Relational Personhood, Social Justice and the Common Good: Catholic Contributions toward a Public Health Ethics

Abstract

Worldwide, there is renewed public and political attention focused on public health fueled by the globally explosive H1N1 pandemic. Pandemic planning emerged as a major area for public action in the absence of an overarching ethics framework appropriate for the community and population focus of public health. Baylis, Sherwin, and Kenny propose relational personhood and relational solidarity as core values for a public health ethics. The Catholic faith tradition makes three useful contributions in support of a relational ethic: first, a religious ontology that aligns with the view that human persons are inherently relational; second, a coherent account of the requisite social and communal ideals and structures that this belief demands; and third, inspiration and motivation for the attitudes and actions that are required in response to a relational ontology.

I. INTRODUCTION

Worldwide, there is renewed public and political attention focused on public health fueled by the globally explosive H1N1 pandemic. National and international bodies have hastened to put in place effective structures to address this threat to public health. Despite repeated calls for attention to public health long before this pandemic, and a robust and growing body of literature on the challenges of chronic illness, high-risk health behavior, the importance of the socioeconomic determinants of health, and the interaction between health and the environment, public health has languished in the shadow of individually focused, cure-oriented, technologically driven health care. The reality of pandemic has demonstrated the urgent need for finding and nurturing support for notions of community, the common good, and solidarity that are central to religious thinking but virtually nonexistent in acute health care. Ideally, pandemic plans themselves should be “… instruments for building mutual trust and solidarity at such time that will likely present a major challenge to our societies” (Kotalik, 2005, 431). The experience of the H1N1 pandemic has demonstrated how fear, uncertainty, and risk provoke personal and policy responses of self-protection and social distancing. Examples of stockpiling of antiviral medications, professional refusal to work in risky circumstances, and inequitable vaccination priorities are a few of the identified issues. These are far from the ideal vision of mutual trust and solidarity in time of crisis.

Pandemic planning emerged as a major area for public action in the absence of an overarching ethics framework appropriate for the community and population focus of public health. Some of the confusion and distress experienced in the development of policy responses to H1N1 are due to this lack of ethical foundation. Paradoxically, the pandemic experience provides a unique window of opportunity for development of an ethic for public health informed by robust notions of community and solidarity and firmly grounded in a commitment to the “twin moral impulses that animate public health: to advance human well-being by improving health and to do so by focusing on the needs of the most disadvantaged” (Powers and Faden, 2006, 80).

Windows of opportunity come and go quickly in the policy world. This opportunity may be squandered by at least three trends. One is a failure to appreciate the centrality of foundational notions of the public good, the common good, and solidarity in public health as distinct from health care. The second is a tendency to develop a public health ethics that relies too heavily on familiar, but morally limited, individualistic bioethical concepts dominating clinical practice and medical research, such as respect for autonomy (of individual patients), beneficence and non-maleficence (as judged by the patient), and justice (primarily understood as nondiscrimination) (Beauchamp and Childress, 2009) with insufficient attention to the communal vision and values essential to public health. Finally, there is the danger that public policy enunciates foundational notions of sharing, community, social justice, and the common good as essential to situations such as pandemic, but we lack the ability to motivate society to these ideals. Religious traditions have much to contribute here.

Unfortunately, faith-based ethics, like its secular counterpart, has focused reflection on the dramatic, life and death, individually focused technological advances in medicine. Despite rich traditions of social justice and the centrality of community and social interdependence, faith-based ethics too has focused insufficiently on the issues of public and population health. The reality of the H1N1 pandemic presents a unique opportunity to those who work in faith-based bioethics to assist policy makers in developing an ethics framework firmly grounded in foundational concepts such as solidarity, social justice, and the common good. These notions are essential in the analysis of ethical issues in public health and for the motivation for public health actions. For the Christian, solidarity is not an option but rather an inevitable consequence of being children of God, brothers and sisters of Christ, and neighbors to one another.

In this paper, we identify the urgent need for an ethic of public health to guide public health issues such as pandemic planning; summarize some promising new work in a relational understanding of public health ethics; and explore the ways in which faith traditions, specifically the Roman Catholic perspective, make important contributions in support of a relational ethic for public health.

