial public debate about long-term care. I shall thirdly explore the main scope of biblical concepts of justice. Next, the German public insurance model will be presented as one possible solution for an approximately just institutional design for organizing long-term care in a society. Finally, my conclusion explores the question of whether religious affiliation matters when we look at good long-term care in the future.

II. THE SITUATION

Norman Daniels, after an overview of the situation in the U.S. and abroad, concludes that the underlying demographic, economic, and technological forces that drive the U.S. discussion of healthcare and the elderly in fact operate worldwide. All countries, Daniels continues, “must openly face the moral issues underlying the explicit rationing of health care. This is true even though some systems have assured universal access and provided better long-term care than we have” (Daniels, 1996, pp. 26–27).

Both in the United States and in Germany, demographic changes generate increasing need for long-term care in the future. Between 2000 and 2040, the U.S. population is projected to grow by 20 percent. The number of people needing extensive long-term care may increase by as much as 60 percent. The group of those over eighty-five constitutes the fastest growing portion of the population, while simultaneously comprising the heaviest users of long-term care (Jecker, 1996, p. 77). Birth rates keep dropping with the consequence that there are more (and ever) older, as well as fewer young, people. The imbalance between the younger and older population “will place greater strain on families because fewer children will be available to share the emotional and financial costs of care giving” (Jecker, 1996, p. 78). In Germany, the situation seems to be even more dramatic. According to recent projections, the number of over 80-year-olds will have risen by 73 percent between 2003 and 2020 (Fröhlingsdorf, Jung, Ludwig, Neumann, & Schmidt, 2005, 91).

There are, however, also voices that warn against an overdramatization of the demographic factor for the future of long-term care. The dramatic increase of life expectancy since 1901—as Peter Jefferey has emphasized—is mainly caused by medical victories over illnesses that cause death before the age of 65. Life expectancy “is reaching its practical maximum” (Jefferey, 2001, p. 12). If this is true, catastrophic prognoses about a “flood” of elderly persons may be questioned. Moreover, since there are fewer children to be taken care of in each family, dependency rates, or the relative numbers of people dependent on care, whether they are children or elderly, are even lower than in the past.

In addition, especially the present baby boom generation in countries like Germany and the United States promises a future vast increase in personal wealth among their (scanty) progeny, which will render the financial burden imposed on the young in view of their obligation to care for the elderly much less onerous than at present. Scenarios that portray the increase of need for long-term care in the future in the rhetoric of catastrophe also overlook how beneficial the development of a considerably increased elderly service section will be for the economy and the job market as a whole.

It is undisputed, however, that there will be an increase in the need for long-term care. Projections for Germany assume numbers rising from 2.0 million now up to 3.1 million in 2030 and 3.4 million in 2040, with the rise expected to end only in 2050. ¹ In whichever way we evaluate these data, it becomes clear that not only from an ethical, but also from a soberly economic point of view, the expected increase of need for long-term care should be seen not only as a threat but also as a chance. Jefferey's suspicion that “the overstatement of the numbers of the old is being used to promote rationing” (Jefferey, 2001, p. 35) is based on good reasons. In any case, it shows that statistics not only point to questions of justice concerning future long-term care, but are often also used as an instrument to promote certain answers to such questions.

What are the possible positions concerning justice, as these often tacitly underlie the various contributions to the political debate?

III. JUSTICE

Fundamental Alternatives in the Philosophical Discussion

It has often been claimed that the word “justice” has become meaningless, since so many different groups, often directly opposed to each other, claim it for their own agenda. Nevertheless this word is too precious to be sacrificed on the altar of a pluralism that gives up all claims to truth just because there is disagreement concerning that truth. ² What justice signifies must be debated. Such debate can help clarify which parts of the disagreement derive from different assessments of facts, and which parts develop out of different fundamental value judgements. For those who argue from a Judeo-Christian background, the term “justice” can never be given up as a point of reference for ethics. The Hebrew term zedakah and the Greek term dikaiosyne are indisputably central for the biblical tradition. Even though the biblical texts primarily address the people of Israel in the Old Testament and the followers of Christ in the New Testament, the respective notions of justice are ultimately relevant for the world as a whole. In Christ, says Paul in 2 Cor 5:19, God has reconciled the world (the Greek word is kosmos) with himself—not just Christ's followers. This is why Dietrich Bonhoeffer has argued against an understanding of faith that divides reality into a religious and a secular part, and why he instead strongly emphasized the relevance of faith for all of reality:

In Christ we are offered the possibility of partaking in the reality of God and in the reality of the world, but not in the one without the other. The reality of God discloses itself only through setting me entirely into the reality of the world, and when I encounter the reality of the world it is always already sustained, accepted and reconciled in the reality of God. This is the inner meaning (mystery, German Geheimnis) of the revelation of God in the man Jesus Christ.

