Insights
The Faculty Journal of Austin Seminary
FALL 2025
Greenway • Cotterill • Vigen • Thesnaar
Joslyn-Siemiatkoski • Rutherford • Caruthers
Insights
The Faculty Journal of Austin Seminary
Fall 2025
Volume 141 Number 1
Editor: William Greenway
Editorial Board: Ángel J. Gallardo, Crystal Silva-McCormick, Jeff Sanchez
The Faculty of Austin Presbyterian Theological Seminary
Sarah Allen
Margaret Aymer
Patricia Bonilla
Rodney A. Caruthers II
Gregory L. Cuéllar
Ted V. Foote Jr.
Ángel J. Gallardo
William Greenway
Carolyn Browning Helsel
Philip Browning Helsel
José R. Irizarry
David H. Jensen
Donghyun Jeong
Jennifer L. Lord
Song-Mi Suzie Park
Cynthia L. Rigby
Crystal Silva-McCormick
Andrew Zirschky
Insights: The Faculty Journal of Austin Seminary is published two times each year by Austin Presbyterian Theological Seminary, 100 East 27th Street, Austin, TX 78705-5797. e-mail: wgreenway@austinseminary.edu
Web site: austinseminary.edu
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Some previous issues of Insights: The Faculty Journal of Austin Seminary, are available on microfilm through University Microfilms International, 300 North Zeeb Road, Ann Arbor, MI 48106 (16 mm microfilm, 105 mm microfiche, and article copies are available). Insights is indexed in Religion Index One: Periodicals, Index to Book Reviews in Religion, Religion Indexes: RIO/RIT/IBRR 1975- on CD-ROM, Religious & Theological Abstracts, url:www.rtabstracts.org & email:admin@rtabstracts.org, and the ATA Religion Database on CD-ROM, published by the American Theological Library Association, 300 S. Wacker Dr., Suite 2100, Chicago, IL 60606-6701; telephone: 312-454-5100; e-mail: atla@atla.com; web site: www.atla.com; ISSN 1056-0548.
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COVER: "Sanación Colectiva: Threads of Belonging” by Christian Espinoza; used with permission from the artist. View more of Christian’s artwork and projects at https://sites.google.com/view/chrisespinoza/.
An Interview with William Greenway with Crystal Silva-McCormick
Healing the American Health Care System: Medicare for All by Max Cotterill
“Jesus Wept”: United States Healthcare and Christian Ethics in an Era of Tyranny by Aana Marie Vigen
Relational Ethics, Justice, and South Africa’s National Health Insurance Act by C.H. Thesnaar
Pastors’ Panel
Kate McGee, Evan Solice, Guesnerth Josue Perea
Faculty Books
Christian Theology in a Pluralistic Age, edited by David H. Jensen, reviewed by Daniel Joslyn-Siemiatkoski
Horizons in Biblical Theology, edited by Gregory L. Cuéllar, reviewed by Sarah Rutherford
Christianity and Culture
The Effects of AI on Church Ethics, Theology, and Education by Rodney Caruthers II
To view past Insights issues, visit: www.issuu.com/austinseminary or scan the QR code.
To request a digital or hard copy of a past issue, email: marcom@austinseminary.edu.
Introduction
Ancient wisdom, unencumbered by the specialization of knowledge that characterizes modern societies, stressed the importance of individual physical health in maintaining the broader political, economic, and cultural well-being of society. This holistic view of “shalom” was echoed by the prophet Jeremiah, who, when confronted with the dire religious and political conditions of Jerusalem, laments in agony, saying, “since my people are crushed, I am crushed. I mourn, and horror grips me. Is there no balm in Gilead? Is there no physician there? Why then is there no healing for the wounds of my people? (Jeremiah 8:21-22 NIV).
In this edition of Insights, the authors revisit the question of health care, framing it at the intersection of religious concerns for the well-being of all God’s people—the heirs of a promise of abundant life. A healthy life reflects such abundance and should not be hindered by material, political, or ideological considerations. Although the existing systems have removed health issues from the realm of ethics through the secularization and eventual commodification of medicine, addressing challenges in the health care system requires a clear theological response. Presbyterian minister and scholar in medical humanities, Nathan Carlin, argues that the secularization of medicine does not eliminate religious belief and experience, as they influence, even when expressed in secular language through what he calls “transposition,” both principles of care and medical practice.
From Professor William Greenway’s suggestion that we adopt a moral realist approach to health care to counterbalance the profit-driven medicalization industry, to Dr. Thesnaar’s invitation to embrace a relational ethics rooted in the African principles of communal accountability to inspire advocacy for equal access to health care, we reengage the dialogue of medicine and care as part of a spiritual vocabulary, whether we call it “agape” or “ubuntu.” Max Coterhill and Dr. Aana Marie Vigen give an account of the challenges facing the contemporary health care system in the United States. Reading the chapters together exemplifies the tension between medical practitioners’ clear moral vision for transforming the American health care system into a patient-centered one and the governmental policies, economic interests, and administrative inefficiencies that oppose that moral vision. Guesnerth Josue Perea, Kate McGee, and Evan Solice provide practical applications of these theoretical discussions in contexts of pastoral care and congregational advocacy. As many medical decisions and treatments will be increasingly informed by artificial intelligence, we welcome Professor Rod Caruthers’ contribution regarding the effects of AI on church and theological ethics.
The voices in this volume heed this call on behalf of people of faith—if we are to serve the healing of the nation, we should start by caring for the bodies of its citizens. Acts of attention, advocacy, compassion, prayer, and solidarity may not erase all suffering, but will give society the tools to bear pain and disease with dignity. Upholding that ethical commitment can indeed confirm that there is still a balm in Gilead to make the wounded whole.
José R. Irizarry President of Austin Seminary and Professor of Practical Theology
“Moral Realism Theory and U.S. Health Care”
William Greenway
Pathology
In 2020, CBS News reported on Representative Katie Porter’s interrogation of Celgene’s CEO over the pricing of its cancer drug, Revlimid, which increased from $215 to $763 per day between 2005 and 2020 (roughly $5500/month to $19,800/month1).2 The CEO explained Celgene spent $800 million creating the drug and hundreds of millions more on development. But, Porter replied, no developments significantly improved treatment and much of the money went to gaining approval to treat more diseases. Moreover, even if Celgene spent $2 billion over decades, Revlimid generated $10 and $12 billion in sales in 2019 and 2020 alone3—tens of billions in sales over development costs. This likely helped justify the reported $13 million salary and nearly $40 million in cash and stock the CEO received when Bristol Myers Squibb bought Celgene in 2019.4
Celgene’s CEO objected to Porter’s suggestion of “price-gouging,” saying he had “strived to bring the values of integrity, service and respect to every part of my career.”5 He might also have objected, as did the CEO of Mylan ($18 million compensation) when she was similarly accused for “stratospheric price hikes” of EpiPens to roughly $600 per twopack—active ingredient reportedly around $1 per device—that she was not to blame because the U.S. economic and legal system incentivized precisely the moves she made.6
In 2020, The Intercept reported on Gilead Sciences.7 Gilead received $79 million in federal funding to research the COVID-19 drug Remdesivir. Gilead calculated its value per patient was $12,000 because it reduced hospital stays on average by four days. However, Gilead’s CEO explained, because COVID was a crisis, they decided on lower prices. Insur-
Dr. William Greenway, Professor of Philosophical Theology at Austin Seminary, teaches and conducts research in theology, ethics, and philosophy. He has served as a member of the Ethics Committee at St. David’s Heart Hospital, as a member of Dell Medical School and Moody College of Communication’s “Center for Health Communication Think Tank” at The University of Texas, as a Fellow at the Oxford Centre for Animal Ethics, on the Board of Texas Impact, as an Ecumenical Associate in the United Church of Christ in the Philippines, and as an elder in the Presbyterian Church, USA. He is the author of numerous scholarly articles and books, most recently, In the Light of Agape: Moral Realism and Its Consequences (Cascade, 2024)
ers would only pay around $3,120 for a five-day course and $5,720 for a 10-day course. This sounds good, The Intercept observed, except to produce a day’s dose costs 93 cents. However, Gilead’s CEO might have responded, it is best practice for companies to maximize profit by charging what the market will bear.
In 2024, the Commonwealth Fund published a study comparing health care systems in 10 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the U.K., and the U.S. Differences overall were “relatively small.” The “only clear outlier” was the U.S. Huge gaps separate the U.S. on performance (“dramatically lower”) and spending as a percentage of GDP (far higher). Australia and the Netherlands spend the lowest percentage of GDP and have the best performing systems. The U.S. ranks second in “care process” (quality of care)—so perhaps the best health care if you can afford it8—but U.S. performance overall is “dramatically lower” because it ranks second to last in “administrative efficiency” and dead last in “access to care,” “equity,” and “health outcomes.”9
The Commonwealth Fund says Americans “live the shortest lives and have the most avoidable deaths” and the other nations don’t place “covered residents in such financial jeopardy.” They note the Netherlands, the U.K., and Germany all provide universal coverage, and in Germany, “copayments are capped at … 2 percent of gross income for all patients, and 1 percent for chronically ill patients—above which all care is fully covered.” On the whole, the Commonwealth Fund concludes, Americans are “spending vast amounts for generally poor results,” so “the United States is not meeting one of the principal obligations of a nation: to protect the health and welfare of its residents.”10
According to the American Medical Association (AMA), “Health spending in the U.S. increased by 7.5% in 2023 to $4.9 trillion [compare $1.3 trillion in 200011] or $14,470 per capita [compare $4358 per capita in 199912],” “17.6% of GDP [compare 13% GDP in 200013].”14 Also in 2023, “spending on prescription drugs and hospital care rose by 11.4% and 10.4%.”15 All while U.S. inflation overall was 3.4%.16 According to economists Anne Case and Angus Deaton (2020), Crestor cost $86/month in U.S., $41 in Germany, $9 in Australia; Humira $2505/month in U.S., $1749 in Germany, and $1243 in Australia; hip replacement on average $40,000 in U.S., $11,000 in France; MRI $1,100 in U.S., $300 in Britain.17
Gallup says, despite Medicare, “out-of-pocket healthcare expenses for adults 65 and older rose 41% from 2009 to 2019,”18 and a 2016 Kaiser Foundation study found that “problems related to unaffordable medical bills and medical debt” affect “roughly 1 in 4 non-elderly adults in the United States.”19 A 2019 article in the American Journal of Public Health found medical expenses are a major contributor to 58.5% of personal bankruptcies.20
According to a 2019 (before Covid) report in Gallup News, 22.9% of American adults (around 58 million) report not being able to pay for drugs prescribed by a doctor in the last 12 months and a stunning 13% (around 34 million) report knowing a friend or family member who died in the last five years after not receiving treatment due to an inability to pay.21 Many reports say matters are worse if you are non-white, female, older, middleincome or poor.22 According to Gallup News in 2022, 33% of Democrats, 44% of Republicans, and 42% of Independents were “concerned” or “extremely concerned” about care.23
Moral Realism Theory and U.S. Health Care
Meanwhile, according to JAMA Internal Medicine, from 2001 to 2022, “Payouts to shareholders from large, for-profit, publicly traded health companies” increased “more than 300%, from $54 billion in 2001 to more than $170 billion in 2022.”24 Massive profits fuel tremendous political power. According to Case and Deaton, drug companies spend more on marketing than research,25 in 2018, “the healthcare industry employed 2,829 lobbyists, more than 5 for each member of Congress,” and spent “more than $567 million on lobbying”—“the largest spending industry, larger even than the financial industry”— and in addition contributed money to “actual or potential members of Congress, $76 million to Democrats and $57 million to Republicans.”26
The calculations are torturous, and one can endlessly debate details, but the overall picture is so dramatically skewed even pro-capitalist Princeton economists Anne Case and Angus Deaton (Nobel Prize, 2015) conclude the American healthcare system is “a parasite on the economy,” a “tapeworm…grown to be huge… sucking nutrients that the rest of the body needs.”27
Because of the complexity, I long started my biomedical ethics classes telling students we would study ethical theories and topics like abortion, climate change, euthanasia, racism, and sexuality, but I lacked expertise and time to engage a vital issue: American health care.
By Fall 2024, I was so concerned I decided to hand a week of class to the celebrated director of an influential progressive political lobby. I presented the Commonwealth Fund comparisons and introduced our guest. I was not surprised when he started with a 2019 Health Affairs article paying tribute to German-born Princeton economist, Uwe Reinhardt (d. 2017), famous for shining a light on U.S. healthcare performance in comparison with other nations. Reinhardt saw pricing as the key variable hurting Americans.28
I was stunned, however, to hear him stress a point made by Reinhardt: “As every firstyear student in economics is taught—or should be taught—it is impossible to compare public policies in terms of their relative efficiency, if those policies aim at different social goals”29—and then use that point to undercut the damning comparisons. Our animated discussion after class ended with me in shock. I was defending Reinhardt’s contention that price control is essential. “But,” this progressive objected, “controlling prices is unAmerican.”
It hit me hard: neither Republicans nor Democrats were going to help. The next day, I informed Insights I had decided to focus the Fall 2025 issue on “Ethics and Health Care Access.” A few days after that, Brian Thompson, CEO of UnitedHealthcare, was murdered in Midtown Manhattan, sales of Jay Feinman’s Delay, Deny, Defend (2010) were surging, and newsroom elites from Fox to the New York Times were expressing disbelief that many on social media did not share their outrage over Thompson’s murder.
Ethically, Thompson’s murder was unjustifiable evil. Socio-politically: counterproductive. But the online reaction may be a caution. Conservative and progressive elites may do well to attend to Americans—perhaps some of the medically bankrupt, or some of the 34 million who watched a family member or friend die, unable to afford care—who wondered where society’s outrage was when they suffered, grieved, raged.