II. PUBLIC HEALTH ETHICS AND THE H1N1 EXPERIENCE

Whereas much attention has been paid to clinical ethics (involving the treatment of individual patients) and to research ethics over the last forty years, relatively little attention has been directed at public health ethics. Faith-based ethical reflections have mirrored these priorities, focusing on dramatic and controversial clinical issues such as reproductive technologies, end-of-life decision making, and new technological developments. As Childress et al. (2002) observe, “Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods and boundaries remain largely undefined” (170). This gap is surprising since ethics is central to the role of public health given its aims of ameliorating the causes of disease and disability in populations and reducing health inequities (Beauchamp, 1999, 101–8). Some of the explanation for the gap lies with the relative lack of attention and resources directed to public health itself in comparison to acute health care; some lies in the dominance of individual autonomy, individual choice, and individual benefit in contemporary health care.

As far back as 1985, Beauchamp (1985) called for an ethic designed explicitly for public health that would recognize community as central. Yet, to date, there is a lack of consensus regarding the appropriate theory and method for public health ethics (Beauchamp and Steinbock, 1999; Kass, 2001; Callahan and Jennings, 2002; Childress et al., 2002; Roberts and Reich, 2002). Public health has been understood to promote human welfare by promoting health outcomes. This view has provided a utilitarian foundation for public health and is primarily concerned with issues of distributive justice. However, an emerging view is that “… the historic dream of public health that preventable death and disability ought to be maximized is a dream of social justice” (Beauchamp, 1999, 105). This theme of public health founded on social justice is a central consideration in recent work (Gostin and Powers, 2006; Kayman and Ablorh-Odjidja, 2006). Indeed, Powers and Faden (2006) claim that “… the foundational moral justification for the social institution of public health is social justice” (80). In this view, public health is about more than distributive justice. The priority is those whose prospects are disadvantaged, and the commitment is to the identification and amelioration of patterns of systematic disadvantage. Work on the ethical issues in pandemic planning has mirrored the limitations of public health ethics (University of Toronto Joint Centre for Bioethics, 2005) but, it too, is beginning to identify the communal and social justice dimensions of public health and the importance of social justice in face of pandemic (Gostin, 2006; Powers and Faden, 2006; Uscher-Pines et al., 2007).

Among recent writings on the need to craft a moral foundation and structure for public health ethics, the paper by Baylis, Kenny, and Sherwin (2008) on “A Relational Ethic for Public Health” provides a strong proposal for this task. Their strategy, influenced by feminist theory, is to construct a public health ethics on the foundation of the inherently relational reality of human existence. They propose two core values for public health ethics that move away from conceptualizing the person solely as an independent individual rational patient: relational autonomy and relational solidarity.

First, they develop the notion of “relational personhood” and draw attention to contextual aspects of historical, social, economic, and political interactions among persons. Many of these contexts have health-related consequences. Relational personhood also functions as an analytical tool to identify patterns and systems of privilege, disadvantage, and discrimination. With relational personhood as a core value, the authors develop the notion of relational autonomy, in contrast to the notion of individual autonomy dominant in modern health care. Relational autonomy recognizes the inherently relational, social, political, and economic aspects of being a person who can consider options and make responsible decisions; it also clarifies potential limits on the options available. Reorienting justice away from merely distributive fairness, a relational approach to justice provides a focus on social justice that highlights “patterns of systemic injustice among different groups” and elicits efforts to change patterns of “systematic disadvantages” in a manner that will contribute to increasing the well-being of all but especially the disadvantaged (Baylis, Kenny, and Sherwin, 2008, 203).

Their second core value builds on the foundations of relational personhood, relational autonomy, and social justice by offering a relational account of solidarity. Notions of solidarity that depend on “common interests, purposes, or sympathies between discrete individuals” are vulnerable to the contemporary social experiences of alienation and fragmentation (Baylis, Kenny, and Sherwin, 2008, 104). If solidarity is understood as a system of reciprocity and mutual advantage, its functional aspect renders it vulnerable to the limitations of social awareness. Where the privileged see little mutuality with the disadvantaged, public health initiatives that address the needs of the oppressed may seem immaterial. Where is the mutual advantage when the disparity in social assets and deficits (and thus health status) is so great? In relational solidarity, based on human relational personhood and social interconnectedness, divisions based on social status, divergent interests, and plural traditions are subordinated and subsumed by “a shared interest in survival, safety and security” (Baylis, Kenny, and Sherwin, 2008, 205). At this higher level, relational solidarity recognizes all persons as integral to our understanding of ourselves, thus expanding the category of “us” to “us all.” For public health programs and services to garner public support, the public requires insight into the ways in which everyone is potentially vulnerable and a willingness to be held responsible for the well-being of all members of society, including those who are most disadvantaged and vulnerable. This conception of relational solidarity highlights “the reality of our mutual interest in survival, safety and security on the one hand, and our mutual vulnerability to disease, violence and death on the other” (Baylis, Kenny, and Sherwin, 2008, 206). It is well-suited to the reality and demands of public health policy and practice.