(Bonhoeffer, 1995, p. 193)

Theology on such a basis is a “public theology” that tries to translate biblical faith and its values into the secular realm in a way that qualifies for being a valuable part of public discourse. ³

There is some common ground in most contributions to that discourse. All theories of justice have one principle in common: “Like case should be treated alike, or, to use the language of equality, equals ought to be treated equally and unequals unequally” (Beauchamp & Walters, 1999, p. 22). Beyond this common ground there are significantly differing further developments. Six principles can be named that map the philosophical landscape of the resulting controversies:

(1) To each person an equal share. (2) To each personal according to individual need. (3) To each person according to acquisition in a free market. (4) To each person according to individual effort. (5) To each person according to societal contribution. (6) To each person according to merit.

(Beauchamp & Walters, 1999, p. 22)

The debate on justice in the last quarter of the twentieth century has been shaped by two prominent positions, which still represent the fundamental alternatives: John Rawls's and Robert Nozick's theories of justice. These two positions can be briefly summarized as follows. ⁴

In John Rawls's 2001 restatement of his theory of justice, first published in 1971, one of the basic unmodified features, especially relevant for our purpose, is the difference principle. The difference principle represents the communitarian dimension of Rawls's liberalism: ⁵ Social and economic inequalities have to be “to the greatest benefit of the least-advantaged members of society” (Rawls, 2001, pp. 42–43). Rawls argues for this principle on the basis of what he called “the original position,” which Robert Paul Wolff has described as “one of the loveliest ideas of social and political theory” (Wolff, 1977, p. 16). It has been stated many times that the methodology developed by reference to that original position rests itself on certain presuppositions. The most important of these presuppositions is the equal worth of every human being. Under the veil of ignorance, nobody knows what his or her position will be once the veil is lifted. Therefore, under the hypothetical conditions of the original position, self-interest becomes identical to genuine interest in the other, since either “self” or “other” can determine one's outcome position in the “real world.”

Misunderstanding this deeply communitarian dimension in Rawls's theory is one of the greatest theoretical deficits of its communitarian critics. ⁶ Rawls's presuppositions do not disqualify the theoretical value of his approach. Yet they have to be evaluated from an ethical point of view. As we will see, the convergence to central themes of the Christian tradition is remarkable.

In his book Anarchy, State, and Utopia, published three years after Rawls's book, Nozick presents an “entitlement theory of justice,” shaped by three principles: first, the original acquisition of holdings must be just, that is, it must have happened without the use of violence in order to entitle a person to the holding gained from it. Second, a holding is just if it is the result of a free transfer from somebody formerly entitled to that holding. Third, no one is entitled to a holding, except by (repeated) applications of the first two principles (Nozick, 1974, p. 151). It is clear that this theory is ultimately based on the priority of individual liberty. Beyond the resources that a minimal state needs (e.g. to pay for a police), all forms of redistribution by the state (e.g. to satisfy the needs of the poor) are unjust because they are based on force instead of the free transfer of goods between people. This is why Nozick can speak of “taxation of earnings from labour” as “on a par with forced labour” (Nozick, 1974, p. 169).

These thoughts imply a strong disagreement with any claim concerning property as a gift from God, as we know it from the Judeo-Christian tradition.

Things come into the world already attached to people having entitlements over them. From the point of view of the historical entitlement conception of justice in holdings, those who start afresh to complete ‘to each according to his ———’ treat objects as if they appeared from nowhere, out of nothing.

(Nozick, 1974, p. 160)

The fact that Nozick uses the biblical image of manna falling from heaven as the only case in which there was no special entitlement to any portion of it (Nozick, 1974, p. 198), a possibility which he (of course) disqualifies, shows that Nozick himself is conscious of the tension between his own view and the communitarian dimension of a faith tradition informed by the Bible. What can be said about this faith tradition?