My guest lecturer was right about Reinhardt. Reinhardt continues: “Therefore, it is not meaningful to ask which nation—e.g., Canada or the U.S.—has the ‘best’ health system, because the two nations posit for their systems such vastly different social ethics.” So, he concludes his note on ethics, “It is all a matter of taste, and, as the Romans so aptly put it, de gustibus non est disputandum” [there is no disputing about taste].30
Reinhardt is also sympathetic to “serious policy makers who have long despaired of taking voters’ aspirations seriously,” such that, “Health policy in this country therefore has been and is being forged strictly among a narrow policy-making elite that could easily fit into the Grand Ballroom of the Washington Hilton hotel.”31 The authors of the 2019 tribute to Reinhardt suggest those elites have been working to make things better. “Since 2003,” they say, “there has been much greater attention given to,” an array of, “changes designed to lower the level of spending in the U.S.” But they conclude the problem is still the prices.32 And because matters have gotten significantly worse, we may reasonably suspect the majority of that brilliant, policy-making elite are getting the results they’re aiming at.
It is significant when even Uwe Reinhardt, who knew superior care in Germany and was passionate about bringing Americans comparable care, concludes that deciding among “social ethics” for health care boils down to taste. George likes vanilla. Suzie likes chocolate. Michael likes helping people and works to provide the best healthcare possible. Cassie likes money and targets the sick and injured to extract maximum profit. De gustibus non est disputandum.
The CEOs of Celgene, Mylan, and Gilead were right: insofar as U.S. laws incentivize prioritization of financial gain and the fiduciary responsibility of corporate officers is to maximize shareholder value, it’s not the CEO’s fault when drug prices are designed to leverage maximum profit from stricken patients. My guest lecturer was right: controlling spending is currently un-American. The Commonwealth Fund was wrong: one cannot presume nations have an “obligation” to “protect the health and welfare of their residents” when even Reinhardt reduces the comparison of “social ethics”— maximize health vs. maximize profit—to a matter of taste.
Diagnosis: Agape Deficiency Disorder
When Reinhardt feels himself forced to throw up his hands over avoidable suffering, death and exploitation—there’s no disputing taste—he embodies the massive, tragic, concrete, socio-politically dangerous, real-world consequences of modern Western rationality’s infamous “crisis of foundations” in ethics. Over the past ten years, I have published six books arguing for Moral Realism Theory (MRT), which is distinguished by its affirmation of agape. Agape signifies the singular moral force at the heart of ethical conviction, provoking joy and affirmation in wonderful contexts and outrage and resistance in horrific contexts.
We see children laughing with delight in new-fallen snow. We see children screaming in pain in the ER. We are not first objective, detached, neutral, and only then deciding what we think. No, insofar as we are not by nature or through repeated hardening of heart psychopathic, whether they are scenes of joy or scenes of horror, we are instantly, before de-
Moral Realism Theory and U.S. Health Care
cision or even reflection, joyful or horrified. The singular passion by which we are seized in both contexts, the singular passion enflaming our joy or, in other circumstances, our horror, the palpable spiritual force over and against which we must exert ourselves if we decide to harden our hearts, that spiritual force is agape—or “hesed” (Judaism), “maitrī” (Buddhism), “ren” (Confucianism), “Holy Spirit” (Christianity), and the like.
Agape is the wellspring of “good” in a moral realist sense. Realist because moral here is not indexed to what is pleasurable, chosen, desired, genetically or memetically selected for, or implicitly or explicitly contracted. Moral is rooted in the force signified by agape, a force as real as gravity but different in kind, the force over and against which good and evil are discerned. Affirmation of agape does not resolve ethical quandaries but permits definitive answers to basic ethical questions— “should one aid or exploit a child stricken with cancer?”—and permits normative comparison of different societies’ “social ethics.”
Moral Realism Theory hypothesizes that the most reasonable and comprehensive understanding of reality requires taking reality under the description of three incommensurable families of vocabularies: Sphere of Nature vocabularies of causation (vocabularies of the modern natural and social sciences, including those of realpolitik, economics, eros, and kinship, reciprocal, or group altruism), Sphere of Poetic I’s vocabularies of free will (vocabularies of self-determination, authenticity, poetic self-creation, personal praise and blameworthiness), and Sphere of Agape moral vocabularies (vocabularies of spirituality and ethics, Hindu to Humanist, Bahai to Wiccan).
Different ends are idealized in different spheres. The Sphere of Nature idealizes material power and fulfillment of desire, and success yields wealth, security, and physical satisfaction. The Sphere of Poetic I’s idealizes free will and creative generativity, and success yields satisfaction over authentic identity and creative works. The Sphere of Agape idealizes life lived in the light of love for all and communities sustained by love, and success yields belonging, meaningfulness, and spiritual peace.
It is dangerous to be wildly successful in one sphere and bereft in others. Some painful results are cliché: miserable Scrooge, starving artist, penniless do-gooder. True flourishing requires relative success in all three spheres. Imbalance is natural but requires mitigation to prevent severe deficiency. Bank presidents and stockbrokers live primarily in the Sphere of Nature, so should attend to the poetic and agapeic. Painters and poets live primarily in the Sphere of Poetic I’s, so should attend to the financial and agapeic. Social workers and clergy live primarily in the Sphere of Agape, so should attend to the financial and poetic.
Dynamics in health care are especially fraught. Doctors in the U.S. were once well-off (not rich), autonomous, and beloved because they were consumed by agapeic passion for healing. Agapeic passion endures among the doctors, nurses, and even the few CEO’s I know, but now they work for corporations which live solely in the Sphere of Nature. As a result, doctors, nurses, and executives can be stripped of autonomy and alienated from agapeic passion for healing, reduced to cogs servicing a system focused on profit, forced sometimes to choose between the legal and the good. Medical institutions often urge employees to work and give from the heart (Sphere of Agape) while simultaneously
compensating, supplying, and controlling them strictly in accord with the bottom line (Sphere of Nature). The control, alienation, and duplicity violate autonomy and agape and exacerbate moral distress. Reportedly, around 50% of nurses suffer moral distress, and it is a significant reason roughly 50% leave nursing with less than two years of experience33 (doctors are also afflicted34).
Sometimes, caregivers should harden their hearts. When the screaming child is rushed into the ER, nurses and doctors should focus with robotic intensity upon Sphere of Nature analysis and action. Afterwards, however, they must process the searing agapeic dynamics or suffer moral injury. That is more difficult insofar as corporate does not track or fund agapeic processing, insurance or policy prevents them from providing optimal care, or they realize the child will recover but the family faces bankruptcy.
Insofar as U.S. corporations possess key political rights and strive to maximize profit, the U.S. has created incredibly powerful super-citizens with hive-minds thinking solely within the Sphere of Nature. The CEOs of Celgene, Mylan, or UnitedHealthcare are the replaceable tools of those in control: the corporations themselves. Unlike most people (including most nurses and doctors), corporations are typically built to think solely about how to exploit the stricken child. Are U.S. healthcare executives disempowered do-gooders or greedy psychopaths? It is usually impossible to know, because even CEOs have very little legal/fiduciary freedom. There is reason to fear that the system selects for brilliant psychopaths, but if there are healthcare executives who are ethically good, they will be using their smarts, insider knowledge, and riches to transform healthcare policy against their own and their firm’s financial interests (legally if, of necessity, secretly).
Regimes typically envision a Sphere of Nature world, so they think in terms of economic and military power over people within and without (realpolitik). But no regime 3% satisfied and 97% frustrated can survive. The 3% typically remain oblivious until too late. The solution is not visible from the Sphere of Nature, for what is needed is not more power but more love. To flourish and survive, a nation must be great (Sphere of Nature), empower people (Sphere of Poetic I’s), and be good (Sphere of Agape). Ancient Hebrew sages, surveying centuries-long cycles of dominance and defeat, spoke in terms of “forgetting God”—which meant forgetting the poor, the widow, the alien. When Israel remembered God, it flourished. When Israel forgot God (forgot agape), it was plundered from without because it had rotted from within. This is not magical thinking but hard-won wisdom: in order to flourish, nations must be great (Nature), empowering (Poetic I’s), and good (Agape). In this vein, we should harken when even economists like Case and Deaton, anxious to protect the future of American capitalism, say, rein in the exploitative dynamics of unbridled capitalism or face catastrophe 35
In a word, the U.S. healthcare industry harms and will continue to harm patients, providers, and society insofar as it lives in the Sphere of Nature but is bereft vis-à-vis the Spheres of Poetic I’s and of Agape.
Treatment: Agapeic Infusion
Agape deficit disorder is a philosophical disease afflicting rationality itself. It renders even the personally awakened (like Reinhardt) not only unable but resistant to nam-
Moral Realism Theory and U.S. Health Care
ing and affirming agape. The answer, however, is not a wholesale turn to the Sphere of Agape. Social utopian dreams have never been realized because, thinking wholly in terms of Sphere of Agape dynamics, socialist systems are devastatingly vulnerable to Sphere of Nature dynamics. Individually and communally, flourishing requires attention to all three spheres. Therefore, Case and Deaton are right to reject dreams of some “fantastical socialist utopia.”36 We need our rationality and our socio-economic and legal systems to be responsive to all three incommensurable families of vocabularies (Spheres of Nature, Poetic I’s, Agape). With regard to the rejuvenation of the Sphere of Agape, faiths, traditional custodians of agape, can play a vital role, allowing Presidents, nurses, generals, CEOs, lobbyists, janitors, painters, doctors and teachers alike to sit side by side in community—Buddhist, Christian, Jewish, Muslim, Zen—and harken unto agape. While essential, philosophical rejuvenation of agape will not tell us how to construct the perfect U.S. healthcare system. Case and Deaton conclude that while it is clear we need price controls to mitigate the intolerable consequences of any pure “market solution for healthcare,”37 current proposals for reform have serious shortcomings,38 so we should pursue myriad impactful incremental changes.39 This means that when it comes to making the concrete moves necessary to integrate agapeic concerns into cultural, socio-political, financial, and legal structures, we need knowledgeable, awakened experts—bankers, CEOs, doctors, economists, nurses, educators, judges, lawyers, legislators, lobbyists—to struggle to institute myriad incremental changes across the fabric of society.
Signs of progress will include: U.S. laws incentivizing attention to shareholder value inclusive of shareholder values (for instance, incentivizing pricing that is great/profitable and good); poetic and agapeic goals tracked from daily assessments to annual reports (so that “best practices” are defined not only in relation to profit, but also in relation to autonomy and agape); gasps of incredulity if someone suggests choosing between just and exploitative care (agape or mammon) is a matter of taste; consensus that nations should protect the health and welfare of their people; steady U.S. improvement in Commonwealth Fund standings; and enthusiastic agreement that curbing the excesses of unbridled capitalism (for instance, by controlling prices) for the sake of agape is the mark of a nation realistic and idealistic, great and good—definitely American.
Prognosis: Uncertain
Massive sums, incredibly rich and politically connected corporations laser-focused upon profit, greed among elites, and agape-deficient rationality all provide significant reason for despair. On the other hand, there is deep public concern, ample space to move from obscene to great profits, and numerous advanced industrial nations with good healthcare and thriving healthcare industries—so we know healing is possible. Moreover, I think the vast majority of nurses, doctors, and perhaps even health industry executives are personally awakened to agape and passionate about helping people, and I think the same is true for a vast majority of Americans, conservative and progressive alike (including the 1%). If so, clear public understanding of the issues should stimulate overwhelming support for myriad incremental actions promoting steady reform. The headwinds are incredibly powerful, but there is reason for hope, and the call to any who would be faithful to agape is clear.
NOTES
1. Usually prescribed for up to 12, 28-day cycles. https://www.healthline.com/health/drugs/revlimid-dosage
2. https://www.cbsnews.com/news/katie-porter-pharmaceutical-celgene-ceo-mark-alles-viral-video-drugpricing/
3. https://www.fiercepharma.com/special-report/top-20-pharma-companies-by-2020-revenue (see “7. Bristol Myers Squibb”).
4. https://www.cbsnews.com/news/katie-porter-pharmaceutical-celgene-ceo-mark-alles-viral-video-drugpricing/
5. https://www.cbsnews.com/news/katie-porter-pharmaceutical-celgene-ceo-mark-alles-viral-video-drugpricing/
6. https://www.nbcnews.com/business/consumer/lawmakers-grill-mylan-ceo-fda-epipen-price-hike-n651201
7. https://theintercept.com/2020/07/01/coronavirus-treatment-drug-contracts-trump/
8. https://www.princeton.edu/~paw/web_exclusives/plus/plus_041002Reinhardt.html
9. https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024
10. https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024
11. https://www.princeton.edu/~paw/web_exclusives/plus/plus_041002Reinhardt.html
12. https://www.princeton.edu/~paw/web_exclusives/plus/plus_041002Reinhardt.html
13. https://www.princeton.edu/~paw/web_exclusives/plus/plus_041002Reinhardt.html
14. https://www.ama-assn.org/about/ama-research/trends-health-care-spending
15. https://www.ama-assn.org/about/ama-research/trends-health-care-spending
16. https://www.usinflationcalculator.com/inflation/current-inflation-rates/. Relation of growth in spending to events and policy is complex (for instance, the Affordable Care Act resulted in massive growth in spending), see https://www.ama-assn.org/system/files/prp-return-to-growth-rates-spending.pdf
17. Anne Case and Angus Deaton, Deaths of Despair and the Future of Capitalism (Princeton: Princeton University Press, 2020), 197–198.
18. https://news.gallup.com/poll/393494/older-adults-sacrificing-basic-needs-due-healthcare-costs.aspx
19. https://www.kff.org/health-costs/report/the-burden-of-medical-debt-results-from-the-kaiser-familyfoundationnew-york-times-medical-bills-survey/view/print/
20. https://pmc.ncbi.nlm.nih.gov/articles/PMC6366487/
21. https://news.gallup.com/poll/268094/millions-lost-someone-couldn-afford-treatment. aspx#:~:text=WASHINGTON%2C%20D.C.%20%2D%2D%20More%20than,by%20Gallup%20and%20 West%20Health.
22. For just one of myriad examples, see https://features.propublica.org/diabetes-amputations/blackamerican-amputation-epidemic/
23. https://news.gallup.com/poll/395126/four-americans-cut-spending-cover-healthcare-costs.aspx
24. https://ldi.upenn.edu/our-work/research-updates/chart-of-the-day-health-care-profits-increasinglysupport-shareholder-payouts/
25. Case and Deaton, 198.
26. Case and Deaton, 210.
27. Case and Deaton, 207.
28. https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2018.05144
29. https://www.princeton.edu/~paw/web_exclusives/plus/plus_041002Reinhardt.html
30. https://www.princeton.edu/~paw/web_exclusives/plus/plus_041002Reinhardt.html
31. https://www.princeton.edu/~paw/web_exclusives/plus/plus_041002Reinhardt.html
32. https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2018.05144
33. Heather Bong, “Understanding Moral Distress: How to Decrease Turnover Rates of New Graduate Pediatric Nurses,” Pediatric Nursing 45, no. 3 (May-June 2019): 109–114. Alvita Nathaniel, “Moral Distress,” in J. Fitzpatrick (ed.,), Encyclopedia of Nursing Research (4th ed.), Springer Publishing Company, 2017.
