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SANCTITY AND SCARCITY:

THE MAKINGS OF TRAGEDY


JOHN VINCENT A. PAGADDU

WHAT is it?

TRAGEDY:

SCARCITY

a very bad event that causes great sadness and often


involves someone's death (Merriam-Webster)
The sad story: people tell very sad stories of or with their
bodies.

the state of having a small supply (Merriam-Webster)

SANCTITY

holiness of life and character (Merriam-Webster)

SANCTITY OF LIFE (INVIOLABILITY)

In religion and ethics:

a principle of implied protection regarding


aspects of sentient life which are said to be
holy, sacred, or otherwise of such value that
they are not to be violated.
MAN: the object of Gods unbounded love.

THE GOOD SAMARITAN


Once upon a time, along the road to Jericho, a man
had fallen half-dead. Some passed by on their way
to Jerichos market or Jerusalems temple

THE GOOD SAMARITAN


but only one who saw him had compassion.
A Samaritan it was who bent over the wounded man
and tended to his care, pouring oil and wine upon his
wounds and bandaging them.

THE GOOD SAMARITAN


then he gently lifted the man,
set him on his donkey, and
brought him to an inn.
When he could stay no longer
himself, he gave the innkeeper
two denarii with instructions to
care for the man and with the
promise to pay for whatever
the wounded man required.

What value has been manifested by the


Samaritan?

COMPASSION

THE GOOD SAMARITAN

familiar to Christians as a model of caring


compassion.
The story seems merely quaint and out of place in
the context of modern health care.
In the context of modern medicine strange story
Considering:

the problem of scarcity


the allocation of limited resources.

Compassion leads to costly care.

The Modern Period

We have assortment of technologies to help and


heal.
Technologies are attached to costs.
The Good Samaritan no longer seems quite so apt
an image for the care of those who hurt and the
reason is simple:

The Samaritan did not face the issue health care is


forced to face today, the issue of scarcity.

Suppose the oil and wine and the stay at the inn left the
wounded man in the story only half-alive.
Would the Samaritan continue to pay for his care?
Suppose he encountered another neighbor on the side of
the road when he returned to pay the bill for the first
wounded traveler.
Would he do the same for this second neighbor?
Suppose he encountered not just one other but more
than his donkey could bear, more than his purse could
afford, more than even the most hospitable inn-keeper
could receive.
What would he do then?

Could he then still be the good Samaritan?

Suddenly he seems a tragic figure, forced to make


unwelcome choices.

Goods collide, and cannot all be


chosen. Evils gather, and cannot all be
avoided.

Can we continue to tell this story of the Good


Samaritan as an image of care for those who hurt,
and acknowledge the limits of our resources?

Can we still be good Samaritansor fair


Samaritansin the midst of tragic choices imposed
by scarcity?

Acknowledging Scarcity

For over two decades "cost containment" has been


something of a political crusadeand something of
a failure.
Costs continue to go upand with them escalates
the sense of urgency that they should be controlled.

Philippine government spending on health care is


short of the at least 5 percent of gross domestic
product (GDP) recommended by the World Health
Organization (WHO) despite above 7 percent
economic growth in the past five quarters

currently about 3 to 3.5 percent of GDP is allocated to


health care

It is not written in Scripture


It is far from obvious how much of a nations
resources should be spent on health care

Perhaps the Philippines can and should spend still more


Other things which a decent society
should value besides health:

To establish and enforce that limit requires decisions


about the allocation of public funds and costcontainment strategies.

Scarcity, the reality of limits, makes


such allocation decisions necessary.

How can the story of the good Samaritan continue to


shape Christian response when we consider the issue
of
limited access to health care (Scarcity of access)

1.

There are some who are hurt are simply passed by


Who have no access to medical care

limited economic resources (Fiscal Scarcity)

2.

There are inn-keepers who must measure their hospitality.


HMO managers and third party payers and fourth-party utilization
reviewers are forced to scrutinize the efforts of a physician on
behalf of one who is hurt not only medically but economically.

limited medical commodities (Scarcity of Commodities)

3.

The oil and wine may be in short supply.


There is a shortage of organs for transplant, or too few beds in
public hospitals.

SANCTITY

It didnt matter that the wounded man was a Jew.


What mattered was the hurt, the pain, and the need
of one who was, after all, like him, the object of
Gods unbounded love.

that unbounded love conferred upon the wounded man is


sanctity, which evoked the limitless care of the
Samaritan.

SANCTITY IN MEDICINE

Sympathy and Care

MEDICINE

It is more than a business


It is a profession, and an avowed and public identity

MEDICINE: SYMPATHY AND CARE

the appropriate, humane, and Christian response to anyone who


hurt is.
The own witness of medicine to the "sanctity" Gods love confers.

Medicine has made it more than a business, a profession


or an avowed and public identity to respond to the sad
stories people tell with and of their bodies with the
sympathy and care appropriate to a persons "sanctity.

