The For-Profit Social Welfare Policy Sector and End-of-Life Issues: A Troublesome Ethical Mixture

This paper discusses for-profit social welfare and end-of-life issues in the U. S., and concludes that the strong profit motive, plus diminishing budgets, growing demands (such as an increased aged population) and other factors will result in increasing ethical problems vis-à-vis end-of-life issues.  The paper divides as follows:  (1) For-Profit Social Welfare Policy Sector and Human-Service Corporations; (2) Profit Motive Trumps End-of-Life Concerns; (3) Conclusion. 

The For-Profit Social Welfare Policy Sector and Human-Service Corporations

In the first place, the for-profit social welfare policy sector and human-service corporations are an increasingly important part of American social welfare policy.  Human-service corporations are “for-profit firms providing social welfare through the marketplace”. 1 The for-profit social welfare sector engages in market-oriented activities with the goal of making a profit, in much the same way that the non-social-welfare business sector does.  The difference is precisely that the “business” of the for-profit social welfare sector is “social welfare”—in all of its dimensions. 

Examples of human-service corporations include Manor Care, Humana, and KinderCare.  While all human-service corporations are for-profit, not all for-profit human services are sizeable “corporations”.  They can range in size from large to small, and are often large.  Examples of the voluntary, non-profit social welfare sector include Catholic Health Initiatives and Ascension Health (two of the larger non-profit Catholic hospitals), Catholic Charities, the St. Vincent de Paul Society, and the Salvation Army.  Examples of the government social welfare sector are programmes like Food Stamps, Medicare, Medicaid and Social Security. 

The modern neoconservative movement has been active in encouraging the “privatization” of social welfare.  Privatization is the “transfer of economic resources from the public to the private sector to meet the social needs of people. . . [This] is seen in the reliance on private health, educational, and social institutions and entrepreneurs to provide services.” 2

The for-profit sector has achieved increasing prominence because of the rise of the conservative and neoconservative movements, and also because of the increasing disenchantment with governmental and welfare-state solutions to social ills. 3 The election of John Paul II to the papacy in 1978, and of Ronald Reagan to the presidency in 1980, were watershed events.  The neoconservative view (echoed by President Reagan) was that government was part of the problem.  Pope John Paul II, in his historic encyclical Centesimus annus (1991), stressed the fundamental importance of the human person.  (The dignity and the rights of the person had been trampled underfoot by the Communism and National Socialism that the pope had experienced at first hand.)  Pope John Paul also stressed the importance of the principle of subsidiarity, echoing Pope Pius XI, who said that one should “not withdraw from individuals and commit to the community what they can accomplish by their own enterprise and industry”. 4

There are contrasting views of the rôle of the state in the thinking of Popes John XXIII and John Paul II.  John XXIII, in his encyclical Mater et magistra (1961), “did a great deal to change our collective attitudes toward state intervention”. 5 It would be crudely simplistic to say that John XXIII was more “liberal” and John Paul II more “conservative” regarding the rôle of the state.  Both argued that governments had a responsibility in social welfare matters.  Still, it might be said that John Paul II was, in a sense, more concerned and more critical about the rôle of the state, based to some extent on his experiences under Communism and Nazism.

A political and ideological debate has been taking place about preferring private-oriented or state-oriented social policy. 6 We can say without very much debate that private-sector social welfare solutions have prevailed.  The emphasis on the important rôle of “subsidiarity” has affected Catholic social thought in noticeable ways.  The late John H. Miller, C.S.C., stated forcefully a few years ago that the rôle of the state must always “remain a strictly limited one:  limited by the principle of subsidiarity”. 7  

The for-profit social welfare sector has risen because of a perceived void that neither government nor the non-profit social welfare sector has been able to fill.  The rapid growth of the for-profit social welfare sector is testimony to that, and it has been dizzying indeed.  In 2002, the National Association of Social Workers (NASW) conducted a survey of its members through the NASW 2002 Practice Research Network (PRN) Survey.  John V. O’Neill reported that the private social welfare sector employed more NASW members than the public sector. 8 The rise of the for-profit social welfare sector was particularly pronounced.  In 2002, 36% of all NASW members were employed by the for-profit sector, whereas in 1988 only 19.8% were.  The private, non-profit sector employed 35% of NASW members.  Thus, a sizeable 71% of all NASW members were employed by the private sector, surely putting to rest the notion that the profession of social work is government-based.  In a larger framework, the private social welfare sector, and particularly its for-profit share, was clearly in a dominant position.  As well-indicated by the title of Neil Gilbert’s book Transformation of the Welfare State:  The Silent Surrender of Public Responsibility, government had retreated—had surrendered public responsibility. 9