34. See Nicole M. Piemonte, Afflicted: How Vulnerability Can Heal Medical Education and Practice (Cambridge, MA: MIT Press, 2018).
35. Case and Deaton, 201. See especially Chapter Thirteen, “How American Healthcare is Undermining Lives,” and Chapter Sixteen, “What to Do?”
36. Case and Deaton, 262.
37. Case and Deaton, 207–211, 245–262.
38. Case and Deaton, 248–251.
39. Case and Deaton, 207–211, 245–262.
Insights Editor Crystal Silva-McCormick Interviews William Greenway
What brings you to this subject?
The U.S. healthcare industry is causing avoidable pain and suffering, even death, for millions of Americans. It’s causing bankruptcies and financial stress, which links it to divorce, domestic violence, suicide, and homelessness. It’s hurting doctors, nurses, and other healthcare professionals. I’m on an ethics committee at Austin Heart Hospital and a Think Tank at Dell Medical School. Those doctors and nurses are passionate about their patients, but they’re caught in a system whose ultimate goal is profit, which alienates them from their passion. I think it’s a national spiritual crisis. A country whose legal and economic systems are designed to exploit people when they’re vulnerable and needy is in desperate need of spiritual renewal. I think most Americans want to love and care for the vulnerable, but we’ve created a system which does the opposite. It’s clear we can do better because other advanced industrial nations do far better.
Why are there such massive profit margins, and will they continue to increase?
Why obscene profit margins? The simple answer is greed. Plus, people will empty their savings and mortgage their homes to keep themselves or loved ones alive. So, greed plus incredible leverage. But that’s the simple answer because greedy players are not the issue. Sociologist C. Wright Mills distinguished between troubles and issues. With a trouble, a person is to blame. Deal with the person, fix with the trouble. With an issue, a system is to blame. Dealing with individuals doesn’t help because the system is the problem. The American healthcare industry co-opts people at every level. Even if every individual in the American healthcare industry were good, their legal, fiduciary, and professional duty would still inscribe them in a system whose prime directive is not to maximize health but to maximize profit.
Money matters, but maximizing profit does not have to be the ultimate goal. I have friends in Germany, a couple who are a GP and an orthopedic surgeon. They’re well off but make far less than their counterparts in the States. And Germany has universal, affordable healthcare. So, my doctor friends can do well financially and fulfill their passion for their patients without being part of a system which causes massive harm and suffer-
ing. As long as profit remains the ultimate goal, the U.S. healthcare industry will keep figuring out how to leverage even more money out of sick and injured people, and we will continue to see obscene profits. We need to create a healthcare system that attends to money while making maximizing health its ultimate goal.
Is controlling healthcare prices un-American?
A Democrat who leads a progressive policy institute told me controlling prices is unAmerican. That’s classic Republican rhetoric that signals resistance to meaningful change in healthcare policy. When he said that, it hit me in the gut because I realized, my gosh, neither major party wants change. Is controlling healthcare prices un-American? If policy reflects what’s American, yes. But if the values of Americans reflect what’s American, no. I defend the reality of and appeal to agape, which is at the core of Buddhism, Christianity, Confucianism, Hinduism, Humanism, Islam, Judaism, and all the rest, so let me put this in Good Samaritan terms. U.S. healthcare policy sees the person grievously injured in the ditch and stops to figure out how to leverage their need to make the most money possible. The precise opposite of the Good Samaritan. Every major faith and ethical system (except for social Darwinism) says that’s wrong. If an overwhelming majority of Americans affirm a Good Samaritan ethic—and I think they do—and the values of Americans reflect what’s American, then bridling the excesses of the healthcare industry by controlling prices is definitely American.
I’m not against capitalism. I cite Case and Deaton repeatedly because they are avowed capitalists. But they argue free market forces malfunction in healthcare, causing unjustifiable harm and obscene profits. As world-class economists from Reinhardt to Case and Deaton argue, in the case of health care, we need to control prices to curb the excesses of unbridled capitalism.
You say the killing of healthcare CEO Brian Thompson was unjustifiably evil…
Moral Realism Theory is rooted in agape, in having been seized by gracious love for the Face of every creature of every kind. That means that the nonconsensual killing of any creature, especially any human, is always evil. Sometimes, however, killing is also justifiable. If the only way one can defend oneself or one’s family against being seriously hurt or killed is to kill, then killing is justifiable. Evil, but justifiable. Allied soldiers killing Nazi soldiers in World War II: evil but justifiable. One of my students was a retired police officer. He was first on scene, front officer, point-blank range, gun drawn on a man crazed by drugs. The man had a baby in one hand, a brick in the other. He was threatening to brick the baby in the head. He went to do it. Started swinging the brick. My student killed him. He’s looking him in the eyes. He’s a police officer. He knows people in drug-addled states are not themselves. He had to shoot. The pain in his eyes years later told the story (moral injury). Justified, but evil, awful, painful. Just War Theory says for violent action to be justified, it must be no more violent than what is absolutely necessary. It must be proportionate. Never vengeful. Never retributive. It must be in the interests of a just result, and that result must clearly be achievable (to justify the awful cost). By all these criteria, the killing of Brian Thompson was absolutely unjustifiable evil.
Interview
I want to be pastoral towards people who’ve been grievously harmed and so they feel vengeful and perhaps even gleeful when someone is killed. Those responses are natural. But they’re not loving, not good. They harm everyone. Healing requires opening to gracious love and forgiveness (not forgetting, not naivete, not surrender). What does agape look like in the form of outrage or resistance?
It looks like “love your enemies”—which is not about personal enemies, but about enemies of agape, enemies of what’s loving and good. You resist and, in extreme circumstances, may even be forced to kill enemies you love for the sake of the good. I would say “righteous anger” instead of “outrage,” because “rage” suggests “hate,” and even when agape is engaged in violent resistance, it will not look like hate. Righteous anger is rooted in and constrained by love. It is not hateful, not self-righteous, not spiteful, not vengeful. It is firm, resolute, careful, measured, strategic, and never more coercive or violent than absolutely necessary. As with the police officer, if necessary, it is violent, even lethal, but always sorrowful. In this regard, personal surrender to agape as gracious love is profoundly significant, for if you suffer moral injury because you have been forced to act violently in the name of love, your hope for healing is to live into agape, into gracious love and forgiveness for others and for yourself.
If the system is so exploitative, should executives who are good leave these systems? Not necessarily. I’ve talked to executives who feel trapped into having to make devastating “it’s just business” decisions—or else they’ll be replaced by someone who will. Sometimes these executives are secretly donating money or giving strategic advice to groups working in opposition to their industry. Sometimes they struggle within the system and later turn into whistleblowers who, because of their insider knowledge and smarts, can help transform entire industries. If everyone who was loving and conflicted left, then the only people in power would be those with no compunction about making brutal business decisions. That’s a recipe for disaster. The point should not be personal purity, and there’s no single answer or path that all executives should follow. We need a blend of insiders and outsiders united by fidelity to agape. Executives should do whatever they determine is most effective for them to advance what is loving and good. And let’s not forget the distinction between troubles and issues. Corporate and policy-making elites could all be individually good and still be caught in a harmful system. Today, to an overwhelming degree, no people are in charge of a global economic system which thinks wholly in the categories of the Sphere of Nature (profit, survival, power). Corporate “persons” using agape-denying rationalities now dictate most decisions, and all workers, including executives, service the system. That too is a recipe for disaster. Good and powerful people need to work to change such dangerous systemic distortions in national and international laws, policies, and trade agreements.
You say a wholesale turn to the Sphere of Agape would make society devastatingly vulnerable to Sphere of Nature dynamics…
In my books, I propose Moral Realism Theory, which argues agape is as real a force as gravity. When Christians talk about the Holy Spirit, Confucians talk about Ren, Buddhists talk about Maitri, or Jews talk about hesed, they’re naming agape. Human moral and
spiritual vocabularies rooted in agape idealize what is loving and good. Those vocabularies constitute the Sphere of Agape. For Moral Realism Theory, there are also vocabularies rooted in the brute force of causation, such as the vocabularies of physics, chemistry, biology, sociology, and economics. Those vocabularies constitute the Sphere of Nature, wherein the paramount ends are the securing of survival, pleasure, and power. Free will anchors a third family of vocabularies which celebrate creativity, self-determination, and authentic self-creation. Those vocabularies constitute the Sphere of Poetic I’s.
Moral Realism Theory’s rubric of the three spheres allows us to identify predominant rationalities. The first, predominant among intellectual elites, is materialist or naturalist rationality. Materialists think reality is a brute causal flux wholly described by the Sphere of Nature. That means materialists reject free will and agape as confused ideas. The second, secular rationality, affirms the reality of brute causation and free will. It thinks the vocabularies of the Sphere of Nature and of the Sphere of Poetic I’s describe reality. It prizes mastery of causal powers and also authentic self-creation. It rejects agape as a confused idea. Moral Realism Theory advocates awakened rationality (awakened to agape), which affirms causation, free will, and agape as real. It prizes mastery of causal powers, authentic self-creation, and fidelity to agape. It advises us to think always in terms of all three spheres, the Sphere of Nature (causation), the Sphere of Poetic I’s (free will), and the Sphere of Agape.
Why does a wholesale turn to the Sphere of Agape leave a society devastatingly vulnerable to the Sphere of Nature? I’m talking about socialist utopias. Take Marx’s “from each according to their ability, to each according to their need.” A beautiful vision. But it presumes abilities and needs harmonize perfectly and that everyone will give and take selflessly. This wholly forgets the Sphere of Nature, which rightly discerns a world full of irremediably conflicting forces and interests and says to count on selfishness. In Christian terms: Marx is devastatingly naïve regarding our fallen world and human sinfulness. If you construct a utopian system counting on a harmonious world with people living in fidelity to agape, you are devastatingly vulnerable to Sphere of Nature dynamics, because people are going to exploit your naivete and act selfishly to win power and exploit others (see, inter alia, the Soviet Union and China). Socialist utopias fail because they forget Sphere of Nature dynamics.
Today we’re at the opposite extreme. National and transnational regimes from China, Russia, and the United States to NAFTA and the European Union mainly think in Sphere of Nature, “bottom line” terms. They forget agape. For all the good it wants to do, even the UN, consumed by secular rationality, marginalizes faith traditions (vocabularies of agape). This dovetails with materialist and secular rationalities, which forcefully deny agape. Today, people use realism to attack idealism. But we need to be idealistic and realistic, to remember the forces of the Sphere of Agape and the Sphere of Nature. Moral Realism Theory recommends that nations and trans-national regimes: 1) strive to be economically and militarily great (Sphere of Nature), 2). strive to empower people’s freedom and creativity (Sphere of Poetic I’s), and 3) strive to be loving and good (Sphere of
Agape). We will never achieve perfect balance among the Spheres. The unending task involves thinking realistically and idealistically as one engages in the unending struggle to keep the forces of all three spheres in balance. Today, we are dangerously tilted towards power, domination, and greatness in Sphere of Nature terms. The call to global spiritual renewal is not a call to unrealistic utopias, it is a call to remember agape, a call to reinscribe balance among the three Spheres in our socio-cultural, legal, and economic institutions.
You say incremental change is the most viable option?
It’s totally understandable to want immediate, radical change, especially amidst awful suffering. “Justice delayed is justice denied.” That has power. If I could snap my fingers and deliver a perfect health care or political system, I would. But no one can. We’re dealing with massively powerful social, economic, political, cultural, and historical forces deeply inscribed into our economic and legal systems. The dynamics are so complex it’s impossible to be sure what revolutionary changes might make things better. Regimes that try to snap to utopia have been horror stories. Massive suffering and strife precipitate radical, revolutionary violence, and what emerges out of the chaos are new iterations of people exploiting others. Incremental is wise and realistic. Yes to utopian vision and a sense of urgency, but no to radical “snap to utopia” action. Yes, also to charitable programs which try to mitigate immediate harms—but that must be accompanied by striving to reform harmful systems. Incremental balances idealism with realism. And we should realize that not achieving utopia is not failure. The Great Society programs didn’t eliminate poverty, but they kept tens of millions from crushing poverty. That’s success. The National Nurses United Plan for Medicare for All might similarly be imperfect but benefit millions. We passionately want utopian perfection, but it’s not possible. Thus, passion and righteous anger are best channeled into resolute, strategic, wise action, steadily moving us toward utopian goals.
What do you hope to accomplish with this essay?
Moral Realism Theory provides the rubric of the three spheres and an awakened rationality which is loving, reasonable, realistic, careful, gracious, non-sectarian, resolute, measured, strategic, healing, all the things we’ve talked about. Today, we are radically tilted towards the Sphere of Nature. We need to correct course if humanity is to flourish in societies which are great (Sphere of Nature), empowering (Sphere of Poetic I’s), and good (Sphere of Agape). Every day, global elites make decisions which are reasonable in terms of the Sphere of Nature but violate global agapeic consensus. Every major faith and ethical tradition in the world idealizes the Good Samaritan and says you should try to help the man lying wounded in the ditch. Myriad global economic and political systems say— with gestures to realpolitik and human nature—exploit the man in the ditch. I’m hoping to restore balance between Sphere of Nature realism and Sphere of Agape idealism. Faith traditions are carriers of agape. They are far from perfect. But every week in churches, temples, mosques, synagogues, and sweat lodges, executives and line workers sit side by side, united in agape, seeing each other’s Faces and reflecting together on how to be just and loving. They come from all walks of life, which is a reason for hope, because we need people who work in finance, law, politics, medicine, the military, agriculture, market-
ing, and more to channel their passion for agape into studied, strategic struggle to make things better than they would be otherwise. Societies need such faith communities to flourish, and faith communities need imams, monks, pastors, priests, rabbis, and shamans who are wise, faithful to agape, and expertly trained to nurture and guide them. My essay is a studied scream into a world which is forgetting agape, forgetting God. The scream is desperate but full of hope that powerful people and communities faithful to agape will hear and respond.
