The Changing Face of Health Care, and Patient-Caregiver Relationships, edited by John F. Kilner, Robert D. Orr and Judith Allen Shelly

Edited by John F. Kilner, Robert D. Orr and Judith Allen Shelly, The Changing Face of Health Care, and Patient-Caregiver Relationships. (Eerdmans, 314 pp.)

The ways in which American health care is delivered and financed are changing dramatically. These changes have important ramifications for Christian administrators of health care facilities and for physicians and nurses who see connections between their professions and their faith. How can they remain faithful to both their Christian identity and their identity as healers?

People with a variety of responsibilities within health care contribute to this collection of essays. The volume proposes no single answer to the questions and dilemmas we face; the essays' varied perspectives reflect the ongoing discussions and divisions within and among the Christian communities. Most of the writers assume that Christians should work within the current health care system and reform it. But one author proposes that we ought to withdraw from the current managed-care and insurance system and learn how to support one another directly.

The Changing Face of Health Care will inspire those of us who feel powerless to do anything about our pres­ent health care system. When no one proposes alternatives, those who want market considerations to rule our lives win the discussion before it starts. This volume makes clear that market economics are inadequate for determining the care of the sick, and that new ideas are needed. At the same time, these writers do not romanticize the past; they acknowledge that one of the reasons why we are where we are today is because of our past profligacy with both monetary and human resources. There is nothing inherently evil in managing our resources, as long as we do not make the poor and the vulnerable bear most of the burdens, or devalue doctors', nurses' or other health care workers' commitments to heal.

The essays explore how managed care affects relationships between and among patients and their physicians and nurses, physicians and their hospitals, and patients and their insurance companies. Managed care can interrupt the dialogue between patients and physicians. Medical treatment changes when getting patients quickly out of the hospital becomes a major goal, and when much of the follow-up care falls upon friends and relatives in the home-most of them women and most without training for this job.

The book's central section gives some suggestions for how we might deal with these and other challenges. Nigel Cameron suggests that Christians should follow the model of dissident Christian communities in the late Soviet Union. Without withdrawing from view, they offered an alternative to the dominant political system. For Cameron, offering an alternative health care system must begin with a theological understanding of medicine. The human beings whom medicine treats are not perfectible, but are sinners who are literally sick unto death. Christians are called to heal as a foretaste of the resurrection. Cameron stresses that since people are mortal, palliative care is important. Christians heal not just to cure, but to prepare their patients for their eventual deaths.

Sondra Ely Wheeler takes the current climate of change as an opportunity for Christians to bring their convictions to life. She offers a trenchant critique of romanticized, individualistic accounts of the relationship between physicians and patients. She argues that a biblically grounded justice requires us to treat equally all who are in need of God's resources, for which we are stewards. Christians must lament the lack of universal access to health care in the U.S. They must also consider how justly we allocate our resources, both to those who do and do not have insurance. Like Cameron, Wheeler finds palliative care especially important.

Judith Allen Shelly reflects on what it means to be a nurse in the current health care scene. She faithfully reports on the upheavals in nursing and the contradictory circumstances in which nurses find themselves. They are expected to know more and more, but are often cut off from the fellowship of other nurses as their profession becomes more of an administrative and less of a "hands-on" activity. Shelly suggests that although parish nursing offers an alternative, it is not a panacea.

Arthur Dyck criticizes the rationing which is deliberately introduced into the health care system, such as understaffing certain areas of the hospital and then refusing to treat patients when the capacity of those areas is reached. Dyck argues for a return to the tradition of taking care of all who are in need of care.

What this reader missed was a discussion of the kind of rationing in which persons are denied care for many different reasons. Further, nowhere in this volume does anyone take up the very difficult issue of how Christians should approach any necessary rationing of health care. That is disappointing because the majority of commentators on justice in health care argue that we ration by price, that this is unjust, and that we must be willing to discuss more just alternatives to our current system.

The closing essay of this collection of 23 offers a nice change from the others; it compares our problems to those found in the United Kingdom's health care system. Other countries face many of the same difficulties that we do. Thus the editors gently remind us that in our search for solutions we need to look not only locally but globally.

Stephen E. Lammers

Stephen E. Lammers is professor of religious studies at Lafayette College in Easton, Pennsylvania.

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