David Stoesz, one of the most sagacious observers and analysts of the emergence of the for-profit social welfare sector and human-service corporations, says:

Human service corporations have established prominent, if not dominant, positions in several human service markets, including nursing home care, hospital management, health maintenance, child care, home care, corrections, and welfare.  In 1981, 34 human service corporations reported annual revenues above $10 million; by 1985, the number of firms had increased to 66; by 2000, the number had risen to 268.  Of these, sixteen corporations reported revenues higher than the total annual contributions to all of the United Ways of America! 10       

The for-profit social welfare sector has played such a dynamic and active rôle in health policies in the U. S. that it is difficult to conceive of a national health plan being developed that does not include an active rôle for the for-profit sector.  The ideological underpinnings for an active rôle for the for-profit sector can be found in both neoconservative and neoliberal thinking.  Neoliberalism “aimed for a more moderate mix of compassion and free-market economics . . . this new Democratic agenda was more optimistic about the potential for corporate contributions to social welfare, and, therefore, more willing to support legislation favourable to the business sector.” 11 Thus, an array of forces have come together to place the for-profit social welfare sector in an enviable position, a position that appears to be one that will prevail for years to come.

Profit Motive Trumps End-of-Life Concerns

The second point to be considered here is that the for-profit motive trumps end-of-life concerns.  Without sufficient profits, business enterprises will not survive.  Profits dominate business thinking.  Profits determine which corporations succeed in the marketplace, and which corporations do not succeed. Profits are “a prime mover of a capitalistic economy”, and “can be said to act as a stimulator of output”. 12 The power of profits, both for good and for ill, has been frequently spoken about in human history.  An Arabic proverb says that one should “live together like brothers and do business like strangers”.  Ambrose Bierce defined a corporation as “an ingenious device for obtaining individual profit without individual responsibility”.  Perhaps the most quoted maxim is that of President Calvin Coolidge, “The business of America is business.”

It should be borne in mind that human-service corporations are indeed profit-oriented businesses, every bit as much as their non-social-welfare counterparts.  Beverly Enterprises, Humana and KinderCare all seek profits with seemingly as much verve and drive as do Cargill, McDonald’s and Wal-Mart.  They collectively often incorporate a “profit maximization” strategy, which can have negative effects.  The Dominican priest-economist Albino Barrera, O. P., states that a “profit-maximizing strategy configures economic life to the unbridled pursuit of private interests, the preferential treatment of capital over labour, a macroeconomic strategy of growth-efficiency, unfettered rights, and an understanding of economic life cast exclusively in terms of wealth accumulation.” 13

Profit should not dominate the business enterprise, but making a reasonable and decent profit is good.  There should be a balance here.  As Pope John Paul II noted in Centesimus annus,

The Church acknowledges the legitimate rôle of profit as an indication that a business is functioning well.  When a firm makes a profit, this means that productive factors have been properly employed and corresponding human needs have been duly satisfied. . .  Profit is a regulator of the life of a business, but it is not the only one; other human and moral factors must also be considered which, in the long term, are at least equally important for the life of a business. 14

Rev. Robert A. Sirico states that it is surely not immoral to profit from our wit, resources, and labour.  He states further that the only alternative to profit is loss, which can constitute a poor stewardship. 15 With profit, the focus must be on the common good, on the good of the society as a whole. 16 If profit is carried too far, if there is an “all-consuming desire for profit”, as John Paul II stated in Sollicitudo rei socialis (“On the Social Teaching of the Church”), then it is clearly wrong. 17 Pius XI aptly referred in Quadragesimo anno to the “imperialism of money”.  On the other hand, as already iterated, profit is a good, if it is generated ethically and directed to the common good.