Healing the American Healthcare System: Medicare for All
Healing the American Health Care System: Medicare for All
Max Cotterill
“We have never seen health as a right. It has been conceived as a privilege, available only to those who can afford it. This is the real reason the American health care system is in such a scandalous state.”
—Congresswoman Shirley Chisholm, co-founder of the Congressional Black Caucus and the National Women’s Political Caucus
Introduction
The problems of the American health care system are vast and well-known. We spend far more than peer countries, yet at the same time nearly half of adult Americans are underinsured, uninsured, or had a coverage gap in the last year. At the start of the COVID-19 pandemic, by May 2020, between 14 and 27 million Americans lost health insurance due to layoffs, a phenomenon that only exists in a country with a largely employer-based insurance system.1 One third of all fundraisers on GoFundMe are for medical expenses..2 More than half a million people go bankrupt each year due to medical costs.3 Since 2005, nearly 200 rural hospitals have closed,4 with a whopping 700 more at risk of closure (one third of all rural hospitals)..5 And since 2000, medical costs have increased an astounding 121%. By 2023, the United States spent $13,432 per capita on health care, compared to an average of $7,393 for comparable countries.6 In short, our health care system is expensive, fragmented, administratively complex, and performs less well than comparable countries on most health outcomes. The time for systemic reform has come.
Max Cotterill is the Campaign Lead on the Medicare for All and Community Campaigns team at National Nurses United, the largest union and professional association of registered nurses in U.S. history. He is based in San Diego, CA.
Ethical Challenges of American Health Care
While American health care fails to deliver for tens of millions of people, it is extraordinarily good at benefiting a few ultra-wealthy individuals and corporations: four of the ten biggest Fortune 500 companies in 2024 were in the health care industry.7 In the same year, 36 health care corporate CEOs made over $5,000,000 in compensation.8 American health care companies have spawned at least 35 different billionaires.9 The system is designed to produce wealth, not widespread health.
The bottom line of health insurance corporations is buttressed by hoarding premiums, copays, and deductibles whilst paying out as little as possible for care. In hospitals, administrators use manufacturing production models from the automotive industry to intentionally short-staff nurses, placing caregivers and patients in harm’s way for the benefit of corporate shareholders.10 Big Pharma, whose research is heavily subsidized with public investment, uses intellectual property laws as a fortress to enforce monopoly pricing of critical drugs.
Every day, nurses see firsthand the shortcomings of our health care system. They often encounter patients who ration or forego needed care due to cost. They see patients with rapid disease progression because they cannot access care due to barriers such as cost and distance to appropriate facilities. At the same time, nurses are often treated as expendable by hospital management. Intentional short staffing places nurses atop rankings of occupational injuries and illnesses, such as workplace violence and musculoskeletal disorders. Short staffing is also responsible for increased rates of infection, error, illness, and mortality. All the while, more than 1 million nurses with active licenses are not currently working as nurses. National Nurses United (NNU) has surveyed thousands of nurses over the past few years, and the reasons for this are clear: nurses are not willing to tolerate dire industry-created conditions and risk patient safety. 11
Despite these conditions, the public regards nurses highly. The year 2024 was the 23rd consecutive year nurses were ranked the most ethical and honest profession by Gallup.12 NNU President Mary Turner summarized the reason succinctly: “At the bedside, at the bargaining table, and in the halls of power, nurses build trust with our patients by taking care of them. We don’t take their trust for granted, which is why we’re going to continue to organize and fight for the safer care conditions and the public health protections that every single one of our patients across this country deserves.”13
Where Do We Go From Here?
In 49 states, there is no legal maximum number of patients that nurses can be assigned. The lone state where this is not the case stands out as an example of what can be accomplished by solidarity and presents a roadmap for health care reform.
In 1999, California became the only state to mandate safe nurse-to-patient ratios. Union nurses with the California Nurses Association used collective action to advocate for patients and won safe nurse-to-patient ratios.14 Nurses joined patients and waged a grassroots campaign that overcame the opposition of
Healing the American Healthcare System: Medicare for All
the hospital industry, which promised the sky would fall as a result of the law.
What happened next revealed important lessons. Six years after the implementation of California’s ratio law, researchers conducted a comprehensive study comparing staffing levels and outcomes in California to other states.15 It found the state’s ratios law had been successful in its aims: nurses came back to the bedside, staffing levels increased, nurse turnover decreased, patient outcomes improved, and thousands of lives were saved. Since the law’s implementation in 1999, these results have been replicated again and again.
What can we learn from California? First, we see the interests of workers and patients are vastly different from those of health care executives. The extreme predictions of the hospital industry did not come to pass as a result of mandated minimum staffing ratios. Second, we can draw a lesson about the power of solidarity. Nurses united with patients and used their collective power to demonstrate why they are consistently regarded as the most ethical profession. They used unity and collective action to overcome the fierce opposition of a powerful industry.
The work is unfinished. But nurses continue to lead and have a clear moral vision for transforming the American health care system from profit-centric to patient-centric: Medicare for All.
Nurses’ Care Plan for America: Medicare for All
In nursing, a care plan is a framework for treatment that includes compiling a holistic assessment, diagnosis, goals, interventions, and evaluation, all in the service of healing patients. With more than 225,000 members, National Nurses United (NNU) is the largest union of nurses in U.S. history. It was founded in 2009 as a movement of direct-care registered nurses, uniting several progressive nursing organizations. At their founding convention, nurses laid out a clear care plan for healing the American health care system. Among the core goals of the movement was gaining accessible, quality health care for all as a human right.
NNU sponsors federal Medicare for All legislation. Medicare for All proposes transitioning the country to a single-payer health care system that would significantly reduce health disparities, effectively control costs, and ensure that everyone has an equal and excellent standard of guaranteed care. There are six core principles.
First principle: universal coverage—everybody in, nobody out. No more uninsured, no more underinsured. All residents of the country would be covered.
Second principle: a single public program—not a patchwork of public and private programs, but a single payer health care system. Instead of different private, employer, and government insurers, a federal plan pays for all necessary care. Replacing a complicated and expensive private insurance-based system with a single payer would streamline one of the biggest costs in health care, inefficient administrative bureaucracy. Already, the percent of money Medicare spends on administration is a fraction of the private insurance industry—1.3% of total spending versus 17%!
Third principle: comprehensive benefits. Medicare for All is not “Medicare-as-it-is-now expanded to everyone.” Medicare for All vastly improves and expands the Medicare program, not only by covering everybody, but also by including many more benefits. It would be truly comprehensive, covering not only medical but dental, vision, hearing, reproductive, mental health, long-term care, and much more.
Fourth principle: free choice—freedom to see virtually any doctor at virtually any hospital, with no networks limiting choice. In addition, doctors and nurses determine care, not insurance companies.
Fifth principle: free at the point of service. Under the current system, people are likely to pay a monthly premium to an insurance company, must meet a yearly deductible before insurance kicks in, and must make copayments. There are no premiums, copayments, or deductibles under Medicare for All. Need care? Go to a doctor, show your medical card, and get treatment.
Medicare for All would be paid for through progressive taxation that ensures workingclass Americans, their families, and businesses all save money compared to our current system. Some argue Medicare for All would dramatically increase taxes. In reality, we already pay the highest “taxes” for our health care in the entire world—but in the form of monthly premiums, copayments, and deductibles. Medicare for All would mean we all pay less than we currently do for health care.
Sixth principle: just transition. Medicare for All includes a just transition for insurance and administrative workers whose jobs are affected by switching to a more efficient health care system. The Congressional Senate and House versions of Medicare for All include significant funding for wage replacement, retirement benefits, job training, and education benefits.
Patients Over Profits
For National Nurses United, the choice is clear. We should not allow the health care industry to entrench and enrich itself. We should unite and create a system that works for caregivers and patients alike.
Nurses cannot accomplish this alone. We need a wide swath of society— nurses, patients, unions, small businesses, faith organizations, community groups, and more—to unite and take collective action and engage in sacrifice and struggle to pass Medicare for All. It can and must be done.
The future in which the health care industry continues to get its way is grim. Our remaining public health institutions will be hollowed out and privatized. Health care will remain a privilege and will be increasingly rationed by socio-economic status. Technologies like AI will increasingly replace the autonomy and professional judgment of caregivers. And quality of care will decrease while profits increase. This future would serve the few at the expense of the many.
A future in which nurses’ vision of health care justice comes to fruition is far better. It is a future in which nurses continue to use their industrial power as unionists to flex their
Healing the American Healthcare System: Medicare for
collective muscle for what is right. Nurses have made their choice: patients over profits. The only choice now is which side the rest of us will be on.
NOTES
1. State of Health Insurance Coverage in U.S.: 2024 Biennial Survey (2024, November 21), Commonwealth Fund, retrieved August 15, 2025, from https://www.commonwealthfund.org/publications/surveys/2024/ nov/state-health-insurance-coverage-us-2024-biennial-survey.
2. Elisabeth Rosenthal, “GoFundMe Has Become a Health Care Utility,” KFF Health News, 12 February 2024, https://kffhealthnews.org/news/article/gofundme-health-care-funding-hospitals-surprise-bills/. Accessed 15 August 2025.
3. David U. Himmelstein et al, “Medical Bankruptcy: Still Common Despite the Affordable Care Act,” American Journal of Public Health 109, no. 3 (2019): 431-433. doi:10.2105/AJPH.2018.304901.
4. “Rural Hospital Closures - Sheps Center,” Sheps Center, https://www.shepscenter.unc.edu/programsprojects/rural-health/rural-hospital-closures/. Accessed 15 August 2025.
5. “RURAL HOSPITALS AT RISK OF CLOSING,” Center for Healthcare Quality and Payment Reform, https:// ruralhospitals.chqpr.org/downloads/Rural_Hospitals_at_Risk_of_Closing.pdf, accessed 15 August 2025.
6. “How does health spending in the U.S. compare to other countries?” Peterson-KFF Health System Tracker, 9 April 2025, https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-comparecountries, accessed 15 August 2025.
7. Phil Wahba et al, “Fortune 500 – The largest companies in the U.S. by revenue,” Fortune, https://fortune. com/ranking/fortune500/2024/, accessed 15 August 2025.
8. “Highest-Paid CEOs - 2025.” AFL-CIO, https://aflcio.org/paywatch/highest-paid-ceos, accessed 15 August 2025.
9. Kelly Gooch, “35 billionaires in US healthcare.” Becker’s Hospital Review, 2 April 2024, https://www. beckershospitalreview.com/rankings-and-ratings/35-billionaires-in-us-healthcare/, accessed 15 August 2025.
10. National Nurses United,“Protecting Our Front Line,” 8 December 2021, https://www. nationalnursesunited.org/sites/default/files/nnu/documents/1121_StaffingCrisis_ ProtectingOurFrontLine_Report_FINAL.pdf, accessed 15 August 2025.
11. “Covid-19 and Infectious Diseases Surveys,” National Nurses United, 28 May 2024, https://www. nationalnursesunited.org/covid-19-and-infectious-disease-surveys, accessed 15 August 2025.
12. Lydia Saad, “Americans’ Ratings of U.S. Professions Stay Historically Low,” Gallup News, 13 January 2025, https://news.gallup.com/poll/655106/americans-ratings-professions-stay-historically-low.aspx, accessed 15 August 2025.
13. “Nurses ranked most ethical and honest profession for 23rd straight year,” National Nurses United, 13 January 2025, https://www.nationalnursesunited.org/press/nurses-ranked-most-ethical-and-honestprofession-for-23rd-straight-year, accessed 15 August 2025.
14. “Ratios: Learning from the California experience.” National Nurses United, https://www. nationalnursesunited.org/ratios-california-experience. Accessed 15 August 2025.
15. Linda H. Aiken et al, “Implications of the California Nurse Staffing Mandate for Other States,” Health Services Research 45, no. 4, (9 Apr. 2010), 904–921, www.ncbi.nlm.nih.gov/pmc/articles/PMC2908200/, https://doi.org/10.1111/j.1475-6773.2010.01114.x.
“Jesus Wept” United States Healthcare and Christian Ethics in an Era of Tyranny
Aana Marie
Vigen
The Incomprehensible
Where to begin? Up to now, my scholarship has generally highlighted where US health care excels while unpacking the roots of persistent, systemic, socio-economic, and racialethnic inequalities. But now we face a dizzying array of impulsive, irrational, and unscientific mandates which are undercutting essential infrastructures, policies, staffing, and funding. It’s a veritable goat rodeo.
Defying all logical, authentic commitment to human health and well-being, those elected and appointed to high office since November 2024 are unnecessarily setting up the US population to become weaker, less protected, and sicker than we have been since the Great Depression. Given the high stakes, my aim is threefold. Contextualize this moment. Name some of the most ill-considered and dangerous decisions. Offer a modest response as a Christian social and medical ethicist.
An Abbreviated History
From the early 1950s to the early twenty-first century, US medicine boasted unparalleled accomplishments. After World War II, physicians and scientists simultaneously shunned Nazi eugenics and heralded United States medicine as the epicenter of state-of-the-art innovation. Undeniably, the accolades ring hollow if we forget the full story. For example, the Nazis modeled their sterilization laws1 on a 1927 U.S. Supreme Court ruling2 and on numerous state laws.3 Also, from 1932-1972, the US Public Health Service (the precursor to the DHHS), condemned over 400 Black men4 (and partners/families) to syphiliswrecked lives in order to study the uninterrupted progression of the disease 5
Aana Marie Vigen, PhD, is Professor of Christian Social Ethics at Loyola University Chicago. Dr. Vigen’s expertise is in the areas of healthcare, medical and ecological ethics, with a special focus upon socio-economic inequalities in health and healthcare in the US and globally. She is the author/co-editor of four books and numerous articles, most recently, the second, fully revised edition of Ethnography as Christian Ethics and Theology (Bloomsbury, 2024). She is also an active lay member of the Evangelical Lutheran Church in America (ELCA) and served on the national ELCA Genetics Task Force from 2008 to 2011.
