DANIEL A. GRAFF, PhD, and KELLI REAGAN HICKEY, MS
University of Notre Dame
Illustration by Nicole Xu
As an X-ray reveals a broken bone hidden beneath the skin, COVID-19 has exposed the economic fault lines fracturing our society and highlighted the costs endured by workers over the past several decades. As exemplified in a 2021 survey, nearly one in four nurses say they are considering leaving direct patient care within the next year, while almost one in three frontline health care workers more generally report the same.1 Nurses cite multiple factors for their dissatisfaction, with six reasons polling higher than pay, including insufficient staffing, excessive workload, emotional toll and not feeling listened to or supported by management.
Given the relentless public health care crisis of the past two years, such numbers shouldn't surprise us. But it would be a mistake to isolate the health care sector from our economy as a whole and miss the larger meaning conveyed by these surveys, for the emergency in health care work is indicative of a broader labor crisis confronting the country, one that cannot be reduced to the straightforward disputes over money that tend to dominate media headlines.
The time to reassess our economic priorities is long overdue — now is the moment to commit to building a more just society rooted in human dignity and its expression through work. No industry is better situated to lead the way than health care, uniquely poised at the intersection of the moral charge of mission and the economic demand of sustainability.
THE EMERGENCE OF WORKFORCE DISPARITIES
When the pandemic produced twin public health and economic crises in 2020, it also prompted a surprising national conversation regarding the place of workers in the U.S. economy. The indispensable but mostly invisible, lowly compensated labor performed by clericals, custodians and health care workers was suddenly deemed essential and undervalued by a nation locked down and desperate to avoid the contagion of the coronavirus. This was a rare and welcome development during the dark days of COVID-19's first year, raising hopes for a long-overdue reconsideration of the five-decade run of flat-lining wages, declining labor unions and deteriorating labor protections.
Yet, despite Americans' seemingly overnight appreciation for the newly christened "essential worker," the stark lines separating actual frontline workers from managers and professionals in terms of pay, job security, workplace safety and household stability seemed only to sharpen. Even as many of the nation's leaders called for a "we're all in this together" recommitment to the common good, the pandemic's effects emphatically exacerbated the already alarming trends in increasing wealth and income inequality.2
With the emergence of COVID-19 vaccines and the economy rebounding in 2021, however, real-life essential workers unexpectedly materialized as potent actors in their own right. In what pundits have termed "The Great Resignation," millions of working Americans silently rejected the COVID economy by taking early retirement or temporarily withdrawing from the labor market. Millions of others took a more vocal approach. From factory floors to the front lines, workers in hospitals, hotels, emergency rooms and eateries demanded not only higher wages, but also safer workplaces, saner schedules and a voice in determining these aspects of their jobs. Embittered by months of unending stress and emboldened by tighter labor markets, workers across the country — from nursing homes to newsrooms to nonprofits — have been soundly rejecting business as usual.
A CALL FOR CHANGE
What we need right now is less of a great resignation than a great reckoning, a nationwide commitment to reaffirm the indispensability of workers to our economy by reforming the American workplace. At the University of Notre Dame's Center for Social Concerns, a group of scholars and students, in consultation with a variety of stakeholders across the employment spectrum, has developed an online tool — to be shared with organizations across the country — in order to promote such a project: the Just Wage Framework.3 Reflecting the interdisciplinary input of experts across the humanities, social sciences, business and law, and rooted in the Catholic social tradition's commitments to decent work, labor rights and community flourishing, the Just Wage Framework insists that morality be integrated into our economic debates and decisions, foremost by recognizing the human questions at the center of our employment relationships. As Pope Francis declared in his 2015 encyclical Laudato Si', "Work is a necessity, part of the meaning of life on this earth, a path to growth, human development and personal fulfillment."4
Answering the foundational question, "What makes any given wage just or unjust?," the Just Wage Framework features seven foundational and intersecting criteria. As we envision it, a just wage 1) fosters a decent life for the worker and the worker's household; 2) enables asset building; 3) provides social security; 4) reflects full inclusion by prohibiting discrimination in all forms; 5) avoids excessiveness to mitigate extreme inequality and enhance sustainability; 6) exhibits participation by all workers; and 7) respects performance, qualification and expertise. As our framework indicates, a just wage involves much more than pay, so it cannot be reduced to a dollar figure. Similarly, reflecting hard-to-calculate features such as safety, stress and inclusivity, a just wage cannot be quantified via a point scale. More robust than a minimum wage or even a living wage, a truly just wage expresses not only the dignity of labor as an ennobling human enterprise but also the process of qualitative discernment, dialogue and debate amongst all economic stakeholders.