However, people are often trodden upon in the interests of profit.  This is certainly in evidence with many human-service corporations.  Howard Karger and David Stoesz list both the advantages and the disadvantages of human-service corporations. 18 The listed advantages include access to capital, innovativeness and flexibility.  The disadvantages include discriminatory selection of clients, attraction of clients away from voluntary agencies, and, perhaps, less cost-effectiveness than provided by other social-welfare models.  To the latter disadvantages, I should like to add an important one:  a pervasive, overriding “profits-over-people” orientation.  Recipients of human services become “consumers”, mere numbers that move through the human-services system, contributing a profit to the human-service corporation.  If they are not “profitable” to the human-service corporation, then they are discarded—perhaps banished to the public sector or, in some cases, to the voluntary, non-profit sector.  “Profit-seeking health and welfare organizations have frequently been charged with ‘cherry-picking’ the most potentially lucrative clients.  Critics of commercial health maintenance organizations (HMOs), for example, charge that they often focus their membership recruitment on the healthy, studiously discouraging enrolments by the sick and disabled.” 19 The for-profit mode of the market dominates all areas, including research itself.  Biotech corporations, for example, “do not promote research for its own sake or promote healing as an end in itself.  Rather, they seek to identify and fill a market niche, then advertise aggressively both to providers and to prospective consumers.” 20    

The for-profit orientation is so strong that even life-and-death concerns often get run over quite easily by human-service corporations, eager to make a profit.  Wesley J. Smith notes that Dutch euthanasia policies are carried out in a welfare-state health care system of virtually universal health coverage. 21 This contrasts with the highly privatized, corporate U. S. health care system, where large numbers of people have no coverage.  For-profit HMOs in the U. S. are known to punish physicians financially for providing care that the HMO deems unnecessary, when in fact such care is necessary in the overall treatment plan.  This is all taking place in a rapidly changing and financially imperiled health care system.  Rising costs and declining coverage by employers are occurring at the same time. 22 Interestingly, Wesley Smith goes on to say that because of all these factors, “The U. S. experience with the death culture would likely be far worse than that in the Netherlands.” 23 Whether this would in fact be the case may be open to discussion.  But assuredly, the profit motive in American health care is so powerful as to seem to throttle other considerations.  The culture-of-death environment, now more troublesome and far-reaching with the advent of cloning, embryonic stem cell research and other developments, paves the way for profit-oriented health care to blaze new and deleterious paths.

This mix of corporate for-profit health care with growing numbers of the aged and growing numbers of survivors of serious accidents and diseases makes for a troublesome brew.  The late Michael Harrington once said that medical technology is wondrous, yet it somehow comes back to haunt us.  Medical technology is keeping people alive longer and longer, creating the future possibility of unprecedented social-welfare policy challenges.  There is talk of a coming “generational storm”. 24 Caring for a growing aged population may indeed call for “the wisdom of Solomon”, 25 and we are warned of major financial and other challenges ahead. 26

Huge fiscal debts compound the problems we are facing.  As of this writing, the national debt is $8.36 trillion, and Congress is preparing to raise the federal debt limit for the fifth time in four years, to nearly $10 trillion.  This is almost double the $5.7 trillion gross federal debt of fiscal 2001, when President George W. Bush took office.  With all of this, many economists fear that a debt crisis lies ahead. 27 Indeed, the cost to the U. S. of two protracted wars, Iraq and Afghanistan, amounts to $10 billion a month, up from $8.2 billion only a year ago.  Costs were $48 billion in 2003, $59 billion in 2004, $81 billion in 2005, and an anticipated $94 billion in 2006. 28     

The war in Iraq is “consuming over $1.4 billion a week—or $200 million a day. . .  The war has cost $200 billion already.  Economists have estimated the war’s ultimate bill will be $1-2 trillion. . .” 29 The war “is taking a terrible toll on the Iraqi people and our military personnel, as well as on the region, our nation, and the world.” 30 The United States Conference of Catholic Bishops has stated that the “very costly conflict in Iraq demands a major commitment of human and financial resources, but Iraq cannot become an excuse for ignoring other pressing needs at home and abroad, especially our moral responsibilities toward the poor in our nation and in developing countries.” 31 

Social Security and Medicare face significant challenges in the years ahead.  The Dependency Ratio is the number of workers paying into the Social Security system to support one retired recipient.  It has changed significantly, from 5-to-1 in 1960 to 3.4-to-1 in 2001, with projections of 2-to-1 in 2025. 32 Medicare may face even more formidable challenges than Social Security in the years ahead.  The combination of rapidly-increasing health care costs, a growing aged population, sophisticated medical technology, prescription drug costs and other factors has contributed to the pressures on Medicare.  Medicare benefit payments have taken an increasing share of Gross Domestic Product (GDP) over the years, from 0.74% in 1970 to (projected) 4.7% in 2030 and 9.0% in 2075. 33 The sheer size of Medicare is enormous.  After Social Security, Medicare is the largest social insurance programme in the U. S., and the largest public payer for health care (about one-fifth of all health care spending in 2000). 34 Both Medicare and Medicaid contribute to for-profit social welfare coffers.  Payments for nursing-home-care accounts are a significant share of the Medicaid budget.  The federal government and the states share in covering Medicaid costs, and the burden is growing yearly.  Increasing Medicaid costs are one of the biggest challenges facing states today.

