Union Organizing in the Health Care Industry - New Unions and Alliances Among Rivals

Though our nation's economy has recently lost millions of jobs, the health care industry has continued to add them. Not surprisingly, unions are eager to sign up health care workers. In the last 10 years, the rate of union wins in the health care industry has grown faster than the national average. Unions are uniting to lobby for labor-friendly legislation to promote increased union membership in the health care sector.

In addition to traditional organizing, health care union organizers are using more radical corporate campaigns that target hospital donors, shareholders, community groups, and even patients. The unions push these target groups to put pressure on hospital owners to allow unions to organize their employees. Many critics have argued that some of these agreements with employers have greatly limited workers' power and emphasized the union's cooperation with management.

The following article provides an overview of the major unions involved in the health care industry, as well as strategies to ensure your organization is prepared and remains successful.

Service Employees International Union
The Service Employees International Union (SEIU) began in 1921 primarily as a janitor's union and branched out to include government, security, and health care workers. By 2000, it was the largest, fastest-growing union in the United States, with much of that growth stemming from a series of strategic mergers with smaller unions. In June 2005, the SEIU and six other unions left the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO) to form the Change to Win coalition. Citing the need for a renewed effort to organize workers, Change to Win purports to be focused on achieving fair wages, health care benefits, and secure retirement for all employees. The coalition also encourages workers to unionize on an industry-wide basis, consolidating smaller unions within larger unions.

SEIU Healthcare
In 2007, the SEIU announced plans to launch a new health care union to serve approximately one million members, such as nurses and service workers at hospitals and nursing homes. SEIU Healthcare combined financial and personnel resources from the 38 local SEIU Healthcare unions. Of the SEIU's 1.9 million members, 900,000 work in health care. In September 2008, the SEIU reported it would begin several high-profile projects to bring business leaders, health care providers, community organizations, and elected officials together to work on the nation's health care system. SEIU leaders were part of a May meeting held by President Obama to discuss a health care overhaul. More recently, SEIU members attended town hall meetings to speak out in support of the proposed health care reform. In August, the SEIU was part of a group-largely funded by the pharmaceutical industry's lobby-that launched $12 million in television advertisements to support Obama's health care proposal. This group, the Americans for Stable Quality Care, could spend tens of millions more this fall.

The SEIU attempted to consolidate three local units representing home health care workers into one unit last December, taking authority away from the local units. The SEIU accused the local unit officials of financial misconduct, and in response, the leaders of the local units criticized the SEIU's practice of centralizing power at its Washington headquarters and making corrupt deals with employers. In January, a 150,000-member SEIU local unit in Oakland was put under trusteeship by the SEIU, and the local officials of that unit were dismissed. The ousted officials formed a new union, the National Union of Healthcare Workers (NUHW).

The NUHW announced the first workers had cast votes in favor of representation by the new union in March. A majority of 350 union-represented workers at four nursing homes in northern California managed by North American Health Care wanted to end their labor relationship with SEIU and join the NUHW. The day after this announcement, the SEIU filed unfair labor practice charges against the four nursing homes, charging that administrators of the facilities had illegally withdrawn union recognition and colluded with a competing labor union. In that same month, a National Labor Relations Board regional director ruled against the NUHW, saying that the contract between the SEIU and the hospital chain prevented the effort by a new labor union to represent 14,000 Catholic Healthcare West workers. Despite the ruling, the founding convention to formally launch the NUHW took place in April 2009. According to the NUHW, approximately 91,000 California health care workers have signed petitions filed at the labor board, stating they would like be members of the new union.

The NUHW also claims that, in response to these decertification drives, the SEIU has resorted to harassment and intimidation and tactics similar to union prevention. The SEIU argues that the new group has unfairly restrained and coerced workers, as well as complained to the National Labor Relations Board. A decisive battle between the two unions will come in 2010, when the SEIU-UHW contract with Kaiser Permanente expires and the opportunity for decertification elections reopens. Kaiser, the largest health care provider in California, has 50,000 workers that could potentially become members of NUHW.

California Nurses Association/National Nurses Organizing Committee
The California Nurses Association (CNA) began as a state chapter of the American Nurses Association (ANA) in 1903. The ANA has a federated structure: Nurses do not typically join the organization directly, but instead join their respective state organization, which has membership in the ANA. After several years of believing the ANA was not providing them adequate financial support to increase collective bargaining activity in California, the CNA broke ties with the ANA in 1995 and formed its own union, becoming the first state organization to secede from the ANA. Since its break from the ANA, the CNA has acquired a reputation as one of the most aggressive labor unions in the country. In 2004, the CNA began establishing itself in other states under the name National Nurses Organizing Committee (NNOC). The CNA voted to seek affiliation in the AFL-CIO in 2007. CNA membership has doubled over the last seven years and represents 80,000 members from all 50 states.

