March 2006
vol. 61 no. 1
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Frederic Fransen has a Ph. D. from the Committee on Social Thought at the University of Chicago, and is a member of First Mennonite Church in Indianapolis, Indiana.
Recently, I found myself sharing dinner with a diverse group of companions: three Lebanese — a Shiite, a Druze, and a Sunni — together with a Palestinian and an Israeli. The formal subject which had brought us together was the compatibility of Islam and a free society but — as such things often go — the mix of ethnic and religious backgrounds soon led to a discussion of more basic questions of who we were and where we came from. It quickly came out that I was Mennonite, and when asked what that meant, I replied, as I generally do, that Mennonites are one of the groups theologically called Anabaptists, and that we were "sort of like the Amish, but with a different dress code." This initiated a more direct discussion of Mennonite beliefs.
Starting with an MCC term working among the diplomatic communities of NATO and the European Community in Brussels from 1988-1991 and continuing in my work today in education and philanthropy, over the past two decades I have had many unexpected opportunities to describe Anabaptists and what they believe to a wide range of non-Mennonite individuals and groups.
One such opportunity came my way in June 2005, when I was invited to give a paper in Jinan, China, at an international bioethics conference. As with almost every aspect of Chinese society, health care law in China is rapidly evolving to encourage market forces to play a more prominent role in the provision of health care in China. The topic of the conference was what it would mean for China to incorporate traditional Chinese (Confucian) ethics into the process of market-based health care reform, and I was asked to explore other examples of ethical communities and the way they approach health care policy within the broader framework of a market-based society, using in particular the case of the Amish. That paper will appear in an edited volume entitled China: Bioethics, Trust, and the Challenge of the Market, edited by Julia Tao (Dordrecht: Springer, 2006).
I am interested in the challenge of writing for a Mennonite audience because the issue of health care involves two different conversations that have been popping up in Mennonite circles over the past few years: the discussion of an appropriate health care policy for Mennonites to advocate, which figured in the Charlotte 2005 Mennonite Church USA assembly; and the parallel discussion of the appropriateness of Mennonite participation in politics, which appeared as a discussion forum in the June 2005 Mennonite Life, and elsewhere. I hope in this article to try to connect these two conversations.
In my view, what distinguishes Anabaptism from a host of other Christian theologies is our interpretation of the Two Kingdoms, and in particular — to adopt John Roth's language — the Non-Resistant Separatist view of the world exemplified in the "paradox" of the Schleitheim Confession. Traditional Two Kingdoms Theology, however, has been steadily evolving — one might say eroding — among Mennonites and it is not clear to me that the core of the traditional Anabaptist Two Kingdoms Theology will survive another generation. Moreover, not surprisingly, as Mennonites jump into the Kingdom of the World as citizens fully engaged in the world of politics, they are discovering that they are landing on different parts of the political spectrum. Now that political ideas have become an important part of Mennonites' moral and ethical identity, they are realizing that the label "Mennonite" no longer reliably predicts one's views on particular issues. As a consequence, knowing whether someone voted for Bush or Kerry is a much more reliable predictor of his or her view on legalized abortion, the Iraq War, Social Security reform, or the display of Christian symbols in the public square than is knowing whether he or she is Mennonite.If we value our roots in Anabaptist theological principles, however, it will be necessary to revitalize (and perhaps modernize) the Two Kingdoms view, and the Non-Resistant Separatist approach to living "in the world, but not of the world" which it implies. To do so will require reflection on how to incorporate such an approach into responses to a wide range of issues affecting us today, including health care. Therefore, although I believe strongly in the details of what I propose, even more important, I hope, is the spirit of the exercise. While it may turn out to be impossible to create a Non-Resistant Separatist ethic that is both meaningful for Mennonites today and provides a way of reconciling political differences within the Church, it would be a mistake, I believe, to allow the Church to continue to split along political lines without first attempting to do so.
The core document establishing Anabaptist principles on the relation between Christians and the State is the Schleitheim Confession. The fourth article is very clear on the extent of separateness:
A separation must be made from the evil and from the wickedness which the devil planted in the world; . . . it is not possible for anything to grow or issue from them except abominable things. . . . From this we should learn that everything which is not united with our God and Christ cannot be other than an abomination which we should shun and flee from. By this is meant . . . [inter alia] civic affairs.
