CMF file 77 – justice in healthcare
Love it or hate it, ‘justice’ is an issue that provokes division and strong opinion. What does justice mean for the Christian doctor or nurse? In this file, we explore what the Bible says about justice, how biblical justice differs from other models of justice, and what implications follow for the practice of healthcare.
All around us, we hear cries for justice, but one thing is clear – both the definition and the outworking of justice mean different things to different people. Competing visions and varying views of what justice should look like are based on different underlying philosophies and assumptions.
some theories of justice
Most theories of justice assume that there are no transcendent, moral absolutes on which to base a system of justice. Moral values are therefore seen as relative, and theories of justice will reflect cultural priorities. For example:
- Libertarian (freedom)
- Liberal (fairness)
- Utilitarian (happiness)
- Postmodern (power)
Although these theories may champion legitimate concerns, Christians will not wholly align themselves with any of them. There will be overlaps, because social and political theories historically have drawn heavily on Christian values, but a theory of justice that leaves God out of the picture will never captivate the Christian.
Without God, each is free to construct his or her own version of reality, his or her own notion of ‘truth’ and justice. Take Critical Theory, for example. It seeks to bring about change by encouraging people to view all authority as oppressive and all truth claims as suspicious. It suggests to people, especially those from minority groups, that all existing power structures exploit them. Societal change, the argument goes, will only be brought about by overturning those power structures through spreading mistrust, suspicion, and division. Lived experience is the key to authentic knowledge and, it is claimed, can only be appreciated by those inside such minority communities. To challenge such personal experience is deemed oppressive or hateful. Claims to absolute moral standards are regarded as offensive and potentially violent. [1]
In the light of this, it is not difficult to understand why some in minority ethnic or gender groups may feel threatened by traditional Christian beliefs. Our challenge is to find ways to engage constructively with those who have embraced Critical Theory and who perceive justice and injustice through its lens.
justice is rooted in God’s character
As Christians, our understanding of justice is rooted in the nature and character of God, who is just, [2] and in the knowledge that he created humanity ‘in his image’ to reflect his nature in the world. [3] All humans are created equal and have the right to be treated justly. At a personal level, Jesus chose to respond to unjust charges and hearings, to abuse and humiliation and, ultimately, to a violent execution, with even greater love, forgiveness and self-sacrifice.
Sadly, this is not what we see around us. What we see is self-preservation – the strong take advantage of the weak. To behave justly is to act in accordance with God’s nature and character and treat people with the fairness and dignity they deserve. What that looks like in practice can be seen in the life of Jesus – the exact representation of God [4] – and from the teaching of Scripture. [5] The life of the Spirit in us, bubbling up like a spring of living water, will result in just behaviour. [6]
what does the Bible say about justice?
The words for justice in the Old Testament can refer to retributive justice (paying for a crime committed), but more commonly refer to restorative justice – seeking out those who are being taken advantage of and helping them. This involves advocating for ‘the quartet of the vulnerable’ [7] – widows, orphans, immigrants, and the poor. ‘Speak up for those who cannot speak for themselves’; [8] ‘Rescue from the hand of the oppressor the one who has been robbed. Do no wrong or violence to the foreigner, the fatherless or the widow…’. [9]
Then, as now, these different groups of vulnerable people had one thing in common – they lacked social power. They had no standing in the community, no voice, no advocate. Restorative justice also involved taking steps to change social structures to prevent injustices. It is the same today. A modern-day quartet might, for example, include refugees, people who have been trafficked, the homeless, and the unborn. We could also add people with dementia or a disability. Justice for these groups of people will not only include the provision of care for their immediate needs, but also the dismantling of undergirding structures and attitudes that perpetuate the injustice.
The New Testament gospel declares how God, as a gift, makes right with himself those who do not deserve it. The natural response from those who have received such generosity is to seek justice for others, whether or not they appear deserving of it. This can bring us uncomfortably face to face with prejudice and judgemental attitudes in our own hearts. And we are not alone. See, for example, the struggle Peter had in visiting the home of Cornelius, a gentile, and accepting hospitality. [10] A concern for justice will force us to face and break through our own racial and cultural prejudices.
According to the Bible, one measure of the ‘justness’ of a society is seen in how it treats its most vulnerable members. Neglect is seen not merely as a lack of mercy or charity, but as a violation of justice. God is revealed as one who champions the cause of those with the least economic and social power, and his people are urged to do likewise. ‘Doing justice’ [11] is, therefore, about courageously making other people’s problems our problems. It includes seeking to reverse the causes of injustice and reaching out to its victims. God’s people are to reflect God’s character as ‘the defender of the poor’, [12] by identifying with the weak and vulnerable in society, taking up their cause, and working to make justice equally available to all.
