Nursing and the Common Good

November-December 2006

BY: NALINI JAIRATH, Ph.D., RN; SR. ROSEMARY DONLEY, SC, Ph.D.; DEBORAH SHELTON, PhD, RN; PATRICIA McMULLEN, PhD, JD; and CYNTHIA GRANDJEAN, Ph.D.
Dr. Jairath is dean, School of Nursing, Catholic University of America, Washington, DC, and Sr. Rosemary is ordinary professor at the school. Dr. Shelton is associate dean for research and associate professor, University of Connecticut, Storrs, CT. Dr. McMullen is associate dean and Dr. Grandjean is assistant professor, School of Nursing, Catholic University.

The common good has been defined within Roman Catholicism as "the sum total of social conditions which allow people, either as groups or as individuals, to reach their fulfillment more fully and more easily."1 Given that nursing is a major contributor to health care, this article analyzes the relationship between nursing practice and the conceptualizations of the common good. Major challenges to integrating the common good into nursing are identified.

The "common good" is a concept that may have utility in analyzing moral and ethical issues affecting care of vulnerable patient groups. Roman Catholicism presents an explicit articulation of the meaning and value of the common good in modern times in which the common good represents both a goal and a manifestation of Catholic social ethics. The authors are practicing nurses and members of nursing faculties. Therefore, we do not claim an in-depth understanding of the philosophical and theological issues associated with the common good. Rather, unresolved issues related to the way in which the common good articulates with nursing are identified.

The Common Good
The term the "common good" has been used in various contexts to identify actions or outcomes that have some definable benefit that extends beyond individual gain. The common good has been addressed in professional literature pertaining to ethics, political action, the environment, nursing, and health care.2 It has also been cited in the popular literature,3 as well as on advocacy and special interest web sites.4 In examining these diverse uses of the term, it is apparent that the common good frequently represents a determination by a select group as to what constitutes "good." Further, specific individuals derive greater or lesser benefit when actions related to the common good are implemented. Therefore, colloquially, the phrase "common good" more aptly reflects perceived "societal good."

In contrast, religious groups address the common good from the perspective that all individuals should benefit.5 Arguably, Roman Catholic theology presents the most explicit religious articulation of this concept. In Catholicism, the common good has been defined as "the sum total of social conditions which allow people, either as groups or as individuals, to reach their fulfillment more fully and more easily."6 The Catholic Social Teaching page of the website of the Office for Social Justice (http://www.osjspm.org/the_ common_good.aspx) identifies social encyclicals, documents of the Second Vatican Council, and various publications of the U. S. Conference of Catholic Bishops that address the common good in Catholic social thought.7 These materials underscore that both individuals and groups working in communion have a responsibility to advance the common good. These groups may include family members, communities within the church, social and societal groups, and all levels of government.

Two broad strategies are used in the Roman Catholic literature regarding the common good. First, prescriptive language such as the instruction to work for the common good underscores the specific obligation to promote the common good. Second, metaphor and descriptive language emphasize the need for reflection and examination of the way in which one can work for the common good. The analogy is drawn to the parts of the human body, underscoring the important role of apparently nonessential body parts in preserving the integrity of the individual. The use of analogy mirrors the use of parable in the Gospels and affirms that in the Catholic explication of the common good, each individual and group has an equally important, though different, role to play. Members of these groups work in concert, and through their respective actions and roles as community members achieve outcomes associated with the common good.

Three major differences exist between the societal good and the common good in Catholicism. First, outcomes related to the common good pertain to the soul as well as the body. Second, the intent of one's actions is as important as the effectiveness of one's actions in working toward the common good. Third, the common good cannot be advanced at the expense of individuals or vulnerable groups within a community.

Health Care, Nursing, and the Common Good
The literature examining the relationship of the common good to nursing and other health professions mainly cites the common good as an impetus for action; literature exploring the common good as a concept of use to nursing and health care is very limited. However, nursing is viewed as promoting the common good.8 In addition, the development of nursing as a discrete profession reflects societal recognition that the constellation of services provided by nurses is supportive of the common good. Although nursing literature does not address the common good from a theological perspective, it clearly addresses related concepts such as concern for the whole person in the community and outcomes associated with the common good, such as distributive justice.9 Consistent with the Catholic perspective of the common good,10 nursing also addresses the need to balance the preservation of individual dignity and respect against societal integrity. The "added value" of the common good to existing nursing concepts may be illustrated by examining instances of ethical misconduct in clinical research and the evolution of the health care delivery system.

