Tobias Winright, M.Div., Ph.D.
Associate Editor, HCEUSA
Mäder Endowed Associate Professor
Gnaegi Center for Health Care Ethics
St. Louis, Missouri
[email protected]

Three decades ago, before I became a moral theologian, I worked my way through college as a correctional officer at a maximum security jail. One of the few duties that I actually enjoyed was guarding inmates who had been admitted into a nearby hospital due to injury or serious illness. Because I usually worked the night shift so I could attend classes during the daytime, I was regularly assigned to the inmate's hospital room, where I would sit for eight dark hours. I also talked with the inmate when he was awake, got to know the nurses and other staff, and sometimes did some reading for school. Of course, I had to be alert, too. I was in uniform — badge and all — and I was armed with a .38 caliber revolver. After all, some inmates were violent felons who posed a serious risk in the hospital. Other inmates had accomplices who might try to help them escape in this less secure setting. Also, a few inmates had enemies who might try to harm them there. It was up to me to protect not only the staff but also the inmate.

I was reminded of that period from my life when I read a New York Times article, "When the Hospital Fires the Bullet," which explores a debate currently underway about whether armed hospital guards increase safety or instead pose more danger for patients.¹ The article begins with an incident that occurred at the St. Joseph Medical Center in Houston, Texas. A 26-year-old student, Alan Pean, had bumped into several vehicles while parking at the hospital for treatment of possible bipolar disorder. With minor injuries, he was kept overnight for observation, although no psychiatrist saw him. After he sang and danced naked in his room, and now and then into the hall, he refused to let two nurses fasten a gown on him. One of the nurses summoned security, and two off-duty Houston police officers, moonlighting as hospital security guards, entered the room. According to the article, there was an altercation, and the officers "shocked Mr. Pean with a Taser, fired a bullet into his chest, then handcuffed him." Pean, "who survived the wound just millimeters from his heart," later reflected, "I thought of the hospital as a beacon, a safe haven .... I can't quite believe that I ended up shot."

His experience is not as uncommon as we might assume. The article highlights several other similar shootings by hospital security officers of patients with mental health problems in the U.S. during the past year. And this coincides with a current trend wherein hospitals in this country are increasingly arming guards with firearms and Tasers. For Catholic health care institutions, which trace their roots to the Prince of Peace, the use of force — especially deadly force — should be carefully addressed in light of Catholic teaching on legitimate defense.

Of course, as the article notes, a hospital can be a very dangerous place — and not only for patients but also for the health care professionals who are serving them. I worry about the safety of my spouse, who is a nurse on the neuro floor in a SSM hospital and has encountered some perilous patients under her care. According to the International Association for Healthcare Security and Safety, between 2012 and 2014, health care institutions reported a 40 percent increase in violent crime, with more than 10,000 incidents directed at employees.² From patients who are under the influence of illegal drugs to those who are angry about their treatment by a doctor or a nurse, there are a number of "motivations" for threatening behavior in a hospital.

In response, 52 percent of medical centers reported in 2014 that their security personnel are armed with handguns, and 47 percent reported that theirs carry Tasers — numbers that are more than double from only three years earlier.³ Many guards have law enforcement or military experience.

Yet, a number of hospitals are reluctant to arm their security guards. As one hospital security administrator put it, "Tasers and guns send a bad message in a health care facility."⁴ After all, hospitals, as Pean suggested, should be a sanctuary where caring and healing are primary for patients. This is especially so for Catholic health care institutions, such as SSM Health, which emphasizes in its mission "the sacredness and dignity of each person" and "the healing presence of God" in its health care services.⁵

