DIFFICULT MORAL QUESTIONS
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Question 74: May physicians and dentists try to maximize income?
I am finishing the first year of medical school, and my studies are going well. My dad is a physician, and I plan to follow in his footsteps, because medicine is a good profession, offering the satisfaction of helping people, the freedom to work as one’s own boss, and adequate income.
My brother, who is finishing his training in orthodontics, brought home a booklet put out by one of the companies that makes dental equipment. The booklet tells people planning to set up their practice in dentistry or one of its specialties how to maximize their income, within parameters set by their other desires regarding the kind of place they want to live. It breaks the whole country down by states and counties, and provides statistics that make it possible to pick out places where dentists and dental specialists are most likely to be able to develop a sizable practice with comparatively high fees. My brother, who is thinking about where to practice, spent a lot of time during the holidays picking out twenty-five counties that promise high income and evaluating them by some of the criteria used in a recent study identifying the fifty U.S. cities offering the best living conditions.
Since I hope to marry and, like my dad, become the father of a large family, I expect to need a good income. Still, it seemed to me that my brother’s approach involved the wrong priorities. We always enjoy a good argument, so I challenged him, taking the position that a better approach—which is much simpler and the one I actually will follow—would be to think first in terms of raising a family. Begin with the study identifying the fifty cities that are good places to live, then use the booklet’s statistics to rank them by their promise of a large practice with high fees, so as to take into account, but only secondarily, each city’s potential for maximizing income.
Starting from what our mother often points out, that as Christians our first concern should be to try to see what is morally right, we agreed that in a question of this sort, where neither alternative violates any of the Commandments, the morally right approach is the one involving the right priorities. Then we argued about whether his approach or mine does that. Needless to say, neither of us convinced the other. Since you are looking for difficult moral questions, I am sending you this one: Should physicians and dentists put maximizing income ahead of practicing where conditions are good for raising a family, as my brother thinks, or the other way around, as I think?
Analysis:
This question calls for clarification of health care service as a possible element of the questioner’s personal vocation, and an explanation of how other possible elements of his vocation—in particular, marriage and family life—can be integrated with a genuinely Christian commitment to professional service. The questioner should make his vocational commitments and use them as the standard for determining how much income to seek and how to use it. He should use available information to see where needs are great and the likelihood that others will meet them is small. Money is only an instrumental good, which always should be subordinated to the basic human goods that fulfill persons: life and health, marriage and family, and so on. So, he should not try to maximize income, but should seek only as much as necessary to fulfill his vocational commitments.
The reply could be along the following lines:
It is commendable that you wish to follow your mother’s advice by trying first to find out what is morally right. Moreover, you have the better of it in your argument with your brother. Money never should be the first consideration for Christians, as it so often is for us as well as for our nonbelieving neighbors. Money and the things it can buy are, after all, only means, while raising a family is something good in itself; and, certainly, basic human goods deserve priority over instrumental ones. Your parents obviously have tried to bring you up as Christians, and their effort has borne some fruit in you. It sounds, though, as if your brother may not have taken in Jesus’ warning about how hard it is for the wealthy to enter the kingdom of heaven (see Mt 19.24, Lk 18.24–25).
While you have a more authentic sense of values, however, I am afraid you still tend to think too much about your self-interest in relation to those values. Is it significant that, in saying why the medical profession is good, you speak of the satisfaction of helping people rather than the benefit to them? Then too, while a man called to be a husband and father certainly ought to consider the likely impact that decisions regarding his profession will have on the good of family life, it is wrong for anyone to regard his or her work as a mere means of making a living, so that others’ needs for the work’s products or services are inadequately considered or even overlooked entirely. Finally, and most importantly, nothing in your question indicates that you have ever seriously asked yourself what God is calling you to do, what his plan for your life is, and how you should follow Jesus, who came not to be served but to serve.251
To hear what God is calling you to do, you must consider, on the one hand, what your gifts are (and also your limitations), and, on the other hand, what needs people have that you could help meet by putting your gifts to work. Comparing the two, and taking into account the likelihood or unlikelihood that others will help people meet their needs if you do not, you will discern rather easily, I believe, the part God is offering you in carrying out his plan for the preparation in this world of material for his heavenly kingdom (see GS 38–39).
Since you are doing well in the first year of medical school, your vocation probably does include caring for people and helping them fulfill their responsibility to sustain life and promote and protect health in themselves, their children, and others. When the medical profession is considered in this way, the booklet’s statistics about various localities will be a helpful index to where you should establish your practice. You should use the statistics, though, not as your brother did or as you proposed to do, but to see where potential for income is poor, for in many such places needs for service will be great and the likelihood that others will come to meet them will be low.
Of course, in deciding where to set up a practice, you also must take into account the requirements of other elements of your vocation. Your hope to marry and raise a large family suggests these might be part of it. At least, however, you should consider the possibility that your gifts for medicine and people’s needs for your service are so great that God is calling you to forgo marrying or to delay having your own family so that you can offer greater and more selfless service to other families. Having considered the question as you should, though, you still may be confident that marrying and raising many children belong to your calling. If so, be sure to consider them in that way, not merely as contributions to your self-satisfaction. Doing that, you will be careful about whom you marry and will have a sound principle for decisions about regulating births.