“Option for the Poor”—The Biblical Tradition

During the last decades, the central term for describing the biblical understanding of justice has become the “preferential option for the poor.” ⁷ It is based on exegetical and theological ethical work dealing with various traditions appealed to in the Bible. These include the creation tradition with its emphasis on the equality of every human being before God, the exodus tradition with its presentation of God as the liberator from slavery and oppression, the covenantal tradition with its covenantal law and commandments especially protecting the poor and needy, the prophetic tradition with its sharp and passionate critique of injustice, the Jesus tradition with its account of Jesus' closeness to the poor and outcasts of society, and the Pauline tradition with its theological interpretation of Jesus' taking up his cross as God's emptying himself, becoming human and, by his own suffering, opening up the “view from below” (Bonhoeffer, 1972, p. 17) for all who believe in Christ (1 Corinthians 1).

The biblical option for the poor stands on firm hermeneutical ground. In contrast to the differences that exist between the Old Testament portrayal of human equality (as, for example, in the conquering stories about Israel entering Canaan, or of the role of women among the biblical patriarchs) and the teaching of Jesus, the option for the poor is a formative characteristic of biblical theology as a whole. ⁸ This strong biblical grounding of the option for the poor has been elaborated on many times and cannot be repeated here. ⁹ But it is noteworthy that this term, originally developed in the 1970s and 1980s in Latin American liberation theology, has forcefully entered the debate in the rich churches of the Western world through the U.S. Catholic Bishops' Pastoral Letter on the Economy in 1986. ¹⁰ The Catholic bishops draw on both the Old and New Testaments, referring to the teaching of Jesus:

The example of Jesus poses a number of challenges to the contemporary church. It imposes a prophetic mandate to speak for those who have no one to speak for them, to be a defender of the defenceless. Who in biblical terms are the poor. It also demands a compassionate vision that enables the church to see things from the side of the poor and powerless and to assess lifestyle, policies and social institutions in terms of their impact on the poor.

(National Conference of Catholic Bishops, 1986, Paragraph 52)

This emphasis on the option for the poor as the core of a biblical understanding of justice in 1986 was widely discussed at the time within the U.S. ¹¹ Even more important, it has made global church history. Inspired by the bishops' letter, many other church bodies of various denominations of the wealthy Western world have issued similar widely discussed statements, each relating the option for the poor to their own social and economic situation. ¹² The German ecumenical document “Für eine Zukunft in Solidarität und Gerechtigkeit” was the result of a participatory process comparable to the one in the U.S. Since its publication in 1997, it has developed into an important basis for the social teaching of the German churches. Ecumenical statements in Austria and in Switzerland followed the German document (Schweizerischer Evangelischer Kirchenbund & Schweizer Bischofskonferenz, 2001, and Ökumenischer Rat der Kirchen in Österreich, 2003). All these documents represent something that I have called a new “ecumenical social teaching from below” (Bedford-Strohm, 2004).

For our purposes it is noteworthy how the option for the poor is understood in this new ecumenical social teaching from below. Justice for the poor means distributive justice, that is, the correction of grave inequalities of wealth and income generated by the market. But justice is more than that. It is participatory justice and enabling justice. It means enabling the poor to participate in society. It means access to education. It means enabling the poor to get decent jobs and make their own living. It means distributing resources that make all this possible. Therefore, distributive justice, participatory justice and enabling justice cannot be played out against one another other. As the new policy document of the German Protestant churches “Gerechte Teilhabe” (Just Participation), published in 2006, emphasizes, they are complementary. ¹³

How does justice relate to the field of healthcare, and what consequences does an understanding of justice, oriented toward the option for the poor, have for this field?

Justice and Healthcare

There is no single system of healthcare in general, or of long-term care in particular, which can be presented as the one and only possible Christian solution. However, the defense of a libertarian system of healthcare that emphasizes the right to free choice and questions the obligation of the state to ensure decent care for everybody is hardly reconcilable with the social obligation which the Bible connects with property in many places (e.g. Dtn. 15; Lev. 25; Amos 5:21–24; Isaiah 1:10–17, 58:1–12, 61; Luke 6:24, 12, 16–21,16:19–31, 18:18–27; Mt. 25:31–46). This includes an obligation of every individual to the community as a whole. “God's claim of final ownership of all material resources” means an “equitable share of the resources which God provides for the well-being of all” (Wheeler, 1998, p. 69). Libertarians, by contrast, draw on an anthropology that defines self-interest as completely disconnected from the relational character of human life (Dabrock, 2000, 187). ¹⁴