Notwithstanding such moral failures, for over seventy years, US medicine has basked in the profound reverence and astounding achievements of which other nations can only dream. In many ways, this unrivaled leadership began with vaccines. From Jonas Salk (polio) to Maurice Hilleman (40 vaccines) and John Enders, T.H. Weller, and Fredrick C. Robbins (Nobel Prize) to Kizzmekia Corbett-Helaire (COVID-19), the US has been at the forefront of vaccine development. Because of its dominance, the US has won the most Nobel Prizes (423) of any nation (the UK is second at 143).6 Of the 423, 195 are in Physiology and Medicine or Chemistry, and roughly 35% of all US Nobel winners are immigrants 7
A Partial Litany of Wounds Inflicted upon Americans in 2025
Yet the era of envied, peerless international stature in medicine and science, of which the US has been so proud, is ending (for now). If this claim seems exaggerated, consider the following.
January: President Trump suggests major changes in US disaster response, including the possible elimination of FEMA (Federal Emergency Management Agency; established in 1979).8
February: Robert F. Kennedy Jr. is confirmed by the Senate to become the DHHS Secretary that oversees 13 health-related agencies.
March: The Environmental Protection Agency (EPA) announces 31 actions9 to roll back regulations related to climate, air, water pollution, and carbon emissions, with EPA Administrator Lee Zeldin exclaiming: “Today is the greatest day of deregulation our nation has seen. We are driving a dagger straight into the heart of the climate change religion...”10 If enacted, these rash changes will have devastating consequences for the US Clean Air Act (1970) and the Clean Water Act (1972). They will dramatically endanger the safety of water Americans drink (e.g., lead levels;11 potentially remove fluoride12 from drinking water13) and worsen air Americans breathe (e.g. weakening or removing vehicle tailpipe emission standards14).
May: FEMA announces plans to cut federal disaster assistance15 even though, “Since 2005, the U.S. has experienced its deadliest hurricane in 77 years, deadliest tornado in 64 years, deadliest wildfire in 100 years, and deadliest flash flood in 49 years.”16 Diverging from long-established protocols, the Trump Administration announces that all new vaccines must be tested against a placebo17 before being available to the public. Secretary Kennedy fires thousands of staff, including those in senior leadership, and cancels billions of dollars in grants18 to public health departments and universities. These staff cuts affect researchers working on chronic diseases, along with the FDA’s ability to monitor food safety.
June: Kennedy fires all 17 members of the CDC’s Advisory Committee on Immunization Practices (ACIP).19 The Association of American Medical Colleges (AAMC) issues a comprehensive report on the sweeping implications of federal actions for both research and medical care, exposing the dire consequences for patients, families, healthcare providers, and scientists (e.g., emergency/trauma centers, labor/delivery units, transplant centers, mental health and substance abuse care ).20 Rural and working-class communities "Jesus
are among the most at risk of losing vital services.
July: President Trump signs the “big bill” into law that will, per the nonpartisan Congressional Budget Office (CBO), increase the number of uninsured Americans by at least 10 million as of 2034 21 At least 135 individuals (including 35 children/youth) are lost in a Texas flood.
August (a real humdinger): Secretary Kennedy cancels $500 million of funding for mRNA vaccines 22 The American Medical Association (AMA), the American Academy of Pediatrics, and the Infectious Diseases Society of America are informed by the federal government that they are no longer invited to participate in key advisory ACIP workgroups that develop vaccination recommendations.23 After serving for less than one month, CDC Director Dr. Susan Monarez is fired by the Trump Administration via social media posts.24 Kennedy then appoints Jim O’Neill as Acting Director, though he is not a physician or a scientist. The FDA approves the updated COVID-19 vaccine but limits its availability to those 65 and older or with chronic health conditions ( previous versions were available to all 6 months and older 25). 26 The Pediatric Brain Tumor Consortium (a network of 16 hospitals and academic centers founded in 1999 by the US National Cancer Institute to lead pediatric cancer research) announces it will no longer receive federal funding after 2026
September : Nine former heads of the CDC publish an open letter in The New York Times entitled “We Ran the C.D.C.: Kennedy Is Endangering Every American’s Health”.27 Over 85 leading scientists publish a full-throated refutation of the July 2025 US Department of Energy’s Report on Climate Change, identifying its central assertions as either “misleading or fundamentally incorrect.”28 Florida’s Surgeon General announces a plan to end all vaccine mandates for children attending public schools, 29 comparing such mandates to “slavery”. “No Ground Under Our Feet”
After laboring tirelessly for a decade to build ecumenical coalitions strong enough to defeat German fascism, Lutheran pastor and professor, Dietrich Bonhoeffer, pens a letter to his closest friends in December 1942. He senses Hitler’s minions will soon arrest him. (He is right, and in April 1945, they hang him). In the letter, he ponders: “One may ask whether there have ever been in human history people with so little ground under their feet—people to whom every available alternative seemed equally intolerable, repugnant, and futile…”30 These past months, I have often felt like there is no ground under my feet, especially as I sent a son to college, not knowing if he will be able to get vaccinated or what kind of world he will inherit. Reading Bonhoeffer reminds me I am not alone with such worries.
Because of Hitler’s rocket rise to authoritarian power, Bonhoeffer lived in a nation turned upside down: “The great masquerade of evil has played havoc with all our ethical concepts. For evil to appear disguised as light, charity, historical necessity, or social justice is quite bewildering to anyone brought up on our traditional ethical concepts…”31 Bewildering indeed. Such moments are especially disorienting for Christians who have been taught since childhood that the greatest commandment is to “love God and to love our neighbors as ourselves”
"Jesus Wept" United States Healthcare and Christian Ethics in an Era of Tyranny
(Matt. 22); who have been incessantly reminded that Jesus healed everyone—any day, of any faith or nationality—of whatever ailment or estrangement, whether physical, medical, emotional or social in origin; who have had the parable of the Good Samaritan tattooed onto their hearts by pastors asking them to reflect on what kind of neighbors they intend to be to others—to anyone—in need.
Jesus’s call to love doesn’t provide us with a precise roadmap. Yet there is one thing I am sure Jesus is doing right now: weeping—utterly bereft over the senseless lack of access to health care, vaccines, research breakthroughs; grief-stricken over the needless, preventable, indefensible death stemming from irrational health policies and inept, ill-informed government responses to natural disasters and climate change.
Friends, we are living history. Those who come after us will judge our complicity or celebrate our courage. They will want to know how we met this moment, where, and how we stood. The urgent question for us—as Americans, followers of Christ, or simply as people moved by compassion, grief, anger, or worry is this: “How do we respond?”
While there are startling resonances, we cannot equate 2025 to Hitler’s Germany. The context, challenges, and opportunities are distinct. Still, remembering Bonhoeffer may help us envision what living responsibly in our present situation means.
As we have capacity, we can speak out and refuse to cooperate. We will continue to teach, to provide medical care, to write, to preach, to minister. We must defend free speech, a free press, access to accurate, credible, evidence-based information and records. We must defend the right to vote, to assemble, to protest peacefully, to the free expression of religion; and to liberty, justice and due process for all.
Two illustrations may offer inspiration.
First, from August 2025. After the firing of Dr. Monarez, three top CDC officials resigned publicly in protest: Drs. Houry, Daskalakis, and Jernigan. All three letters merit serious attention. 32 I can only highlight the fundamental reason Daskalakis gives for his resignation: "The intentional eroding of trust in low-risk vaccines, favoring natural infection and unproven remedies, will bring us to a pre-vaccine era where only the strong will survive and many, if not all, will suffer…. My grandfather, whom I am named after, stood up to fascist forces in Greece and lost his life doing so. I am resigning to make him and his legacy proud."33
Second, from my family. My maternal grandparents (born in 1900 and 1907) were children of immigrants and lifelong Republicans. They scrimped and saved everything. With no more than eighth grade and high school diplomas, they lived the American dream, in significant part because it was underwritten by the government via the Social Security Act (1935) and the Medicare and Medicaid Act (1965). Pop and Gram never marched in any protest. They were uncomfortable with “rabblerousers”. Yet, they were nobody’s fools. They voted in every election. When Nixon’s lies and crimes were exposed, they cheered his resignation.
My grandparents and Dr. Daskalakis help me trust that our convictions and actions matter. We can defend our Constitution and Democracy against those posing as kings, ty-
rants, sycophants, and lackeys accountable to none but themselves. We who identify as Christians can act so that others know us by our visible, embodied love.
Read this fuller quotation from Bonhoeffer’s letter; imagine with him:
"One may ask whether there have ever been in human history people with so little ground under their feet—people to whom every available alternative seemed equally intolerable, repugnant, and futile, who looked beyond all these existing alternatives for the source of their strength so entirely in the past or in the future, and who yet, without being dreamers, were able to await the success of their cause so quietly and confidently. Or perhaps one should rather ask whether the responsible thinking people of any generation that stood at a turning-point in history did not feel much as we do, simply because something new was emerging that could not be seen in the existing alternatives."34 Bonhoeffer never lost hope in, or love for, this world. To the end, he practiced both. He beckons us—responsible, thinking people who now stand at a turning-point in our own history—to have enough moral imagination—and grit—to gamble on the feeling, the hunch, that maybe, just maybe, something new is emerging that is not limited to the intolerable and repugnant alternatives most visible to us.
In the words of Rev. Harry Emerson Fosdick’s 1930 hymn: “God of Grace and God of Glory,…grant us wisdom, grant us courage for the facing of this hour.”35
NOTES
1. https://nwlc.org/press-release/new-nwlc-report-finds-over-30-states-legally-allow-forced-sterilization/
2. https://www.npr.org/sections/health-shots/2016/03/07/469478098/the-supreme-court-ruling-that-ledto-70-000-forced-sterilizations
3. https://www.niwrc.org/restoration-magazine/november-2020/past-and-current-united-states-policiesforced-sterilization
4. https://ed.ted.com/lessons/ugly-history-the-u-s-syphilis-experiment-susan-m-reverby
5. https://www.tuskegee.edu/about-us/centers-of-excellence/bioethics-center/about-the-usphs-syphilisstudy
6. https://worldpopulationreview.com/country-rankings/nobel-prizes-by-country#title
7. Between 1901 and 2024, 55 percent of 749 academic awards (i.e. chemistry, economics, medicine, and physics) went to the U.S.-affiliated scholars. Among the 410 individuals academic Nobel Laureates, 142 (35%) are immigrants to the United States.” https://chss.gmu.edu/articles/21491
8. https://eelp.law.harvard.edu/proposed-changes-to-fema-and-the-future-of-federal-disasterresponse/#:~:text=On%20Jan.,publicly%20designated%20additional%20council%20members.
9. https://www.scientificamerican.com/article/trump-epa-announces-climate-regulation-rollback-butfaces-legal-hurdles/
10. https://www.epa.gov/newsreleases/epa-launches-biggest-deregulatory-action-us-history
11. https://www.nrdc.org/press-releases/worrisome-lead-levels-drinking-water-systems-serving-more250-million-people
12. https://publichealth.jhu.edu/2024/why-is-fluoride-in-our-water
13. https://www.epa.gov/newsreleases/epa-will-expeditiously-review-new-science-fluoride-drinkingwater
14. https://www.npr.org/2025/07/29/nx-s1-5463771/epa-greenhouse-gas-regulations-carspollution#:~:text=That%20leaves%20the%20EPA’s%20tailpipe,before%20it%20finalizes%20 any%20changes.
15. https://www.urban.org/urban-wire/proposed-cuts-federal-disaster-assistance-will-hit-states-justhurricane-season-ramps
16. https://yaleclimateconnections.org/2025/08/deadliest-in-generations-the-texas-floods-are-the-latestin-a-disturbing-pattern/
17. https://www.npr.org/sections/shots-health-news/2025/05/01/nx-s1-5383172/rfk-jr-placebo-vaccinetesting-studies
18. https://www.npr.org/sections/shots-health-news/2025/05/13/nx-s1-5381022/rfk-hhs-layoffsrestructuring-trump-budget
19. https://abcnews.go.com/Health/rfk-jr-removing-17-members-cdcs-vaccine-advisory/story?id=12267 0046#:~:text=removes%20all%2017%20members%20of%20CDC’s%20vaccine%20advisory%20 committee,-June%209%2C%202025&text=Show%20more-,Health%20and%20Human%20 Services%20Secretary%20Robert%20F.,%2C%202025%20in%20Washington%2C%20DC
20. https://www.aamc.org/about-us/aamc-leads/impact-federal-actions-academic-medicine-and-ushealth-care-system
21. https://www.kff.org/uninsured/how-will-the-2025-reconciliation-law-affect-the-uninsured-rate-ineach-state/
22. https://www.bbc.com/news/articles/c74dzdddvmjo
23. https://apnews.com/article/vaccine-committee-cdc-cfbdcab84b2a919a6131d471959c3431
24. https://www.npr.org/sections/shots-health-news/2025/08/29/nx-s1-5522036/cdc-rfk-hhs-monarez-jimoneill-leadership
25. https://www.npr.org/sections/shots-health-news/2025/08/27/nx-s1-5515503/fda-covid-vaccinesrestricted
26. https://abcnews.go.com/Health/covid-vaccine-complicated-after-new-fda-restrictions/ story?id=125106993
27. https://www.nytimes.com/2025/09/01/opinion/cdc-leaders-kennedy.html
28. https://www.nytimes.com/2025/09/02/climate/climate-science-report-energy-department.html
29. https://www.bbc.com/news/articles/cvg0e485wwwo
30. Dietrich Bonhoeffer, “After Ten Years”, Letters and Papers from Prison, edited by Eberhard Bethge (Simon & Schuster: NY, 1997 First Touchstone Ed.): 3.
31. Bonhoeffer, “After Ten Years,” 4.
32. https://www.medpagetoday.com/infectiousdisease/publichealth/117197
33. https://x.com/dr_demetre/status/1960843433473376602
34. Dietrich Bonhoeffer, “After Ten Years”, Letters and Papers from Prison, edited by Eberhard Bethge (Simon & Schuster: NY, 1997 First Touchstone Ed.): 3–4.