A most important part of discerning God’s will for your life will be seeing how central elements of your vocation—especially profession, on the one hand, and, on the other, marriage and fatherhood—are to be integrated harmoniously, each complementing the other. Of course, there are other elements: religious responsibilities, civic duties, friendships, recreation, and so on; indeed, personal vocation includes every sphere of activity and even conditions beyond one’s control. So, you must discover every part of the life of good deeds God has prepared for you and then weave all of those elements together into a seamless whole.
Having begun to understand your life in this way, and not before, you will begin to be able to judge what financial and other resources you need to fulfill your vocational responsibilities. Only then will you be in a position to consider how to obtain those resources. Of course, if marriage and family life are part of your vocation, you will need to live where conditions are suitable for raising your children. But a suitable place need not be among the “fifty cities that are good places to live.”
Unless you find that you are called to practice medicine in some very poor locality, you probably will be able to earn the money you need in return for your services.252 Indeed, your problem may well be how best to limit your income to that justly due you. Since there is no real market in medical services, competition usually does not serve as an effective brake on fees. Those who supply medical care greatly influence people’s judgments whether they need it, and when patients think they need care, they have little choice but to get it if they can. Moreover, the supply of care often is quite limited, and the conditions under which it is provided make it virtually impossible for people to shop for good values for price. Then too, patients generally cannot obtain the information they would need to evaluate available providers, and once a provider has been chosen, changing is often difficult. Under these conditions, physicians in the United States, and perhaps in other affluent nations, have been very well compensated. In defense of their fees, physicians often point to their costly education, additional years of training at low pay, high overhead, large insurance premiums, long hours, and so on. Even taking all those factors into account, however, most physicians’ net income appears more than adequate. How, then, are you to tell how much to ask for your services?
The answer will depend upon who is paying and from what resources the payment is to be made. Where government programs and/or insurance provide a certain amount, I doubt that you will have any reasonable basis for charging any but wealthy patients more than the required copayments. At the same time, I think you can justly accept what such payers provide; if the payment is excessive, the structure determining it is not of your making and is so complex and shot through with injustices that you cannot reasonably be expected to rectify it case by case. However, when you serve the uninsured working poor who must personally pay your fee or go without care, you should charge only what they can pay without giving up other necessities—an adequate diet, decent shelter, and the other things you regard as essential for yourself and your family. Of course, if some of your patients are wealthy people who are ready, willing, and able to pay what generally are regarded as reasonable and customary fees, you may charge accordingly and use that income to meet your responsibilities.
You perhaps have the gifts and will find opportunities to work toward reforming the medical profession so as to subordinate it, as it should be subordinated, to people’s needs and accommodate it justly to their means. Therefore, consider the possibility of working in professional associations and/or trying to influence legislation as ways of bringing about needed reforms.
What should you do if, proceeding as I have outlined, you find the income from your practice either exceeding or falling short of your own true needs? If the former, you may simply assign the excess to meeting the responsibility to help others in need. If the latter, you should seek other sources of funding, such as governmental subsidies or foundation grants. Finding no such sources, you should share the poverty of those you serve insofar as you can do so in good conscience—considering, for example, family responsibilities—and then, if necessary, shape your professional practice to serve a sufficient proportion of more prosperous people so that you will earn the income you need.
I realize my reply offers far more advice than you asked for. Still, I hope you will take what I have written to heart and, having done so, share it with your brother and your fellow medical students. I also hope it will help him and at least some of them to think more uprightly about their profession. Yet I fear you might say: “If I undertake to follow your advice, I might as well become a monk and take a vow of poverty!”
Not so. Jesus’ teaching about relationships with others is: “You shall love your neighbor as yourself” (Mt 22.39) and “Love one another as I have loved you” (Jn 15.12)—that is, with an other-serving, self-sacrificing love. Applied to matters of income and wealth, this teaching makes radical demands on Christians, especially the affluent (see LCL, 780–82, 789–92, 800–806, 811–14). Following so-called common sense, of course, most of us, including many who have taken a vow of poverty, do not take those demands seriously. But even though Jesus’ reply to the rich young man was not in keeping with his listeners’ common sense, it was part of the saving good news he preached. That young man went away sad, but he would have been more sensible and also happier had he followed Jesus’ advice, which all Christians, not only an elite, are called to follow.253 Considered as a whole, that advice is nothing less than a prescription for a good and holy life, in which alone one also finds true self-fulfillment. Just as Jesus endured the cross not only for our salvation but for the joy that was set before him (see Heb 12.2), so we, if faithful to his gifts, will deserve and receive a payment that will never lose its value: “Come, you that are blessed by my Father, inherit the kingdom prepared for you from the foundation of the world” (Mt 25.34).
251. Personal vocation has been treated in general and more fully in LCL, 113–29.
253. See John Paul II, Veritatis splendor, 16–24, AAS 85 (1993) 1146–53, OR, 6 Oct. 1993, iii–iv.