The growth of the for-profit nursing-home industry has paralleled the growth of Medicaid expenditures.  For-profit hospitals are also heavily dependent on Medicare money.  The “mixed economy of welfare” 35 implies the coexistence, as the major components of social welfare, of the governmental, the voluntary non-profit, and the corporate for-profit sectors.  The two latter are private-sector entities, both heavily dependent on governmental revenues.  They can be ethically compromised by the government’s laws, financial support, and philosophical assumptions. 

The following cardinal example of this ethical compromise has been explicated well by John B. Shea, M.D. 36  The National Research Act of 1974 resulted, by Congressional order, in the production of the Belmont Report, a seminal document which espoused a set of ethical principles that has permeated all dimensions of medical ethics.  The “Belmont ethics” derive from the philosophy of Kant, Mill and Rawls, and contradict Catholic ethics.  Natural law and divine law are ignored, and medical ethics today have come into thrall to a postmodernist ideology with Kantian roots.  Kant espoused “a critical philosophy [which] undermined the status of metaphysics [and] revolutionized epistemology”. 37 For Kant, who has been called the father of postmodernism, “one cannot achieve either rational or empirical knowledge of the first principles of metaphysics”. 38 Kant has had a significant impact on social welfare policies. 39 One can see where this might be leading, vis-à-vis social policies—to an ultimate denial of objective truth and the natural law, moving toward the “slippery slope” of euthanasia policies that enshrine human freedom and autonomy (a Kantian ideal) with such dicta as “the right to die” (paralleling the “right-to-choose” language of the “pro-choicers”).  According to Kant, “the death of dogma is the beginning of morality.” 40

Richard C. Eyer states that there are three things that are characteristic of postmodern medicine:  the shift from moral to ethical medicine, the shift from community to autonomy, and the shift from healing to relief of suffering.  He goes on to say that Hume and Kant introduced the notion of autonomy into modern ethics, so much so that in medicine today, the “autonomy of the patient’s self-legislating will is recognized as the methodology of ethics”. 41 Perhaps the liberal euthanasia legislation of the Netherlands and some other European countries is an example of this kind of thinking. 

The driving acquisitive force of the profit motive trumps end-of-life concerns, and causes the natural law to be ignored.  But business enterprises “have an obligation to consider the good of persons and not only the increase of profits”. 42 And Pope John Paul II quotes St. Thomas Aquinas on natural law—the rational creature’s participation in the eternal law—going on to say that “the Church has often made reference to the Thomistic doctrine of natural law, including it in her own teaching on morality”. 43 Unfortunately, the prevailing tide of Kantianism, postmodernism and secularism has blinded many Catholics to these great truths.  Thus, we have a concatenation of forces besieging medical ethics and health policies—the profit motive of the for-profit social welfare sector; a postmodernist philosophical climate, growing aged populations; and rapidly increasing health care costs.  These and other factors all contribute to a troublesome ethical mixture which could become worse in the future, with inevitable Medicare and Medicaid cuts by government, reducing the bottom line for for-profit hospitals and producing cuts by these hospitals for perceived “extraneous” items.  (This is already happening.)  The U. S. may see euthanasia come in by the “back door” as a result. 

“If assisted suicide were legalized, managed-care providers would inevitably embrace it as a money-saving technique,” notes Eric Pavlat.  He continues by stating that a study reported that “doctors who are cost-conscious and practice resource-conserving medicine were six times more likely to write illegal, lethal prescriptions for their terminally ill patients”.  He discusses the experience of the physician-assisted suicide programme in Oregon, and asks whether “there is any doubt how profit-minded managed-care providers would react if assisted suicide were legalized throughout the United States?  We would see a new stratification of society, where the underinsured would be advised to settle for assisted suicide, while those with better insurance could get the medical assistance they needed.” 44 Such a result is surely unethical and unjust, going directly against Church teaching in manifest ways.

