Editor's Note: This is the second of a two-part article about "Four Ways to Approach Equity and the Opening to Justice" by Darren M. Henson, Ph.D., STL. The first part of the article appeared in the spring 2021 issue of HCEUSA. The author describes the principle, consequence, moral sentiment and virtue approaches to moral reasoning, and examines how these approaches are reflected in the Catholic Health Association's statement "A Call for Racial Justice and Reconciliation", and the American Hospital Association's "Statement on George Floyd's Death and Unrest in America.

Analysis
Prior to the coronavirus pandemic, many leaders in health systems and professionals leading equity, diversity and inclusion (EDI) strategies grappled with justifications to executive leadership and governing bodies about making public and strategic commitments to health equity. These appeals commonly involved arguments grounded in outcomes — or a consequential approach. Inevitably, financial and related analysis of return-on-investment (ROI) for monies and employees' time (FTEs) committed to EDI tipped the scales in the minds of decision makers. Prior to the pandemic, few if any made equity commitments grounded in either a principle or virtue approach, despite a prevailing belief among EDI leaders that equity commitments are the right thing to do.

At the time, I aver that no health system had equity commitments founded in moral indignation at the disproportionately high prevalence of deleterious healthcare outcomes among black, brown, indigenous, and other historically marginalized populations. The moral sentiment approach was nowhere on the table.

Yet, in reviewing the CHA and AHA statements, it seems that all four approaches have coalesced to catapult equity onto strategic initiatives. Each of the four approaches provides a valuable contribution to the complexity of the EDI discourse.

Principle Approach: The principle approach provides strong arguments for pursuing EDI strategies, especially for Catholic and other faith-based health care organizations. CHA's statement provides a broad affirmation for the sanctity of human life. Additional principles for advancing EDI strategies include the fundamental human right to health care and provider obligations to avoid harm and pursue good. Moreover, in addition to access, all people in the country, in principle, ought to receive high-quality care regardless of race, ethnicity, gender, socioeconomic status, or ability to pay. In a related vein is the principle that all persons have a fundamental right
to work.

Consequence Approach: The consequence approach will continue to have an important role in advancing EDI strategies. Just as the quality, safety, performance improvement and human resources departments have developed scorecards and metrics for executives and governing boards to monitor strategic progress, these areas are now called upon to integrate relevant EDI data. These data revealed gross inequities in the nation's health care system. Coupled with other social and economic factors, the awareness led to emotional outcries for substantive, sustained, and serious changes to systemic inequalities.

Moral Sentiment Approach: Profound lamentations over inequities has now placed moral sentiment on the table as a redeemed and legitimate mode of moral reasoning and rationale for equity strategies. This is not to turn a blind eye to its shortcomings any more than one cannot dismiss the limitations of the other modes of moral approaches which O'Toole aptly addressed. This is to say that the gut-wrenching dis-ease at seeing years of data reflect disparities for black, brown, indigenous, rural, veteran, LGBT communities, and persons with disabilities, cannot be set aside as they have been historically deprioritized. Just as philosophy historically eschewed emotion, business and organizational leaders have generally followed suit. In health care, leaders tend to relegate strong emotional discourse to be managed by spiritual care, behavioral health, or worse, compliance (also known as the place for complaints). Events in 2020 have created an opening that recognizes the significance of emotion. It is not uncommon to hear people in meetings express indignation, sadness, or despair at the sight of inequities in health, economic distress by disadvantaged populations, and social disinvestment. It seems that 2020 could be a turning point in terms of the role of moral sentiment in ethical decision-making. Executives moved by the outcries of injustice had little to no interest in ROI analysis (as consequentialist approach, and often favored by business strategists). They were asking for resources on where and how to begin EDI strategies. Something had to be done. Echoing the words of the psalmist, the cries of the poor were heard (Ps 34).

Virtue Approach: Lastly, the virtue approach poses an important question: What type of health care organization do we want to be? How do we want to be known for responding to the plight of these pandemics? Many more voices are rising and asking, "Are you who you say you are?" For Catholic health care organizations with public commitments to human dignity, the common good, and solidarity with the marginalized, translating these Catholic sensibilities into the public narrative on equity is increasingly critical. While the public narrative has currently landed on the term, equity, an apt equivalent in the theological tradition is justice. With a groundswell of support in health care and across society for equitable approaches and dismantling structures of injustice, Catholic health care leaders and ethics professionals have an opportunity to influence the burgeoning swell of equity with the theological virtue
of justice.