At root, ‘poverty’ is about powerlessness. It takes the forms of marginalisation, vulnerability, isolation, and exclusion – broken social relationships – and may lead to loneliness and a sense of helplessness and hopelessness. Economic poverty – the lack of income or access to other resources – is, of course, one kind of poverty, but we should remember that people who may be well-off economically can also be impoverished socially and relationally.
responding to injustice
A community living out a biblical view of justice will be characterised by:
■ Radical generosity – the Bible makes clear that all our money and possessions belong to God and are therefore to be stewarded wisely. The New Testament church shared resources so that there was not a needy person among them. [13] They also sent gifts to help sustain the church in Jerusalem through a time of famine. [14]
■ Radical equality. [15]
■ Redemptive outcomes – God alone can judge; we are too parochial, too partially-sighted, too prejudiced. Vengeance belongs to God alone. [16] Just outcomes to disputes focus on redemptive measures, reconciliation, understanding, mutual respect, restoration, accommodation of difference, etc
■ Respect for authorities – as God’s servants, sent for our good. [17]
■ Robust advocacy – a readiness to be a voice for the voiceless, a champion of the powerless.
■ Realistic expectations – Christians recognise that the full expression of God’s kingdom on earth, under his perfectly just reign, awaits his return. Meanwhile, they give themselves to living justly and serving the interests of justice, knowing that not everything will be fixed this side of the new heavens and earth, as realistic optimists!
gospel proclamation and social action
For those who may be wary that a focus on ‘doing justice’ detracts from gospel proclamation, it is worth making clear that humanity’s greatest need is to be reconciled to God and rescued from his righteous judgement through faith in Jesus Christ.
The greatest challenge facing Christians engaged in social action is to keep in view the greatest gift we have to offer a needy world: the gospel of Christ. The greatest challenge facing evangelicals is to keep in view that social action is a legitimate expression of the gospel, and not just a means to ‘hook’ people. [18]
The ultimate fulfilment of God’s blessings is in the future. While Christians are called to be people of justice after God’s own heart, we are to remember that we can never expect to fix the world fully or achieve utopia in this life. That must await the return of Christ in his glory and the full expression of his reign here on a (new or renewed) earth. Humanity’s eternal destiny is more important than what happens to us in this life.
Gospel proclamation must therefore walk in step with Christian social involvement – it is one message, as recognised by the Lausanne Movement [19] and the Micah Network. [20]
justice in healthcare
In the appendix, I have written about three of my patients (anonymity preserved) whose cases illustrate some of the justice challenges that surround us daily as Christians in healthcare, and for which there are often no simple solutions. Yet God has given us the heart, the skills and the opportunities to do what we can to address injustices and inequalities, each of us in the settings where he has placed us.
I am struck by a couple of stories in the Bible that inspire me to be courageous and compassionate. Firstly, the Hebrew midwives in Exodus 1, who feared God and allowed the Hebrew baby boys to live, contrary to Pharaoh’s command. They were prepared to face dire consequences from doing what was right in the Lord’s sight. [21] Secondly, the woman who caught hold of the hem of Jesus’ garment, having suffered from bleeding for twelve years. She was a social and religious outcast because of her condition, without status or dignity. Despite the demands and pressures on him, Jesus, in his tenderness and compassion, ‘saw’ her, healed, and restored her. [22]
How we view, care for, and interact with the patient in front of us, or anyone we encounter (whether a healthcare team member, cleaner, canteen staff, porter, etc.) is an opportunity to be a person of justice.
Imagine the impact we could make if, together, as God’s people, we stand up and speak out for those who cannot speak for themselves and empower others to use their own voices. What a powerful witness to honour our God.
Often, as healthcare workers, we become so daunted and overwhelmed by the layers of complexity in the systems surrounding us that we do nothing. Or worse, we become cynical and hard-hearted because ‘righting the wrongs’ feels impossible or hopeless, or we have burnt out trying.
It is my hope that this CMF file will foster in us the determination not to give up. We know that ‘doing justice’ requires a mindset, heart attitude and actions that reflect the character of God, and we can be confident that the Holy Spirit will encourage and empower us in that endeavour, whatever the cost or complexity.
Many of us do not realise that we are already in positions where we can exert some influence, whether large or small, in our team, on our ward, with our colleagues and patients. How will we use that influence intentionally as Christians? We may one day be in a position to influence the design or delivery of services and, therein, be able to consider the vulnerable, poor, marginalised, weak and powerless. We may head up a department, or even an NHS trust, or be in another strategic management or oversight role. Different seasons in our careers bring different opportunities. The thing is to be watchful for, and alive to, them at every stage.