Baylis, Kenny, and Sherwin thus propose a scaffold for a public health ethics that embraces relational personhood, relational autonomy, social justice, and relational solidarity as its core foundational values. The framework is sound, and their structure is both substantial and relevant. Its epistemological avowal is that human persons are essentially and inherently relational beings. However, this affirmation may ring hollow for the many people whose experience is marked by isolation, loneliness, alienation, or neglect, whether at the privileged or disadvantaged ends of the social spectrum. It may ring discordantly for those whose worldview is individualistic. Even if this relational framework is accepted intellectually by many, much work needs to be done to motivate society to this notion of interdependence. Faith communities have much to offer here. Christian understandings of the family of God and of responsibilities in care and justice to each other and to the most disadvantaged can promote deeper understanding of solidarity and its demands. The Roman Catholic tradition with its strong and well-developed social justice tradition has much to bring to public policy debate as pandemic plans are developed and implemented. An exploration of ways in which this tradition supports relational notions of public health can be very useful in motivating civic response that is both compassionate and just in times of high personal and communal risk.

III. ROMAN CATHOLIC CONTRIBUTIONS TO A RELATIONAL ETHIC

Religious faith traditions offer perspectives and convictions that make three useful contributions in support of a relational ethic: first, they provide a religious ontology that aligns with the view that human persons are inherently relational; second, they offer a coherent account of the requisite social and communal ideals and structures that this belief demands; and third, for members of religious communities (and perhaps for nonmembers as well), they are intrinsically inspirational in eliciting the attitudes and actions that are required in response to a relational ontology.

Religious Ontology and Relational Personhood

Within the Roman Catholic faith tradition, the ontology of humanity is a well-developed teaching in papal encyclicals, doctrinal documents, and public letters from bishops’ synods. The consistent understanding throughout these texts is that the human person is constituted as both uniquely individual and social. Most often this is articulated in terms such as the dignity of the human person and the inherent social, relational, or communal nature of humanity. The Catholic Church teaches that the dignity of the human person is grounded in the affirmation that persons are created by God and bear the image and likeness of God in a way that is unique to humanity out of all creation; the “divine image is present” (Catechism of the Catholic Church, 1993, #1702) in every person. Human life is thus sacred, and every person is endowed with sacred dignity and transcendent worth regardless of his or her beliefs, actions, or choices. By their very nature as created beings, persons are also characterized by reason or intelligence, freedom and autonomy, and a “spiritual soul” (Catechism, #1711). It is because of a person's rationality and free will that he or she may be held responsible and accountable for his or her voluntary choices and actions; the “right to the exercise of freedom … is an inalienable requirement of the dignity of the human person” (Catechism, #1738). The notion of respect for the dignity of the human person may be directly linked to modern formulations of human rights. In Pacem in Terris, for example, Pope John XXIII refers to the role of the United Nations Organization in safeguarding “the rights which derive directly from [one’s] dignity as a person, and which are therefore universal, inviolable and inalienable rights” (John XXIII, 1963, #145). Reflecting the notions of human intelligence and freedom, alongside inalienable rights, lie concomitant obligations to respect and further the rights of all persons.

Ensuring the mutual fulfillment of human dignity, equality, rights, and responsibilities, Catholic teaching provides a second foundational aspect of human nature: “men [and women] are by nature social beings” (John XXIII, 1961, #194). The Catechism teaches that humanity is inherently social and that the individual person by nature requires a community of other persons to fulfill his or her personhood (Catechism, #1878–80). Primary among human communities are the family and the state, both of which are seen as essential for human growth and well-being. Describing the “conjugal community” of spouses and their children as the “original cell of social life,” the Church teaches that the family provides a foundation for the larger society (Catechism, #1882). Schooled in “authority, stability, and a life of relationships,” children learn social skills that enable them to be attentive to the needs of others. Members of the larger community of persons are to be seen as “neighbors” who similarly have inherent rights and mutual responsibilities for the well-being of society. According to the Catechism, “charity is the greatest social commandment” (#1889). It is the virtue that gives substance to one's love of God and love of neighbor, and it both inspires and requires the practice of justice. The principles of respect for the dignity of the human person, equality of all persons, and regard for all persons as neighbors (with whom one shares mutual rights and responsibilities) undergird the orientation of society toward human flourishing. In the words of Pope John XXIII, “individual human beings are the foundation, the cause and the end of every social institution… for men [and women] are by nature social beings” (John XXIII, 1961, #219).

