Understanding responsibilization in healthcare: Differentiations in Reformation theology

The responsibilization of patients for their disease and care may imply reduced access to medical care or overly moralize the doctor–patient relationship. This article first examines Luther’s early readings of the penitential Psalms, in which he transposes the nexus between sin and disease into the sphere of faith. His subsequent emphasis on the imputation of salvation further diminishes responsibilization: medical and pastoral care become distinct. This will be contrasted with Calvin’s cathartic, forward-looking understanding of disease and with Melanchthon’s moralist merging of humanism and theology into dietetics. These theological tendencies all represent present-day options.


Introduction
One premise of public healthcare today is the shift towards patients as autonomous, pragmatic self-managers. Patient choice and 'empowerment' are positively received, consigning medical paternalism to the dustbin of history. But this emphasis on patients' individual personal responsibility harbours unsavoury implications. Medical treatment and care can become dependent on a patient's 'good ' behaviour, open to regimes of 'transparency' or 'accountability' and more or less subtle discriminations between 'innocent' and self-inflicted diseases. Healthcare systems in Western market-states under permanent financial pressures are sure to seize on any justificatory potential such differentiations might offer and refuse to pay for what patients may 'responsibly' take care of themselves -or may have prevented altogether.
In this article I look at how Luther, and to an extent Calvin and Melanchthon, distribute the responsibility for disease through their soteriological anthropologies, biblical hermeneutics and integration of other traditions. Medicine and theology are connected in two ways here, but these need to be disentangled first. First, medical language illuminates the nature of salvation. In that regard, the Reformers' theologia medicinalis follows a long tradition. Second, this (medico-)theology determines the relationship between sin, responsibility/forgiveness and the medicina corporalis. Particularly Luther, as we will see, engenders a distinction between medicine and the moral-pastoral task of the theologian. Calvin and Melanchthon then take the Reformation in distinct different directions. Whereas Calvin adopts a social transformism that is more forward-looking, Melanchthon merges humanist medicine with the exercises of faith and so moralizes medicine.

Luther
Luther's apocalyptic mindset, his existential All-or-Nothing between 'God and the devil', 1 was not just one of the Anfechtungen (trials, contestations) terrorizing him as a young monk. It was quite in line with the late medieval spirit of the age. Before this overall horizon Luther asked, 'How can God be for me: by revelation or through a legal, even monastic regime of penitence, observance, and discipline?' His watershed moment was of course the insight that human beings are freed from sin not by their own doing, but saved by God's grace alone. Precisely this existential relief categorically breaks apart a clearly visible nexus of disease and sin, and hence medical healing and moral penitence.

Christological readings of the Psalms
This development can be traced early in Luther's works, such as his first lectures on the Psalms (Dictata super Psalterium, 1513-18), which are above all hermeneutically significant. 2 With a view to the Psalms as prayers, Luther emphasizes in the preface: 'To sing with the spirit is to sing with spiritual devotion and emotion. This is said in opposition to those who sing only with the flesh.' 3 He then turns, for example, to Psalm 38: 'There is no soundness in my flesh because of thine anger; neither is there any rest in my bones because of my sin. / For mine iniquities are gone over mine head: as an heavy burden they are too heavy for me. / My wounds have putrefied and festered because of my foolishness.' This is responsibilization at its extreme: disease is not only a divine punishment, it results in hostile social exclusion. 4 But Luther glosses: 'Since . . . Christ . . . bore himself our sins, this psalm speaks in the person of Christ. In it he recalls and confesses our sins for us before God the Father and asks for His release from them (that is, our release through Him and in Him). Therefore, whoever wants to pray this psalm profitably should pray it not in his own person but in Christ's and, as it were, should hear Him pray it and thus add his own wishes and say ''Amen''.' 5 Similarly, Psalm 32.3-4: 'When I kept silent, my bones wasted away through my groaning all day long. / For day and night your hand was heavy on me; my strength was sapped as in the heat of summer.' Luther emphasizes the spiritual sense: 'The bones, which are the firmness of faith and hope, are reduced in their capacity to trust in God by the fact that he puts off confessing.' 6 The Dictata's (not always consistent) christological reading of disease already emphasizes a loss of faith. Physical disease is primarily a parable of sin, even though the two may or may not go hand in hand. Importantly, the speaker is standing before God (coram Dei) in the presence of God. 7