What complicates this position, which seems to condemn the state, is the sixth article, on the sword:
The sword is ordained of God outside the perfection of Christ. It punishes and puts to death the wicked, and guards and protects the good. In the Law the sword was ordained for the punishment of the wicked and for their death, and the same [sword] is [now] ordained to be used by the worldly magistrates.
Two points stand out: first, Anabaptism is extremely skeptical of the ability of those outside God's grace to pursue the good: "it is not possible for anything to grow or issue from them except abominable things" (emphasis added). Second, the State is ordained of God to mete out justice, using God-approved means not available to Christians in their resolution of disputes: "[The state] punishes and puts to death the wicked, and guards and protects the good" (emphasis added).
The paradox, therefore, is that Anabaptists are called by the Schleitheim Confession to live in a way distinct from others, and by other rules. This works both ways. Just as we are prohibited from taking up the sword, magistrates are obligated to do so. This position, applied to the area of security studies, is sometimes referred to as "vocational pacifism." I would like to extend this idea of vocational pacifism to the area of health care policy, and in particular to the idea of third-party payer financing of health care through national or other compulsory insurance proposals.
It is probably no accident that in the seven articles of the Schleitheim Confession the articles on relations of Anabaptists to society and the state do not appear at the beginning of the list. The first article, on baptism, is the crucial one, and the cornerstone of Anabaptist beliefs. Baptism is only to be given to "those who have learned repentance and amendment of life, and who believe truly that their sins are taken away by Christ, and to all those who walk in the resurrection of Jesus Christ" and who "demand [baptism] for themselves." In other words, baptism is reserved for adult believers alone, those who "demand" it. Membership in the moral and religious community of Anabaptists, therefore, is a matter of choice. In North America today we take religious freedom and freedom of conscience for granted, but in 1527 this was revolutionary, precisely because in demanding that membership in the Church be a free decision of adults, the Schleitheim Confession implicitly lays the groundwork for a pluralistic society based upon radically different value systems. Proposing to carve out separate communities on the basis of consent and choice, however, was too radical for rulers at the time to accept. Almost everywhere Anabaptism sprang up, it was viciously suppressed by both Papists and Protestants, to the extent that, to the best of my ability to count, more than twice as many Anabaptists were executed in the Netherlands as other heretics in the much more famous Inquisition in Spain.
Even after the end of the Inquisition, for most of post-Reformation history political leaders and the leaders of established churches reacted with extreme skepticism or outright violence to individuals and groups (both religious and otherwise), who wanted voluntarily to live what they believed to be ethically higher lives. Mennonites have sometimes been caught up in this, such as when their conscientious objector status has been given, and then taken away, leading them to move from place to place.
The basis upon which states — and the dominant ideologies that support them — have tried to justify the suppression of minority moral and ethical communities has been their confidence in the legitimacy of their own viewpoint, including, as noted above, the liberal one. Until the Reformation, they grounded that legitimacy in the authority of the Church. Starting in the seventeenth and eighteenth centuries, theorists believed that reason would provide the tools to grant legitimacy to "reasonable" views of morals and ethics. Developments in the past century, and particularly in the past thirty years or so, have begun to undermine that confidence. Post-modern ethics, which emerged in the 1970s, claims that no system of values, including liberal ones, can be justified through reasoned argument (as opposed to imposed with violence) without becoming self-referential and circular. In other words, believing in one value system over another requires agreement on what is to be valued. One cannot assume such agreement without prior agreement on which values to value, and so on, in infinite regress. Appeals to revelation, the Bible, or any other religious or secular authority do not get around this problem: one must first agree that the Bible is authoritative before one can refer to it as an authority. One needs a reason to accept Reason as a legitimating authority. The tragic conclusion of this line of thought is that the necessary attitude for peaceably agreeing to an ethical system can only be reached through non-rational means, such as through conversion (whether secular or religious). Barring the mass conversion of the whole world to one ethical system, therefore, we are left with the sad conclusion that we must accept a radically pluralistic world. Philosopher and physician H. Tristram Engelhardt, Jr., has articulated and applied these ideas in the area of bioethics in Foundations of Bioethics (2nd Ed.) and drawn out its conclusions for orthodox Christians in Foundations of Christian Bioethics. (1)
In such an ethically pluralistic world, as Engelhardt points out, we are left with two choices. Either we so water down our ethical commitments as to accept everything that does not harm someone else (euthanasia, sex change operations, etc) or we allow ethical communities to form irrational, but voluntary communities, defining distinct rules for themselves, rules which only apply to members.