It is one of the great glories of medicine that its story


could be told in images that remembered the story of
Jesus.

SOCIETY and MEDICINE

developed a science and a technology that permit us


now to care, if not more intensely, at least more
effectually.

Medicine has learned to intervene in some sad


stories of human suffering and premature dying so
that sad story may at least have a happy ending,
after all.
Compassion
Sense

of sanctity

SUCCESS LEADS BACK TO SCARCITY

Compassion has led to very costly care.


NO resources for medicine to do all it can do or all it
wants to do for all who are hurt.
Scarcity makes allocation decisions necessary, and
those decisions sadly limit the good a Samaritan can
do.
HENCE:
If we do not have the resources to do all we can do
and want to do for all patients, then we MUST LIMIT
what we will do for AT LEAST SOME PATIENTS.

HOWEVER...

Sanctity makes allocative decisions necessarily


TRAGIC.
WHEN?

when the goods and services to be allocated


are goods and services upon which life and
health may depend.
when the life and health contingent upon
allocative choices are the life and health of
those who are the objects of Gods unbounded
love (who therefore may rightfully invoke the
respect and care of others).

TRAGIC CHOICES

to let anyone die when not all can live


to let anyone suffer when not all can be spared
to let the health of anyone go unnurtured when the
health of all cannot be served

WHAT CAN BE DONE TO REJECT


TRAGEDY?

Two strategies for denying the tragedy


1. To deny scarcity
2. To deny sanctity

SCENARIO 1

Seattle Artificial Kidney Center (1961)

A committee was formed to select those patients who


would receive kidney dialysis when not all could.
They allocated the scarce resource to those whom they
considered the most worthy, the most valuable to society.

WHAT HAS BEEN DENIED IN THIS STRATEGY?

In using social worth as their criterion for selection, they


denied the equal SANCTITY of each of the medically
acceptable candidates whose lives were at stake.

SCENARIO 2

The United States Congress (1972)

WHAT HAS BEEN DENIED IN THIS STRATEGY?

voted to provide almost universal funding for kidney dialysis.


to acknowledge and affirm sanctity, the Congress voted to
provide dialysis for any who needed it.
The program proved far more expensive than Congress
originally thought.

Strategy of denying SCARCITY: self-deceptive


a policy providing kidney dialysis for everyone still distinguishes
those dying from end-stage renal disease from those dying
from other equally grave diseases.

There are limits!


Scarcity is "a fact of life"and death.
The necessity of allocative decisions, of facing up to
scarcity, cannot be denied or ignored indefinitely.

WHICH STRATEGY IS MORE ACCEPTABLE?

The strategy of denying scarcity is NOT more acceptable.

Given scarcity and the tragic choices it imposes,


can we still be good Samaritans?

Contemporary Samaritan: requires VIRTUES beside


compassion to be "good.

Truthfulness

Humility

a readiness to acknowledge the truth about the limits imposed


by our mortality and by the finitude of our resources.
the readiness to acknowledge that we are not gods but the
creatures of God, finite and mortal creatures cherished by God,
in need finally of Gods care, and watching finally for Gods
future.

Gratitude

thankfulness for opportunities within our limits:


to save a life, or to relieve someones pain, or to ease the
bitterness of someones tears, or at least to wipe those tears
away with compassion.

VIRTUE of JUSTICE

The contemporary Samaritan cannot be good with


just compassion, but JUST compassion is indeed
required.

The virtue of justice is essential to those who would


be GOOD in the midst of scarcity.

A readiness to do justice and to insist that justice be


done is required of any who would be even a FAIR
Samaritan in response to scarcity.

How can a good samaritan decide of WHO SHOULD


RECEIVE SCARCE COMMODITIES?

RANDOM SELECTION
is not arbitrary; or illogical

it is what were left with when we refuse to


use arbitrary criteria for the distribution of
scarce commodities.

is not irrational;

it is the rational refusal to deny either


scarcity or sanctity.

RANDOM SELECTION

fair to all who need some scarce commodity.


Can endure and nurture truthfulness.

To tell the truth that we didnt think their life or health was
"worth" as much as anothers life or health.

Can sustain compassion even for those not chosen.

to care for one we may not cure,


to respond to their hurt in other ways, less costly and less
technological, and sadly sometimes no less scarce.
a human touch that signals compassion,
a silent presence to voiceless pain,
a listening ear to a plaintive lament,
a helping hand in the direction of the tasks which remain,
even to the dying.

Can we continue to tell the story of the Good


Samaritan as an image of care for those who hurt
and acknowledge the limits of our resources?
YESyes, we can and yes, we must
as long as we understand the goodness of the
Samaritan by the measures of

truthfulness and humility,


justice and gratitude,
compassion and care.

Telling its story and struggling to


live it may form in some the
character we need
....The good Samaritan.

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