Conclusion

The third, and concluding, portion of this paper might best be summed up by Pope Paul VI’s statement, in Humanae vitae (1968), that “it is not surprising that the Church finds herself a sign of contradiction—just as was her Founder”. 45 The Church stands for the dignity of the human person all the way through the life cycle, birth to death.  This is a counter to the “culture of death” mentality of so much of the world.  Indeed, the gospel of life is at the heart of Jesus’ message. 46 The columnist Cal Thomas, a Protestant, has noted that John Paul II, in Evangelium vitae, “condemns in the strongest terms yet abortion and euthanasia . . . The pope was right and America’s contemporary leaders are wrong, no matter what a majority might think at the moment.” 47 The Church stands with the marginalized and oppressed (who may well be the first to die in any euthanasia policy venture), advocating for justice and equality, for equal access to health care.  In both Catholic and Jewish ethics “all members of the community must be provided with access to needed health care—at least a ‘decent minimum’ that preserves life and meets other basic needs.” 48

I wrote, a few years ago, that “the aggressively secular, post-Enlightenment welfare state leaves little wiggle room for the individual.  Indeed, the individual gets in the way of state objectives. . .” 49 One “state objective” could be getting rid of undesirable, unproductive and expensive-to-maintain individuals—those being fed intravenously, children with severe cystic fibrosis, etc.  The Church stands up for such persons, countering any attempts at ending their lives.  The Church respects and honours the dignity of the person. Pope John Paul titled the sixth chapter of Centesimus annus “The Person Is the Way of the Church”, firmly asserting that the Church’s social doctrine “focuses especially on the person as he is involved in a complex network of relationships within modern societies”. 50

So, how do we make the “troublesome ethical mixture” of the for-profit sector and end-of-life issues less troublesome?  Assuredly, we must begin with prayer and spiritual renewal.  A. G. Sertillanges, O.P., reminds us that St. Thomas “tells the passionate seeker after knowledge:  ‘Orationi vacare non decinas:  never give up praying. . .’  St. Thomas Aquinas discusses many aspects of prayer, one being that it ‘makes us friends of God. . .’” 51 This is of special significance because we are involved in life-and-death decisions that are perhaps unprecedented. The science and technology at our disposal involves risks that can lead us in positive directions, or the opposite. 52

We must keep the common good in mind at all times.  An essential ingredient of the common good is charity, which St. Thomas states is the “most powerful of the virtues”. 53 The common good is the “sum total of social conditions which allow people, either as groups or as individuals, to reach their fulfilment more fully and more easily”. 54 The common good “concerns the life of all.  It calls for prudence from each, and even more from those who exercise the office of authority. . .” 55 Certainly, important principles like solidarity (something particularly missing in today’s world) subsidiarity and, of course, the natural law must be maintained.  The natural law is the very bedrock here, and especially vis-à-vis end-of-life issues.

An active interest in social policy (and, especially, moral issues in social policy) must be encouraged.  The U. S. government has a Council of Economic Advisors, but not a Council of Social Advisors.  Social policies must focus more on empowerment of the individual through asset accumulation (rather than on more “welfare programmes” that encourage dependence on government).  The principle of subsidiarity would assist us to move away from excessive reliance on the state.  Father John H. Miller, as quoted earlier, 56 reminded us that there is certainly a place for the state, but that it is always “limited by the principle of subsidiarity”.  Asset-based policies are important, because when end-of-life decisions come into conjunction with the motives of the for-profit sector, “money talks”.  Those with the greatest capital assets have the greatest control over their lives.  Michael Sherraden 57 proposed the creation of Individual Development Accounts (IDAs), as a remedy for the abysmal savings rate of Americans.  This is the route we must go, to avoid the pull toward euthanasia:  building up the savings and assets of individuals so that they can resist the blandishments of “economic necessity” vis-à-vis end-of-life decisions.  Early and lifelong saving must be encouraged in every way possible.  As pointed out previously, it will be the poor, unfortunately, and not the well-off, who experience the brunt of liberal euthanasia policies.

The United States must come to grips with budget deficits, as Laurence Kotlikoff and Scott Burns point out in their riveting book, The Coming Generational Storm.  One helpful way of addressing the problem, they aver, is to adopt “generational accounting”, which “directly measures the fiscal burden we are leaving our kids. . .” 58 This would provide us with a more realistic picture of the severe budgetary challenges that we face. 59 These budgetary challenges will have many effects, including pushing us toward liberal, Dutch-style euthanasia legislation, with the parallel move by for-profit human-service corporations to “cut costs”, especially focusing on the severely disabled and bedridden, the “expensive” cases.

