BY: RON HAMEL, PhD, and ANN NEALE, PhD
Mary Harmon dreads her upcoming performance evaluation. For four years in succession these have been satisfactory experiences. She has been regarded as a valuable, talented member of the health center's finance department, trusted with important responsibilities, invited to report to the board of trustees on the results of two successful projects she designed and implemented, praised for her interpersonal skills, and evaluated accordingly by the chief financial officer (CFO). She anticipates a different experience this year. Her productivity has not changed, nor has her commitment to the organization or the excellence of her work. But the CFO has. He just does not like Mary. It is evident in his sarcastic tone, his cutting remarks, and the fact that he never credits Mary's accomplishments. Indeed, he claims them as his own.
St. Francis Medical Center recently dedicated its long-anticipated skilled nursing facility, a wholly owned subsidiary located six blocks from the main campus. At a board meeting, Mark Thomas, St. Francis's CEO, is caught off guard by a line of questioning from a new board member, a retired long-term care administrator. He is pressing for justification of the wage scale at the new nursing home, which is significantly lower than that for similar jobs at the medical center.
The governor announced in October his intention to work with the legislature to "fast track" a bill that would funnel all Medicaid patients into managed care by July 1, the beginning of the new fiscal year. Cathy Richardson, St. Mary Hospital's CEO, has been summoned to a meeting of the state health association to brainstorm the best approach for opposing the governor's strategy. She has convened her advocacy and ethics committees to help her think through the issues.
These are ordinary situations. Each in its own way raises a question of justice. Taken together, they suggest the ordinariness of justice concerns, and the many opportunities leaders have to promote justice. Justice in Catholic healthcare has to do not only with the care of the poor and the underserved; it also bears on the various relationships that exist within the organization, as well as on the organization's relationships with external entities: vendors, payers, the community, government, and the larger society, for example.
This article attempts to make concrete the commitment, so often expressed in Catholic healthcare, to being just and pursuing justice.
Justice Central to Ministry
Justice is an omnipresent concern; acting in accord with justice is neither optional nor at the edges of what we are about. In fact, doing justice is core to our ministry. This is so because "action on behalf of justice and participation in the transformation of the world fully appear to us as a constitutive dimension of the preaching of the Gospel, or in other words, of the Church's mission for the redemption of the human race and its liberation from every oppressive situation."1
At the outset of his ministry, Jesus proclaimed that "the reign of God is at hand" (Mk. 1:15) — a reign characterized by "right relationships" with God and one's neighbor and special care for society's marginalized. God demands justice from, and provides the standard of justice for, God's people, those who are faithful to the covenant God. In his life and ministry, Jesus is the exemplar of how justice should be carried out. He makes present and embodies the reign of God and calls his followers to do the same: to transform the world so that the reign of God becomes ever more realized (although followers know that its full realization is yet to come). Catholic healthcare contributes to the mission of the Church by carrying on the healing ministry of Jesus and advancing the reign of God in society. Justice is, therefore, integral to the ministry and its leadership.
Human Dignity, the Foundation of Justice
Justice is based in the dignity and sacredness of persons. Because of persons' dignity we owe them. As theologian David Hollenbach puts it: "Justice is rooted in the fact that man himself is a certain ought with respect to his fellow man."2 What we owe others, at the very least, is respect. Or, put differently, what we owe others is whatever affirms, protects, and enhances their worth as unique persons — the worth that comes from their being created in the image and likeness of God. We are being just, then, when we give evidence of respecting other persons. Very often what affirms, protects, and enhances is manifested in concrete, essential needs — those things without which human dignity is negated, without which the person cannot survive and flourish. So, for instance, ministry leaders need to address matters of salary, benefits, and downsizing with the same thoroughness and intensity they use in achieving optimal financial performance standards, securing managed care contracts, or increasing productivity and efficiency. There is a serious "disconnect" when ministry leaders and others who claim to believe that all persons have dignity and are sacred fail to demonstrate those convictions in their behavior.