Ethical Misconduct in Clinical Research
Balancing risk/harm against benefit to individuals and societies has long been a consideration in clinical research. Three studies involving vulnerable populations illustrate the way in which the common good, as opposed to societal good, could have potentially decreased ethical misconduct in clinical research.

In the 40-year Tuskegee study, the natural history of syphilis was studied in poor, black male sharecroppers. Even after penicillin was shown to be effective in the treatment of syphilis, study subjects were not informed of the availability of treatment and were actively discouraged from seeking help by the research nurse and the physicians conducting the study.11 In the Willowbrook Hepatitis Study, which lasted from 1963 to 1966, mentally deficient children were required to enroll in a research study to gain placement in a residential facility. In the 1963 Jewish Chronic Disease Study, older and senile patients were injected with cancer cells to examine cell rejection.

It is noteworthy that at the time it was conducted, each study was deemed ethical and consistent with the standards of the time. Each study arguably advanced societal good but clearly did not advance the common good as articulated in Catholic thought. In retrospect, each study was deemed unethical. Given the limited ability of those within a culture to identify examples of ethical misconduct, it is probable that future generations will identify some current studies as unethical. Thus, the common good may be an important tool to use in anticipating instances of misconduct. For example, the common good may be of value in understanding ethical issues related to stem cell research and the relevance of stem cell lineages, discussions regarding cloning, and fertility treatment, among other subjects.

Current Health Care
Nationwide, debate exists over the structure of our health care system. Currently in the United States, a tiered public/private party system exists. In this approach, access to health care and the range of services provided are based on the ability to pay. The most prosperous derive the greatest benefit at a proportionately lower cost. The working poor derive the least benefit and have lower-quality health care than do those with Social Security benefits. In contrast, the universal, low-cost, or free health care offered in other nations is more in concert with the common good as articulated in Catholic theology. Such health care derives from approaches that stress equity, sharing, and sacrifice on the part of some for the benefit of others.

The rise of complex Catholic health care networks integrating services across the inpatient and outpatient settings reflects an implementation of the Catholic understanding of the common good; it also reflects the impact of Catholic social thought related to the concepts of equity, dignity, and distributive justice. Although other faith-based groups, such as the Seventh Day Adventists, have also developed excellent health care networks, Catholicism introduced and institutionalized the concept of religious orders with nursing care as a manifestation of a religious charism. Furthermore, in North America, Catholic health care institutions provided the earliest and sometimes the only health care option for the poor and certain immigrant groups. Finally, Catholic health care institutions such as Holy Cross, Mercy, and Providence hospitals were among the first of the hospital systems to provide health care coverage to large regions in North America. Currently, the Catholic contributions to hospitals, nursing homes, clinics, and other health care resources remain a major factor contributing to the health of underserved individuals and communities.12

Challenges to Integrating the Common Good Construct into Nursing
Despite the benefit of integrating the common good into nursing and health care, several challenges exist.

The Role of the Common Good in Shaping the Development of Nursing
The first challenge deals with identifying the way in which the common good, as distinct from other concepts, plays a role in shaping the advancement of the nursing profession and practice. The authors of this article contend that nursing as a profession exists because of societal support and the perception that nursing is important to the preservation of health-related aspects of the common good. Societal forces have strengthened nursing by supporting the professional education of students and promoting the conceptualization, implementation, and growth of advanced nursing practice roles, such as that of the nurse practitioner. Societal forces have also shaped funding priorities for nursing research, such as the current emphasis on the interplay of genetics, health-related behaviors, and disease prevention. Thus, society shapes those elements of the common good that nursing chooses to address, and nursing as a profession survives in societies that deem it an element necessary to promote the both the common good and societal good. Conversely, were society not to perceive nursing as an element of both the common good and societal good, nursing as a profession could become obsolete. Therefore, consideration of the common good, in addition to societal good, has potential to strengthen the power base of nursing and its benefit to society.

If nursing fails to establish its benefit to society through promotion of the common good, professional nursing — with its elements of caring, compassion, and concern — could potentially be replaced by technology and managed by machines and technicians. Although this statement may seem alarmist, several relatively recent changes in health care document the profession's increasing vulnerability. First, society is increasingly accepting of the use of other paraprofessional groups that have relatively high autonomy to perform traditional nursing activities. It is common in the hospital setting to encounter a wide variety of technicians and aides who deliver the majority of hands-on care.

