BY: SR. ROSEMARY DONLEY, SC, PH.D., APRN, BC, FAAN
People are generally familiar with the Catholic viewpoint on bioethical issues such as embryonic stem cell research, and they are quite aware of the church's teachings on sexual morality. They are less familiar with Catholic social thought. In fact, some scholars believe that the church's teachings on social justice are one of its best-kept secrets.1
Our social justice teachings challenge people of good will to work to fill in the gaps separating the "haves" from the "have-nots"; to choose, in a preferential manner, to stand with the poor; to eliminate discrimination; to protect vulnerable people, especially children; and to make peace. In the New Testament's recording of the two great commandments, the mandate to love one's neighbor is intricately linked with, and perhaps a manifestation of, the capacity to love God (Matthew 22: 36-40).
Nursing's traditional ethos — respect for patients, a concern for their well-being that transcends their illness or disability; caring, compassion — finds its roots in this social justice tradition. However, the influence of market-oriented philosophies in the delivery of health care in the United States has made it hard for nursing to articulate a social-justice framework. Unfortunately, health care has become a commodity that is for sale, and the behavior of many health care providers and administrators reflects a profit, more than a caring, motif. In fact, it can no longer be assumed that clinicians or health care agencies will altruistically provide care and protection for vulnerable patients.
Three of the American Nurses Association's significant contemporary documents — the 2001 "Code of Ethics for Nurses," the 2003 "Social Policy Statement" and the 2004 "Scope and Standards of Nursing Practice" — contain ambiguous and conflicting statements about the meaning and the application of social justice theory.2 Similarly, the American Association of Deans of Colleges of Nursing has named social justice as an essential component of the baccalaureate and the doctor of nursing practice curricula, but the term lacks definitional clarity.3 So, while nurses and nursing literature reflect appreciation and support for health systems and practices that are just, there is ambiguity and lack of agreement about what social justice means.4
Often the term is used in place of "fairness," but lacking benchmarks to determine what is fair or unfair, justice is difficult to teach, practice or model. It is an idea or construct whose meaning is highly personalized or changes with experience or circumstance.
Although the principle of common good is sometimes evoked in the debate about national health insurance, Catholic ethicists, at least in the United States, are more engaged in the moral dilemmas of high-technology medicine. They are concerned with the individual, rather than the common, good. Contemporary social issues, including the ethics of vulnerability and access to health care services, have not been systematically analyzed or studied within the Catholic ethical tradition. Catholic and other faith-based ethicists and health care professionals need to challenge the ideologies that drive market economies operative in health care and engage in the dialogue about what type of justice should guide professionals in the field.
Similarly, if nursing is serious in its commitment to social justice, then it is incumbent on nursing's theorists and scholars to study and engage in dialogue about the social justice tradition and its relevance in contemporary nursing practice.
But that's not enough. Nursing must move beyond writing policies and standards that support social justice; it needs to use these principles to ground, direct and change practice.
Social justice is action-oriented. It needs to be applied in two levels: direct action to assure that the care of patients or populations is just; and action and advocacy at the level of policy and regulation to institute structures or to remove the barriers that keep people vulnerable.
This approach isn't new. If we look back at such social justice icons as Lillian Wald, we see early nursing leaders who not only improved the lives of vulnerable populations; they also worked creatively to change legal and social structures to advance health and well-being.
But ours is not the world of Lillian Wald. Working among the immigrant poor in New York's Lower East Side tenements at the turn of the 20th century, Wald and her nurses had to overcome lots of apathy, indifference and prejudice, but in those days, social and regulatory structures were not so organized — nor were they so monolithic. She was able to get the attention of government and get government to do something about the health of children. This is social justice.
Contemporary public health nurses and, in fact, hospital nurses and really all health workers find themselves in an environment that is regulated, sometimes driven by liability concerns and always governed by reimbursement. This is market justice.