It is the combination of respect for human dignity and recognition of the social nature of humanity that functions to support ontology of relational personhood. If human persons have transcendent value because of their essence as created beings who bear the likeness of their Creator, then diversities in gender, race, ethnicity, culture, religion, and economic, political, or social status are inessential variations rather than grounds for discrimination, oppression, or privilege. Pope Paul VI, in Octogesima Adveniens, contrasts these perspectives on the human person and human community with philosophical liberalism that he sees as “an erroneous affirmation of the autonomy of the individual in his activity, his motivation and the exercise of his liberty” (Paul VI, 1971, #35). The relational vocation of humanity is rooted in the mutual recognition of every person as one's neighbor, “another self,” created in God's image, to whom one is intrinsically related and with whom one shares human rights and responsibilities (Second Vatican Council, 1965, #27). There is no “other” in this understanding.

Social and Communal Ideals and Structures

Pope Leo XIII's Rerum Novarum (1891) is widely regarded as the foundation of the Catholic Church's teachings on social justice. The encyclical addresses the situation and rights of the working classes in Europe at a time when the Industrial Revolution had led to two distinct economic classes of people. Leo XIII (1891) describes the “abounding wealth among a very small number and destitution among the masses” (#1). The primary goal of Communists and Catholics alike was to remedy the exploitation and poverty of the laboring class. The means by which Pope Leo XIII (1891) proposed to address these demands of equity was the development of a civil society in which “one class [becomes] neighbour to the other” (#66) within a State governance directed toward a common and inclusive social welfare. Leo XIII develops a centrist political stance that rejects collective ownership through the state as in Marxist socialism and also rejects liberal capitalism with its free market system and emphasis on individual freedom and tolerance. The role of the State, according to Leo XIII (1891), was to “protect equitably each and every class of citizens,” ensuring that all citizens “contribute something to the sum-total common goods, some share of which naturally goes back to each individual” (#49–50). Leo XIII (1891) elucidates the process by which society promotes human welfare with equity: “from what [the workers] contribute to the common good [they] may receive what will enable [them], housed, clothed, and secure, to live … life without hardship” (#51).

Over the next one hundred years, the fortieth, eightieth, and one-hundredth anniversaries of Rerum Novarum were celebrated with papal encyclicals expanding and enriching this notion of social justice. On the occasion of the fortieth anniversary, Pope Pius XI reaffirmed Pope Leo XIII's foundational contribution to “a true Catholic social science” dedicated to vigorous protection against injustice, exploitation, and poverty on behalf of the workers (1931, #20). Pius XI continues to support the right of workers to own private property and to form trade associations and labor unions for the purpose of receiving just wages and safe and dignified working conditions. In Quadragesimo Anno (1931), Pius XI calls on the principles of social justice and social charity to undergird civil and juridical authority and to challenge the concentration of power and wealth that characterized capitalism during the Great Depression.

In addition to the development of social justice teaching for which Rerum Novarum was foundational, Pope John XXIII led the Catholic Church into the revolutionary transformations ushered in by the Second Vatican Council. Two encyclicals preceded Vatican II, Mater et Magistra in 1961 and Pacem in Terris in 1963. The 1960s were a time of increasing disparities in economic and social welfare within every country and in the international context fueled by scientific and technological innovations, mass communications, modernization of agriculture, and automation in industry. According to John XXIII, the Church's social teaching had permanent validity and “one basic principle: individual human beings are the foundation, the cause and the end of every social institution … for men [and women] are by nature social beings” (1961, #219). Where “enormous wealth” and “unbridled luxury” of the privileged few stood “in violent, offensive contrast to the utter poverty of the vast majority” (1961, #69), there was no justice. Human society must be structured and function so that every person would have enough for the necessities of life. In Pacem in Terris, John XXIII enunciated the rights of humanity including the right to bodily integrity, medical care, and the social services required to meet human needs “whenever through no fault of [their] own [they are] deprived of the means of livelihood” (1963, #11). In order for these rights to be met, a corresponding duty would have to be fulfilled. Society would need to be ordered by mutual collaboration among all its members to create a civic order with governmental authority and legal protections. John XXIII's vision for peace had human relationships governed by truth, justice, charity, and freedom—within civil societies, between citizens and their government, between countries—with global interdependence and global justice at its core (1963, #163). The structure of social justice is given substance in its movement toward its goal.