This relational character, as it endorses the option for the poor, does not necessarily impose a complete equality of resources. As we have seen, looking at the Rawlsian “difference principle,” differences in income and resources can be justified if, for example, by encouraging incentives for productivity, these differences also work out to the benefit of the poor. But since there is a public responsibility for a life in dignity for everybody, public healthcare systems must involve at least a compromise between the use of communal resources for the provision of decent basic healthcare for all and respect for private property as securing resources for some who may be used to purchasing better care (cf. Engelhardt, 1999, p. 386).

The emphasis, however, must be on the right to decent healthcare for everybody. The communitarian proviso, as expressed in Rawls's methodological design of the original position and as one of the basic assumptions of Christian ethics, implies an obligation of the community as a whole to guarantee care for everybody who needs it. Since long-term care is to meet the needs of the most vulnerable, this communitarian obligation is especially evident in this field. ¹⁵ As Rawls himself has even noted (Rawls, 1999, 594, footnote 55, cf. Bedford-Strohm, 2005, pp. 180–183), his “difference principle” converges with the “option for the poor” developed by Catholic and now further, by ecumenical social teaching. What biblical thinking generates can thus be shown to be plausible also on philosophical grounds. ¹⁶ The German Model of Soziale Pflegeversicherung was built upon this ethical basis and might provide a model for similar efforts in the U.S.

The German Model of Soziale Pflegeversicherung

In 1994, after twenty years of discussion and planning, Germany introduced a new public insurance for long-term care based on a broad political consensus. In analogy to the already existing system of public health insurance, it made sure that every citizen has insurance that helps carry the financial burden of a long-term care situation by paying into a public system of insurance based on intergenerational solidarity. The financial burdens of today's elderly are paid by those who work now and who, in turn, can rely on the contribution of future generations for their own future long-term care. The core of this system thus consists in “delayed reciprocity.” Such delayed reciprocity naturally depends on today's payers' ability to trust the readiness of tomorrow's payers. It is clear that such a trust can only be assumed if the system as a whole can be made plausible as an expression of intergenerational justice.

How does the system work and why was it introduced? Before the introduction of the Soziale Pflegeversicherung (social long-term care insurance), everybody who did not have private insurance (i.e. most of the people) had to pay for long-term care themselves. Whoever could no longer pay had to apply for welfare. The result was a heavy burden on the towns and cities, which were responsible for this part of the German welfare system—a burden which they could not shoulder any longer, given the rising costs of long-term care. After more than ten years of its existence, it can be said that, despite needs for improvement and reform, the Soziale Pflegeversicherung has worked and has met the goal of taking the burden off local welfare carriers. It has also improved the situation of those who care for their loved ones at home. ¹⁷

The system leaves intact the possibility of opting for the alternative of private insurance. However, out of the 79 million insured, 71 million are integrated into the public insurance system (Rürup-Kommission, 2003, p. 185). The system requires a contribution of 1.7 percent of workers' income to the long-term care fund. Half of that contribution is paid by the employer and half by the employee. Since the burden on wages that resulst from Germany's “social system” was already high beforehand, the 1.7 percent was fixed so as to not excessively increase those wage costs. Yet in the meantime costs for long-term care have increased more than the general level of wages. This has led to a conflict of interest between insuring the quality of long-term care on the one side and limiting the burden of additional wage costs on the other side. The latter concern has been widely recognized as a decisive factor for reducing the high unemployment rate in Germany by rendering German labor more competitive in the world market.

Nevertheless, the Rürup-Kommission has voted against reducing the quality of care or reducing the Pflegeversicherung' s share of the costs. ¹⁸ Already the insurance currently carries only part of the financial burden. The need for care is assessed in each individual case according to three levels. At level I, 90 minutes of care a day are assumed and the insurance pays 384 [euro] a month for professional care at home, or 1023 [euro] for institutional care. At level II, at least three hours of necessary daily care are assumed and the monthly contribution of the insurance is 921 [euro] at home or 1.279 [euro] to the institution. At level III, which includes people who need care around the clock, at least five hours of active daily care are assumed. The monthly contribution of the insurance amounts to 1.432 [euro] , both for care at home and in an institution. In addition to professional care, which is partly covered by the insurance, nonprofessional care is reimbursed as well, although on a much lower level. Relatives who care for their loved ones at home get a monthly amount of 205 [euro] at level I, 410 [euro] at level II, and 665 [euro] at level III.