MORAL VS. ECONOMIC CHALLENGES
The pandemic presents the perfect moment for a long-overdue reconsideration of our economy along just wage lines, and health care provides the ideal sector for the application of just wage principles. But in practice, honoring moral principles like the dignity of work in the midst of competitive economic realities can be a challenge. This matter calls to light a broader critique of Catholic social tradition: that its principles are beautiful, but for employers, also idealistic and impractical. This potentially creates a dilemma for the Church by asking employers to walk a fine line between economic viability and moral purpose.
The health care sector encounters this tension acutely. It is sensitive to the moral dimensions of work because, as a field, it is profoundly human and profoundly moral. Institutions like hospitals and doctors' offices are places of dignity. They are spaces where people fully confront the inevitable aspects of the truly human life: vulnerability, weakness, dependence and death. The authentic purpose of health care is predicated on the Christian command to "heal and visit the sick," a work of mercy derived from the Sermon on the Mount. At its best, health care "is" the work of mercy.
And yet, not unlike our field of higher education, health care as practiced has been increasingly pulled toward an approach defined more by a "market ethos" than human dignity. Artificially stripping out the moral component of economic decision-making, it fosters an entrepreneurial culture narrowly focused on relentless cost cutting, profit maximization and short-term gains in the guise of a neutral-sounding effort to increase efficiency. This ethos has slowly crept into the daily operations of health care institutions, changing the very nature of their work. Political philosopher Michael Sandel explains this transformation well: "Sometimes, market values crowd out nonmarket values worth caring about. … [and] without quite realizing it — without ever deciding to do so — we drifted from having a market economy to being a market society."5
To further explain this mindset, we offer two examples. We spoke with a family doctor of 35 years who, like others, described how new technologies and time-saving advancements have changed the very practice of medicine. He recounted his experience in a routine electronic medical records training, where an IT consultant reacted to his appointment style. "Do you always do this?" the consultant asked. "Chat with the patient for five to 10 minutes before logging into the computer to take notes?" When the doctor confirmed, the consultant responded with surprise: "Whoa. You're the only doctor I have ever worked with that does this. Most don't even look at the patient."
It's no secret that new, more "efficient" technologies can detach even the most fundamental elements of the doctor-patient relationship. This sense of detachment can spill out into the larger organizational culture, too. Atul Gawande, surgeon and assistant administrator for Global Health at USAID, writes that as he observed more of his colleagues, he "began to see the insidious ways that the software changed how people work together. They'd become more disconnected; less likely to see and help one another, and often less able to."6
A second example is perhaps more poignant. In his study of a union's struggle to organize a Catholic hospital (one that explicitly probes the tensions between markets and morals in the health care sphere), sociologist Adam Reich writes of a phlebotomist instructed by managers to "use the bigger needles, because they're cheaper." He thought, "Bigger needles? You're only looking at a seventeen cents difference. At the end of the year you might save a couple of bucks, but that's it. … You're going to make little kids suffer [a] twenty, sixteen, eighteen gauge needle."7
THE VALUE OF WELL-BEING
The subtle effects of a "business as usual" attitude on the culture of health care — while perhaps convenient to ignore during normal times — are easier to see in the context of the pandemic. Like the labor market in general, the systematic devaluing of workers and unyielding pressure to cut costs have exacerbated the burnout and shortage of medical staff when we need it most. As the Just Wage Framework holds, the way labor is valued and managed affects not only the well-being of the individual worker, but also of society as a whole. Labor questions are public health questions.
The existing status of nurses in the U.S. health care system, mentioned at the beginning of this article, reveals the dangerous consequences of economic decision-making without full consideration of its moral dimensions. While demographic trends like the aging population, longer lifespans and increased comorbidities have undoubtedly contributed to the nursing shortage, burnout and staffing problems also play leading roles.8 With more patients and longer hours, nurses are unable to give patients the practical and emotional attention intrinsic to their vocation, leaving feelings of helplessness and ineffectiveness. From their overloaded schedules to their wages, nurses can feel as though they are at the whims of a management keen on pursuing economic ends for their own sake.