The Bishops at the Second Vatican Council counseled in Gaudium et Spes, the Pastoral Constitution on the Church in the Modern World (1965), “the best way to fulfil one's obligations of justice and love is to contribute to the common good according to one's means and the needs of others” (1965, #30). The common good is elaborated in detail by Pope John XXIII and in documents from the Second Vatican Council. Civil authority garners its justification by means of its role in seeking the common good and administering its principles of justice and equity. Forms of oppression, discrimination, privilege, and greed all militate against the common good by their injustice and the way in which they undermine human personhood. In Pacem in Terris, John XXIII explicitly identifies discrimination on the grounds of race, ethnicity, refugee status, class, and gender. With increasing levels of globalization in communications, economic and industrial activities, and wide discrepancies in economic and social development among countries, the Pope considered the universal nature of the common good that present “problems which are world-wide in their dimensions” (1963, #137).

Similarly, in Gaudium et Spes, Pastoral Constitution on the Church in the Modern World, the Bishops of the Second Vatican Council addressed “the entire human family seen in its total environment” with “the world as the theatre of human history” (1965, #2). They identified “excessive economic and social differences” among local, national, and global populations as a “scandal” that undermined “social justice, equity, the dignity of the human person, as well as social and international peace” (1965, #29). Even more strongly, the Bishops asserted that “[p]ersons in extreme necessity are entitled to take what they need from the riches of others” (1965, #69). Social justice directed toward the common good would ensure that some portion of wealth was redistributed to guarantee “the sum total of all those conditions of social life which enable individuals, families, and organizations to achieve complete and effective fulfillment” (1965, #74). Among the necessities for living a life of human dignity, Gaudium et Spes names food, clothing, housing, family, education, work, respect, privacy, and freedom from social, cultural, or religious discrimination. The common good would be achieved when through the fulfillment of rights and obligations, duties, and responsibilities, all members of the global human family had the means of subsistence and dignity.

Pope Paul VI marked the eightieth anniversary of Rerum Novarum in 1971 with Octogesima Adveniens. Affirming Leo XIII's contribution to the social teaching of the Church and its emphasis on the scandalous poverty of the workers, Paul VI addressed his words to “new social problems” facing humanity; chief among these was urbanization. Social problems associated with urbanization were the weakening of agriculture, significant demographic growth in “megalopolis” centers, industrialization, unemployment, rampant consumerism, and increasing gaps between the luxuries of the rich and the misery of the poor. The encyclical identified the degrading and dehumanizing living conditions associated with poverty and the resultant victimization of the poor through discrimination, exploitation, domination, and social ills such as delinquency, promiscuity, and criminality. Reaffirming the right of workers to hold private property and to organize labor unions, the social teaching once again set a path that would veer toward neither the collectivism of Marxist ideology nor the exalted individual freedom of a liberal ideology. Instead of these, the path of social justice would call for cooperation, dialogue, and sharing both within and between countries. A just exercise of political power would be directed toward “the common good,” a principle that will be addressed more completely below.

On the one-hundredth anniversary of Rerum Novarum, Pope John Paul II (1991) promulgated his Encyclical Letter Centesimus Annus. The Berlin Wall had fallen in 1989, the United Soviet Socialist Republic was within months of being dissolved, and the economic and social chasm between the developed and underdeveloped worlds had never been greater. Within the developed world, material poverty was only one cause of marginalization; refugees, migrants, the elderly, the sick, and the unemployed were all excluded from the benefits of technological and economic progress. These “victims” of modern capitalism and consumerism constituted “the poor” on whose behalf the Church took a “preferential option” (1991, #57). John Paul II reasserted the Christian social doctrine initiated by Leo XIII, broadening its scope to include concern for environmental loss and destruction and introducing the concept of an authentic “human ecology” (1991, #38) that preserves human dignity and freedom and overcomes alienation by means of solidarity and communion (1991, #41). The Christian Gospel message of love for God and love for one's neighbor would be “made concrete in the promotion of justice” (1991, #58).