In its reform proposal, the Rürup-Commission described five requirements for successful and sustainable long-term care insurance. These may contain valuable inspiration for possible reform proposals in other countries like the U.S.: (1) appropriate security for the risk of long-term care for all citizens, (2) conservation of the high quality of existing long-term care, (3) no increase of additional burden on the cost of wages and salaries, (4) equal distribution of the financial burden of long-term care insurance to all generations, and (5) sustainability of the long-term care benefits in the future (Rürup-Kommission, 2003, pp. 190–191). In order to meet these requirements, the committee has proposed a mix of measures including balancing intergenerational burdens for improving the efficiency of care. The insurance rate was increased from 1.7 to 2.25 percent and financial support for home care and outpatient nursing was matched with support for care in nursing institutions (Rürup-Kommission, 2003, pp. 191–199).

There is an ongoing political debate in Germany on how to ensure the future financial viability of the Pflegeversicherung. On the one side, the liberals (Free Democratic Party) advocate a wholesale privatization, supporting the insurance by private capital exclusively. The decisive disadvantage of this proposal lies in its tendency to weaken solidarity, as well as in the unpredictability of investment markets. On the other side, the Social Democrats and the Green Party advocate integrating everybody into one single public insurance, thus including those wealthy citizens who have so far chosen private insurance. They also opt for expanding the financial basis of the insurance by including, in addition to wages, all other forms of income (such as stocks and rents) as basis for the insurance rate. The latter proposal was also advocated by the then president of the Diakonisches Werk, the social services institution of the German Protestant churches, Jürgen Gohde, in a newspaper interview two weeks before the German elections of 2005. Gohde criticized all parties in Germany for what he called a “long-term care lie,” meaning a deception of the people about the insufficient level of long-term care in Germany and its insufficient financial basis. ¹⁹

Despite the fact that the Soziale Pflegeversicherung does not cover all the costs of long-term care, there is a considerable difference to the situation in the U.S. In the U.S., more than 50 percent of long-term care is financed by the elderly and their families themselves, 40 percent by state and federal tax revenues used to fund the Medicaid program, five percent through social security taxes used for Medicare, and five percent from miscellaneous sources, including just over one percent from private long-term care insurance. Nancy Jecker confronts these numbers with the fact that, “by contrast, less than 10 percent of hospital expenditures come directly from patients, and over 90 percent are paid through private and social insurance mechanisms.” She concludes: “It is not clear what the justification is for this discrepancy” (Jecker, 1996, p. 82). Consequently she states as one possible strategy to reform long-term care in the U.S. “a more far-reaching social program involving the provision of public insurance for long-term care to all older Americans. This might be accomplished through expanding Medicare so that all people over age sixty-five are eligible for long-term care” (Jecker, 1996, p. 86).

The German model of Soziale Pflegeversicherung might be helpful in developing a long-term care insurance that all American citizens can rely on. In any case, the search for a social-political solution guaranteeing reliable and decent long-term care for everybody, no matter whether poor or wealthy, is a clear consequence of a faith-based understanding of justice oriented toward the option for the poor. However, for a Christian view of long-term care, a social-political solution is not sufficient. Long-term care, in a faith perspective, must reflect the specific quality of relationships that the biblical commandment of love implies. Thus, we have to ask: Does religious affiliation matter?

Does Religious Affiliation Matter?

There is little empirical research on the question of how the religious affiliation of nursing institutions affects the quality of care. ²⁰ In an older study, Burton Weisbrod found considerable differences between for-profit and nonprofit nursing homes, e.g. in the use of sedatives to reduce demands on nursing home staff, staff-to-patient ratio, and consumer satisfaction. He found that nonprofit institutions in general and religious nonprofits in particular were significantly more positive in all aspects (Weisbrod, 1998). In a recent study, using data from 2002, Julie Boatright Wilson looked at the 626 Pennsylvania nursing homes certified to accept Medicaid residents, comparing for-profits and nonprofits, and among the latter especially religiously affiliated ones (Wilson, 2005). Differences were not as clearly visible as in Weisbrod's earlier study. But some results are significant. Occupancy rates in nonprofit religious nursing homes are the highest among all types of nursing homes. ²¹ Religiously affiliated nursing homes have significantly more certified nurse aids' hours and more total staff hours per resident per day than do for-profit nursing homes. They also have significantly more nursing coverage and licensed nurse coverage per resident per day than do government nursing homes (Wilson, 2005, p. 235). Based on the data of government inspections, religiously affiliated nursing homes average the lowest in deficiency rates, and here the difference from for-profit institutions is quite striking. ²² To be sure, the results are much less conclusive than Weisbrod's earlier ones. One possible reason may lie in a tendency toward weaker faith identity. Still, the supposition seems warranted that the quality of care is higher than in other institutions.

