The Christian bioethics of long-term care and diaconia raise foundational concerns about Christian presence in the world. Christian bioethics confronts a central moral-theological question: can Christian bioethical understandings be derived from and/or assimilated to those of secular bioethics? In particular, can the commitments of a Christian bioethics of long-term care and diaconia be adequately understood in terms of secular moral concerns for social justice, human rights, human dignity, and solidarity? In the area of long-term care and diaconia, this cluster of problems is central, because in Western Europe and elsewhere there is a considerable history of church-state collaboration marked by increasing demands by secular societies and polities that the moral, religious, and institutional character of Christian diaconia conform to the secular moral and institutional norms of post-Christian societies. There is as well the issue of ecumenical collaboration, when this cooperation obscures the particularity and integrity of right worship and right belief. Together, these are matters for bearing an authentic Christian presence in the public space.
The essays in this issue of Christian Bioethics, by addressing Christian long-term care and more generally Christian diaconia, explore the intersection between (1) a specific field of medicine (medical and nursing care for the chronically ill), (2) an area of social services (primarily for the severely handicapped, and for those approaching the end of their lives who can no longer care for themselves), (3) social politics, and (4) theology (in view of the Church's service to the world). The essays, by touching on issues such as “justice,” “social justice,” “relations between Church and state,” “the ethics of caring,” “social care,” “the Christian profile of Christian diaconic services,” and “the relation between individual and Church-organized charity” underscore the challenge of Christian witness in a secular context.
These subjects are approached from diverse Christian perspectives. The introductory essay by Miltiades Vantsos and Marina Kiroudi, as well as the concluding contribution by Father Dan Ovidiu, represent the Orthodox Christian position, while the second and third essays (by Heinrich Bedford-Strohm and Christian Spiess) draw from Protestant and Roman Catholic traditions. All agree that for Christians, faith and works are inseparable: “You see that a person is justified by works, and not by faith alone” (Js. 2:24). The service that a Christian offers his neighbor is a service he offers to Christ Himself. Man's life as a servant of God is linked with his life as a servant of his fellow men. This service obliges man to participate in the many and diverse levels of worldly existence. Philanthropy, diaconic work, and charity thus are manifestations of faith through works.
All of this grounds the responsibility of every single Christian, as well as the Church as a whole, to contribute to the mutual upbuilding (Rom. 14:19, 15:2) of the members of the Church, each according to his capacities. Thus the Apostle Paul states: “We have gifts that differ according to the grace given us … ministry, in ministering¸ the teacher, in teaching, … the giver, in generosity, … the compassionate, in cheerfulness” (Rom. 12:6–8). By serving one another, by sharing in the service of the Church, Christians become the coworkers of God, God's farmland, God's building (1 Cor. 3:9). The goal of their service is not only their personal perfection, but also the coming kingdom of peace. Through such diaconic service, the world is transformed into a kingdom in which (1 Cor. 15:28) “God may be all in all.” Accordingly, if we identify, as we should philanthropia with orthopraxia, then the service that leads to our own perfection and to the perfection of our fellow humans is not a service offered to the world, or for its progressive development, but a service offered to God. But all such effort will forever remain an incomplete “striving for the kingdom of God” (Mt. 6:33). Hence, the question arises as to whether the Christian model for social change is of this world or beyond and against it.
This Christian Bioethics issue combines three German contributions with one from Greece, and a smaller report about a particular diaconic endeavor from Romania. The Protestant and Roman Catholic essays strongly underscore the Christian obligation to establish just societies on this earth in terms of the Christian norms that are compatible with the norms of this world. Both invoke the Pastoral Letter of the United States Conference of Catholic Bishops, Economic Justice for All (1986), as one of their major theological sources. The three Orthodox authors, by contrast, give priority to Christianity's transcendent calling, which calls people beyond this world in terms of norms often at odds with this world. Accordingly, the Protestant and Roman Catholic theologians welcome the (German) social justice framework as one into which they believe that they may and should integrate what they portray as the Christian approach to care for the chronically ill and for those approaching the end of their lives. By contrast, the Orthodox contributions betray a significantly greater reserve about placing their diaconia within the public healthcare and social services networks.