In spite of strong, clear, and consistent teachings on the demands of social justice and the nature of the common good, global history from the time of Pope Leo XXIII's Rerum Novarum (1891), through the Great Depression and Pope Pius XI's Quadragesimo Anno (1931), continuing through the reign of Pope John XXIII in Mater et Magistra (1961), Pacem in Terris (1963), and the Second Vatican Council (1962 to 1965), was a history of increasing gaps between rich and poor citizens, rich and poor countries, and developed and underdeveloped regions. In Populorum Progressio (On the Development of Peoples 1967), Pope Paul VI reprimanded the rich who in their greed continued to amass wealth while others lived in misery and poverty. He insisted that “the superfluous wealth of rich countries should be placed at the service of poor nations” and noted that global conflicts were fueled by inequity and poverty (1967, #49). Twenty years later, in Sollicitudo rei Socialis (On Social Concern 1987), Pope John Paul II (1987) grieved over the “innumerable multitude of people—children, adults and the elderly, in other words, real and unique human persons—who are suffering under the intolerable burden of poverty” (#13). He drew attention to global “fragmentation,” homelessness and unemployment, production and trade in military arms, refugees, terrorism, and international debt.

As important as it was to develop a robust understanding of the demands of social justice and to orient it to the common good of human persons and all forms of human communities, these principles required an additional component that would make them operational; a dynamic element that would translate the principles into concrete actions. Catholic social justice teachings provided this element by means of the concept of solidarity.

Motivating a Response in Social Solidarity

In the words of Pope John Paul II:

Solidarity helps us to see the “other” whether a person, people or nation not just as some kind of instrument, with a work capacity and physical strength to be exploited at low cost and then discarded when no longer useful, but as our “neighbor,” a “helper,” to be made a sharer, on a par with ourselves, in the banquet of life to which all are equally invited by God. (1987, #39)

Social solidarity is constructed on the foundations of the dignity of human persons, created in the image of God; the inherently social and relational nature of humanity; recognition of the call to social justice at all levels of human interaction; and the orientation of social relations, interactions, and institutions toward the common good of humanity. Social solidarity translates the demands of social justice into concrete gestures of concern, respect, assistance, generosity, and sustenance. In the history of its development in Catholic teaching, solidarity functions as a call to action with the objective of realizing human rights and responsibilities toward one another as familial sisters and brothers, neighbors, and fellow citizens of the world. Whereas social interdependence can be a merely analytical conjecture, Pope John Paul II insists that “[i]nterdependence must be transformed into solidarity” (1987, #39).

In a uniquely Christian manner, social solidarity was shaped by a “preferential respect” for the poor, the weak, and the vulnerable. Pope John Paul II, in his encyclical of 1987, spoke of “the option or love of preference for the poor … [as] a special form of primacy in the exercise of Christian charity, to which the whole tradition of the Church bears witness” (1987, #42). Elsewhere, John Paul II explained that “[l]ove for others, and in the first place love for the poor, in whom the Church sees Christ himself, is made concrete in the promotion of justice” (1991, #58). This notion of “preference” for the poor was prominent in Latin American liberation theology as elaborated by Gustavo Gutiérrez, Juan Luis Segundo, and Jon Sobrino, in the early 1970s. Within that context, the liberation sought was liberation from oppression and social and economic marginalization, and the image of “listening to the cry of the poor” expressed its focus. Although the Catholic Magisterium would eventually reject the suspected alliance between liberationists and Marxists, the “preferential option for the poor” remained prominent in the post-Vatican Two mindset and theology. Pope Paul VI, in his Apostolic Exhortation Evangelii Nuntiandi (1975), expressly voiced the Church's duty:

to proclaim the liberation of millions of human beings … [in their] struggle to overcome everything which condemns them to remain on the margin of life: famine, chronic disease, illiteracy, poverty, injustices in international relations and especially in commercial exchanges, situations of economic and cultural neo-colonialism sometimes as cruel as the old political colonialism. (1975, #30)

Catholic papal writings move beyond solidarity among the poor to promote solidarity with the poor and marginalized—“the hungry, the needy, the homeless, those without medical care, and those without hope”—and then proceed to explicate the concomitant demands on those with wealth (John Paul II, 1987, #42). Their accumulation of goods, based on “arrogation to oneself” of an unjust portion of property and possessions, must be shared out among all members of society. If people are starving and homeless, it is because of the self-indulgence of the rich. The Bishops of the Second Vatican Council said that if the rich do not feed the hungry, they are “killing” them (Second Vatican Council, 1965, #69). In Solicitudo rei Socialis, Pope John Paul II said that solidarity is “not a feeling of vague compassion or shallow distress at the misfortunes” of the poor but “a firm and persevering determination to commit oneself to the common good” (1987, #38). Are we, then, our brothers’ and sisters’ keepers? Catholic social teachings say, Yes, absolutely yes.