Such a world of thick, voluntary moral communities was described by Robert Nozick in his famous 1974 book, Anarchy, State, and Utopia. (2) Nozick realized, of course, that the members of such communities would have to interact. Therefore, a thin institutional "framework" society would need to be created to mediate such interactions. Interactions within a particular community would be governed by the rules of that community; the primary role of the state would be to insure that interactions between members of different communities were consensual. Although members of different groups might be bound to different ethical principles in those exchanges, by making consent a prerequisite for the legitimacy of a transaction in the "framework society," it should be possible nevertheless to allow a multitude of successful interactions wherever ethical conflicts do not occur (for instance, I could confidently buy bandages from a pharmacy without concern for the view of the pharmacist on abortion, the existence of God, or Bush's Iraq policy; but I would rightly worry about the effectiveness of a birth control device sold by a Vatican-run store offering "Papally approved family planning devices").
What is most interesting about this way of organizing society for Anabaptists is that it describes, almost perfectly, their own relation to the outside world. For centuries Mennonites lived in communities often both physically and legally separate from the outside world. Old Order Mennonites and the Amish still do so today, and Mennonite church members did as well, until about two generations ago.
The main institution which provides for such voluntary exchanges, including among people with different ethical commitments, is the market. A market is nothing more than a physical or virtual place in which two owners of things can exchange them if they would prefer what the other owner has. A market is nothing more, nothing less. For markets to exist, they require many things, but the most important are property rights (which guarantee that what I possess is really mine to exchange) and the rule of law (which guarantees that the exchange is consensual).
Markets are important because they provide a venue for people to act according to their conscience, but they are also important because they provide some important positive benefits to society as a whole, through their function as a mechanism for communicating information. That information comes in the form of prices.
Because most owners do not regularly encounter others with exactly what they want (and when they want it) human society developed money. This allows people to exchange money for goods, rather than having to use other goods. Instead, we can simply agree on a price in money. In this sense, prices facilitate exchange. But they also do something more, and this is extremely important for complex societies: prices convey knowledge about what is valuable and not valuable (according to whatever scale of value or ethical system a person holds) and also information about scarcity. When a good becomes scarce, the price rises. When it is abundant, it goes down. This sends a signal to all users, but especially those at the margin, that they should change their consumption patterns, preserving the good for those who need it most, as indicated by their willingness to pay a higher price.
Before going on to how all this relates to Anabaptist health care ethics, one final thought on the notion of value. Value can have two senses. Something might be of value on my own absolute scale of values: for an Anabaptist this might mean something like: discipleship is more valuable than my life, and my life is more valuable than my right to a jury trial. But it might also mean value relative to other things I might buy: HDTV is more valuable than dinners in restaurants; dinners are more valuable than Lasik eye surgery.
Markets and prices have little or no role in resolving the former kind of value judgments, but they matter greatly for the latter kind, because producers, in allocating scarce resources to fulfill demand for such items, need not only an accurate assessment of each individual's ordering of value, but also need to know his or her assessment of where on the scale a particular item might fall. For instance, how much more valuable dinners in restaurants are than Lasik surgery might depend on how many dinners I must forego to pay for the surgery. If the price of the surgery is one dinner, I might forgo that dinner. If it is dinners for a decade, I would likely decide not to have the surgery.
The information about what is of more value in such cases is highly personal, subjective, and capricious. For this reason, it is not only practically, but also theoretically impossible to aggregate such judgments into accurate conclusions upon which a public policy on the proper price of Lasik surgery or dinner in a restaurant might be decided. I have been told that communist planners in the Soviet Union had agents acquire copies of the Sears catalog, so that they would have the relative prices Sears charged to use as a starting point in setting their own prices within their command economy! Our wants and needs are simply too diverse and changing to be captured through rational processes, no matter how good the data are. Through prices, however, the market does so effortlessly, through information about changes in scarcity transmitted in the form of changes in prices.
The accuracy of this information, however, depends on one more very important condition: Each purchaser must be responsible for the consequences of the decisions his or her purchases carry with them. Anyone who has played poker knows what I mean. The game is radically different depending on whether one plays for real money, or simply for chips. Without responsibility for one's decision-making, one cannot inform the market about the relative value of one's choices, because if one is spending someone else's money, purchasing decisions are not made relative to some hierarchy of values, but rather in the abstract. Almost everything is worth "buying" if one does not have to pay for it.
