By Sr. Patricia Talone, RSM, Ph.D., Vice President, Mission Services,
Catholic Health Association of the United States
Catholic health care in the United States prides itself on living the values and principles set forth by Catholic social teaching. Sponsors, trustees, executive leaders, and mission and ethics executives often refer to the normative principles set forth in Part One of the Ethical and Religious Directives for Catholic Health Care Services as foundations upon which the ministry stands and builds for the future. And yet, facilities and systems might benefit from a critical reading and analysis of the principle of subsidiarity, a principle that is core to its social teaching. This standard, first articulated in the 1930s, and bedrock of Catholic social teaching, faces unique challenges as hospitals and systems grow larger, and at a time when decisions that affect patients and workers are often made far from the halls traversed by patients and their caretakers.
A Poignant Example
A few years ago, while giving an ethics presentation on the topic of stewardship of resources at a large hospital that was part of a larger system, I was challenged by a nurse manager. Her query really confronted the system's living out of subsidiarity. The presentation covered scarce resources, economies of scale, and individual and corporate responsibility. The nurse noted that her unit (a large and profitable one) was "forced" by the system's materials management vice president to use a certain pretesting treatment, one that was provided by a vendor with whom the system had negotiated a particularly good price. Her staff had complained about this preparation, noting that many patients did not react well to it, although patient complaints were more discomfiting than life-threatening. The nurse questioned the use of this particular treatment and received the answer that it was more economical. However, when networking with peers across the city, she learned that another, better preparation could be obtained even more inexpensively.
The nurse manager's words and tone evinced a good deal of anger, so I sought her out after the lecture was finished, trying to learn more about her concerns. As we spoke, several things became quite clear. This professional was deeply committed to her patients, her staff and to the institution she served. She was not a disgruntled worker. This nurse felt a deep sense of pride and accomplishment in her work, and believed that it was her duty to report and rectify the things that adversely affected those in her charge. Furthermore, she had a strong sense of dignity, and felt that the fact that the materials management executive brushed her off was a signal that the "system" did not value its workers. Ultimately, by working through facility channels, and consistently stating her case, she was able to change the preparation administered to patients, thus providing better care to patients and reinforcing her staff 's conviction that she cared about their opinions.
Church Teaching
Often, those closest to the bedside understand best the challenges they face, thus embodying the meaning of the principle of subsidiarity. What do we mean by subsidiarity within the context of Catholic social teaching? The notion was first articulated in church teaching by Pope Pius XI in his 1931 encyclical, Quadragesimo Anno. Pius' predecessor, Leo XIII, in his 1891 encyclical Rerum Novarum, had emphasized the important role that state and business leaders play in improving the conditions of the working class and binding rich and poor together. Pius XI then proposed "subsidiarity," outlining the relationship that ought to exist between government and business, between business owners and workers, between labor and capital. Pius described subsidiarity as "that most weighty principle, which cannot be set aside or changed, [and] remains fixed and unshaken in social philosophy: Just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community, so also it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher association what lesser and subordinate organizations can do. For every social activity ought of its very nature to furnish
help to the members of the body social, and never destroy and absorb them."1
How does this work within business, especially within the business of health care? Helen Alford and Michael J. Naughton, in Managing As If Faith Mattered, assert that "responsibility should always be accompanied by commensurate authority, so that people at higher levels of administration or management neither absorb nor supplant the work or responsibility of those in the lower levels."2 Grounded on human dignity and respect for each person, subsidiarity benefits the worker, allowing decision making at its proper level, so that the organization as a whole benefits from all employees' talents and experience and employees fully participate in challenging and rewarding tasks, thus enhancing their human dignity. Managers committed to subsidiarity avoid bureaucratic "top down" forms of organization and decision making. They do so both for the organization's ultimate success and in recognition of the richness of their human capital in each and every employee. Alford and Naughton caution that there is no magic formula available for all the situations in our daily work. The principles, they contend, "point the direction, they do not show the way."3 The onus of responsibility falls upon each one of us, but particularly upon those bearing management responsibility to seek out ways to build upon this principle.