IV. DISCUSSION

The 2009 H1N1 pandemic had been anticipated for some time. Although it was far less damaging than anticipated, it resulted in much concerned, confused, and frightened public attention. Careful analysis of the policy responses to the pandemic is underway, but it is clear that there was a gap in understanding and planning for the major ethical and moral issues such an emerging global threat presented to the public health. Although there had been an emerging consensus on the need for a public health ethic distinct from the individually focused bioethics of health care and research, the H1N1 pandemic arrived before such an ethic was fully developed. We have presented here some of the recent developments in forging an ethic for public health appropriate to its focus on populations and communities. These advances include recognition of social justice as the foundational value of public health and identification of the prevalence of systems of social privilege and social disadvantage (Powers and Faden, 2006, 81); attention to the mechanisms of social injustice and their consequences for the most vulnerable in times such as pandemic (Powers and Faden, 2006; Baylis, Kenny, and Sherwin, 2008, 2); recognition of the essential relationality rather than discreteness of human persons as embodied beings (Baylis, Kenny, and Sherwin, 2008, 200–2); and the need for a human rights foundation for public health ethics (Mann, 1997; Gostin, 2001; Marks, 2001; Farmer, 2002).

We have focused on Baylis and colleagues framework for public health ethics structured by relational personhood, relational autonomy, social justice, and relational solidarity. We believe that these notions can assist in shaping a new and more appropriate ethic for public health. Furthermore, we propose that faith traditions are natural sources for insight into and education about these relational notions. We look specifically at the Catholic tradition and identify four potential contributions to public and policy conversations about public health and the foundational relational values of public health ethics.

The Tradition Supports a Moral Foundation for Public Health Ethics and Practice

Relational autonomy demands respect for the dignity of the human person. Within the tradition of the Catholic Church, the “dignity” of the human person serves as an epistemological foundation for any ethical framework (John XXIII, 1961, #194, 219, 220; 1963, #9, #44, #144; Second Vatican Council, 1965, #26–7). Human persons bear the image of God and thus reflect God to and for one another's lives (John XXIII, 1963, #3; US Bishops, 1983, #15; Catechism, 1993, #225, #1700). Persons are simultaneously individual and social, unique beings created within a social context (Second Vatican Council, 1965, #26; Catechism, #1879). Because of the sacredness of life, every person is entitled to fundamental human rights including the right to life and to the necessities of life—adequate food, shelter, clothing, and so on (John XXIII, 1961, #157; Paul VI, 1967, #21–3). Human dignity thus includes reciprocal responsibilities and duties to oneself and to others (John Paul II, 1987, #42; John XXIII, 1963, #35; Synod of Bishops, 1971, #7, #34; US Catholic Bishops, 1986, #365; John Paul II, 1987, #38). Catholic social justice requires fair access to social goods and is characterized by low levels of systematic disadvantage, discrimination, oppression, domination, and injustice. Central to this tradition, social justice is achieved by taking a preferential option for the poor, the weak, and the vulnerable (Paul VI, 1971, #23; US Bishops, 1986, #16, #87; John Paul II, 1987, #41–2; John Paul II, 1991, #58). In the just society, citizens undertake the necessary civic and social duties to provide the means of subsistence for all.

Social solidarity is forged when interdependence is transformed into solidarity by mutual responsibility, equal regard, and mutual respect (Leo XIII, 1891, #33; John XXIII, 1961, #157; Synod of Bishops, 1971, #7, #30; John Paul II, 1987, #38). Solidarity can, of course, have a negative value if it serves privilege or promotes an “us” and “them” perspective; if it functions in a manner that distorts the inherent interdependence of human persons; or if it neglects the interdependence of humanity within global and ecological perspectives. The Catholic tradition calls all members of the human community to fulfill their duties to one another and to acknowledge and protect the human rights of all persons.