In light of these challenges, what can a tool like the Just Wage Framework contribute? The idea of valuing workers through a more just wage — in the form of pay, protection and in their flourishing on the job — undoubtedly impacts the bottom line. But it also uplifts morale and has the potential to create value, including and beyond the purely economic sense. In nursing and elsewhere, a just wage may be one step toward better resolving enduring, costly problems through long-term solutions: drawing more young people to the profession, reducing burnout and turnover, addressing staffing inefficiencies, lowering patient ratios and improving health outcomes for patients.
Like Catholic social tradition, the Just Wage Framework does not ask that employers throw economic considerations to the wayside. But it does require that they not always have the "last word." Approaching economic decisions with moral and theological ends in mind makes a difference beyond the transaction, beyond the quarter and beyond the annual report. Valuing workers on the basis of their being human — on the basis of valuing a "decent life" for its own sake — can have a broader impact. It can help reclaim the very nature and joys of medicine. More importantly, it can help make "decency" a criterion relevant not only for labor, but also for every aspect of society itself.9
THE ROAD AHEAD TO A MORE JUST ECONOMY
Whether the current labor upsurge in health care and elsewhere proves temporary, or whether it portends enduring gains in pay and power for workers is an open question, especially as a slew of proposed pro-worker reforms and anti-poverty programs sit stalemated in a divided Congress. Still, however brief the economic tailwinds and whatever the fate of the labor law logjam, this is the ideal time for all of our economic stakeholders — employers, unions, trade groups, faith communities and all people of good will — to recognize an opportunity to redress the regressive labor trends of the past half-century.
The labor crises facing us are daunting, but we must reverse several decades of workplace deterioration and worker demoralization by recognizing the inherent moral issues inextricably connected to our employment relationships and economic policies. The Just Wage Framework, by restoring the dignity of work to its rightful place at the center of our decision-making, offers a road map toward a fairer, more inclusive and more just economy. At this moment in particular, the distinctly, wonderfully human practice of health care is an ideal place to put this Catholic social tradition-inspired guide to work.
DANIEL A. GRAFF is director of the Higgins Labor Program for the Center for Social Concerns and professor of the practice in the department of history at University of Notre Dame. KELLI REAGAN HICKEY is a research associate for the Center for Social Concerns at University of Notre Dame.
- Gretchen Berlin et al., "Nursing in 2021: Retaining the Healthcare Workforce When We Need It Most," McKinsey & Company, May 11, 2021, https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/nursing-in-2021-retaining-the-healthcare-workforce-when-we-need-it-most; Ashley Kirzinger et al., "KFF/The Washington Post Frontline Health Care Workers Survey," Kaiser Family Foundation, April 6, 2021, https://www.kff.org/coronavirus-covid-19/poll-finding/kff-washington-post-health-care-workers/.
- Zia Qureshi, "Tackling the Inequality Pandemic: Is There a Cure?," Brookings, November 17, 2020, https://www.brookings.edu/research/tackling-the-inequality-pandemic-is-there-a-cure/; Christian Weller, "Wealth Inequality on the Rise during Pandemic," Forbes, December 22, 2021, https://www.forbes.com/sites/christianweller/2021/12/22/wealth-rises-at-all-income-levels-but-faster-at-the-top/?sh=42a7258c6524.
- "Introducing the Just Wage Initiative," Center for Social Concerns, https://socialconcerns.nd.edu/justwagetool.
- Pope Francis, "Laudato Si': On Care for our Common Home," paragraph 128, http://www.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si.html.
- Michael J. Sandel, What Money Can't Buy: The Moral Limits of Markets (New York: Farrar, Straus and Giroux, 2012), 9-10.
- Atul Gawande, "Why Doctors Hate Their Computers," The New Yorker, November 5, 2018, https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers.
- Adam D. Reich, With God on Our Side: The Struggle for Workers' Rights in a Catholic Hospital (Ithaca, New York: ILR Press, 2012), 40.
- Lisa M. Haddad, Pavan Annamaraju, and Tammy J. Toney-Butler, "Nursing Shortage," StatPearls (December 2021): https://www.ncbi.nlm.nih.gov/books/NBK493175/.
- Avishai Margalit, The Decent Society (Cambridge: Harvard University Press, 1998).