In February, CNA/NNOC, United American Nurses (UAN), and the Massachusetts Nurses Association (MNA) announced the formation of another new union: the United American Nurses-National Nurses Organizing Committee (UAN-NNOC). With a combined membership of more than 150,000 affiliates in 19 states, it is the largest nursing union in the history of the United States.

National Federation of Nurses
The National Federation of Nurses (NFN) was officially launched in April at an event in Portland, Oregon. The NFN represents more than 70,000 nurses in six state nurses' associations, including New York, New Jersey, Ohio, Montana, Oregon, and Washington. Based on a federated model (much like the ANA), the NFN recognizes the independence of each member organization. Membership is open to state nurses' associations and other labor organizations that represent RNs. The NFN is tied to the ANA, which outlines standards for nursing practices, but has historically opposed nurse unionism and includes managers in its leadership. Since nurse union leaders expect many of the 15 unions with nurse memberships to flood hospitals with authorization cards if the Employee Free Choice Act (EFCA) passes, they want to establish their own national union to ensure nurses are organized by nurses.

SEIU and CNA: From Violent Disputes to Cooperative Agreements
The SEIU signed a neutrality agreement in March 2008 with an Ohio Catholic hospital to organize 8,000 workers. The day before voting was scheduled to begin, members of the CNA distributed leaflets to discourage workers from joining the SEIU. After the workers received the leaflets attacking SEIU and its arrangement with management for an election, SEIU called off the vote. Then at an April 2008 conference in Detroit, SEIU staff and members protested at a banquet of CNA members, resulting in violence. The two unions have also launched raids and counter-raids across the country, and both have sent mailings to thousands of nurses (including nurses in other unions, as well as nurses whose unions are currently trying to organize) attacking each other.

After more than a year of fighting, the SEIU and CNA signed a cooperation agreement in March. They will work together to bring union representation to all non-union RNs and other health care employees, as well as improve patient care standards. The unions have also agreed to refrain from raiding each other's members and will work together toward common goals, including lobbying for congressional passage of the EFCA. SEIU and CNA will coordinate campaigns at the largest health care systems and launch an intensive national organizing campaign. Catholic hospital chains will likely be among the first targets.

In June, the U.S. Conference of Catholic Bishops and the nation's largest unions (including the SEIU and the AFL-CIO) signed an agreement describing how union organizing will be conducted at Catholic health care facilities. (The document is similar to the one Catholic Healthcare Partners and Community Mercy Health Partners created last year with the SEIU before the CNA protest canceled the vote.) This agreement is significant because Catholic health care providers represent the largest employers and providers of services in many communities. The agreement provides seven guidelines for management at Catholic health care facilities and unions, making it easier organize health care workers at these facilities.

What This Means for Your Organization
Many experts agree that expanded unionization, along with the passage of the EFCA, will negatively impact our health care system. Both health care providers and industry analysts fear that unionization could mean higher costs and more restrictive work rules, adding to the soaring cost of delivering health care. Hospital and health care facilities need to be aware of these issues and how they can educate their supervisors and workers about the threat of unionization.

Communication with your employees is a critical first step. Many issues are involved in the possible unionization of a health care facility (economic factors, working conditions, quality of patient care, employee satisfaction, etc.). To prepare for possible union activity, identify issues that are relevant to your facility and address those needs publicly. Train leadership and include information about your union-free policy in the employee hiring and orientation procedures. Assess your wage and benefit structure, and be sure to promote what you offer.

You can use brochures, meetings, video, webinars, e-mail, Web sites, or eLearning tools to reach your employees. The most effective efforts include an employee feedback system that encourages two-way communication.

Making the Choice to Execute a Health Care Power of Attorney and Living Will

Advances in medical technology, recent court rulings and emerging political trends have brought with them a number of life-and-death choices which many have never before considered. The looming prospect of legalized physician-assisted suicide is one such choice which severely erodes the inherent value and dignity of human life. The much-publicized efforts of certain doctors to provide carbon monoxide poisoning or prescribe lethal drugs for their terminally ill patients constitute euthanasia. So may the removal of certain life-sustaining treatments from a patient who is not in a terminal condition. Euthanasia and willful suicide, in any form, are offenses against life; they must be and are rejected by the vast majority of U.S. states.

However, people faced with these difficult dilemmas should be made aware that there are morally-appropriate, life-affirming legal options available to them. One such option, for Catholics and others, can be a "health care power of attorney" and "living will." South Carolina State law allows you to appoint someone as your agent to make health care decisions for you in the event you lose the ability to decide for yourself. This appointment is executed by means of a "health care power of attorney" form, a model for which can be obtained from your attorney.