Embedding an Enduring Hermeneutic: The Virtue of Justice
The pandemic provided health care ethics professionals with the opportunity to solidify justice as an enduring hermeneutic. Great strides have been made over the past century to shift Catholic health care ethics methodology from the manualist tradition to a virtue approach.¹ While the first edition of the popular Principles of Biomedical Ethics by Beauchamp and Childress in 1979 enumerated justice among the four principles, it languished in the backwaters of scholarly discourse and had not meaningfully found its way into operations.² It failed in substantive ways to penetrate into strategy enacted by medical staffs, C-suites and board rooms.

In 1990, theologian Jean Porter gifted the field with her breakthrough virtue ethics.³ She recovered a Thomistic lens, showing its relevance for contemporary ethics. Catholic health care ethics appeared to track in a similar direction when the 1994 expansion of the ERDs included a broader consideration of social justice.⁴ Yet, subsequent revisions in 2001, 2009 and 2018 reflect a field clinging to principles pertaining to clinical and transactional processes.

Now is the time for health care ethicists and theologians in Catholic health ministries to enliven the equity discourse with the gift of virtue ethics and a theological grounding in justice. The 2020 experience of the coronavirus pandemic and the swell of discourse for equity from bords of directors to executive suites, clinical leaders, and community partners, provide a unique opportunity to infuse justice into the structures of health care delivery and related structures. Ministries will benefit from revisiting the contributions and applications of virtue ethics to the changing landscape of health care in light of equity, diversity and inclusion.

Virtue ethics holds together both a personal- and communal-based view of ethics. James Keenan observes how virtues are proper character traits in individuals or communities to "promote right moral action and the right moral goals or ends of the good life."⁵ Rules and actionable norms follow once the character or virtue has been established. This virtue ethic aptly fits with the contemporary movements afoot. Keenan notes that virtue ethics has served well in cross-cultural dialogue. Virtue ethics, he summarizes, "is rooted in the priority of being over action and argues [for] the cultivation of normative dispositions and attendant practices."⁶ The appeal to virtue works well across diverse populations because, he argues, every culture has a sense of justice and treating others fairly, at least in some analogous way.

Similarly, Thomas Aquinas' articulation of justice as the ordering of operations to bring about what is good and right can support the work of equity within ministries. For Aquinas, the virtue of justice provides what is due between equals.⁷ It also directs the actions of the other virtues toward the common good, and directs people to relate to one another.⁸ This, coupled with the virtue of prudence, or practical wisdom, are the theological underpinnings of equity strategies for Catholic health ministries. The inequities exposed by the pandemic reveal a dis-ordering of health resources and breeches in human relationships. Engaging the wave of discourse on equity, ethics leaders can leverage this to establish new just structures to replace the unjust ones that caused great harm. As O'Toole and Porter described, the virtues pose questions about character. Thus, in light of the past two years and the social and political discourse, questions for health care leaders, clinicians, and governing bodies include: What kind of leaders, and what kind of organization do we want to be? How do we realize our healing ministry amid hurting people and a hurting society? The most effective strategies in Catholic health care ministries will enlist partnerships with mission, formation and sponsorship. Together, ministry leaders can bring about the changes needed in thinking and strategy so that justice becomes a sustained commitment, visible in actions, policy and outcomes for generations to come.

Darren M. Henson, Ph.D., STL
Assistant Vice President, Formation Innovation and Design
Providence St. Joseph Health
Renton, Washington

ENDNOTES

1. Keenan, James F., A history of Catholic Moral Theology in the Twentieth Century: From Confessing Sins to Liberating Consciences (London: Continuum) 2010.
2. Beauchamp, Tom L., & Childress, James F. Principles of Biomedical Ethics. (Oxford: Oxford University Press) 1979.
3. Porter, Jean. The Recovery of Virtue: The Relevance of Aquinas for Christian Ethics. (Louisville, KY: Westminster/John Knox Press), 1990.
4. O'Rourke, Kevin D; Kopfensteiner, Thomas; Hamel, Ron. Health Progress; Nov/Dec 2001, 18-21.
5. Keenan, 76.
6. Ibid., 217.
7. Summa Theologiae, I-II, Q. 61, a.3.
8. Summa Theologiae, II-II, Q.58, art. 6, 7.

Reflection Questions

1. Which ethical approach do you see operationalized in your organization?
2. Which approach do you identify most in your decision making?
3. During the pandemic, how have the different approaches appeared in the cultural discussion?