This file has focused primarily on justice from the point of view of individual healthcare professionals. There is, of course, a role for the state to play, and God may call some of us to have an influence at that level, too. Whatever the stage of our career or the level of responsibility we carry, let us be those who pray for opportunities to influence systems and structures, and not shy away when those opportunities come along. ‘Who knows but…for such a time as this.‘ [23]
Here are some specific areas where we can address injustices and inequalities. It is not an exhaustive list but will hopefully start us thinking about the many ways in which we can make a difference, with a holistic and Christ-centred mindset (Tables 1 & 2).
summary
Doing justice covers a broad range of activities:
■ be simple, fair, and honest in dealings with those whom we encounter in daily life
■ develop the habit of regular, generous giving of our time and resources, beyond the call of duty, to vulnerable people
■ engage in activism that seeks to end forms of injustice, violence, and oppression
■ be careful not to lock vulnerable people into their sense of powerlessness by being overready to ride to their rescue, even if it makes us feel good. If, inadvertently, it encourages passive dependency, then sustainable change will not be achieved. Our aim must be to help people find their own solutions, be proactive in their lives, and regain their God-given dignity as people able to contribute to community life. It is about changing people, attitudes and structures rather than simply providing goods and services [24]
■ influence and shape culture, wherever God has placed us. Irrespective of our role or status in healthcare, God can work in and through us for the good works which he prepared beforehand for us to do [25]
■ justice and evangelism go hand in hand – neither are optional, but both are essential to our witness as God’s people, presenting Jesus Christ to a world without hope.
CMF, as a fellowship of Christian doctors, nurses, and midwives, offers a unique and credible platform for justice in healthcare. Our vision as Christians is to advocate for the weak and vulnerable and address injustices by seeking to change social structures and institutions. At the same time, we hold out the hope of the glorious gospel message of Christ. We remember that full and complete justice will only ever be achieved in the new heaven and the new earth, where God’s rule will be fully expressed, and where he will wipe every tear from our eyes, and when there will be no more death or mourning or crying or pain. [26]
We will be known in healthcare and society as people who love, care, stand up, and speak out for the voiceless; those who embody true hope in the midst of suffering and injustice, because we have read the end of the story; and those who are unashamed of the gospel – the power of God at work, saving everyone who believes. [27]
appendix
Mrs Patel
He was sitting anxiously in the waiting room when I called his wife’s name. She was smiling happily in a vacant restless way, oblivious of why she was there. They were dressed smartly and moved slowly, leaning heavily on each other for support as they hobbled into the consultation room. For us, this was a routine annual dementia review with a ‘generous’ 20-minute allocation; a necessary box-ticking exercise, more for remuneration than for patient care. For them, this was an important appointment in the diary, an opportunity to see their GP about the things that were worrying them most and to explore the help and hope we could give them. Their eldest son had driven three hours that morning from the coast to accompany them to this ‘important’ doctor’s appointment. Even before they sat down, I could sense the heaviness of Mr Patel’s burdens and the unspoken hopelessness he brought into the room. Although he did not know what to expect, he certainly had not imagined that he would be leaving so soon and remain desperate with many of his concerns unaddressed and questions unanswered. He barely had time to explain what was happening at home. When would they see the GP again? Who was going to help them with the deteriorating situation? Where would they get the answers? He felt so alone and frightened.
I felt hopeless and helpless. It served as a raw reminder of my own experience with my mother only a few years earlier. She had depended on the doctor’s mercy in a complicated healthcare system. I remember praying that the team caring for my demented mother would be compassionate, caring, conscientious, and willing to listen to our concerns, anxieties, and fears. I tried to remain strong for her while my heart broke for my once strong mother who had loved, nurtured, and cheered for me, teaching me everything I knew, as she became so weak, vulnerable, and voiceless.
Why are patients and their families having to blindly navigate a complex and harsh healthcare system by themselves at such a grievous and tragic time of their lives? Why is the care, service provision, and support so variable in different areas?
As we pause to consider how we can make a difference, however big or small, wherever God has placed us, we can use biblical justice principles to provide a framework for action.
For a start, it is about how we see the patient and the family, and how we listen and communicate with compassion, love, and care as we commit to walk alongside them in this season. We can lament and say sorry. It is about using our spheres of influence to speak up and make changes to tailor times, access, and appointments where possible and think about the arrangement and welcome we offer in the waiting rooms.
Kevin
His gaze remained motionless and fixed on his trainers as he sagged despairingly in the chair. His mother communicated her desperation with weariness in her eyes and trembling in her voice. He was seen in the local A&E last week for an overdose. I could see from his notes that there had been several unsuccessful attempts by his mother to get a GP appointment in the week leading up to the incident. However, there was only one telephone entry on the Friday evening from a colleague advising her to contact the local mental health crisis team. In between her despairing sobs, she related her harrowing account of how her desperate cries for help were met only with answer phones or what felt like unhelpful or obstructive administrative staff. She told me she was a single mother working two cleaning jobs to provide for her three boys. They lived in a one-bedroom, mouldy council flat with noisy and abusive neighbours who used racial slurs, turned up the television, and smoked weed all day long. Her eldest teenage son had been getting poor grades, and she only found out last year that he was being bullied at school. She could see him getting increasingly withdrawn and depressed as he shut himself away from the noise of the world and the mess of a poor family. Although he had been referred by the GP to the community mental health team several months ago, two appointments had been cancelled at the last minute by the clinic, and she never received the letter for another as the post was unreliable.