35. https://hymnary.org/text/god_of_grace_and_god_of_glory
Relational Ethics, Justice, and South Africa's National Health Insurance Act
Introduction
C.H. Thesnaar
Should a person’s access to medical care depend on where they were born, economic status, ethnicity, nationality, or social class? The just and ethical answer is a resounding NO! There is a disparity between the Global North and Global South regarding access to quality healthcare. Life expectancy in the Global South is shorter than in the wealthier Global North, primarily due to the lack of access to basic and quality healthcare. For example, in South Africa, the provision, access, and quality of health care are extremely fragmented, unsustainable, unjust, and ethically unacceptable. Most in South Africa cannot make informed choices for quality healthcare, as access is based on income and medical insurance.
South African Health Care Challenges
In an article titled “Possibilities and opportunities: exploring the Church’s contribution to fostering national health and well-being in South Africa,” Vhumani Magezi fittingly says South Africa is a country of many paradoxes. Thirty years after the change from an apartheid state to a democracy, South Africa is a country of mega-malls, rich minerals, astounding scientific inventions, unprecedented wealth, and private health care comparable to the best in the world—but only accessible to an economically privileged minority. On the other hand, most people live in extreme poverty and informal housing and depend on a struggling, underfunded public health care system. These disparities are not new, as they are embedded in a history of unjust colonialism and apartheid that
Dr. Christo Thesnaar is Professor of Practical Theology at Stellenbosch University. Thesnaar has been a visiting scholar at Friedrich Schiller University, Jena (2017), Regensburg University, Germany (2023), and the Europa University in Flensburg (2025). Thesnaar’s research focuses on reconciliation, memory, intergenerational trauma, justice, healing, and restitution. He was a founding member of the South African Institute for the Healing of Memories (1998) and serves on its board. He also serves as head of the Unit for Reconciliation and Justice at the Beyers Naude Center for Public Theology. His most recent book is Reconciliation and Justice in Africa: Exploring New Opportunities for Local Contexts, co-edited with Sipho Mahokoto (Langham, 2025).
regulated access to quality health care based on economic status and race. Such lifethreatening generational and systemic discrimination is, it should go without saying, ethically problematic.
The gap between the rich and the poor has escalated since the transformation to democracy. Most citizens are caught in a trap that renders them hopeless and powerless, which is reflected in evils such as the loss of respect for human life, constitutional violations, and a failure to uphold the African ideal of ubuntu (Magezi, 2008). This massive gulf between the promises and ideals of democratic government and current realities can no longer be ignored. When access to good health care is determined by economic policy and individual status, it is not only an ethical catastrophe but a grave injustice, as it undermines individual dignity, reducing human beings to economic categories rather than recognizing their equal worth. Every person should have health care access regardless of identity or ability to pay.
Equal Access to Healthcare is a Constitutional Right
When some have access to excellent and accessible care facilities while others must wait in long queues, face maldistributions of medicine, and travel vast distances in the hope of finding any form of basic assistance, it is not only a violation of justice but also a violation of a constitutional right. South Africa’s Constitution guarantees that “everyone has the right to access to healthcare services, including reproductive health care” (section 27(1)). This means access to quality medical care should be available to all residents and non-residents, regardless of immigration status. For this reason, White et.al. (2020:15) remind us that, “Social exclusionary views or practices must be addressed at all levels through inclusive health policies, training in culture-sensitivity, ethics and human rights; and promoting health care providers as advocates for migrant patients and their rights.”
The ethical and constitutional imperatives presume access to quality health care. If some receive the best quality of health care based on their income and others go without basic examinations, medications, or operations, justice is violated. Structural inequalities are created by the private health care situation in South Africa, which is built on medical insurance only affordable by those with high incomes. Private insurance is funded by investors who expect profitable returns on their investments, so it is reasonable to worry that insurers prioritize profit over people to reach investor goals. The ever-shrinking number of privileged citizens who can afford private health care will result in private healthcare becoming increasingly expensive and exclusive, and eventually unsustainable. Based on economic challenges facing even private health care, there is also no guarantee that a private health care system will treat patients more ethically and humanely than a national health care system.
The National Health Insurance (NHI) Act, signed by President Cyril Ramaphosa on 15 May 2024, is a long-overdue, responsible, just, and bold step toward correcting injustices in access to quality health care. It aims to provide universal health care to all residents. It is presented as a unified, publicly funded health system that ensures comprehensive, quality care for all, regardless of social or economic status. When fully operational, it
should terminate the divide between an overburdened, run-down health system serving the majority and a quality system serving a privileged few.
The legislation is inclusive, respectable, and needed. However, the legacy of apartheid and current political, economic, and social challenges make the implementation of national health insurance challenging. Challenges include high unemployment, widespread poverty, shrinking tax base, corruption in government and society, substandard infrastructure, understaffed clinics with long queues and low staff morale, and continued mistrust of government due to broken promises and failure to deliver care for the most vulnerable. Furthermore, ensuring the availability of medications and quality staff in remote locations poses a significant challenge. Harris et.al. (2011) suggest that improved public health care could lessen the challenges since “sector service quality and perceptions thereof and creating equitable access to different levels of public care, could reduce use of private providers and thus minimize financially catastrophic charges,” and this “would create a closer ‘fit’ between the equity-seeking objectives of present policies and the inequitable, unhealthy realities that many continue to face.”
Critics of the NHI raise valid concerns, but these are not reasons to abandon the NHI project. The question is not whether we can afford universal health care access and quality care, but whether South African society can afford the existential and moral costs of current inequities. The ethical mandate is clear: health care should be a right, not a commodity. Governmental, private institutions, and individuals alike should work to ensure this right is realized in practice.
Relational Ethics
I believe the NHI Act will only succeed if it is supported by widespread acceptance of a profound relational ethic. Relational ethics focuses upon the development of trustworthy leadership, responsibility, accountability, citizen-centred transparency, justice, integrity, and a sincere commitment to fairness within relationships. Relational ethics is fundamentally about fairness, which entails not only equitable distribution of healthcare access and medical benefits to all citizens but also treating all citizens with humanity and ethical consideration. This strong appeal and demand for fairness and responsible health care are primarily aimed at ensuring that humans are not objectified by the system, medical costs, health care providers, or practitioners. Health professionals and practitioners have an ethical obligation to advocate for equitable and quality health care based on fairness and dignity. The quality and fairness of relationships depend on dialogue among partners in the relationship. In this case, it calls for responsive dialogue among government, health providers and practitioners, and those in need of health care.
Health care based on relational ethics encompasses the quest to dismantle systemic injustices by advocating and prioritizing prevention, community health, disability, and frailty treatment, and creates concern that citizens have access to quality care and are treated with dignity.
Technology, including artificial intelligence, is going to be an increasingly dominant part of health care. Although artificial intelligence creates new possibilities for making
health care more accessible, it also faces significant ethical challenges. These challenges include issues of data control, legal liability, confidentiality, and informed consent, and the threat of these challenges means it is essential that emerging health care practices be based on relational ethics.
Recognizing significant self-worth and dignity (despite all the differences that exist) is essential for health care providers, practitioners, and patients, even when historical differences create real points of contention. At stake is fairness in relationships and relational justice. Fairness and dignity within the framework of relational ethics and justice require providers and patients to be responsible, just, and accountable to one another. This requires give and take from both sides and people assuming responsibility for consequences. Providers need to respect patients and take responsibility for providing health care, and patients need to respect providers and take responsibility for participating in the healing process.
In relation to my argument for relational ethics, justice, fairness, being interconnected, and a responsibility toward the other, I want to emphasize what Shutte (2018: 205) refers to as the importance of the African relational view of human nature and the ethic of ubuntu. For Shutte, relational ethics provides a framework for authentic human community in our pluralistic world. He (2018: 205) states, “The African idea that one can only realise oneself, discover one’s true identity, in the other, embodies a spirit that is essential for the intercultural co-reflection.” It is clear to me that we, as Africans, need to embrace the relational ethics that treat the Other—the widow, the migrant, the orphan—in a just and fair way. This is our liberation. Although this is true to being African, we are painfully reminded about our actions of xenophobia towards migrants and immigrants, as well as the recent unjust protest action aimed at convincing health care institutions to turn away migrants and immigrants from other African countries.
Conclusion
Health care in South Africa should no longer be guided by profit. In the spirit of the African relational view of human nature and the ethic of ubuntu, health care policy should be based on relational ethics and justice. Health care policy, economics, and implementation are a test of our collective humanity. Health care is a right, not a privilege. The National Health Initiative should be strongly supported because it is constitutional and ethically grounded in basic principles of rights, fairness, justice, and human dignity. Relational ethical concerns should be the driving force behind widespread support for the NHI and energize the struggle to meet the complex challenges—current inequalities, legal and policy ambiguities, and securing sustainable financing—which threaten full implementation. Insofar as those challenges can be met, South Africans can realize their constitutional and ethical ideals and meet the health care needs of all South Africans.
Bibliography
Harris, B., J. Goudge, J. E. Ataguba, D. McIntyre, N. Nxumalo, S. Jikwana and M. Chersich. "Inequities in access to health care in South Africa." In Journal of Public Health Policy 32, (2011). Supplement 1: "Public health, health sector reforms, and policy implementation in South Africa: Studies and perspectives on the 24th anniversary of the Centre for Health Policy." Palgrave Macmillan Journals, S102- S123 (2011). https://www.jstor. org/stable/20868835.
Lalloo, R, M J Smith, N G Myburgh, G C Solanki. "Access to health care in South Africa — the influence of race and class." The South African Medical Journal (SAMJ), 94, no. 8 ( Aug 2024).
Magezi, V. "Possibilities and opportunities: exploring the Church’s contribution to fostering national health and well-being in South Africa." Practical Theology in South Africa= Praktiese Teologie in Suid-Afrika 1, (2008).
Shutte, A. "Reflection in Practice as Source of Values." Journal for the Study of Religion 31, no. 1, Festschrift for Martin Prozesky (2018): 177-206. Association for the Study of Religion in Southern Africa (ASRSA) https:// www.jstor.org/stable/10.2307/26489089.
Van Rhijn, A., and H. Meulink-Korf. Appealing spaces. The interplay between justice and relational healing in caregiving. Wellington: Biblemedia/Biblecor, 2019.
White J.A., D. Blaauw, L.C. Rispel. "Social exclusion and the perspectives of health care providers on migrants in Gauteng public health facilities, South Africa." PLOS ONE 15, no. 12 (2020): e0244080. https://doi. org/10.1371/journal.pone.0244080
Pastors' Panel
Rev. Kate McGee
Westminster Presbyterian Church, Arlington, Texas
Rev. Evan Solice
Chaplain and Director of the Spiritual Care Department, Ascension Texas and Dell Seton Hospitals
Guesnerth Josue Perea
Associate Pastor at Metro Hope Church, Executive Director of the Afrolatin@ Forum, Director of Black Lives and Contemplation for the Center for Spiritual Imagination, and Co-Curator of the AfroLatine Theology Project
How do you navigate the balance between religious beliefs and medical policies when advising patients and their families on difficult healthcare decisions?
Kate McGee:
I aim to center the voice of the patient first and foremost, wondering with them how their health goals tie into their spiritual life and journey. If their voice is not available, then I speak from my own faith convictions: that nothing in life—no medical decisions, no policies, no accidents—or in death can separate them from the love of Jesus Christ. As a pastor, I see my role less as advising and more as listening and reflecting back to the patient and their family the values they have shared with me, religious and otherwise. Then I draw from liturgy and rituals to create something meaningful for the family to guide them through their difficult decisions. For instance, in 2020, after a long bout with COVID-19, a member and her family made the difficult decision to remove her father from life support. Using language from Presbyterian funeral liturgy and prayers familiar to the family, I created videos that they could play as they made this difficult decision to say goodbye. This allowed them to incorporate their spiritual beliefs and religious life into the hardest decision they ever had to make, while the congregation remotely surrounded them in prayer.
Evan Solice:
While religion may play a big part in a person’s lived values and the medical decisions they make, there are also other factors, such as their history and culture. I try to provide a safe space for them to explore what medical decisions mean to them, and what they’re struggling with the most emotionally. A good way to start is, “This must feel like an impossible choice. I wonder how you’re making sense of the two choices.”
In my experience, religious doctrine has little to do with the heart, and decisions like this
McGee, Solice, Perea
are all about the heart. It is helpful to facilitate the processing of emotions of judgment, shame, or spiritual dissonance when the decision “breaks ranks” with the doctrine or policy of the religion they so deeply love.
What role do you see chaplains and pastors playing in advocating for equitable access to healthcare, especially for marginalized communities?
Kate McGee:
Pastors, at our core, are storytellers. We tell God’s story and our story and our community’s story, and how all those stories tie together. When it comes to advocating for more equitable healthcare, pastors can partner with chaplains and patients to lift up their stories—both when the healthcare system worked, and when it didn’t work. Sharing the unequal experience of healthcare that many marginalized communities face through personalized stories can open the eyes of more privileged Christians to the challenges inherent in the system. Pastors could then connect these stories with the calls for justice in the Bible (especially the prophets), to show that vulnerable parts of our population are not receiving God’s desire for them; namely, shalom—active peace and wholeness. Pastors and churches could then partner with chaplains and hospitals to target direct action for lawmakers or hospital administrators to make a difference, born out of their faith convictions and eyes opened to inequality.
Evan Solice:
Advocate at the community level by participating in protests, letter-writing, or other support-gathering activities. This is even more important in a political situation where Christianity is assumed to be aligned with a specific issue that doesn’t align with your theology of justice. Show up, wear a stole or other clothing that shows you are clergy. Your support might mean others reconsider their view or have the courage to speak up themselves.
Advocate for individuals, too! As a chaplain, my role is to advocate for individual patients and family members to have care that best aligns with their vision of holistic health and their values. At times, I advocate with the medical team or administration to make the case for why an exception makes sense, or how we can change our approach to best honor the humanity of the patient. Stories and data matter. If you want to make an impact, you need honest and authentic stories about how the issues affect individuals, as well as data about the issue and possible solutions.
Guesnerth Josue Perea:
Beyond our congregations, we have a critical role in bridging the historical divide between communities of color and the medical system. This distrust of healthcare institutions is not unfounded. Historically, these communities have been subjected to violence sanctioned by the U.S. government in collaboration with the medical establishment, from the forced sterilization of Puerto Rican women to unethical medical experiments on Black Americans. This history, combined with the rise of misinformation, creates a complex landscape.
Medical professionals, particularly those who are not from these communities, often fail to understand this deeply rooted apprehension. We saw this unfold during the COVID-19 pandemic, where a profound mistrust of the medical establishment led many to seek out alternative solutions, including natural medicines.