To be sure, there is definitely a need for security in health care settings today. However, such security should always be guided by the overarching purpose of health care rather than the now-dominant "military" model of law enforcement in the U.S. that views the gun central to its identity, an approach that is "us-versus-them" and more likely to resort to the use of lethal force.⁶ Indeed, just as health care professionals should always treat the patient as person, so too should health care security strive to deal with the patient-who-is-a-perpetrator as a person.⁷ For Catholics and their health care institutions, the personhood of anyone, including those who pose a threat, intentionally or not, must be respected. One never loses one's dignity, not even a murderer, as image of God.⁸ This is the fundamental basis for Catholic teaching on "legitimate defense" or, as more recently labeled, the "responsibility to protect."⁹

This ethic of protecting others goes hand in hand with an ethic of service. These are, I think, fused in the Catholic virtue of solidarity, which Pope John Paul II described as "a firm and persevering determination to commit oneself to the common good; that is to say to the good of all and of each individual, because we are all really responsible for all."¹⁰ We are, contrary to Cain's attempt to say otherwise, our "brother's keeper" — indeed, Pope Francis adds that we are our sister's and our mother's — that is the earth' — keeper, too. We "have a shared responsibility for others and the world."¹¹ Ours is a "vocation to be protectors of God's handiwork," which includes people and planet. But the means of protection should be congruent with the God-given sanctity of the other, human or otherwise.

Of course, many Catholics believe that only nonviolent methods are consistent with their faith, and they are affirmed as a "legitimate witness to the gravity of the physical and moral risks of recourse to violence, with all its destruction and death" — as long as these pacifists are not passive, but are making use of nonviolent means for protecting the lives and human rights of others.¹² Otherwise, non-pacifist Catholics may use force — as military personnel, police or correctional officers, or even as private citizens in cases of self-defense or defense of others when no police are readily available — but such force, especially lethal force, requires "rigorous consideration."¹³ While the Catechism makes this point in connection with military force, I think it applies to any uses of armed force. And it means that there are strict guidelines governing when and how armed force is used.

In view of this, Catholic hospitals should do all that they can to make sure every feasible means for providing security without resorting to firearms have been explored and exhausted. In some other countries, for instance, firearms and lethal force are rare with the police, who subscribe to more of a community-based model of law enforcement, one that a prominent criminal justice ethicist, John Kleinig, refers to as the "social peacekeeper" model.¹⁴ In this approach to protecting others, there continues to be concern about the person who poses the threat — that person is not an "enemy" but a fellow human being and citizen.

Security personnel should therefore receive sufficient training to listen, to see what is really happening, to be able to talk persuasively with the threatening person, to employ de-escalation techniques and the like, if possible, before more coercive means such as hand-holds or pepper spray are tried. In law enforcement, this is often referred to as a use-of-force continuum, wherein the proportionate amount of force is to be determined and applied given the circumstances. Perhaps more training could be done with regard to martial arts techniques, especially those of the "softer" martial arts such as aikido which channel a threat's energy rather than strike against him or her.¹⁵ Thus, lethal force is truly a last resort if ever used at all. As Kleinig states, "there is a presumption against the use of force" and, especially, deadly force.¹⁶ And, to be honest, I am not convinced at this time that hospital security personnel should normally carry guns.

But in the rare case that deadly force may be necessary, even then it is to be regretted. It should pass what Catholic bioethicist Charles Camosy calls, in connection with another issue, the "pissed test" — would the security officer and hospital staff be upset if the patient/perpetrator survived the force used against him or her?¹⁷ This echoes how Saint Thomas Aquinas used what we now call the principle of double effect to justify and govern the use of lethal force in self-defense.¹⁸ He taught that one's intent is not to kill the attacker, even though the defender foresees that her defensive action will likely kill him. The intent is to protect one's life, and the likely death of the attacker is a secondary effect, with the means used being the proportionate way to do so. One of my teachers, Richard A. McCormick, S.J., linked this "theory of self-defense" with what he called "a theory of tolerable indirect killing."¹⁹ This may sound like academic hairsplitting, but this is taught even to some police and, personally, it has meant a lot to me.