A health care power of attorney can be a morally and legally acceptable means of protecting your wishes, values and religious beliefs when faced with a serious illness or debilitating accident. Accordingly, for persons wishing to execute health care powers of attorney, see the following instructions and guidance from the authoritative teachings and traditions of various religious faiths.

The intent of the health care power of attorney law is to allow adults to delegate their God-given, legally-recognized right to make health care decisions to a designated and trusted agent. The law does not intend to encourage or discourage any particular health care treatment. Nor does it legalize or promote euthanasia, suicide or assisted suicide. The health care power of attorney law allows you, or any competent adult, to designate an "agent," such as a family member or close friend, to make health care decisions for you if you lose the ability to decide for yourself in the future. This is done by completing a health care power of attorney form.


o Have the right to make all of your own health care decisions while capable of doing so. The health care power of attorney only becomes effective when and if you become incapacitated through illness or accident.

o Have the right to challenge your doctor's determination that you are not capable of making your own medical decisions.

o CAN give special instructions about your medical treatment to your agent and can forbid your agent from making certain treatment decisions. To do so, you simply need to communicate your wishes, beliefs and instructions to your agent. Instructions about any specific treatments or procedures which you desire or do not desire under special conditions can also be written in your health care power of attorney and/or provided in a separate living will.

o Can revoke your health care power of attorney or the appointment of your agent at any time while competent.

o May not designate as your agent an administrator or employee of the hospital, nursing home or mental hygiene facility to which you are admitted, unless they are related by blood, marriage or adoption. 1996

Your agent...

o Can begin making decisions for you only when your doctor determines that you are no longer able to make health care decisions for yourself.

o May make any and all health care decisions for you, including treatments for physical or mental conditions and decisions regarding life-sustaining procedures, unless you limit the power of your agent.

o Will not have authority to make decisions about the artificial provision of nutrition and hydration (nourishment and water through feeding tubes) unless he or she clearly knows that these decisions are in accord with your wishes about those measures.

o Is protected from legal liability when acting in good faith.

o Must base his or her decisions on your wishes or, if your wishes cannot be reasonably ascertained, in your "best interests." The agent's decisions will take precedence over the decisions of all other persons, regardless of family relationships.

o May have his or her decision challenged if your family, health care provider or close friend believes the agent is acting in bad faith or is not acting in accord with your wishes, including your religious/moral beliefs, or is not acting in your best interests.


The following is an attempt to gather information from the doctrines of Christianity, Catholicism, and Judaism to see if there are any commonalities with regard to health care agencies and living wills. We will see that all three religions have placed a value on dying with dignity and the right of the person to direct how their dying process will occur.

A major tenet of the faith is that it is unethical to take a life. It is not the highest of all values to stay alive, but you cannot affirmatively take steps to kill someone. The church is strongly against euthanasia and suicide. But often if the patient and medical care providers permit nature to take its course without heroic intervention, the person's life may be taken by God.

This is a narrow path. Taking a life is inappropriate; on the other hand, using heroic medical measures to keep a body biologically functioning would not be appropriate either. Mere biological existence is not considered a value. It is not a sin to allow someone to die peacefully and with dignity. We see death as an evil to be transformed into a victory by faith in God. The difficulty is discussing these issues in abstraction; they must be addressed on a case-by-case basis. The Christian church's view of life-and-death issues should ideally be reflected in the living will and health-care proxy.

Roman Catholic teaching celebrates life as a gift of a loving God and respects each human life because each is created in the image and likeness of God. It is consistent with Church teaching that each person has a right to make his or her own health care decisions. Further, a person's family or trusted delegate may have to assume that responsibility for someone who has become incapable of making their decisions. Accordingly, it is morally acceptable to appoint a health care agent by executing a health care power of attorney, provided it conforms to the teachings and traditions of the Catholic faith.

While the health care power of attorney law allows us to designate someone to make health care decisions for us, we must bear in mind that life is a sacred trust over which we have been given stewardship. We have a duty to preserve it, while recognizing that we have no unlimited power over it. Therefore, the Catholic Church encourages us to keep the following considerations in mind if we decide to sign a health care power of attorney.

1. As Christians, we believe that our physical life is sacred but that our ultimate goal is everlasting life with God. We are called to accept death as a part of the human condition. Death need not be avoided at all costs.

2. Suffering is "a fact of human life, and has special significance for the Christian as an opportunity to share in Christ's redemptive suffering. Nevertheless there is nothing wrong in trying to relieve someone's suffering as long as this does not interfere with other moral and religious duties. For example, it is permissible in the case of terminal illness to use pain killers which carry the risk of shortening life, so long as the intent is to relieve pain effectively rather than to cause death."