My heart sank as I felt the weight of corporate responsibility for these all too familiar but highly significant failures in our systems. But more than that, I felt I had failed as an advocate for this desperate boy whose cries for help were either repeatedly ignored or deemed irrelevant or insignificant. What could I do? Biblical justice is about due rights, protection, and care, but it is also about right relationships, restoration, and wholeness.
So, although I may not be able to solve the systemic issues of school, local council, and primary and secondary care, I should intentionally look out for God-given opportunities to highlight and address these problems wherever and whenever possible. And I can work within the sphere of influence God has put me in at any given time, whether it is treating the patient as God sees them with love, care, and compassion; being an advocate for them with local services and hospital; and ensuring proper follow up and continuity of care or wider support for the family.
Shona
She looked like a schoolgirl out of uniform as she deftly navigated the twin pushchair into the consultation room. In between pacifying the crying children with snacks, she was yelling at the very active toddler who was excitedly exploring all the cupboards, bins, and equipment in the room. She stopped for air and cried out in anguish that her period was late. And no, she had not done a pregnancy test as she could not afford it. Going through her notes, she had missed her last depot contraceptive injection. Why? Because she had not had the money to top up her ‘pay as you go’ mobile plan, and therefore missed the text reminder from the surgery. And she had not been able to make an appointment for the GP surgery until she had enough credit to call. There was ‘no way’ she could keep the baby. Her previous partner, dad to the toddler, was no longer on the scene, and her current partner, dad to the twins, had just started a prison sentence for armed robbery and would not be out for a long time. She had no other support.
I found myself conflicted – compassion, pity, exasperation at the family mess, while at the same time hearing that reprimand in my head ‘she just has to navigate the system and make it work – she knows the score, she needs to take responsibility for herself’.
Often, we are trained to deal with the clinical situation at hand when the patient is in front of us, but we are either oblivious to, or do not see it as our responsibility to address the wider issues. Or perhaps we are cynical, hardened, or may simply feel hopeless and helpless to do anything about the circumstances. So, like our colleague who saw her the last time this happened, we do nothing.
Yet, as people reflecting God’s character, how do we show honesty, equity and generosity when faced with this kind of scenario? What does it look like to ‘do justice’?
First, personally, it is about my disposition of compassion and tenderness towards her in my tone of voice, in my non-verbal communication, in my little touches of kindness. I am to look on her as made in God’s image and treat her with compassion in the way God sees her in her brokenness, struggle, pain, and mess.
As busy and often weary healthcare workers, how easy it can be to forget that grace, kindness, and compassion are valuable and significant qualities in our interactions, which have become vanishingly rare. This is an area where we can show God’s character in the strength that he gives us. Let’s think about biblical justice principles. We can take wider actions. We can investigate and may even be able to influence patient access to important reminders such as the contraceptive injection, consider the layout, safety, and provision of the waiting and consultation rooms (particularly for busy families, those with mental health or mobility problems, etc.), and continuity of care.
This is just a snapshot of the patients I have encountered in my world of general practice, and you will have your own stories. It is my prayer that the stories of all those whom God has placed in your path will shape you to be a person of justice after God’s own heart, reflecting his character and glory throughout your life. �
Table 1
Areas of Injustice and inequality in healthcare
■ Services and Systems – waiting lists, appointment times, ease of access, transport, ‘postcode lottery’
■ Continuity of care – a familiar face in primary care, primary and secondary care transition and communication, pressure to discharge early, care in the community, follow-up
■ Treatment – access to and cost of appropriate treatment. Fair distribution of resources
■ Conflicts of interest – research, clinical trials, pharmaceutical companies
■ Policy – shaping policies with the patients’ best interests uppermost
■ Quality of care – reaching across linguistic, cultural and social divides. Consider families, not just patients
Table 2
wider actions we can take to address injustice in healthcare
■ Pray – our dependence on God to challenge and change unjust practices and policies
■ Influence – using our influence wherever God has placed us; nobody is too small to make a difference
■ Advocate – stand up, speak out, write to your MP, raise awareness, be active in campaigning
■ Engage – in partnerships and alliances with other Christian organisations in addressing injustice
■ Lead – be open to, and embrace, leadership roles that will shape policy and change culture, at all levels of responsibility (team, ward, department, commissioning services, PCN, ICB, Hospital, Practice, BMA, Royal Colleges, etc…)