When I first became an ethics professor some years ago, on the side I taught ethics at a nearby police academy. Given my background, the police department there also invited me to serve as a reserve police officer in my spare time. During the use of force training, cadets were taught that their intent should not be to kill, but to incapacitate the threat. Although they must shoot "center mass," which seems like they "shoot to kill," it is done in this framing of it in order to increase the likelihood of stopping the suspect and to decrease the likelihood of harming innocent bystanders (i.e., avoiding "collateral damage," which is why, contrary to TV and the movies, police do not fire warning shots in populated areas or aim to shoot a person's hand or leg). For me, I hoped I would never have to shoot someone, but if I had to do so, I truly would have wished otherwise for the sake of the perpetrator.

Using force, any level of force, does something not only to the person it is used against, but also to the person using it. For their sake, too, security personnel in Catholic health care institutions should have education and training consistent with our tradition's teachings regarding serving and protecting our neighbor, including the neighbor who threatens another neighbor.

1. Elisabeth Rosenthal, "When the Hospital Fires the Bullet," New York Times, February 12, 2016, http://www.nytimes.com/2016/02/14/us/hospital-guns-mental-health.html.
2. See the International Association for Healthcare Security and Safety website: https://iahss.site-ym.com/. For the report, see http://ihssf.org/PDF/2015crimesurvey.pdf.
3. See http://ihssf.org/PDF/weaponsuseamonghosptialsecuritypersonnel2014.pdf.
4. Quoted in Rosenthal, "When the Hospital Fires the Bullet."
5. Http://www.ssmhealth.com/system/about-ssm/mission-values/.
6. I have written on this in numerous places, including in my Ph.D. dissertation, "The Challenge of Policing: An Analysis in Christian Social Ethics" (University of Notre Dame, 2002).
7. The title of one of my first peer-reviewed publications when I was a graduate student was inspired by Paul Ramsey's classic The Patient as Person: Explorations in Medical Ethics (New Haven and London: Yale University Press, 1970): Tobias Winright, "The Perpetrator as Person: Theological Reflections on the Just War Tradition and the Use of Force by Police," Criminal Justice Ethics 14, no. 2 (Summer/Fall 1995): 37-56.
8. Pope John Paul II, Evangelium Vitae ("The Gospel of Life"), 9.
9. Pope Benedict XVI, Caritas in Veritate ("Charity in Truth"), 67.
10. Pope John Paul II, Sollicitudo Rei Socialis ("On Social Concern"), 38, http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_30121987_sollicitudo-rei-socialis.html.
11. Pope Francis, Laudato Si' ("On Care for Our Common Home"), 229, http://w2.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si.html.
12. Catechism of the Catholic Church, 2306.
13. Ibid., 2309.
14. John Kleinig, The Ethics of Policing (New York: Cambridge University Press, 1996), 12. See, for example, Al Baker, "U.S. Police Leaders, Visiting Scotland, Get Lessons on Avoiding Deadly Force," New York Times, December 11, 2015, http://www.nytimes.com/2015/12/12/nyregion/us-police-leaders-visiting-scotland-get-lessons-on-avoiding-deadly-force.html?_r=0.
15. See, for example, Rory Miller, Meditations on Violence: A Comparison of Martial Arts Training and Real World Violence (Wolfeboro, NH: YMAA Publication Center, 2008).
16. Kleinig, The Ethics of Policing, 101, 107.
17. Charles C. Camosy, Beyond the Abortion Wars: A Way Forward for a New Generation (Grand Rapids and Cambridge: William B. Eerdmans Publishing Company, 2015), 64.
18. Thomas Aquinas, Summa Theologiae, II-II, q. 64, a. 7.
19. Richard A. McCormick, S.J., "Reflections on the Literature," in Readings in Moral Theology No. 1: Moral Norms and Catholic Tradition, eds. Charles E. Curran and Richard A. McCormick, S.J. (New York: Paulist Press, 1979), 308.

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