How is the role of knowledge in society relevant to Mennonite debates about health care policy? Mennonite position papers on health care access advocate extension of health insurance coverage to all Americans. There are two problems with this:
The first problem is that any system of third party payers takes economic decision-making about health care away from the people with the information to know what makes the most sense in any particular case, the providers and the customers — that is, doctors, hospitals, and their patients — and puts it in the hands of third parties, that is insurance companies. When government regulators also get involved, requiring that companies cover all sorts of things that many patients would never desire, thus raising their costs. If you are the administrator of a health insurance system, whether government or private, there is no alternative to basing decisions on general principles and using aggregate data to formulate policy, because this is the only data available for collective decision-making. An administrator cannot tabulate all the information about each and every individual's needs — including health care needs — much less take either their needs or their values into account when setting policy. As pointed out above, the knowledge necessary to make such decisions is necessarily local and contextual. This should make us highly skeptical of any third-party payer system of health care financing.
Although this is probably not what Schleitheim had first in mind when it declared that, "it is not possible for anything to grow or issue from them except abominable things," it is perfectly consistent with the sentiment behind that statement. One of the reasons Schleitheim rejects the ability of people outside God's Grace to do good is because without Grace, people cannot know enough about what any good is to pursue it. On the account of Schleitheim, such knowledge is only available to those within the Church. That is not to say that the state has no function to perform — it is, after all, ordained to provide order — but, perhaps because it performs such functions through the use or threat of violence (including the compulsory collection of taxes), even an orderly state might be described as necessary, but not as "good." What is good, returning to the first article of Schleitheim, is necessarily founded upon choice, and the values chosen by (or, from a Christian point of view, revealed to) a given voluntary community.
So what do the Amish have to do with any of this? The second problem of third-party payer systems is that they take responsibility for health and health care away from moral and ethical communities, where Anabaptist principles would suggest it belongs, and places them into morally "neutral" hands. The Amish have resisted this across the board, and were the United States ever to move to a compulsory single payer health insurance system, I have no doubt the Amish would refuse to participate, on theological grounds.
Although I am no expert on the Amish, I believe that they are exemplary in continuing to live out the core principles of the Schleitheim Confession, including their application to health care policy. In describing them as exemplary, I do not intend to advocate giving up electricity or modern transportation, but rather to encourage us to consider ways in which we might bring our own practice as Mennonites into closer conformity with the principles of Schleitheim. First, assuming that few readers know much about the details of Amish practices with regard to health care, let me offer a sketch of the principles of Amish health care policy as I understand them.The Amish exhibit a great deal of personal and communal responsibility over issues of health care for their community. Most births occur at home or in Amish birthing centers, with many deliveries conducted by midwives. They avoid buying health insurance, but rather pay out of pocket when they need to use outside medical facilities or see doctors. With regard to various health care protocols, they generally accept the principles of modern medicine, but are reluctant to accept radical measures to prolong life, preferring to let nature run its course and to die at home in the care of their family. With regard to health care innovation, the Amish apply a kind of precautionary principle. That is, rather than allowing a new technique or procedure to be used without question, they examine it to see whether it is in keeping with their moral values. If they are persuaded that it is, then they will adopt it. Thus, although they were initially skeptical about the value of many immunizations, they have been persuaded that it is important for public health to do so, and now generally receive vaccinations. It is noteworthy that in persuading the Amish to be immunized, it was important to argue that it would be harmful to others for them not to be vaccinated, and it was in keeping with their desire to be helpful to strangers, rather than out of concern for their own safety, that compelled them to accept immunization programs. For the same reason, the Amish donate organs above the rate of the general population, and frequently allow tissue samples to be taken for genetic studies, something for which their close-knit communities make them especially well suited. Mentally ill members are integrated into the work of the community if possible, and often cared for at home, although the Amish have also begun to establish their own facilities to care for the severely mentally ill. For our purposes, what is most relevant is the Amish refusal to participate in insurance schemes. In their successful appeal to be exempted from Social Security, a group of Amish bishops wrote the following:
We feel the Social Security Act and Old Age Survivors Insurance [OASI] is abridging and infringing to our religious freedom. We believe in giving alms in the church according to Christ's teaching.
It has been our Christian concern from the birth of our church group to supply those of our group who have a need, financial or otherwise. . . . Our faith has always been sufficient to meet the needs as they come about, and we feel the present OASI is an infringement on our responsibilities.