One important factor here is probably the higher volunteer turnout in religiously affiliated care institutions, even though there are no data on the average number of volunteer hours provided at each type of nursing home (Wilson, 2005, p. 236). Volunteers can provide more intimate care than overworked staff. They can take their time, especially with the neediest residents. And they are a bridge between the nursing home and the broader community, thus preventing a ghetto situation.

These data, even though gained in a very limited environment, point toward additional specific strengths that religiously affiliated long-term care institutions can offer. Faith communities offer a distinctively holistic understanding of the human being. Here not only physical and psychological needs are recognized, but also spiritual needs. Good care, in a faith perspective, needs a context that also meets these spiritual needs. This context requires not only a specific religious practice to be offered in the care institution, but also a spirit of openness to the religious dimension of life, which can be felt by those who live in the institution.

I want to describe seven important commitments that can contribute to the cultivation of such a spirit. They come from a Lutheran point of view but may be shared by other faith traditions as well. ²³ (1) Every person is a unique and infinitely valuable child of God. As the idea of justification by faith alone makes clear, worthiness before God cannot be earned and does not have to be earned. The more this truth enters the hearts and souls of those who need long-term care, the more they can lead a meaningful life, even if they need increasingly more outside help. (2) This understanding of human life imposes special attention to the ethical questions of long-term care, especially around the end of life. Staff in religiously affiliated care institutions will therefore be regularly trained in dealing with these ethical questions. (3) The care people get always has an economic dimension, involving salaries, organization of services, and balanced budgets. But the main motivation for care in faith-based institutions will not be economic profit but the relationship to the other. “Becoming a Christ to the other”—as Martin Luther described Christian freedom ²⁴ —may be a rather strong description of the motivation for care. But indeed, it expresses a crucial aspect of Christian motivation for care: to give to the other from what one has been given so abundantly from God. (4) Religiously affiliated institutions, just as other institutions, need paid professionals to provide good care. However, additional volunteer work not only improves care, but also the special emphasis on volunteer work can also be a reminder of the fact that reward for care ultimately does not come from payrolls, but from the experience of being connected to God and to the neighbor. (5) Not only those who are cared for should benefit from the spirit of brotherhood and sisterhood which comes from such understanding, but also those who are employed to care. The leadership of faith-based care institutions has the responsibility to create an atmosphere of teamwork and mutual support that reflects Paul's image of the body of Christ in which one part supports the other (1 Corinthians 12). (6) To nourish the spiritual dimension of life, a regular spiritual practice is needed. Regular worship services and good pastoral care are therefore no additions to good long-term care, but crucial conditions for such care. (7) In the perspective of Christian faith, death has lost its power. The finiteness of life is something to be accepted if we know that God's relationship with us goes on. To provide the context for “good death,” that is a death in the context of faith, love, and hope, is maybe the most important mission that faith-based long-term care can undertake.

Religious affiliation does matter. The motive for keeping a strong presence of religiously affiliated institutions in the long-term care sector, however, should neither lie in the hope to prove a particular religion's special strength on the market nor in the attempt to convert people in need of care to a certain faith. For Christian faith communities the reason is much simpler. It is listening to Jesus words: “Love your neighbor as yourself.”

Notes

1. Fröhlingsdorf et al. (2005, p. 91) and Rürup-Kommission (2003, p. 189).

2. For a more thorough treatment of this form of pluralism and its alternatives, see Bedford-Strohm (1999), pp. 399–420.

3. By using the term “public theology,” I refer to a phrase that has been proposed in the U.S. especially by Ronald Thiemann, Max Stackhouse, Don Browning, and David Tracy, in Great Britain by Duncan Forrester and Will Storrar, and in Germany by Jürgen Moltmann and Wolfgang Huber. For the newest discussion on this term see Storrar & Morton (2004) and Bedford-Strohm (2007a and b)

4. For my own more thorough account, see Bedford-Strohm (1993 and 2006).

5. I have elsewhere elaborated this communitarian dimension and its reconcilability with liberalism (Bedford-Strohm, 1999, pp. 383–398).