Our Social Nature
Justice is a recognition of our social nature. Our Catholic tradition tells us (in contrast to the way Americans frequently behave) that we are not isolated individuals; rather, we are inherently social. We are relational beings not by choice but by birth. In fact, it is only in solidarity with others that human beings are able to flourish and find fulfillment. Justice underscores our interdependence as well as our mutuality. Because of our dignity and the dignity of other persons, we owe them and they owe us. Precisely what we owe them is determined by who they are, as well as by the nature and the context of the relationship. What a CEO owes her employees is different, for instance, from what a physician owes his patients, or what an HMO owes its enrollees. Justice thus focuses our attention not only on the quality of our one-on-one relationships; it also orients us to groups of individuals — family, workplace, religious organization, local community, government, and society, among others. We owe the groups to which we belong and with which we relate just as we owe individuals, and vice versa. Hence, ministry leaders demonstrate their real commitment to justice in the quality of the multiple and various relationships in which they are engaged (e.g., with fellow executives and managers, other employees, recipients of care and their families, vendors, payers, and the community).
Justice in Multiple Realms3
The scenarios at the beginning of this article illustrate various contexts for the exercise of justice.
Individual Realm We recognize in the first scenario, concerning a performance appraisal, obligations that exist between individuals (a CFO and Mary Harmon, one of his direct reports) and between an individual and an organization (Mary and the medical center). The CFO, in justice, owes Mary a fair evaluation, one that reflects how well Mary has discharged her justice obligation to the organization. If Mary's intuition is correct, and her evaluation by the CFO does not reflect her performance and contributions, she will have been done an injustice. There is in such interactions — especially those marked by a contract, an exchange or promise of some sort — a requirement of justice that must be honored.
Institutional Realm The new board member in the second scenario suggests that the medical center is being unjust by having a higher pay scale for employees of the acute care organization and a lower one for employees of the long-term care facility. To his credit, this retired long-term care administrator recognizes that organizations themselves have obligations in justice — to their employees and other individuals (e.g., vendors), to other organizations (e.g., related agencies in the community, partners, hospitals to whom they send their residents), and to society (e.g., to be a good corporate citizen; to faithfully discharge its mission in a manner deserving the community's trust and tax-exempt status). In addition to providing fair wages, benefits, and a good working environment for its employees, budgeting and allocating resources fairly, and giving high-quality service at fair prices, the medical center also discharges its justice responsibilities in various other ways. These may include senior management team's participation in the chamber of commerce and the Rotary Club; alternative investment in community-based micro enterprises; and partnering with schools to improve health and promote careers in healthcare. Working to achieve justice in the way an organization structures itself and functions is not easy. There will almost always be conflicting goods at stake, requiring difficult judgments about how to balance those goods fairly.
Societal Realm
The advocacy and ethics committees mentioned in the third scenario — the one concerning Medicaid managed care — will undoubtedly discuss a number of significant justice issues: the obligation of the state (a surrogate for society) to ensure access to healthcare for its poorer citizens; the obligation of healthcare organizations, especially faith-based organizations, to promote universal access; the importance of working, not simply to accomplish the governor's objective of reducing Medicaid spending, but also to simultaneously increase the number of Medicaid beneficiaries. Each of these is a justice issue.
There are other ways, of course, for healthcare organizations and their leaders to contribute in justice to the common good, either that of the local community or of society as a whole. Among these are identifying and responding to community needs (e.g., problems with substance abuse, youth violence, teen pregnancy, and unmet needs of the elderly), supporting legislative efforts that protect patients in the managed care environment, or facilitating pain control in end-of-life care. "Leading with and for justice" means being attuned to the common good, identifying ways in which the common good might be enhanced, and marshaling the organization's available resources to enhance it.
