Charity in Health Care: Safety Net or (Moral) Safety Valve?

Charity in health care has a vast and rich history that crosses boundaries with religious traditions and professional moral obligations. Charity can be considered a virtue that entails altruism, beneficence, generosity, mercy, and kindness. The health care safety net is a newer term that refers to a variety of programs and policies that are directed toward people who are poor, underserved, or uninsured. The safety net arguably derives much of its moral meaning from its association with charity. Charity in health care is not only a powerful symbol of deep moral significance to Americans and to medical professionals; it is also a practical real-world experience and it is integral to a wide range of practices and policies. Charity entails ambivalent meanings for recipients who may be considered dependent and subjected to judgments of worthiness; no one wants to need charity. At the conceptual as well as policy level, charity also has ambiguous meanings. Charity in health care is defined by laws, sometimes in conflicting ways, and it is understood by traditions. Our nation has relied as much on charity as it has on private or free market forces for the provision of health care. As a symbol, charity in health care functions politically to create a sense of well-being and to resolve tensions. One aim of this dissertation is to clarify the distortions and assumptions that are present in health care related to charity. Charity care at the community level in free clinics, physicians’ offices, and other local programs is analyzed. The role of charity care in medical education, in emergency departments, in hospitals, and in the Medicaid program is scrutinized. Among the themes that are pervasive in each of these settings, one is that charity is, at its essence, optional and discretionary and does not guarantee care for any person. The financing of charity care has resulted in opaque and complex mechanisms. While the ideal of charity as an altruistic response to the health care needs of poor persons is a worthy moral goal, a more just health care system would not rely on charity.