Two points are relevant. First, the Amish differentiate anonymous insurance from mutual aid within the community. Thus, there is no sense in which they expect individuals simply to look out for themselves. Second, they view forced participation in national insurance plans as a threat to their religious beliefs, by undermining their responsibilities within their community. In addition, there is evidence that Amish insistence on out-of-pocket, fee-for-service health care has kept their outlays lower than that of the population at large — sometimes significantly lower, as in the case of maternity services — not only because they economize on usage, but also because, to a certain extent, they have been able to work around the existing, Byzantine price structure created by our Byzantine third party payer system.
What relevance does this have for Mennonites, and what policies might Mennonites advocate that would allow them to develop a health care policy in keeping with Anabaptist principles?
The first point is probably the hardest one for Mennonite proponents of universal health care to swallow. The Schleitheim Confession, the core document for Anabaptist principles on the relation to the state, provides no basis upon which to argue that Anabaptists should be advocates in favor of one or another policy to be conducted by the state. By contrast, it argues strongly that nothing can be gained through Anabaptists mixing themselves in the details of public policy. In other words, it encourages us to be agnostic on public policy. Anabaptists are not Quakers, who have a strong theological calling to "speak truth to power," who do not share the same Two Kingdoms theology, and who can derive political positions from their anthropology (there is "that of God in every Man").
Instead, we should limit ourselves, as do the Amish, to petitioning the government for the non-interference of the state in the development of our own system of mutual aid in health care for our members.
Second, for this same reason, we should take seriously the Amish admonition against traditional insurance, moving toward a system of mutual aid. If all Mennonites participated, this could easily be done without having to exclude anyone. Sid Richard, actuary for Mennonite Mutual Aid (MMA), indicated that 75% is generally thought to be the minimum participation required to avoid underwriting for traditional group insurance policies for a large group of participants. The proposals described below might allow that number to be even lower.
What might such a system entail, and what role would Mennonite organizations such as MMA or MCC's Washington Offices play in developing it?
The Mennonite Church would propose a new "Anabaptist Health Care Initiative" which would include the following elements:
For advocates of universal national health insurance, the response will surely be, "OK, so you've described a system of universal coverage for Mennonites, but what about everybody else?"
First, I would point out that even if the tax laws were changed (even just for Mennonites), as difficult as dealing with the financial side of the issue within the Church would be, it would pale beside other considerations: should a mutual aid fund pay for a liver transplant in an elderly Mennonite alcoholic? How much cosmetic reconstructive surgery should be included in the major medical coverage? How should such issues be decided? What about members who prefer not to participate, and therefore refuse on principle not to contribute (rather than those who do not have the resources to do so)? The difficulties in reaching Church-wide consensus or even near consensus in dealing with these matters only point out the reason why a national one-size-fits-all program cannot satisfy everyone. But asking them and dealing with them is an important part of the responsibility of the Church as a moral and ethical community.
More importantly, to return to the Schleitheim Confession, whatever changes we advocate for dealing with the problem of access to health care by the poor, the solution is not to advocate using the weapons of government to take money from some people to pay for the health care of others. Doing "good" with resources collected at the point of a (tax collector's) gun is not, and cannot be "good."
If Mennonites were successful in separating insurance from employment, we might encourage others to adopt similar programs, such that Lutherans, Catholics, Muslims, and other moral communities would create their own ways of covering their own members. In addition, some percentage of those without insurance does choose not to have it, rather than is unable to get it. The real concern is for those who cannot afford their health care, rather than for those without insurance. Toward these neighbors, of course, we do have obligations.
An Anabaptist response to the problems of these poor must, however, be based upon voluntary action. It may be, for instance, that savings generated by universal Mennonite MSAs and a mutual aid system could be put into a fund for extending aid to non-Mennonites in need of health care, rather than returned to members. For instance, we might ask members to contribute to such a benevolence fund at a level equal to the increased tax burden of extending the current insurance system to all Americans. This would allow new Mennonite initiatives for extending health care to the poor in this country. Such charitable action would not rely upon the use of force by the state to extend our values, but rather would be in keeping with the core principles of our theology, and begin the process of reinvigorating the Anabaptist Two Kingdoms theology for the contemporary world.
1. H. Tristram Engelhardt, Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996); The Foundations of Christian Bioethics (Lisse, Netherlands; Exton, PA: Swets and Zeitlinger, 2000).
2. Robert Nozick, Anarchy, State, and Utopia (New York: Basic Books, 1974).