Second, many activities and procedures within the scope of practice of one health profession have subsequently been assumed by another profession. For example, nursing-focused activities related to public health and risk reduction have been adopted by medicine; conversely, certain medical procedures have been assumed by nurses. Examples of such shifts include nursing's responsibility for anesthesia administration through certified nurse anesthetists. Less-glaring shifts include nursing's assuming responsibility for interpreting electrocardiograms, telemetry output, and physiological indicators in critical care units.

Third, there appears to be an increase in nondiscipline-specific responsibilities among the health professions. For example, physical examinations may be performed by a wide variety of individuals.

Finally, the emphasis on cost and evidence-based practice, though important, is reductionistic and may fail to capture the unique contributions of nursing to health care, and by inference to the common good.

The Utility of the Common Good for Documenting the Contribution of Nursing
The second challenge deals with whether the common good is empirically useful for examining the contribution of nursing to society. The value of the common good as a construct for use in the development of nursing theory and guidance of nursing practice has been established. For example, it may be contended that a version of the common good construct has fueled major public health advances, including widespread immunization and greater access to antibiotics. Benchmarks, or indicators of progress toward achieving health-related goals pertaining to the common good, have moved from the minimization of disease and the prolongation of life to prevention of disease progression and preservation and enhancement of health-related quality of life. Additionally, the common good has implications for those nurses who work with individuals but whose work will affect social groups. For example, one of the authors (Deborah Shelton) addresses societal violence by helping children develop communication and anger management skills. Her work influences the quality of the child's interaction with family members and peers. This ultimately has a positive impact on society and promotes common good values related to societal peace and harmony.

However, additional issues related to utility remain unresolved. These include (1) the way in which the operational definition of the common good construct changes or evolves in response to societal changes, (2) the intersection between the common good as a construct articulated within a theological context and practice disciplines with a different context, and (3) the way in which the common good construct can be linked to knowledge development.

Evidence-Based Practice and the Common Good
The third challenge deals with the evidence base for nursing practice. As a professional practice discipline, nursing ideally requires a base or core of evidence to support specific nursing interventions and actions. In the evidence-based environment, the actions of health care professionals, including nurses, are driven by the best available evidence. Knowledge emanates from data, whether acquired through research or analysis of clinical results. If the evidence base does not support a particular nursing activity or action, it may be viewed as of dubious benefit or value. Currently, the common good has not been operationally defined for nursing, and the evidence base supporting its use is limited. Thus, an important relationship between the common good and the nature of scientific thought and knowledge remains to be elucidated. Furthermore, the Roman Catholic articulation of the common good emphasizes intentionality as an important dimension of care. However, intentionality is not a criterion used to evaluate the evidence base in practice. Rather, evidence-based practice focuses upon quantifiable outcomes in clinical populations. Thus, if the common good as a concept incorporates actions that indirectly benefit society, or if the time horizon against which direct benefit is measured is long, the ability of nursing to promote the common good in a more global sense is questionable.

The Impact of Cost/Benefit Considerations on the Ability to Promote the Common Good
The fourth challenge to integration of the common good into nursing practice is related to financing. Lack of societal agreement regarding the ways in which health care costs are balanced against benefits constitutes another challenge to implementing the common good. For example, in seeking to promote the common good, what is the tradeoff between decreasing the Catholic identity of an institution to gain greater access to government or private funding for health care initiatives? What criteria should be used to determine whether Catholic health care institutions should merge with secular hospitals? How do nurses address the spiritual nature and needs of patients while recognizing the divergence of worldviews? How does a school of nursing prepare nurses in a uniquely Catholic way for practice in a non-Catholic environment, and with patients who have a wide variety of religious beliefs or who may have no belief or interest in the spiritual dimension of the common good?

Conflicting/Competing Priorities in Discerning Societal Good
The fifth challenge to integrating the common good into nursing and health care occurs when sufficient ambiguity exists that the nature of the common good is not clear. This is evident in debates regarding public health approaches to infectious disease. In the past, individuals with certain highly communicable infectious diseases, such as tuberculosis, were documented on registries and, if necessary, restricted to sanitariums or health care facilities. Today, these practices are modified because of better understanding of the epidemiology of infectious disease and the availability of vaccines and treatments. Unanswered questions pertain to whether the common good is served by identifying all instances of communicable disease in repositories where anonymity and possibly confidentiality cannot be assured, or whether the common good is served by promoting confidential treatment and maintaining the dignity of the individual within society.

