It is customary at the end of the year for editors of journals and magazines to publish “the best and the worst of the year” or top 10 lists of events or articles of the year, or even the “most important” discoveries or people of the year. Some publications survey their readers; others invite experts to opine on the selection. What is nearly always missing from these newsworthy roundups are the criteria for determining what meets the mark. But this is a crucial piece of missing information, and without it, many of these rankings have little worth.
Words like important, best, and worst are not factual claims but value judgments. For a value judgment to have validity, there must be a substantive basis for making the determination. Put less ponderously, readers need to understand what makes a person, action, or decision valuable or important.
Being a medical ethicist, I tend to think in terms of good and bad, right and wrong—hence, the title of this editorial. But even these essential terms of evaluation in our language must have a frame of reference or at least a description to have meaning when applied, especially if the terms are to be compared. For moral philosophy, the parent of medical ethics, these frames or bases for making judgments about the rightness or wrongness of conduct are often found in ethical theories.
Three of the most recognized and significant ethical theories are consequentialist, deontology, and virtue ethics. It is important to understand these theories to grasp how I decided on my list of the right and wrong of 2017. However due to space limitations, I will only provide a nutshell summary of these theories. Readers interested in cracking the nut wider may want to consult the references on ethical theory at the end of the essay.1
Consequentialist theories—utilitarianism being the most well known in health care—argue that what makes an action right or good is what brings about the most happiness for the most people. What is determinative of rightness is the outcome.
In direct opposition to consequentialism is deontology. The consequences do not matter at all to the deontologist, right and good have to do with intent, and the only truly right intent is acting for the sake of duty alone.
Virtue ethics finds the core of right and good in the character of the virtuous person. Right actions and good intent each spring from the root of an individual of moral excellence.2
Establishing these ethical theories as the criteria for judgment, I now turn to my choice for the right and the good, the “best” of federal practice in 2017. (Next month my editorial will focus on the bad or the “worst” of 2017 federal health care.) Upfront, I acknowledge these choices are subjective, but I justify them by using the theories set forth. We welcome readers to send us their selections.
While journalists and politicians have widely criticized the White House response (or lack thereof) to the destructive storms that occurred during this hurricane season, little attention has been paid to the response of the 3 federal health care agencies, which was quick, dedicated, and caring. And it is this response that makes it my best of 2017. The vulnerability of areas from Houston to Puerto Rico, some of which still lack the basic services of civilization, are struggling with loss of life and hope, powerless to protect what is left in the wake of the storms, only amplifies the desperate need for the human and material resources that the DoD, VA, and PHS have committed.
Testifying before the Senate Homeland Security and Governmental Affairs Committee, Robert G. Salesses, deputy assistant secretary of defense, chronicled the outpouring of DoD aid. “Military units cleared critical roadways, transported life-sustaining commodities, provided fuel distribution, conducted assessments of civilian hospitals, and provided medical support to include evacuating patients back to the continental United States.”3
The VA Disaster Emergency Medical Personnel system also went into high gear. In my facility and in many others, there were so many volunteers that facility leaders had to balance their clinical needs with the selfless desire to help the veterans and fellow federal practitioners who were in harm’s way.
According to Susan Wentzell, VISN 8 deputy communication manager and content manager:
“Despite the destruction caused by these monster storms, Veterans continued to receive vital health care and other support, thanks to the selfless efforts of thousands of dedicated VA employees who rallied together to provide around-the-clock care for patients sheltered-in-place in the eight large, hurricane-constructed VA hospitals and to get services back up and running in dozens of outpatient clinics impacted in the Southeast corridor of the U.S. and the Caribbean.”4
When Hurricane Maria ravaged Puerto Rico, medical personnel from the VA and the PHS Commissioned Corps staffed Federal Medical Stations in Manati and Bayamon, Puerto Rico, which provided cared for up to 250 people at a time. The officers of the Commissioned Corps also helped support the civilian health care infrastructure.
From a utilitarian perspective, the benefit of these relief efforts is obvious. They were literally life-saving and health preserving for the thousands who were injured in the wreckage of wind and rain, ill from the collapse of public services, as well as those psychologically traumatized. And had these men and women of the VA, PHS, and DoD not come to the aid of the victims of these unprecedented national disasters, the toll of human suffering and bereavement would have been far worse.
Deontologically, each of these government employees did their duty; many volunteered, and even those who were ordered to assist did so with a compassion and dedication that went far beyond doing a job. None of the historic drives of humankind to place themselves in harm’s way—power, money, or fame—motivated those who answered the call; only a duty to serve and an intention to help.
Each person who left the security of home and the comfort of friends and family displayed the highest qualities of virtue ethics: altruism, professionalism, empathy, and integrity among other virtues.
In preparing for this column, I read stories of health care practitioners and nonclinical staff who not only reached out, but also reached beyond any expectation, clearly demonstrating outstanding professionalism and humanism.