Practitioners who approach their work with compassion and concern for the poor risk facing ridicule and misunderstanding in market-oriented environments. Authors Kneipp and Snider describe the frustrating experiences of educators who wish to teach young nurses how to integrate core nursing values and social justice teachings into their practices in health delivery systems that are rooted in market justice. They note, too, there is no assurance that the next generations of teachers will be grounded in the values nursing has espoused. As a consequence, they may not be willing or able to communicate these values to the next generation of nurses.5
Market justice, dominant in the acute-care environment, is influencing the practice of public health nursing, as well. Denise Drevdahl, RN, in writing about the conflicting missions of for-profit health care and public health, discussed the strange marriage between managed-care organizations and public health agencies. Recognizing that this linkage promised benefits to both partners (privatization increased the market share of managed-care organizations; efficient, outcome-oriented and cost-effective care improved access to care for the population served by the health department), the author records how managed care's use of a medical model, its focus on treatment of individuals rather than populations, and its responsiveness to market demands and shareholders' preferences are incompatible with the public health ethic or its concern with social justice.6
Another impediment to the union of managed care and public health became apparent soon after the partnership developed with public health agencies. Many managed-care organizations had no experience with the vulnerable populations that have traditionally received care in safety-net organizations like health departments. Enrollments of many underserved people in managed-care programs present a challenge to a health system that is increasingly driven by market, not social, justice principles. Managed-care organizations need to find ways to provide respectful health services for people with compromised health status, people whose ability to seek care and to adhere to regimens is complicated by poverty and social, psychological and political factors.
Although public health nurses, nursing's historic champions of social justice, still embrace the social justice ethos, their work places, public health agencies and community-based care centers are no longer free of bureaucracy, standardization and medical models. Social justice advocates recognize that significant work needs to be done, within and outside of nursing, so that the care of vulnerable populations is not compromised by market concerns. Daniel Beauchamp has been more explicit in positing that the ethical foundation of public health is social justice: "Public health should be a way of doing justice … a way of asserting the value and priority of all human life."7
The cost-saving, money-making climate in health care environments, coupled with some ambiguity about the meaning of social justice in contemporary nursing literature, reaffirm the need for study, analysis and dialogue about the social justice tradition as it has been articulated by faith communities, secular writers and the nursing community.
Realistically, we can't be nostalgic about the past and hold up Lillian Wald as our chief inspiration. Her day is over. We need contemporary models. In the absence of models, my concern is that social justice can become an apple-pie kind of term. Nursing is for social justice, but what, exactly, does it mean and how do you do it in a market-driven era?
If social justice is to inform nursing practice and education in the future, nursing leaders must do more than name social justice as a value in nursing. Educators, clinicians and administrators must reinvest in and advocate for a health system that manifests and advocates for its principles.
Attention to the mission of health care, rather than its margin, will be one outcome. The impetus starts with individuals, each of us. Examples of health practices that reflect Catholic social justice must, as the noted Catholic pacifist and sociologist Gordon Zahn put it, bubble up.8
SR. ROSEMARY DONLEY, SC, is a professor of nursing and the holder of the Jacques Laval Chair for Justice for Vulnerable Populations at Duquesne University School of Nursing, Pittsburgh. She is a former member of the Catholic Health Association board.
NOTES
- P. Henriot, J. Holland and E. DeBerri, Catholic Social Teaching: Our Best Kept Secret (Washington, D.C.: Center of Concern, 1978).
- American Nurses Association, www.nursingworld.org.
- American Association of Colleges of Nursing, The Essentials of Baccalaureate Education for Professional Nursing Practice (1998); AACN Position Statement on the Practice Doctorate in Nursing (Oct. 2004), www.aacn.nche.edu.
- B. Bekemeier and P. Butterfield, "Unreconciled Inconsistencies: A Critical Review of the Concept of Social Justice in 3 National Nursing Documents," Advances in Nursing Science 28, no. 2 (2005): 152-162.
- S. Kneipp and M.J. Snider, "Social Justice in a Market Model World," Journal of Professional Nursing 17, no. 3 (May-June 2001): 113.
- D. Drevdahl, "Social Justice or Market Justice? The Paradoxes of Public Health Partnerships with Managed Care," Public Health Nursing 10, no. 3 (May-June 2002): 161-169.
- D. Beauchamp, "Public Health as Social Justice," Inquiry 13 (1976): 101-109.
- G. Zahn, "Social Movements and Catholic Social Thought," in One Hundred Years of Catholic Social Thought, ed. J. Coleman (Maryknoll, NY: Orbis Books, 1991), 43-54.