Call for the Articulation of Common Good in Health Care Disciplines
Although professional organizations within nursing have not explicitly incorporated the common good within nursing theory, we believe that a clearer definition and articulation of the common good as a concept within nursing and other health disciplines is beneficial to patients, the professions, and society. The common good may be viewed as a unifying approach accepted by diverse professions and thus a core concept to benefit society. It may have great value in the realm of health policy and health care administration, as well as in the areas of nursing and health care ethics and public health.

NOTES

  1. "Gaudium et Spes," Catechism of the Catholic Church, part 3, section 1, chapter 2, article 2.II, available at www.vatican.va/archive/eng 0015/__p6k.htm.
  2. See, for example, E. P. Meux, "Concern for the Common Good in an N-Person Game," Journal of Personality & Social Psychology, vol. 28, no. 3, December 1973, pp. 414-418; M. van Baalen and V. A. Jansen, "Dangerous Liaisons: The Ecology of Private Interest and Common Good," Oikos, vol. 95, no. 2, November 2001, pp. 211-224; and C. Cochran, "The Common Good and Healthcare Policy," Health Progress, May-June 1999, pp. 41-44, 47.
  3. N. Chomsky and D. Barsamian, The Common Good, Odonian Press, Tucson, AZ, 1998; and P. Newman and A. E. Hotchner, Shameless Exploitation in Pursuit of the Common Good: The Madcap Business Adventure by the Truly Oddest Couple, Doubleday, New York City, 2003.
  4. "Common Good: Restoring Common Sense to American Law," available at www.cgood.org; and M. Velasquez et al., "The Common Good," Markula Center for Applied Ethics, available at www.scu.edu/ethics/practicing/decision/commongood.html.
  5. Protestants for the Common Good, Position Papers, available at www. thecommongood.org/positionpapers.asp.
  6. "Gaudium et Spes."
  7. See, for example, Pope Pius XI, Quadragesimo Anno, May 15, 1931, available at http://www.osjspm.org/majordoc_quadragesimo_anno_ officialtext.aspx; Pope John XXIII, Pacem in Terris, USCC Office for Publishing and Promotion Services, no. 140, 1963, available at http://ww.osjspm.org/majordoc_pacem_in_terris_official_text.aspx.; and National Conference of Catholic Bishops, "Economic Justice for All: Pastoral Letter on Catholic Social Teaching and the U.S. Economy," 1986, available at http://www.osjspm.org/economic_justice_for_all.aspx.
  8. Susan Hume, "Catholic Theology Informs Thinking on Health Care Reform," Health Progress, May-June 1999, p. 43.
  9. See, for example, S. Kneipp and J. M. Snider, "Legal and Ethical Issues: Social Justice in a Market Model World," Journal of Professional Nursing, vol. 17, no. 3, May-June 2001, p. 113; W. Austin, "Nursing Ethics in an Era of Globalization," Advances in Nursing Science, vol. 24, no. 2, December 2001, pp. 1-18; and K. Chafey, "'Caring Is Not Enough: Ethical Paradigms for Community-Based Care," National League of Nursing, vol. 17, no. 1, January-February 1996, pp. 10-15.
  10. Cochran; Hume; C. Bouchard, "Catholic Healthcare and the Common Good," Health Progress, May-June 1999, pp. 34-40; R. Hamel, "Of What Good Is the Common Good?" Health Progress, May-June 1999, pp. 45-47.
  11. J. H. Jones, Bad Blood: The Tuskegee Syphilis Experiment, rev. ed., Free Press, New York City, 1993; and G. E. Pence, Classic Cases in Medical Ethics: Accounts of Cases That Have Shaped Medical Ethics, with Philosophical, Legal, and Historical Backgrounds, McGraw-Hill, New York City, 2003.
  12. See, for example, B. McCauley, Who Shall Take Care of Our Sick? Roman Catholic Sisters and the Development of Catholic Hospitals in New York City, Johns Hopkins University Press, Baltimore, 2005; and J. J. Fialka, Sisters: Catholic Nuns and the Making of America, St. Martin's Press, New York City, 2003.

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