U. S. health care policy must emphasize more equitable access.  Despite the huge amount of money spent on health care in the U. S., the state of American health care access is less than satisfactory.  The U. S. “remains the only industrialized nation that does not have a system of health care with access to services for all of its citizens. . . ” 60 There is hope for change at the state level:  in 2006 the Commonwealth of Massachusetts enacted a mandated health insurance plan for all its citizens.  (There is a parallel here with required automobile insurance coverage.)  To forestall coverage problems ahead, citizens should be required (as in the Social Security programme) to contribute to the health insurance plan—a self-care and family-care “pot”—from a relatively early age.  We could certainly go a long way toward restructuring (or even replacing) large, government-run programmes like Medicare, Medicaid and Social Security by doing these things. 61 Parallel to this, we must “mandate saving” by putting into place policies and programmes that would require citizens to save money over the long run which can benefit them later, and reduce their dependence on government, and on the whims of a for-profit human-service corporation with respect to end-of-life decisions.  Long-term savings and capital accumulation translate into greater independence for the citizen.  (Things such as complicated and expensive surgery can pose many significant challenges to health care savings accounts; therefore, the purchase of health care insurance in addition to one’s health savings account would be necessary to make it work.  Health insurance would be a kind of backup to the HSA 62—a second piece in the model. 63

Lastly, an intensive dialogue with those advocating euthanasia needs to take place.  Eric Pavlat argues cogently that dialogue and persuasion are indeed possible on this issue. 64 As a convert from “pro-choice” agnosticism, whose conversion story was printed in the book Surprised by Truth 2, and as a member of Democrats for Life of Maryland, he has a wealth of experience and knowledge to bring to such an undertaking.  Glenn Tinder notes that “Liberals believe in the possibility of correcting injustice.” 65 Democrats in the last several decades have been associated with “greater economic intervention, protection of minorities, a social safety net, including Social Security and Medicare, government regulation, protection of the environment, a less aggressive foreign policy, and the cause of poor and working-class people.” 66 The Democratic Party has been called the “Party of Compassion”.  So, why not use “compassion”—with respect to end-of-life issues—as a seminal debating point?  A number of Democrats have been persuaded by the fine organization Democrats for Life (www.democratsforlife.org) that the unborn child deserves a healthy dose of Democratic Party “compassion”.  There is no reason to believe that a compassion directed toward the sick, frail, and terminally ill cannot be elicited.  A group that has already done much good in this respect is the Not Dead Yet organization (www.notdeadyet.org), founded in 1996 by Diane Coleman, an attorney with significant disabilities, who has used a motorized wheelchair since the age of eleven. 

Despite the pressures on the for-profit sector to terminate lives in the interest of greater profits, there is hope.  I end with excerpts from Pope John Paul II’s great encyclical Evangelium vitae:

In such a context suffering, an inescapable burden of human existence but also a factor of possible personal growth, is ‘censored’, rejected as useless, indeed opposed as an evil, always and in every way to be avoided. . .  In the materialistic perspective described so far, interpersonal relations are seriously impoverished.  The first to be harmed are women, children, the sick or suffering, and the elderly.  The criterion of personal dignity—which demands respect, generosity and service—is replaced by the criterion of efficiency, functionality and usefulness:  others are considered not for what they ‘are’, but for what they ‘have, do and produce’.  This is the supremacy of the strong over the weak. 67

Notes

1.   Howard Jacob Karger and David Stoesz, American Social-Welfare Policy:  A Pluralist Approach, 5th ed. (Boston:  Allyn & Bacon, 2006), p. 2.

2.   Robert L. Barker, The Social Work Dictionary (Washington:  Georgetown University Press, 2003), p. 339.

3.   Roger A. Freeman, The Wayward Welfare State (Stanford, Calif.:  Hoover Institution Press, 1981); Charles Murray, Losing Ground:  American Social Policy 1950-1980 (New York:  Basic Books, 1984).

4.   Pius XI, Pope, Encyclical letter Quadragesimo anno (1931), §79.

5.   Thomas D. Watts, “Freedom and the Welfare State”, Social Justice Review 93: 11-12 (Nov.-Dec., 2002), pp. 167-72.

6.   Thomas D. Watts, “Two Social Policy Orientations:  Some Current Theological Dimensions”, The Journal of Religious Thought 52: 1 (Summer/Fall 1995), pp. 45-60.