Leading with Justice
We must be just to do justice. If justice is to flourish in Catholic healthcare, it must first be part of who we are as individuals, as organizations, and as a ministry. Only then will it be reflected in all that we do. For justice to truly characterize an individual's, an organization's, or the ministry's multiple relationships, it must first be integral to the character of ministry leaders. When ministry leaders are steeped in the Catholic justice tradition, it will shape their worldview — how they see and what they see — as well as their beliefs, values, intentions, motives, dispositions, and, ultimately, their behavior.4 The leader will have a keen regard for human dignity and for those conditions which respect, protect, and nourish it; a sensitivity to ways in which it is violated and to those who suffer injustice; a concern for the common good; and a concern for how justice can be reflected in the multiple relationships within the organization, as well as in the organization's relationships with other individuals and groups. Hence, the leader's first challenge with regard to leading with and for justice is personal embodiment and modeling. Without these, it is doubtful whether others in the organization will take justice as seriously as it should be taken.
Coherence in being and doing on the part of ministry leaders is the first step in fostering a culture of justice. Leaders bear a special responsibility for the culture of their organizations. They help shape that culture through the vision they communicate (with its accompanying beliefs and values); the behavior they demonstrate; the expectations they establish; and the practices, procedures and policies they implement and support. Ministry leaders need to be sure that there is an organizational commitment to justice, because only then will everyone within the organization be committed to the pursuit and realization of justice. Only then will justice be the criterion for interpersonal relationships within the organization and for the organization's relationships with other entities. Only then will justice find expression not only in particular decisions and actions, but also in various institutional practices, procedures, and policies (e.g., those affecting downsizing, severance packages, and the elimination of double standards applied to managers and staff). If justice is to flourish in an organization, it must be structured into the organization's life.
Finally, ministry leaders who are committed to a more just organization will of necessity be engaged in transformative leadership. They will recognize and name instances and patterns of injustice that occur both within the organization and between the organization and its various constituencies. Once these violations are identified, ministry leaders will address them. Moral imagination, an ability to envision alternatives to the status quo, and courage will be of great assistance here.
Leading with and for justice should not be something "added on" to the many responsibilities and challenges of ministry leaders. Rather, it should characterize the way these responsibilities are carried out, for the pursuit of justice is, ultimately, at the heart of the healing ministry. Restoring wholeness to persons whose dignity has been violated or whose essential human needs have not been met is a healing activity, one that should result in healthier individuals, healthier relationships, and healthier communities. The work of justice is difficult, partly because justice issues are pervasive and partly because of what justice requires. In addition, human finitude and sinfulness render the realization of justice imperfect and partial. Despite these obstacles, the Gospel call remains to make present here and now God's reign of justice even as we know that its full realization lies beyond us. The fulfillment of justice is, ultimately, an eschatological hope.
NOTES
- Synod of Bishops, Justice in the World, 1971.
- David Hollenbach, Claims in Conflict, Paulist Press, New York City, 1979, p. 209, emphasis added.
- Jack Glaser, in his book Three Realms of Ethics (Sheed and Ward, Kansas City, MO, 1994), maintains that ethical reflection must take into account not only the individual realm, but also the institutional and societal realms. Too often, he argues, ethics is limited to individual considerations and issues, and the other two domains of life are neglected.
- See Organizational Integrity in Catholic Healthcare Ministry: The Role of the Leader, Catholic Health Association, St. Louis, 1998 (also available online at www.chausa.org), for further illustration of such a worldview.
Drs. Hamel and Neale are senior associates, ethics, Catholic Health Association, St. Louis.
YEAR DEVOTED TO JUSTICE
While justice and its pursuit should always be of concern to ministry leaders, it is particularly fitting that these leaders promote it in a special way in 1999. That year has been designated by the Church as the year of charity and justice, in preparation for the Jubilee Year 2000 and the Third Millennium. CHA also suggests that justice should be the theme for Catholic health ministry during this time.