3. Euthanasia is "an action or omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated." "[Euthanasia] is an attack on human life which no one has a right to make or request."

4. "Everyone has the duty to care for his or her own health and to seek necessary medical care from others, but this does not mean that all possible remedies must be used in all circumstances. One is not obliged to use 'extraordinary' means - that is, means which offer no reasonable hope of benefit or which involve excessive hardship.

5. No health care agent may be authorized to deny personal services which every patient can rightfully expect, such as appropriate food, water, bed rest, room temperature and hygiene.

6. The patient's condition, however, may affect the moral obligation of providing food and water when they are being administered artificially. Factors that must be weighed in making this judgment include: the patient's ability to assimilate the artificially provided nutrition and hydration, the imminence of death and the risks of the procedures for the patient. While medically-administered food and water pose unique questions, especially for patients who are permanently unconscious, decisions about these measures should be guided by a presumption in favor of their use. Food and water must never be withdrawn in order to cause death. They may be withdrawn if they offer no reasonable hope of maintaining life or if they pose excessive risks or burdens.

7. Life-sustaining treatment must be maintained for a pregnant patient if continued treatment may benefit her unborn child.

Such principles and guidelines from the Christian heritage may guide Catholics and others as they strive to make responsible health care decisions and execute health care proxies. They may also guide Catholic health care facilities and providers in deciding when to accept and when to refuse to honor an agent's decision.


Jewish tradition as understood by Conservative Judaism teaches that life is a blessing and a gift from God. Each human being is valued as created b'tselem elohim, in God's image. Whatever the level of our physical and mental abilities, whatever the extent of our dependence on others, each person has intrinsic dignity and value in God's eyes. Judaism values life and respects our bodies as the creation of God. We have the responsibility to care for ourselves and seek medical treatment needed for our recovery-we owe that to ourselves, to our loved ones, and to God.

In accordance with our tradition's respect for the life God has given us and its consequent bans on murder and suicide, Judaism rejects any form of active euthanasia ("mercy killing") or assisted suicide. Within these broad guidelines, decisions may be required about which treatment would best promote recovery and would offer the greatest benefit. Accordingly, each patient may face important choices concerning what mode of treatment he or she feels would be both beneficial and tolerable.

The breadth of the Conservative movement and its intellectual vitality have produced two differing positions put forward by Rabbis Avram Israel Reisner and Elliot N. Dorff, both approved by the Conservative movement's Committee on Jewish Law and Standards. Both positions agree on the value of life and the individual's responsibility to protect his or her life and seek healing. Both agree on a large area of autonomy in which a patient can make decisions about treatment when risk or uncertainty is involved. Both would allow terminally ill patients to rule out certain treatment options (such as those with significant side effects), to forgo mechanical life support, and to choose hospice care as a treatment option.

Nevertheless, important differences between the two positions may be found regarding both theoretical commitments and practical applications. Rabbi Reisner affirms the supreme value of protecting all life. Even the most difficult life and that of the shortest duration is yet God given, purposeful, and ours to nurture and protect. All nutrition, hydration, and medication should be provided whenever these are understood to be effective measures for sustaining life. Some medical interventions, however, do not sustain life so much as they prolong the dying process. These interventions are not required. The distinction may best be judged by our intent. We may choose to avoid treatments causing us fear or entailing risk or pain, in the interest of the remaining moments of life. We may not avoid treatment in an attempt to speed an escape into death.

Rabbi Dorff finds basis in Jewish law to grant greater latitude to the patient who wishes to reject life-sustaining measures. He sees a life under the siege of a terminal illness as an impaired life. In such a circumstance, a patient might be justified in deciding that a treatment that extends life without hope for cure would not benefit him or her, and may be forgone.

Both Rabbis Dorff and Reisner agree that advance directives should only be used to indicate preferences within the range allowed by Jewish law. They disagree as to what those acceptable ranges are. In completing a health care power of attorney and living will, it is recommended that you consult with your rabbi to discuss the values and norms of Jewish ethics and halakhah. You also may wish to talk with your physician to learn about the medical significance of your choices, in particular any decisions your physician feels are likely to be faced in light of your medical circumstances. You may find it helpful to discuss these concerns with family members.


In the end, the decision to execute a health care power of attorney and living will is a uniquely individual choice. Every person has their own set of principles by which they will live, and by which they will eventually pass on. When executing these documents, it is wise to examine how these documents assimilate into your worldview and religious beliefs. While the topic of death and dying is an uncomfortable one, you are well advised to discuss this decision with your family members, friends, and members and leaders of your religious community that you respect. Having done this, you can rest easy knowing that you have made a good decision with regard to your health care power of attorney and last will, and that your last wishes will be respected and undertaken.