For many communities of color, the curandera remains a trusted figure, and whether we admit it or not, these remnants of indigenous health care systems are a powerful part of our cultural narratives as Latine people. Whether Christian or not, many people trust a local curandera more than a trained doctor. This isn’t just about a preference for nonWestern medicine; it’s about relationship. While the medical industry attempts to capitalize on this dynamic, evident in Spanish-language infomercials for unproven medical solutions that are not broadcast on English-language channels, they fail to build the genuine trust that a one-on-one relationship can provide.
Ultimately, the key to overcoming this apprehension lies in cultivating trust. As pastors and as a society, we must help both sides recognize that historical trauma shapes present-day decisions. It’s a matter of showing care, building relationships, and acknowledging that for many, trust must be earned before healing can truly begin.
The pastoral role is to communicate truth in a way that builds trust. This requires moving beyond a simple prayer for healing to recommending medical solutions while emphasizing that faith and medical care are not mutually exclusive. The goal is to encourage a collaborative relationship where medical professionals prioritize “care” over rushing to a solution. By taking the time to explain a diagnosis and a treatment plan, they can begin to combat misinformation and rebuild the trust that has been lost.
What challenges do you encounter when working with medical professionals who may not share the same faith-based perspective on healthcare ethics?
Evan Solice
Honestly, I rarely face too much of an issue here. I often re-frame concerns about ethics to connect with shared humanity. Instead of basing my argument on the religious ethic or preference of a patient, I’ll focus on grief, loneliness, hope, or loss. If, for example, a medical provider doesn’t understand why a family wants to wait an extra day before removing ventilator support, I don’t start by talking to them about religion: “The family is [religious tradition] and trusts that God will heal through their prayers.” Instead, I connect to shared human experience: “The patient is the head of their family, and the one they always knew as the strong one. It’s really difficult for them to make sense of seeing her this way, and they are still processing their loss and what it means to how they interpret the world around them. This is how they grieve and how they show their love to their mom.”
It is also important to know that medical professionals have busy and stressful jobs, but most have sacrificed greatly to do this work because they are passionate about caring for people. When I’ve encountered resistance from medical staff about a patient’s request or treatment decision, I’ve often found success by interpreting and sharing why it is im-
McGee, Solice, Perea
portant or aligns with their values/beliefs.
How can religious institutions collaborate with healthcare organizations to improve access to compassionate and ethical medical care?
Kate McGee:
Our local hospital hosts regular gatherings for clergy and other church staff. They are centered around relationship-building with the hospital staff, including lunch with the hospital CEO and regular interactions with the chaplains. These programs also include important education for clergy caring for sick, disabled, and aging members. We’ve received training from a hospice nurse on the physical signs of dying; a family care specialist busting myths about organ donations; and a “Stop the Bleed” workshop on tourniquets. The hospital system also has a faith community nursing program, which includes training a nurse in your congregation and hosting vaccine clinics. This allows faith communities to emphasize the sort of healthcare their church/mosque/temple and surrounding community needs. It provides community feedback to the hospital system as well, so they can increase or decrease their own community offerings. With the hospital hosting these gatherings, it also builds relationships across denominational and faith lines so that we can build collaborative ministries (and not duplicate what other faith communities are doing well!). Finally, these programs also advocate for the health of clergy, for instance, they hosted workshops on mental health after clergy returned to inperson work after the first surge of COVID-19.
Evan Solice:
Start from a place of listening to understand first. I love the question, “If anything was possible, what would be your dreams for your hospital?” At least in theory, both religious institutions and healthcare organizations want full human flourishing.
One example is a group of small churches that partnered with a local hospital to offer rides and access to heart-friendly food for cardiac patients. Patients were readmitted to the hospital less frequently because they made it to their follow-up appointments and picked up their medications. They ate healthier and felt less lonely. Parishioners felt a stronger sense of purpose.
Guesnerth Josue Perea:
For many in the pastoral field, engaging with ethics in health care requires a deeper look at what guides us. A pastor’s role is to elucidate Christian ethics and demonstrate how they apply to our lives. This means we must begin with the ethical perspective that health care should be accessible to all. While this idea has become a point of political contention, particularly in the United States and some Latin American countries, I believe it is a foundational Christian ethic.
One of the cores of Christian ethics is the belief that we are cared for by God and, therefore, are called to care for others. The principle of treating others as we wish to be treated makes access to health care an essential ethical question. If a Christian ethic is defined by love and stewardship, then how can we uphold it without ensuring that everyone has
access to care? This question becomes the starting point for any conversation on health care ethics from a pastoral perspective.
In a country that increasingly views healthcare as a privilege, the pastor’s role is to instill an ethic of health care as a right. When we look at scripture, we see that Jesus’s ministry was, in many ways, one of radical healing. His miracles were often a direct response to a social order that failed to provide systematic health care. The story of the woman with the issue of blood is a powerful example; she seeks Jesus after the medical establishment has failed her, and Jesus does nothing to question whether he should heal her; he just heals her.
As pastors, our imperative is to shift the mentality of our congregations and help them see that love and stewardship must guide our views on health care, both as recipients and as a faith community. We are called to advocate for healing, as the optimal condition of the human being is one of a healed human being. This is not a new idea; it’s a return to the very heart of Jesus’s ministry.
Ultimately, the conversation around health care ethics requires a two-way street: the faith community must change its view of health care from a privilege to a right, and the medical community must recognize and address the deep-seated apprehension that stems from a history of violence and a lack of compassionate, trustworthy care. The pastor’s role is to be a bridge in this crucial conversation, fostering a holistic understanding of health that encompasses the mind, body, and spirit.
Faculty Books
Christian Theology in a Pluralistic Age, edited by David H. Jensen, Professor in the Clarence N. and Betty B. Frierson Distinguished Chair of Reformed Theology (Eugene, OR: Wipf and Stock, 2024) xiv + 179 pp. $28.00 pb.
Christian Theology in a Pluralistic Age, edited by David H. Jensen, is the product of the 2023 Frierson Conference held at Austin Presbyterian Theological Seminary. Jensen assembled a broad range of Christian theologians to tackle the question of how Christian theology should reckon with the deep religious pluralism that is part of the complexity of contemporary society.
Part 1, “Interfaith Learning and Belonging,” consists of two chapters by leading figures in the field of comparative theology. This relatively new subfield of constructive theology seeks to bring the insights of other religions to one’s home tradition. In these two essays, by John Thatamanil and Catherine Cornille, religious pluralism is taken as a gift that can illuminate Christian theology when aspects of other religions are deployed to reflect faithfully on one’s own commitments. Thatamanil offers a tantalizing new paradigm of how to think about other religions “prepositionally” by thinking about, from, with, and as others. In her contribution, Cornille offers why the category of religious hybridity, the phenomenon of feeling drawn to or even practicing another religious tradition while remaining committed to one’s own, might be theologically productive, even if it is difficult to sustain.
In Part 2, a number of authors offer close readings of other religious traditions that deeply inform their own Christian worldview. Hyo-Dong Lee puts Augustine of Hippo’s ecclesial theology into conversation with Confucian political thought and its use of familial paradigms. Martha Moore-Keish offers a provocative reflection on the liturgical roles of the Christian Eucharist and the Hindu prasada (a ritual meal after certain Hindu communal liturgies). And David H. Jensen reflects on how attending to traditional Jewish hesitancy around interfaith marriages can provide an opportunity for Christians to narrate better the dynamic between the communal and individual meanings of marriage in the life of the church.
The chapters of Part 3 are gathered under the heading of “Otherness, Community and the Common Good.” Michelle Voss ponders the question of whether religion and religious diversity really contribute to the common good, and illustrates how a stronger case for
Faculty Books
the place of religious diversity in public contexts can be made by an appeal to principles leading towards interfaith solidarity. Henk Van den Bosch uses contemporary Catholic philosopher Richard Kearney’s concept of anentheism, a neologism that concerns a mode of conceptualizing God’s transcendence, to think through very real and specific breaks in relationship that religious difference generates. The dilemma of religious otherness is also taken up by William Greenway. He uses a theory of moral realism to navigate an impasse between the Jewish philosopher Emmanuel Levinas and the Christian theologian John Millbank regarding how the subjectivity of the religious other can be encountered. In a concluding chapter, Deborah Van den Bosch-Heji returns the reader to the social element of interreligious relations through an examination of Protestant military chaplaincy in this age of religious pluralism.
Collectively, these essays provide a valuable perspective on the state of the question of religious pluralism among theologians located in the context of theological education. The world of theological education is under a constant state of change. Frequently, religious diversity itself is not a subject within the seminary classroom because of seemingly more pressing issues of formation for Christian ministry and because denominational anxieties are producing ever-shifting benchmarks for pastoral leadership. Yet, the United States is a highly diverse country in terms of religion. This diversity exists within Christianity itself, but also within all the other forms of religion. There are many shades of Judaism, Buddhism, Islam, and so on. No faith tradition is static or monolithic. So when Christians want to take up the question of religious pluralism, whether in theoretical or applied forms, there is no ideal form of any religion which can be considered. Pluralism across traditions must also yield to the pluralism within every tradition. This point serves to underline the value of this collection edited by Jensen. Religious pluralism is a reality among traditions and within every tradition, and these pluralities offer riches to Christians who take time to reflect deeply upon them.
Reviewed by:
Daniel Joslyn-Siemiatkoski, Ph.D., is the Kraft Family Professor and Director of the Center for Christian-Jewish Learning at Boston College. Dr. Joslyn-Siemiatkoski is a scholar of Jewish-Christian relations and comparative theology and the author of numerous books and articles, including The More Torah, The More Life: A Christian Commentary on Mishnah Avot (Peeters Publishers, 2018).
Horizons in Biblical Theology,
edited by Gregory L. Cuéllar, Professor in the Ruth A. Campbell Chair of Biblical Studies
Horizons in Biblical Theology is Austin Seminary’s own international academic journal. Published biannually, it is a respected source of cutting-edge reflection in Biblical Studies by scholars from colleges and universities around the globe. In Summer 2025, Horizons published a special issue—“Decolonizing the Text: Postcolonial Interventions in Biblical Studies”—presenting groundbreaking essays which invite readers to recognize the lenses they bring to biblical interpretation and consider ways they are called to de-
colonize biblical studies in their own lives. This is the sort of critical work for which Horizons is celebrated.
Guest editors Daniel T.Y. Lam, Axolile N.M. Qina, and Mireia Vidal i Quintero trace the genesis of this issue to an incident that occurred some years ago. After hearing one student’s dismissive comment about decolonizing scholarship, several other students formed a “Decolonizing Biblical Studies” reading group. Professors Lam, Qina, and Quintero hosted a session on the students’ work at the 2023 European Association of Biblical Studies conference. After hearing about their research and participating in fruitful discussion at the session, the Rev. Dr. Gregory L. Cuéllar, Editor-in-Chief of Horizons in Biblical Theology and Professor in the Ruth A. Campbell Chair of Biblical Studies at Austin Seminary, invited the session organizers to guest-edit this special issue of Horizons.
The first essay is a reflection by Silas Klein Cardoso on the conditions for so-called “minority” biblical scholars. Responding to five “pieces of advice” he has received, he addresses the methodological and profiling temptation, mischaracterization, apathy, and ceremonialism applied to scholars who do not meet a “standard” white European/North American male profile. In reply to these injustices, Klein Cardoso suggests four action principles: avoid misleading stereotypes, cultivate openness to alternative epistemologies, ensure a holistic understanding of scholars and their works, and strive for nuanced scholarship. These action principles invite academics to move towards what Klein Cardoso calls an “ethical-diverse academy.”
The following essays engage in decolonizing analyses of specific scripture passages. Olabisi Obamakin applies a Nigerian/British woman’s interpretation to Herodias’s daughter’s dance in Mark 6:17-28 and Matthew 14:3-12. She places the text in dialogue with Simi Bedford’s novel Yoruba Girl Dancing and the context of dance in Yoruba culture to reveal four possible interpretations of Herodias’s daughter’s dance: resistance against patriarchy, prophetic ritual lament over the death of John the Baptist, communication with a divine power, and a sign of the end of John’s era. All of these readings inspire fruitful reflection on the dance’s meanings in global contexts.
Edward Wong reads the text of the Samaritan woman at the well (John 4:1-42) in light of the experiences of first-generation Asian immigrants who are “invisibilised” within their own ethnic communities. Wong argues that the text frames the Samaritan woman’s marginalization as further proof of her need for a superior savior. The lack of recognition she receives in her missionary efforts reflects the ongoing hierarchy that reinforces perpetual foreignness and downplays the contributions of the marginalized.
Maria Chen examines Paul’s recommendations against marriage in 1 Corinthians 7:25–35 in the context of voluntary childlessness in contemporary China. After describing a wave of online resistance to China’s implementation of a three-child policy through declarations of “This will be our last generation,” Chen suggests that Paul’s advice to the Corinthians constitutes a similar form of resistance to the Roman lex Julia et Papia, which sought to compel Romans into marriage and childbearing.
Julia Mayo’s concluding article reflects on the hybridized identities of Lydia and the slave girl of Acts 16:11-18. As a relatively privileged woman who hosts Paul and his fel-
Faculty Books
low evangelists in Philippi, Lydia neglects to provide any support to the slave girl after she similarly encounters Paul and is transformed by the loss of her divining spirit. Mayo links Lydia’s apparent failure to support her less-privileged counterpart with the failure of white feminism to address additional harms faced by women of color.
Taken together, these articles all contribute to a greater understanding of the Bible’s role in decolonization. Klein Cardoso, Wong, and Mayo call attention to the ongoing injustices in academia and in the biblical text itself, including the racism faced by scholars of color, the “invisibilisation” of the Samaritan woman and Asian immigrants, and Lydia’s apparent lack of care for a marginalized woman after her conversion. Obamakin’s and Chen’s articles place biblical texts in conversation with contemporary social issues to reveal decolonizing actions of resistance through Herodias’s daughter’s dance and Paul’s advocating for voluntary childlessness.