Lectures on Romans and after
In the Lectures on the Romans (1515/16) Luther drew on the theologia medicinalis tradition to explain what is effectively his central theological insight. For a start, original sin afflicts the human '. . . like a sick man whose mortal illness is not only the loss of health in all his members'. It also includes 'the weakness of all of his sense and power, culminating even in his disdain for those things which are healthful and in his desire for those things which make him sick'. 8 It is therefore a mistake, Luther thinks, that the patient can somehow heal himself, 9 a self-salvation implied in present-day calls for 'self-compassion'. 10 In the face of a corrupt conditio humana, one can only admit the futility of one's efforts and cry out for help in humility. 11 All one can 'do' is passively listen, wait and hope for grace.
In Luther's medical-theological locus classicus, then, Christ for the sinner is analogous to the doctor for the patient. 12 The doctor has promised a sure recovery; hoping for it, the patient follows his prescriptions (the law), abstaining from harmful things until the doctor can fulfil the promise. Luther asks: 'Now is this sick man well? The fact is that he is both sick and well at the same time. He is sick in fact, but he is well because of the sure promise of the doctor, whom he trusts and who has reckoned him as already cured, because he is sure that he will cure him; for he has already begun to cure him and no longer reckons to him a sickness unto death.' The same goes for 'Christ, our Samaritan', who begins to heal the half-dead man, promising the cure of eternal life. The man is not righteous, healed or justified, but simul iustus et peccator, 'a sinner in fact, but a righteous man by the sure imputation and promise of God'. 13 As Johann Anselm Steiger notes, '. . . medical practice and pharmacy emerge as spaces of experience into which something shines, or through which the divine method of healing can be somewhat perceived, eschatologically geared towards bringing about ultimate and complete healing and making the medical art superfluous.' 14 These themes are further developed in the Heidelberg Disputation (1518) and the Freedom of a Christian (1520), where Luther clarifies the soteriological and hence epistemic -though not ontological -distinction between a person's inner freedom and their external actions. 15 Theologically, the living, 'ensouled' person is subject to a double analysis, 'complementarily relating two perspectives that cannot mutually represent each other'. 16 Ko¨rtner particularly underlines that 'personhood, or rather being a human being. . . transcends every possibility of biological description. It has the character of a secret. And precisely in this secretness Christian faith discerns the image of God's hiddenness.' 17 This implies a significant imbalance of transparency: on the one hand, absolute transparency and freedom before God and in Christ, reflected in the singing of the Psalms. On the other hand, coram mundi, the possible transparency of acts is incomplete; knowledge fizzles out, disappears and is lost. In Luther's view, with God's grace given gratuitously, the social structures of transgression, subsequent disciplining and ritual penitence are irreversibly eroded.

Disease and medicine
Precisely the distinctions between gospel and law, faith and work cohere with a differentiation between theologian and doctor. Disease is an 'epiphenomenon' of the human being suffering in their essence, his 'original sin'. 18 It sits within the overall critical, apocalyptic Either-Or: 'The sick person is a battlefield on which God and the devil meet, he is the object of the dispute between them, and both powers vie for the rule over him.' 19 Where not a divine trial of faith, as for Job, it can be an instrumentum diaboli; either way, without free will, the human being has his hands tied behind his back. However, in a later 'table talk', Luther does insist all diseases such as blindness or gout are actually the result of sinful actions -if they weren't, all children would be born blind or with gout. 20 Due to the simul iustus et peccator, Luther never systematically distinguishes between self-inflicted and randomly occurring diseases, i.e. between punishment and a trial of faith. 21 Indeed, he regards the very search for the origins of evil and disease as a diabolic trial. 22 What matters is the true healing achieved by the word of Christ, the 'true doctor'. The spiritual pharmaka are the preached word, justification by faith, the Eucharist administered for the sick, words of consolation. And because the ensouled Word is music, Luther accorded 'to music the first place after theology', 23 a 'medicine against evil' and 'nourishment to the soul'.
The visitation of the sick is then a separate pastoral duty. And in this context, Luther would '[ask] whether [the patient] wanted to bear his disease patiently, as God had sent it to him out of His gracious fatherly will, and that he had deserved this infliction with his sins'. 24 With remarkable sensitivity he also recognized that a suffering, sad heart leads to physical suffering. He regarded phenomena such as low mood (tristitia), identity disorders (tentationes) and depressions (maerores) as vere morbi at a time when his contemporaries were still seeking to address them by means of astrology or rituals.
When it came to his own ailments, Luther was notoriously sceptical of doctors, not least retaining a monastic suspicion of the body, calling his own a 'stinking sack of maggots'. 25 Yet the primacy of the divine word, spoken and sung, neither grounded an anti-medicalism, nor did it result in an amalgamation of medicine and theology. Luther particularly rejected, even scolded, the spiritualist Karlstadt for his suggestion that, at the outbreak of the plague, those afflicted should be left 'in the hands of God'. For Luther, this was 'not to trust in God, but to tempt God, for God has created medicine and reason, responsible to care for the body, so that it may be healthy and live'. 26 As to the second possibility, Luther emphasized a clear division of labour: 'A doctor is our Lord God's kludger [unsers Herrn Gotts Flicker], [he] helps physically; we theologians help spiritually, so that we make good what the devil has marred. The devil gives poison to kill the human being; a doctor gives theriac or other medicine, so as to help the creature.' 27 Medicine is hardly a divine act of grace. Rather, the medicina corporalis is rooted in God's providential care (creatio continuata). It is a 'creature, which comes not out of books, but God has revealed it, or, as Sirach says in Ch. 38: ''it comes from the Most High, and the Lord has brought it forth from the ground''.' Medicine is on a par with law, 'which flows out of nature and is created from it'. 28 So the doctor preserves that which is always already there, the human being as a given physical, bodily subject, a beseelter Leib, an ensouled body. Hence, medical healing is neither conditional nor consequent upon patients' existential healing. 29 Theology and medicine apply to the distinct 'perspectives' of the human being. Institutionally, this was solidified early on. In 1520, keen to reform the university faculties, Luther left it to the doctors to reform theirs. 30