Moreover, the Protestant and Roman Catholic authors combine their endorsement of state-funded, and hence state-controlled and state-dependent, Christian diaconia with a willingness to reframe the Christian profile of that service so as to make it conform to the demands of the normative principles guiding the secular provision of public welfare. Again in contrast, the Orthodox authors understand the theological basis for Christian diaconia in a theocentric manner. Roman Catholic and Protestant theologians have reshaped their theological understandings in the field of health and nursing care as a result of more than a century of state-supported cooperation, and therefore of increasingly secularized collaboration between church and state. This dialectic has recast the church more than the state. In order to justify the support received from increasingly secular democratic voters, such Christian diaconia has had to adjust the religious integrity of its care so as to continue receiving public support for its ever more nominally church-related health and nursing facilities. The political necessity of defending in secular terms the public support of Christian healthcare and nursing facilities has come to inform and guide the theological perceptions of those defending such collaboration.
Thus Spiess, in “Recognition and Social Justice: A Roman Catholic view of Christian Bioethics of Long-Term Care and Community Service,” (the third essay in this issue) from the very start undertakes to render normatively Christian orientations comprehensible to a secular audience “out there.” Even more, he reconstructs these orientations by reference to what he himself considers rationally compelling nontheological, moral-philosophical grounds. For instance, he draws on Axel Honneth's reception of Hegel's theory of recognition, as interpreted in anthropological terms. This moral-philosophical account is developed by Spiess so as to portray the needs of persons as generating expectations that can morally demand recognition, thus grounding a moral obligation on the part of others, and even on society as a whole (i.e., on the state), to offer relief. In a further step, the author links this moral-philosophical basis with Roman Catholic accounts of social justice. He gives special attention to the “personalist” approach which his ethical theory endorses, and which he also finds embodied in the subsidiarity principle. In order to protect patients within bureaucratized public health and nursing care institutions against the risk of being depersonalized, Spiess amplifies the Catholic teaching on social justice by adding further public obligations that are designed to activate and socially include the recipients of such care.
The biblical motif of Jesus' healing stories is invoked by Spiess for the purpose of showing how the pity that moves the healer can be secularly reconstrued as a recognition of a moral obligation to meet patients' need for physical and by extension psychological healing. Thus, in his final definition of Christian charity in long-term care, the author affirms the need politically to advocate for more just social structures. In keeping with the philosophical-theological personalism he endorses, Spiess also insists on offering immediate relief of individuals' needs for medical and nursing care. In contrast to the rather encompassing way in which Spiess harmonizes his Christian approach to long-term care with the secular philosophical account of social services, Bedford-Strohm seeks to reserve some explicitly special role for the Christian character of such care within the secular state's social service program. He emphasizes the need to reserve space for addressing patients' spiritual dimension, and for training staff members in such a way as to enable them for this task.
Bedford-Strohm, in “Justice and Long-Term Care—A Theological Ethical Perspective” (the second essay in this issue), opens his theological discussion with an appeal to matters of justice that are raised by the growing demand for long-term care in countries such as the United States and Germany and the decreasing public resources to meet this demand. The author critically addresses the frequently claimed contrast between individual patients' medical and nursing needs and their material means, as well as the state's obligation to remedy inequalities in needs-satisfaction through redistributive measures. In a second step, Bedford-Strohm points to the biblical relevance of justice issues, underscoring a continuity he claims exists between such Judeo-Christian concerns and John Rawls's theory of justice. Focusing on a common assumption in both, namely the “preferred option for the poor,” he also endorses ecumenical cooperation in all fields of social services. Linking this “option” to the state's obligation to correct grave inequalities in chances (and opposing Robert Nozick's libertarian approach), the author recommends the German Social Nursing Insurance (Soziale Pflegeversicherung) as one way of politically implementing that biblical option in a way that is concordant with dominant secular conceptions of justice.