7.   John H. Miller, C.S.C. (Ed.), Curing World Poverty:  The New Rôle of Property (Saint Louis, Mo.:  Social Justice Review, 1994), p. iv.

8.   John V. O’Neill, “Private Sector Employs Most Members”, NASW News 48: 2 (February, 2003), p. 8.

9.   Neil Gilbert, Transformation of the Welfare State:  The Silent Surrender of Public Responsibility (New York:  Oxford University Press, 2002).

10.  David Stoesz, Quixote’s Ghost:  The Right, the Liberati, and the Future of Social Policy (New York:  Oxford University Press, 2005), p. 53.

11.  Jerry D. Marx, Social Welfare:  the American Partnership (Boston:  Allyn & Bacon, 2004), p. 151.

12.  Gerald A. Whitney, “Profits”, The Encyclopedic Dictionary of Economics, 4th ed. (Guilford, Conn.:  Dushkin Publishing Group, Inc., 1991), p. 200-01.

13.  Albino Barrera, Modern Catholic Social Documents & Political Economy (Washington:  Georgetown University Press, 2001), p. 169.

14.  John Paul II, Pope, Encyclical letter Centesimus annus (1991), §35.

15.  Robert A. Sirico, The Entrepreneurial Vocation (Grand Rapids, Mich.:  Acton Institute, 2001), p. 26.

16.  Curt Cadorette, “Profit”, The New Dictionary of Catholic Social Thought, ed. Judith A. Dwyer (Collegeville, Minn.:  The Liturgical Press, 1994), p. 790.

17.  John Paul II, Pope, Encyclical letter Sollicitudo rei socialis (1987), §37.

18.  Karger & Stoesz, op. cit., pp. 197-98.

19.  Neil Gilbert and Paul Terrell, Dimensions of Social Welfare Policy, 6th ed. (Boston:  Allyn & Bacon, 2005), p. 127.

20.  Lisa Sowle Cahill, Theological Bioethics:  Participation, Justice, and Change (Washington:  Georgetown University Press, 2005), p. 215.

21.  Wesley J. Smith, Forced Exit:  The Slippery Slope from Assisted Suicide to Legalized Murder (Dallas:  Spence Publishing Company, 2003), p. 134.

22.  Cynthia Moniz and Stephen Gorin, Health and Health Care Policy:  A Social Work Perspective (Boston:  Allyn & Bacon, 2003), p. 76.

23.  W. J. Smith, op. cit., p. 134.

24.  Laurence J. Kotlikoff and Scott Burns, The Coming Generational Storm:  What You Need to Know about America’s Economic Future (Cambridge, Mass.:  MIT Press, 2004).

25.  Robert Royal, “Caring for an Elderly Society Will Demand the Wisdom of Solomon”, National Catholic Reporter 42: 3 (Nov., 2005), p. 21.

26.  Peter G. Peterson, Running on Empty:  How the Democratic and Republican Parties Are Bankrupting Our Future and What Americans Can Do about It (New York:  Farrar, Straus & Giroux, 2004); (Idem), Gray Dawn:  How the Coming Age Wave Will Transform America (New York:  Times Books, 1999); P. G. Peterson and Neil Howe, On Borrowed Time:  How the Growth in Entitlement Spending Threatens America’s Future (New York:  Simon & Schuster, 1989).

27.  “House Backs Tax Cuts”, Fort Worth Star-Telegram (11 May, 2006), p. 3C.

28.  Jonathan Weisman, “Unforeseen Spending on Materiel Pumps Up Iraq War Bill”, Washington Post (20 April, 2006).  www.washingtonpost.com

29.  Jonathan Coopersmith, “Who Will Pay for Iraq and When?”, History News Network, 11-13-06.  www.hnn.us/articles/31431.html.

30.  Bishop William S. Skylstad, “Call for Dialogue and Action on Responsible Transition in Iraq” (Washington:  United States Conference of Catholic Bishops, Nov. 13, 2006).

31.  Bishop Thomas G. Wenski, “Toward a Responsible Transition in Iraq”, (Washington:  United States Conference of Catholic Bishops, Jan. 12, 2006).

32.  United States House of Representative Committee on Ways and Means, 2004 Green Book (Washington:  U. S. Government Printing Office, 2004).

33.  Kotlikoff & Burns, op.cit., p. 130.

34.  Karger & Stoesz, op. cit., p. 304.

35.  Sheila Kamerman, “The New Mixed Economy of Welfare:  Public and Private”, Social Work 28: 1 (Jan./Feb., 1983), pp. 5-10.

