Darren M. Henson, Ph.D., STL

Editor's Note: This is the first of a two-part article about "Four Ways to Approach Equity and the Opening to Justice" by Darren M. Henson, Ph.D., STL. The second part of the article will appear in the summer 2021 issue of HCEUSA. Dr. Henson served as system vice president of mission and discernment at Presence Health and subsequently at AMITA Health in Chicago. Most recently, he was director at the American Hospital Association's Institute for Diversity and Health Equity.

As the coronavirus pandemic ripped across the U.S. in spring 2020, the nation saw gut-wrenching inequities in infection and mortality rates. Initial outbreaks exposed inequities among black and brown populations in metropolitan areas, followed by inequities among the rural, immigrant, Hispanic, and Native American communities. As these jarring realities ripped across national headlines, and flooded ICUs and tent morgues, a different pandemic took hold. Black women and men were fatal victims of shootings in the early months of 2020: Ahmaud Arbery in Glynn County, GA; Breonna Taylor in Louisville, KY; and George Floyd in Minneapolis, MN. A second pandemic of systemic racism and violence collided with the coronavirus. Together, they impacted the health, well-being, and lives of historically marginalized populations. The deadly mixture motivated hospitals, health systems, and their partner organizations like the Catholic Health Association (CHA) and the American Hospital Association (AHA) to publicly respond.

This essay uses the statements by the two national associations to exemplify a range of moral analysis among contemporary ethical currents. Each of four traditional modes of moral reasoning will be reviewed following Brian O'Toole's assessment and application of them in his 1998 Health Progress article. I will show how these modes of moral reasoning appear in the CHA and AHA statements. This essay posits that all four modes have value in the current discourse of health equity strategies by health systems today. An analysis will reflect the contribution of each method. Then, the essay will posit that the current spotlight on equity provides an opportunity to accelerate and solidify an enduring shift in health care ethics grounded in the virtue of justice.

Four Approaches to Moral Decision Making
CHA's statement on May 29, 2020 calling for racial justice and reconciliation opens by affirming a central principle: "that each person is sacred and worthy of our deepest reverence."¹ The AHA's statement on June 1, 2020, opens with a contrasting tone: "The senseless killing of an unarmed black man in Minneapolis and the protests that are occurring in cities across the country have shaken our nation to its core."² The AHA statement is an example of the moral sentiment approach to moral reasoning. After these opening lines, both the CHA and AHA statements included elements of moral reasoning from the other two approaches, namely consequential and virtue. To better understand each of these four traditional approaches to moral argument, I turn to Brian O'Toole's application of these four methodologies to a health care setting.³ These distinct approaches to moral reasoning can provide helpful insight to the chorus of pleas for equity. Each sheds a unique light on the disproportionate inequities in health outcomes experienced by black, brown, indigenous, and other historically marginalized populations.

In the Principle Approach, decisions are made according to a principle, law, or regulation. A classic example is the ‘Golden Rule' to treat others as you would want to be treated. Today, this is often replaced by the ‘Platinum Rule' to treat others as they want to be treated. Many parts of health care operate by rules that delineate a process. Thus, the principle approach may be the most familiar. Laws and regulations spell out requirements to uphold our American ideal that all people are created equal. This echoes the Catholic principle that all human life enjoys an intrinsic and inviolable dignity. As O'Toole notes, "a principle is a general normative standard of conduct, holding that a particular decision or action is true or right or good for all people in all times and in all places… Everyone should sometimes use the principle approach to ethical decision making; without principles, decision makers have no parameters limiting what they will or will not do."⁴

The CHA statement, as noted above, opened with a principled argument. The AHA statement also included references to principles. It expressed how speaking out against injustice, an appeal to the principle of free speech, "is an essential part of our democracy." O'Toole explains how references to obligations or duty, as well as cautions signaled by the word "never," point toward a principle approach. The AHA statement echoes the CHA's principle of human dignity when the former envisions how all individuals ought to have the means to reach their highest potential for health.

Second, the Consequence Approach also appears frequently in health care settings. Here, decisions are made according to their likely outcome. This approach anticipates the results of action or inaction. Dashboards and scorecards, for example, from quality, finance and other departments guide decisions toward a desired endpoint. When outcomes fall short of stated goals, leaders make changes so that the next reports hopefully show improvements, or better consequences. O'Toole notices the consequential approach when people pose questions such as: "What effect will this have? What good will that bring about? And will this help in the long run? In the consequence approach, the decision maker weighs several possible results and arrives at the decision likely to produce the best result. The problem is that not everyone weighs and evaluates possible results in the same way."⁵ A further problem O'Toole omits is that the outcome becomes primary and the means to achieving it is secondary, if scrutinized at all. It is quite possible, and not uncommon, to gloss over principles for the sake of achieving the desired outcome. Such situations end up in the dangerous rationalization of "the ends justify the means." People who favor the principle or virtue approach may sparingly apply the consequential approach. When they do, they will likely ensure that the means to the desired ends honors fundamental values.