The Catholic Tradition Directs the Goal of Public Health to the Common Good

This concept of the common good is multidimensional, inclusive of all humanity, and is related to ecological health and integrity (Leo XIII, 1891, #66; John XXIII, 1961, #20, #65, #78–9; John XXIII, 1963, #56, #137; Second Vatican Council, 1965, #74; United States Catholic Bishops, 2001, #15, #25). The common good demands a political governance that is fully inclusive and representative (John XXIII, 1961, #20); public laws and policies that are fair and equitable (Paul VI, 1967, #23, #33); an economy that provides productive work, fair wages, safe working conditions, wealth sharing, and poverty reduction (Leo XIII, 1891, #66); and social institutions that promote equality, protect human rights, foster community, and meet social responsibilities (John XXIII, 1963, #54, #98). Within the common good, promoting health and well-being has an inherently communal and social dimension. The common good is characterized by human flourishing; its potential becomes feasible when no one's pursuit of well-being is inhibited by the disadvantage or suffering that arises from neglect, discrimination, marginalization, or unnecessary vulnerability.

The Catholic Tradition Supports the Importance of the Socioeconomic Determinants of Health as Integral to Justice

Attention to the socioeconomic determinants of health is currently widespread and includes the World Health Organizations’ Commission on Social Determinants of Health (WHO, 2008) and Canada's National Collaborating Centre on Determinants of Health (inaugurated in 2004). Evidence demonstrates compellingly that higher levels of socioeconomic status correlate with higher levels of health and increased longevity throughout the spectrum of income levels even in countries where poverty is minimal and human rights are protected (Mann, 1997; Public Health Agency of Canada [PHAC], 2004, iv, vii, 3). Among the issues recognized for their potential to promote or undermine health are poverty and wealth; race and gender; food security; adequacy in shelter and clothing; opportunities for employment and fair wages; healthy working conditions; and political stability, instability, or war. There are clearly numerous commonalities between the social justice teachings of the Catholic tradition and these issues.

The most significant contribution made by a “determinants of health” perspective to public health is its ability to account for health status variables that are clearly not the result of personal health-promoting or health-harming choices. The pivotal affirmation being made is that economic, social, and political structures within society have direct correlations with community and individual levels of well-being that are stronger than individual choices and behaviors (PHAC, 2004, 3; WHO, 2008). Understanding the scope of public health in such a comprehensive manner serves as a corrective to piecemeal and discrete initiatives.

The Catholic Tradition Provides Motivation for Public Health Advocacy

Baylis, Kenny, and Sherwin (2008) identify “mutual vulnerability and interdependence,” a “shared interest in survival, safety and security,” and “mutual vulnerability to disease, violence and death” as central to their understanding of relational solidarity (205-–6). These powerful perspectives in high-risk situations, such as pandemic, cohere with the Catholic epistemological view of the inherently social nature of the human person. The Catholic tradition also provides an essential link between knowledge and action. Each uniquely individual and social human person created by and in the image of God,has transcendent worth. The dignity due to each person because of this transcendent worth recognizes inalienable rights to the necessities of life and bodily integrity, freedom to choose and act, and, therefore, personal responsibility and accountability. Accordingly, human persons are neighbors to one another on both a worldly and a transcendent plane, responsible for one another's well-being. The human vocation in the Catholic tradition is fulfilled by love for one's neighbor as manifested in acts of dignity, provision for needs, redressing of inequities, pursuit of social justice, and contribution to the common good. Seen in this way, relational solidarity is an anthropological reality that demands to be fulfilled in understanding and action; to articulate it as a concept is to simultaneously specify the actions that are required.

Because of this essential link between knowledge and action, a Catholic understanding of public health suggests an ethic of advocacy. The characteristic roles, activities, and tasks of public health would be shaped by the demands of the common good and the goal of promoting flourishing among all human persons (John XXIII, 1963, #11, #145). Public health initiatives to promote health and well-being would encompass amelioration of human suffering and specifically attend to violations of human dignity. Reducing health risks and harms would include reductions of health inequities due to privilege and disadvantage, wealth and poverty, strength, and vulnerability. Planning for and responding to a global threat such as pandemic require a healthy dose of religious insight into our situation as brothers and sisters in Christ. In our individual autonomy, unlimited individual benefit from technology world of health care politicians and public health officials alike can use all the help they can get to motivate to solidarity and the common good.