A very different picture of diaconic care for long-term patients is presented by the three orthodox articles in this issue. Vantsos and Kiroudi, in “An Orthodox View of Philanthropy and Church Diaconia” (which sets the theological stage for the subsequent discussions), describe that service as a reflection of God's love for man. Diaconic services are recognized as primarily a responsibility of the Church. Just as Christ came not to be served, but in order to serve, and to bring fallen man back from his fallen state, so the Church exists in order to serve people on their path to the kingdom of heaven. The Church's primarily spiritual service should as far as possible be joined to a care for worldly human needs. The authors agree with Bedford-Strohm and Spiess that Christians, as members of the Church, are commanded to follow the example of Christ in charitably attending to those in need, and that this forms part of their pursuit of the kingdom of heaven. Unlike those authors, however, Vantsos and Kiroudi contrast the Church's and Christians' attention to those needs with that offered by secular agencies. Both with regard to the recipients and with regard to the providers of such care, man's eternal fate lies at the center. At the same time, inequalities in wealth and chances are perceived as chances for freely offered philanthropy. In a historical survey of the development of Church philanthropy in Byzantium, a model for church-state cooperation is presented that pointedly contrasts with the situation of secularized modernity. It gives priority to the goals pursued by the Church. In considering the contemporary situation, cooperation with the state is critically evaluated so as to not jeopardize diaconia's predominantly Christian purpose.
A helpful example of how such cooperation can be realized today is offered by Father Dan's short report, “The Philanthropy of the Orthodox Church: A Romanian Case Study” (the fourth essay in this issue). On the basis of a theological account that agrees with that of Vantsos and Kiroudi, he adds important details, giving an illustration of Christ's identification with the “least of His brethren” by reference to one particular project realized within the Alba Iulia diocesan Social Services Department: the Social Services Day-Care Center for Older Citizens at the town of Sighisoara. This center does not simply offer aid to those in immediate need of food, clothing, elementary care, and medical services, it also offers extensive religious care. As a consequence, the diaconic work accomplished by two priests and their families, along with a number of volunteers from various professions, has by its presence transformed the population of the town itself, as well as that of surrounding villages. Ever more voluntary helpers contribute food, clothing, heating material, and other support to the center. Now, after the fall of communism, such diaconic work helps to reconnect those estranged from the Church with her offer of love. This philanthropic outreach program fulfills a missionary function even apart from its narrow charitable focus. (Those readers of Christian Bioethics who wish to support the planned expansion of these services to the needs of children are invited to send contributions to the account supporting this diaconia at the Romanian Commercial Bank, the Sighişoara Branch: “FILANTROPI[Abreve] ORTODOX[Abreve] SIGHIŞOARA,” Banca Comercială Română S.A.,Sucursala Sighişoara. Cont IBAN : RO 60 RNCB 0191 015666990001).
These essays thus raise foundational issues in the Christian bioethics of long-term care and diaconia bearing on the Christian integrity of that diaconia and its proper place in increasingly secular cultures and polities. As this issue shows, quite contrasting views are emerging. The Roman Catholic and Protestant contributions celebrate what traditional Christians should view as a threat to the Christian integrity of their diaconia: the prospect that their diaconia will be recast in the “image and likeness” of secular moral and political demands. What is in traditional Christian bioethical terms a threat to the Christian character of Christian charity and diaconia is viewed by many as an appropriate moral-theological development, which correctly recasts that charity and diaconia in terms of secular moral obligations. The reader is given an opportunity to explore the extent to which Christian diaconia is enhanced or distorted as it becomes conjoined with secular concerns for social justice and eventually integrated within secular commitments to social welfare. Issues of religious integrity are raised as well when the contribution of churches to diaconia becomes embedded within a fabric of ecumenical cooperation. The price for such collaboration is often that one discounts the particular character and content of right worship and right belief. These conflicting visions regarding the nature of Christian integrity and its adaptability to the demands of secular social justice lie at the foundation of cardinal controversies at the core of the Christian bioethics of long-term care and diaconia.