36.  John B. Shea, M.D., “Freedom of Conscience in the Practice of Medicine”, Social Justice Review 93: 11-12 (Nov.-Dec., 2002), pp. 173-76.

37.  Chris Rohmann, A World of Ideas:  A Dictionary of Important Theories, Concepts, Beliefs and Thinkers (New York:  Ballantine Books, 1999), p. 217.

38.  Donald Tannenbaum and David Schultz, Inventors of Ideas:  An Introduction to Political Philosophy (Belmont, Calif.:  Thomson/Wadsworth Publishing, 2004), p. 234.

39.  Alexander A. Kaufman, Welfare in the Kantian State (New York:  Oxford University Press, 1999).

40.  David E. Ingersoll, Richard K. Matthews, and Andrew Davison, The Philosophic Roots of Modern Ideology:  Liberalism, Communism, Fascism, Islamism (Upper Saddle River, N. J.:  Prentice-Hall, 2001), p. 298.

41.  Richard C. Eyer, “Ethics and Suffering:  From Healing to Relief of Suffering” (Campus Presentation Series at Concordia University, Mequon, Wisconsin), accessed 11/12/2006 at     www.issuesetc.org/resource/archives/eyer.htm.

42.  Catechism of the Catholic Church, 1st ed. (1994), §2432.

43.  John Paul II, Pope, Veritatis splendor (1993), §§43, 44.

44.  Eric Pavlat, “Pulling the Plug: Five Strategies for Talking to Democrats about Euthanasia”, Crisis:  Politics, Culture and the Church 24: 3 (April, 2006), p. 18.

45.  Paul VI, Pope, Encyclical letter Humanae vitae (1968), §18.

46.  Vide John Paul II, Pope, Encyclical letter Evangelium vitae (1995).

47.  Cal Thomas, “Church-State Talk Doesn’t Invalidate Pontiff’s Message”, Fort Worth Star-Telegram (4 April, 1995).

48.  Aaron L. Mackler, Introduction to Jewish and Catholic Bioethics:  A Comparative Analysis (Washington:  Georgetown University Press, 2003), p. 229.

49.  Thomas D. Watts, “Compromised Physicians:  Would Medical Savings Accounts Help?”, Social Justice Review 95: 1-2 (Jan.-Feb., 2004), p. 17.

50.  John Paul II, Centesimus annus §54. 

51.  A. G. Sertillanges, O.P., The Intellectual Life:  Its Spirit, Conditions, Methods (Washington:  Catholic University of America Press, 1987), pp. 29-30.

52.  John Paul II, Pope, Crossing the Threshold of Hope, ed. Vittorio Messori (New York:  Alfred Knopf, 1994), p. 18.

53.  Thomas Aquinas, St., De Caritate:  On Charity (Medieval Philosophical Texts in Translation, No. 10) (Milwaukee, Wis.:  Marquette University Press, 1960), p. 30.

54.  Vatican Council II, Gaudium et spes (1965), §26.

55.  Catechism, op. cit., §1906.

56.  Vide note 7, supra.

57.  Michael Sherraden, Assets and the Poor:  A New American Welfare Policy (Armonk, N. Y.:  M. E. Sharpe Publishing, 1991).

58.  Kotlikoff & Burns, op. cit., p. 45.

59.  Laurence J. Kotlikoff, Generational Accounting:  Knowing Who Pays, and When, for What We Spend (New York:  Free Press, 1992), p. 45.

60.  Moniz & Gorin, op. cit., p. 75.

61.  Watts, “Freedom and the Welfare State”, op. cit., and “Compromised Physicians”, op. cit.

62.  Watts, “Compromised Physicians”, op. cit., p. 17.

63.  Thomas J. Hendrix and Kathleen Kaufman, “Medical Savings Accounts:  Theory, Politics, Pros and Cons”, Policy, Politics, and Nursing Practice 4: 1 (Feb., 2003), p. 85.

64.  Eric Pavlat, “Pulling the Plug”, op. cit.

65.  Glenn Tinder, Political Thinking:  The Perennial Questions, 6th ed. (Boston:  Pearson/Longman Publ., 2004), p. 217.

66.  Karen O’Connor and Larry J. Sabato, American Government:  Continuity and Change (Boston:  Addison Wesley Longman, Inc., 2002), p. 455.

67.  John Paul II, Evangelium vitae, §26.