Unsurprisingly, the CHA statement sparingly references a consequential argument when it identifies an end to racism and violence as markers for the fruit of their work. Conversely, the statement by the nonsectarian AHA provides several examples of consequential argumentation for embracing and pursing equity strategies. It cites disproportionate effects on diverse communities. The message implies that the efforts of health systems ought to change outcomes clinically and economically.

The third is theMoral Sentiment Approach. O'Toole rightly observes how people experience strong and powerful feelings of approval or disapproval. As he points out, the difficulty in a direct correlation between one's feelings and moral decision making is precisely the subjective nature of those feelings. O'Toole writes, "No appeal to principles, weighing of consequences, or reliance on personal integrity is involved. For the person guided by moral sentiment, something either feels right or it does not feel right."⁶ The feeling that an action is right for one person or feels uncomfortable for another poses a difficulty. The subjective nature of the feeling makes it impossible to apply universally – the very quest of the principled approach. O'Toole suggests those using the moral sentiment approach may find themselves disadvantaged from others. Yet, his article predated philosopher Martha Nussbaum's compelling arguments on emotion as a centerpiece to moral and ethical discourse.⁷ She confronts philosophy's history of dismissing emotions and detaching them from intelligence and discernment, and she rebuts critiques that bifurcate emotion from one's integrity. Instead, Nussbaum builds an ethics methodology that takes seriously the power and influence of emotion amidst the complexity of human reasoning.

The CHA statement appeals to emotion immediately following the opening sentence. It references feeling "appalled by the recent killings of African Americans" and acknowledges "deep grief and anger." The AHA statement, as noted above, is striking in that it opens with an acknowledgement of emotion, signaled by descriptors of "senseless killing" and a nation shaken to its core. It continues by recognizing "deep-seated frustration and hurt," and anger. Both statements unambiguously arise from a place of emotional distress palpably present not just in individuals but within society.

The fourth and final approach is Virtue. O'Toole identifies it as making decisions according to one's responsibilities. The virtue approach bears similarities to the principle approach, in that both apply "moral oughts" to situations. The difference is that virtue is not applied universally, but rather to a particular person, role, group or organization. The virtue approach focuses on the character, or the virtue of a physician, nurse, or therapist for example. It probes ideals such as, what type of health care system or hospital do we want to be? O'Toole observes "'Integrity' and ‘walking the walk' are very important to people who use the virtue/character approach."⁸

The CHA statement appeals to virtue arguments when it suggests that one must not respond with violence, but rather be a people who commit to justice and peace. The end of CHA's statement posits that our nation ought to pursue the virtue of justice, specifically racial justice and reconciliation. It describes a desired characteristic. The statement does not posit these virtue generally the way a principle approach would. Rather, it is more specific to its member organizations and to this nation. This personalization of the desired characteristic is seen in the AHA statement. It specifies that "hospitals have an important role to play in the well-being of their communities." Even more, the AHA statement questions the very integrity and character of our nation when it suggests taking a moment to "hold up the mirror and honestly look at ourselves." This is precisely the virtue/character approach to moral argumentation in action.

Darren M. Henson, Ph.D., STL

ENDNOTES

1. The Catholic Health Association, "A Call for Racial Justice and Reconciliation," News Release, May 29, 2020. https://www.chausa.org/newsroom/news-releases/2020/05/29/a-call-for-racial-justice-and-reconciliation
2. The American Hospital Association, "Statement on George Floyd's Death and Unrest in America," News Release, June 1, 2020. https://www.aha.org/press-releases/2020-06-01-statement-george-floyds-death-and-unrest-america
3. O'Toole, Brian, "Four Ways People Approach Ethics," Health Progress, Vol. 75.6, Nov.-Dec. 1998, 38-43.
4. Ibid., 40.
5. Ibid., 41.
6. Ibid., 43.
7. Nussbaum, Martha, Upheavals of Thought: The Intelligence of Emotions, (New York: Cambridge University Press) 2001. Nussbaum expands upon this seminal work in several other books. Themes include shame and disgust in law and politics in Hiding from Humanity (2006) and then From Disgust to Humanity (2010). In more recent years her work takes up topics of anger, forgiveness, resentment, generosity, justice, fear, and love.
8. O'Toole, 41.

Reflection Questions

1. Which of these four ethical approaches do you use most often?
2. Which of these approaches do you believe your colleagues use most often?
3. How does knowing these approaches help you to discuss ethical matters with your team? With your patients or residents?