6. I can only mention this important point here. It is further elaborated in Bedford-Strohm (1993, pp. 250–261 and 1999, pp. 383–398).

7. For the newest discussion on the option for the poor see Sedmak (2005) and Holztrattner (2005).

8. For a more thorough account of this hermeneutical grounding see Bedford-Strohm (1993), pp. 123–149.

9. See Lohfink (1987) and Neuhaus (1988). For a recent account cf. Massaro (2004).

10. National Conference of Catholic Bishops (1986).

11. For an account of this discussion see Gannon (1987). For an extensive analysis of the letter and the discussion of it, see Bedford-Strohm (1993), pp. 41–122.

12. For an overview of the statements in North America see Brown & Brown (1989).

13. Kirchenamt der EKD (2006), pp. 43f. The statement is available in English at www.ekd.de. These dimensions have also been repeatedly emphasized by the presiding bishop of the German Protestant Churches, the Lutheran Bishop of Berlin-Brandenburg Wolfgang Huber, a social ethicist who has widely published on the topic of social justice and has come to be a prominent public voice in the German discussion on the reform of the welfare state. His thoughts on this topic can be found in Huber (2005). For the three forms of justice see especially pp. 48–49.

14. Dabrock's analysis of different concepts of justice and healthcare and the role of self-reliance is currently the best account of the discussion of this problem in German theological ethics. For the German discussion see also Dabrock (2003), Körtner (2004, pp. 119–125), and Höffe (2000). For a critique of libertarian models of healthcare from the viewpoint of a Catholic theory of justice, see Lavastida (2000), pp. 131–136.

15. For a similar argument based on Rawls's theory, see Veatch (1999, pp. 368–373). For an account of the consequences of both Rawls's and Nozick's theories for healthcare, see Engelhardt (1999, pp. 384–386).

16. Differing from what Tristram Engelhardt seems to assume, faith and reason are not to be put against each other but can be critically integrated in medical ethics, see Engelhardt, 2002, p. 16, and Engelhardt (2000).

17. This is the result of the assessment by a committee of scholars, politicians, and long-term care professionals, named “Rürup-Kommission” after its chairman Prof. Bert Rürup, which was established by the German government with the assignment of developing proposals to insure the future financial solidity of the Pflegeversicherung (see Rürup-Kommission, 2003, p. 186) and which published its report in the fall of 2003.

18. Interview in Der Tagesspiegel, September 3, 2005.

19. See note 18.

20. Frank, Reis, & Wolf (1994) only look at the value orientations in welfare institutions (see especially pp. 142–165), but do not say anything on their effects on the quality of care.

21. 91.9 percent, compared to 87.7 in the nonprofit sector, 86.8 in the for-profit corporate sector, 87.6 in for-profit other, and 85.3 in government-run nursing homes (Wilson, 2005, p. 232).

22. The number of total deficiencies is 3.66 for nonprofit religious, 4.06 for the whole nonprofit sector, 4.95 for the for-profit corporate, 5.38 for the for-profit other, and 4.26 for the government sector (Wilson, 2005, p. 238).

23. For a Lutheran view on the Allocation of Medical Services in general, see Rössler (2002).

24. “For such a Father, then, who has overwhelmed me with these inestimable riches of His, why should I not freely, cheerfully, and with my whole heart, and from voluntary zeal, do all that I know will be pleasing to Him and acceptable in His sight? I will therefore give myself as a sort of Christ, to my neighbour, as Christ has given Himself to me (German: … gegen meinen Nächsten auch werden ein Christ, wie Christus mir geworden ist); and will do nothing in this life except what I see will be needful, advantageous, and wholesome for my neighbour, since by faith I abound in all good things in Christ. Thus from faith flow forth love and joy in the Lord, and from love a cheerful, willing, free spirit, disposed to serve our neighbour voluntarily, without taking any account of gratitude or ingratitude, praise or blame, gain or loss.” (Luther, 1520, paragraph 27).