Calvin and Melanchthon
Unlike the partly medieval, transitional figure Luther, the second-generation Reformer Jean Calvin saw himself as standing at the beginning of a new era, paving the way for a more rationalist approach to medicine. First, in his commentary on Romans (1540), Calvin drew much less of a sharp distinction between law and gospel. 31 This conditioned a socially transformative understanding of faith reflected in Calvin's Geneva. In the Genevan Academy, founded in 1559, medical work was an intrinsic part of 'orienting oneself to the biblical social model'.
The potentially moralizing, even politicizing tendencies inherent in this view are offset by Calvin's notion of predestination: '. . . all things come to pass by the dispensation of God, and . . . nothing happens fortuitously'. The Christian 'will have no doubt that a special providence is awake for his preservation, and will not suffer anything to happen that will not turn to his good and safety'. 32 Disease itself is a medicine that 'frees us from all passions of the world and etches away whatever is superfluous. They are, moreover, messages of death and are to teach us to free our feet so that we are free to go out when God likes us to.' 33 No longer a temptation or instrument of the devil, disease has a cathartic, albeit forwardlooking, function. So while pushing Luther's de-magification of medicine further, Calvin encourages active transformation. But, contingent on that, his dogmatic development of predestination effectively ends the speculative enquiry into the origins of disease.
Early on, Luther's colleague Philip Melanchthon moved in yet another direction, integrating Reformation and Renaissance. In his system, the newly edited works of Galen, Hippocrates and Vesalius, but also astrology, became part of the revealed knowledge of creation. In De arte medica Melanchthon equates the spiritus sanctus with the physical 'spirits' animating the body. Made of clay, the body was a 'holy temple'; the spiritus animales and vitales were to be sanctified by the spiritus sanctus. Paul's injunction to honour the body became a medical duty, exemplified by Melanchthon's dietetics, moral-medical injunctions on behaviour, hygiene, dieting and sexual abstinence. If they are followed, 'the knowledge of God becomes clearer, agreement becomes stronger, and the movements toward God become more ardent'. 34 Conversely, disease was caused by sin, preventing the presence of God in the body. As a result, in Melanchthon there is 'a moralizing tendency, leading to a signficant strenghthening of the doctor before the patient, because the latter in principle had to present to the doctor with a bad conscience, as their disease hinted at sins they had committed'. 35

Conclusion
The relationship between sin and disease in Reformation theology is far from unified, and the different strands of thought remain present options. Several dogmatic questions come to the fore. First, the nature of freedom and hence soteriological anthropology: in particular Luther's spiritual hermeneutics suggests that absolute transparency is only available coram Deo. Presuming an attributability of causes for a disease would both profane the relationship the Psalmist seeks and parody an answer. Second, Luther's distinction between law and gospel, between word and creatio continuata, sustains a practical distinction between the medical and theological professions. In a pastoral context, however, Luther invites the patient to confessional reflections quite different from contemporary primacy of patients' 'choice'. Similarly, Calvin's view implies that we don't know exhaustively why someone is sick: our knowledge fizzles out. Before the backdrop of divine predestination, patient and doctor are encouraged to be hopeful -either in acceptance of suffering as a task, or in remedying the effects of disease. Quite different, then, is Melanchthon's systematic continuity of creation, natural sciences and moral precepts. Perhaps ironically, this humanist heritage, in a secularized and updated version, is most prominent in present-day tendencies towards responsibilization and discrimination on the grounds of particular diseases.

Funding details
This work was supported by the University of Oxford Wellcome Trust ISSF (105605/Z/14/Z) and the Arts and Humanities Research Council (AH/N009770/1). The author gratefully acknowledges this funding.