Today's Challenge
One of the reasons that living the principle of subsidiarity is a particular challenge in today's health care environment is that, for the most part, Catholic facilities and systems are becoming larger. A quick perusal of the Catholic Health Association's membership rolls over the past 20 years reveals this truth. There are many good reasons for the shift from individual, freestanding hospitals and nursing homes to larger, more centralized systems. Systems desire to achieve economies of scale, particularly as states and private payers squeeze more and more out of each health care dollar. Larger size gives the system greater negotiating power for purchasing, bargaining for cost savings, and the opportunity to benchmark successful practices across a broader service area. Furthermore, and perhaps most importantly, systems should insure that mission commitments flourish for greater numbers of the sick and needy.
Opportunities for Subsidiarity
Given the realities they face, few systems can risk losing these opportunities to sustain their ministry. How, then, do they ensure that the principle of subsidiarity is as vibrant within their ranks as is their undisputed commitment to care of the poor? Two endeavors, currently operational within many facilities and systems, provide unique opportunities to reinforce the principle of subsidiarity within Catholic health care. While they are given distinct names in different systems, they are initiatives for quality and safety. A careful perusal of many Catholic systems' values statements show words like "excellence," and "quality." In 1996, the Institute of Medicine launched its effort to insure quality of care when it published Crossing the Quality Chasm: the IOM Health Care Quality Initiative. Whether labeling facility efforts as continuous quality improvement or other monikers, the result should be similar. Each and every employee, from the highest ranking to the most menial, assumes responsibility not just for doing an excellent job, but for improving that job annually. In the best run programs, the burden of responsibility is shared equally among line workers, managers and executives for continuous improvement of the total organization.
Safety initiatives, most instituted after the Institute of Medicine issued its 1999 report, To Err is Human, serve to empower the persons closest to the bedside to offer safe, excellent care to patients. LPNs, CNAs and RNs are encouraged to report near misses or medical mistakes in order to improve patient care and prevent further sentinel events. Safety initiatives insure a culture of responsibility, rather than a culture of blame. Employees who experience encouragement to express themselves, to be heard, to have opinions, and to take pride in their daily work, are engaged employees. They are men and women who know that their dignity is respected, their work matters, and they have ownership in the organization to which they dedicate themselves.
These are merely two ways that facilities and systems seek to do what Alford and Naughton promote — they find ways for the social justice principle of subsidiarity, to which Catholic health care commits itself, to become alive in our organizations. The Catholic health ministry must intentionally seek creative ways to operationalize the church's principle of subsidiarity throughout its many organizations. To support these efforts, the Catholic Health Association, through Health Care Ethics USA, invites other examples of successful practices applying the principle of subsidiarity to the ministry that we share. We will gladly communicate these examples either on these pages or on the CHA website in an effort to foster "authentic development." Please e-mail examples to Ron Hamel, Ph.D., CHA's senior director of ethics, at [email protected].
NOTES
- Pope Pius XI, Quadragesimo Anno, para. 79, May 15, 1931. www.vatican.va/holy_father/pius_xi/encyclicals/documents/ hf_p-xi_enc_19310515_quadragesimo-anno_en.html.
- Helen Alford and Michael Naughton, Managing As If Faith Mattered (Notre Dame: University of Notre Dame, 2001), 77.
- Alford and Naughton, 80.
- Pope John Paul II, Sollicitudo rei socialis, para. 1. www.vatican.va/holy_father/john_paul_ii/encyclicals/documents/ hf_jp-ii_enc_30121987_sollicitudo-rei-socialis_en.html.
New Guide for Advanced Care Planning
The Catholic Health Association has recently published "Advance Directives: A Guide to Help You Express Your Health Care Wishes." This updated, comprehensive brochure is designed to help patients, families and health care professionals understand how an advance health care directive is beneficial to everyone, and highlights important considerations for creating a document that expresses an individual's health care wishes in advance. The booklet contains an easy-to-read question and answer section, information about Catholic teaching and a list of helpful websites and resources. PDF copies may be downloaded at www.chausa.org/advancedirective. Printed copies, for distribution to patients, families and staff, may be purchased — with quantity discounts — at CHA's online resource catalog, www.chausa.org/resources.
Copyright © 2008 CHA. Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purposes. For reprint permission, contact Betty Crosby or call (314) 253-3490.