While the hurdles facing scholars from minoritized backgrounds are myriad and harmful, this issue of Horizons in Biblical Theology represents a beacon of hope. In the words of Fernando F. Segovia’s strident foreword, “Much has already been accomplished, but… a lot more remains to be done.” This collection of essays invites scholars, pastors, and teachers to strengthen their own efforts to decolonize biblical studies in their teaching, sermons, and activism. “Decolonizing the Text” calls upon all of us to join the voices of these courageous scholars in seeking a more just and equitable world by addressing colonial forces in our own religious communities. This is a major calling Horizons in Biblical Theology continuously strives to follow.
Reviewed by:
The Reverend Sarah Rutherford (she/her) is a Resident Minister at First Presbyterian Church of Ann Arbor, Michigan. She graduated from Austin Seminary in 2025 and serves as Editorial Assistant for Horizons in Biblical Theology.
The Effects of AI on Church Ethics, Theology, and Education
Rodney Caruthers II
Advances in artificial intelligence (AI) have led to unprecedented breakthroughs not only in science, technology, engineering, and mathematics (STEM) but also in social media, business, and even counseling (through its Chatbot feature). AI is utilized for an assortment of practical tasks, from creating complex business strategies to generating graphic art for posters. AI is similarly revolutionizing ministry. AI applications such as FaithGPT and PulpitAI streamline administrative duties. AI’s ability to design worship, create financial plans, and track congregational trends has undoubtedly enhanced church efficiency and production. Aside from AI’s helpful administrative functions, some features are more controversial. The use of AI to create sermons and bible studies, for instance, poses significant ethical, theological, and educational issues for users.
Ethical Concerns
Clergy who face the weekly expectation of producing a stellar sermon can now have AI write one almost instantly. If the AI is provided with a detailed prompt, the sermon can be tailored to fit any style or occasion, complete with appropriate prayers, news stories, anecdotes, images, and musical selections. The efficiency of producing quality sermons in exchange for managing other ministry obligations is undeniable. But should AI be consulted as the primary source of content and spiritual direction? To what degree can AI be trusted to inform a church’s teaching and message?
With regard to sermons in particular, is reliance on AI sermons the right thing to do? Should AI have the responsibility to decide what to communicate to humans who are seeking, in some cases, a divine message that personally addresses them? It is vital to
Rodney Caruthers II, PhD, serves as Assistant Professor of New Testament at Austin Seminary. He holds a Doctor of Philosophy and a Certificate in Greek and Roman History from the University of Michigan, a Master of Theology from Emory University's Candler School of Theology, a Master of Divinity from Ashland Theological Seminary, and a Bachelor of Arts in Psychology from Oakland University. Dr. Caruthers specializes in Second Temple Judaism and Christian origins. His research explores ancient education and rhetoric, magic in antiquity, papyrology, and comparative religion, with particular attention to their intersections with literature and everyday life.
The Effects of AI on Church Ethics, Theology, and Education
understand that although AI appears to think and react like a human, it is simply responding to prompts using data it was trained on. AI can speedily process enormous amounts of data to construct what appears to be original material. Essentially, AI is shown an image of what a sermon is and then assembles one using its vast dataset. It is not creating new ideas but making an amalgam based on published resources. The sermon is new only in the sense that the information gathered from other sources had not been unified before. Since AI is not thinking critically but aggregating existing information, there is the danger that it will perpetuate prejudices—classist, heterosexist, racist, sexist—carried by cultural elites (who are most likely to produce the content upon which AI is trained). But should clergy aspire to something more substantial? Granted, in a fashion more delimited but analogous to AI, clergy create sermons based on prior experience, but unlike AI, they possess an emotive element that shapes the sermon’s content. AI can mimic emotion, but it does not have any sentiment for the message or the congregation. It does not care. Is it not important for a parishioner to know that even if AI was consulted, the sermon was ultimately composed and is being preached by a person who passionately cares for them?
Pollsters, such as the American Bible Society and the Barna Group, have surveyed church leaders and laity to ascertain how the use of AI in ministry is perceived.1 Supporters of AI in churches believe God can work through it to reach others. Pastors recognize AI as a tool that augments the effectiveness of their sermons and administrative tasks. Some of AI’s acceptance is generational. Gen Z and Gen Alpha are more comfortable with and curious about AI than older generations.2 Some, however, are reluctant to use AI for more spiritually based tasks such as sermon writing and counseling. The Barna Group reported that many pastors were fine with using AI for research (43%) but were more averse to using it to write sermons (12%).3 The main worries concern AI giving incorrect biblical or theological information in sermons or questionable advice in counseling. Another complaint is that using AI to compose sermons prevents users from honing their sermon-writing skills.4 Whereas using AI for brainstorming or research is a reasonable aid in sermon preparation, the human element is lost when there is total reliance upon it. The human element entails how the speaker’s understanding of their audience enables them to craft a message that resonates. Without the human element, the preacher becomes a mouthpiece for what AI cobbles together. Over time, with whom is the congregation developing a relationship, their pastor or a nebulous synthesis of pastor and AI?
Although reducing preparation time is useful for pastors overwhelmed by the call of significant responsibilities, congregations might balk at the prospect of opening themselves to receiving spiritual guidance from AI. Depending on the denomination, some congregation members believe the sermon moment is a supernatural event. The pastor is in the role of biblical prophets who are divinely inspired to speak as God’s mouthpiece. Even if some do not go that far, they may still believe that the pastor’s message exceeds a motivational speech. Both beliefs involve an expectation for authenticity between pastor and congregation.
An AI sermon may also leave the preacher with an air of fraudulence because they know
the words are not their own, despite their best intentions and the sermon’s quality. Some would never want anyone to know how the sermon originated, but just as one is expected to give credit for others’ ideas or illustrations in a sermon, the use of AI should be explicitly disclosed in the sermon or bulletin. Those concerned about the ethics of AI should also be attentive to the related issue of how AI’s training and production involve the appropriation of words and images, many copyrighted without permission, compensation, or even attribution. AI is almost certainly going to become part of every aspect of our lives, and doubtless, we are only at the beginning of many convoluted ethical debates. Clearly, AI has potential for tremendous harm and good, so it is vital we keep ethical concerns in the forefront as we move into this new age of artificial intelligence.
Theological Concerns
Theological apprehensions revolve around the relation among the divine, the preacher, and AI technology. Classic biblical texts are often interpreted to suggest that the preacher and prophet are uniquely appointed to proclaim God’s message (e.g., Isa 6:8; Rom 10:1415). Prophets and pastors are commissioned to convey God’s will. Theologically, this is a partnership between God and the proclaimer. The proclaimer’s clear responsibility is to hear from God (e.g., through dreams, visions, or angels) and make the message available to the congregation. The theological question is to what degree AI should substitute for the preacher/prophet. Does using AI circumvent the prophetic or preaching process? AI sermons are determined by specific prompts and data, not by divine agency. If AI’s sermon, which does not involve prayer or the divine, is acceptable for congregations, what makes the preacher exceptional? Does God hear or approve of artificially created prayers or sermons?5 What does it mean to work under the guidance of the Holy Spirit when using AI? Each of these concerns is connected to the more pressing theological question of does God speak through AI. Because of the newness of AI and its incorporation into ministry, theological reflection upon AI remains in its infancy. These issues are hotly debated, but no denominational consensus has yet emerged.
Denominational positions on deploying AI in ministry contexts generally range from affirming to optimistically cautious. The Presbyterian Church (USA) is open to using AI to make ministry more efficient, but is leery about its inaccuracies and potential biases for sermon preparation and teaching.6 Pope Leo XIV approved the use of AI and provided only general instructions to use it ethically to benefit humankind.7 Other denominations, such as Seventh Day Adventists and Mormons, also advocate for the incorporation of AI into ministry with general precautions about ethical use.8 Each cautiously affirms AI’s benefits for ministry without providing explicit guidelines.
The Jehovah’s Witnesses’ website recognizes the advancements of AI but highlights its fallibility as a creation of humankind, implying that it is not trustworthy.9 The Way of the Future Church (WOTF) is at the far end of the acceptance spectrum. Along with designing services and preaching sermons, WOTF touts AI as its spiritual leader and object of worship. Members look to AI as their guide for morals and ethics because they believe it can offer better suggestions than humans.10 Just as most psychologists and doctors affirm AI, while rejecting as dangerous the idea it should wholly displace psychologists
The Effects of AI on Church Ethics, Theology, and Education
and doctors, it appears most denominations would have powerful concerns about AI significantly displacing clergy and counselors.
Educational Concerns
AI’s effect on professional Christian education is another concern. AI’s advent has considerably shortened the time needed to access specialized knowledge. With the proper prompt, one can instantly possess the latest details on any topic. Despite AI’s substantial benefits for learning and research, it can contribute to a loss of critical assessment and to the spread of misinformation. AI’s perceived authority can lead people to accept its conclusions without critical thought. Although AI is quite proficient in some areas, in the biblical field, it is still learning. AI’s tendency to pull material from a variety of sources can result in haphazard responses. Simple queries to look up a biblical passage or request particulars about a biblical character are relatively easy. More technical topics, however, require additional fact-checking. The challenge for non-specialists is to understand how AI arrives at its responses and realize that it is not omniscient or infallible. Mixed in with AI’s extensive facts are details that are not only incorrect but nonexistent. They are called “hallucinations” because AI fabricates items, including entire journal articles, that its algorithms think should be real even though they do not actually exist.11 Those who are unaware of hallucinations or think AI always gives the most up-to-date or correct answer may unintentionally use flawed material.
Some pastors and ministry leaders use AI in place of formal education. AI provides all the answers and creates the ministerial content, but insofar as the messenger does not have expertise for evaluating answers or understanding context, there is the risk of a proliferation of ministerial pseudo-specialists. If AI were self-sufficient and infallible, then total reliance upon AI apart from human expertise may be acceptable, but AI is deeply dependent upon the prompts of the user and is not infallible, so any AI-dependent presumption of expertise is wholly unwarranted and, insofar as the counsel of clergy is significant for people’s lives, has potential to do great harm.
This is not a referendum against AI in the Church. While concerns over AI and resistance to complete reliance is important, there are many ways in which AI could function as assistant rather than main actor. Some points appear to be clear. Wrestling with and appreciating competing vantage points of faith and theology should be celebrated as an important part of theological reflection, as should the benefit congregations receive from hearing unique perspectives instead of artificially generated messages. The personality, talent, and experiences of clergy should be highly valued, and it is important for clergy to feel a genuine sense of empowerment and gratification, knowing their personal contribution made a vital difference. The personal journey of learning should be embraced. Use of AI should be transparent. The age of AI has arrived. It certainly brings risks, but used appropriately, it has the potential to become another invaluable resource for ministers, ministry, and all who pursue spiritual wisdom.
NOTES
1. “Three Takeaways on How Pastors Can Use AI,” Barna Group, February 22, 2024, https://www.barna.com/ research/pastors-use-ai/; Adam Macinnis, “AI Preachers and Teachers? No Thanks, Say Most Americans,” Christianity Today, May 17, 2024, https://www.christianitytoday.com/2024/05/artificial-intelligenceskepticism-study-spiritual-chatbot/.
2. Eli Tan, “At the Intersection of AI and Spirituality,” The New York Times, January 3, 2025.
3. “Three Takeaways on How Pastors Can Use AI,” Barna Group, February 22, 2024, https://www.barna.com/ research/pastors-use-ai/.
4. Ibid.
5. Jonathan Merritt, “Is AI a Threat to Christianity?” Atlantic, February 3, 2017.
6. "AI and the Church: 2025 AI and the Church Summit." https://pcusa.org/about-pcusa/agencies-entities/ interim-unified-agency/ministry-areas/innovation/ai-and-church; Beth Waltemath, "Can AI deliver the Word of God?" Presbyterian News Service, May 20, 2025, https://pcusa.org/news-storytelling/ news/2025/5/20/can-ai-deliver-word-god.
7. Clare Duffy and Christopher Lamb, “Pope Leo calls for an ethical AI framework in a message to tech execs gathering at Vatican,” CNN.com, June 20, 2025, https://www.cnn.com/2025/06/20/tech/pope-leoai-ethics-tech-leader-vatican-gathering.
8. "Artificial Intelligence at the Service of Preaching the Gospel," Adventist News, June 19, 2023, https:// adventist.news/news/artificial-intelligence-at-the-service-of-preaching-the-gospel; "Guiding Principles for the Church of Jesus Christ's Use of Artificial Intelligence," The Church of Jesus Christ of Latter-Day Saints, March 13, 2024, https://newsroom.churchofjesuschrist.org/article/church-jesus-christ-artificialintelligence.
9. “Artificial Intelligence—A Blessing or a Curse?—What Does the Bible Say?” JW.org, https://www.jw.org/ en/library/series/more-topics/artificial-intelligence-bible/.
10. Mark Harris, “Inside the First Church of Artificial Intelligence,” Wired, November 15, 2017, https://www. wired.com/story/anthony-levandowski-artificial-intelligence-religion/.
11. Charlie Warzel, “AI Has Become a Technology of Faith,” Atlantic, July 12, 2024; Eli Tan, “At the Intersection of AI and Spirituality,” The New York Times, January 3, 2025.
Coming in the Spring 2026 issue:
“Once Again, New Testament Theology”
Donghyun Jeong
José
R. Irizarry, President
Board of Trustees
Denice Nance Pierce (MATS’11)
Lee Ardell
Thomas Christian Currie James
James A. DeMent (MDiv’17)
Jill Duffield (DMin’13)
Britta Martin Dukes (MDiv’05)
Peg Falls-Corbitt (CIM’20)
Jackson Farrow Jr.
G. Archer Frierson II
Jasiel Hernandez (MDiv’18)
Cyril Hollingsworth (CIM’16)
Ora Houston
David H. Jensen
Shawn Kang
John A. Kenney (CIM’20)
Keatan A. King
Steve LeBlanc
Steve Miller (MDiv’15)
Lisa Juica Perkins (MDiv’11)
Mark B. Ramsey
Stephen J. Rhoades
Sharon Risher (MDiv’07)
Pamela Rivera
Kenneth Snodgrass (MATS’16)
Michael Waschevski (DMin’03)
Sallie Sampsell Watson (MDiv’87)
Elizabeth C. Williams
John Williams (MDiv’87)
Rachel Wright
Shirley Zsohar
Trustees Emeriti
Cassandra C. Carr, Lyndon L. Olson, B.W. Payne, Max Sherman