By Josh Hyatt DHSc, MHL, MBE(c), DFASHRM, CPHRM, CPPS, HEC-C
Take a group of five people and give them an orange to split in whatever way they believe is fair. We know there are generally 8 slices in an orange. So how do you fairly divide 8 slices between 5 people? Do you cast out members of your team? Do you pull out the calculator and start dividing into fractions? Do some people get more slices because of seniority or rank? Do you develop a calculus to determine who gets how many slices? Now image that orange is a ventilator or Remdesivir or the COVID-19 vaccine.
The “just” orange thought experiment is a deceptively complex, yet effect, approach to discussing the elemental nuances of equality and justice in an ethical frame. When I first tried this experiment, my initial approach was to distribute and employing simple fairness without considering the myriad of factors of justice. This seemed the most logical and utilitarian approach, appropriate for a risk manager. Fortunately, I was working with a diverse team that began digging deeper into how to maximize the social benefit of this orange. This team consisted of students in a Masters of Bioethics program consisting of a Baby Boomer RN, a Generation Z’er heading off to medical school the next semester, a millennial social worker, a Generation X RN, and I. During this experiment, I became self-aware of personal biases and beliefs about equality and justice that called my mind home. As I reflected on this exercise, I began to ask critical questions about situations I thought I truly appreciated, and I began to think differently about them. This is my journey.
The team started the exercise very indifferent to the fate of this orange. There were initial academic discussions of the application of Rawls’ view of distributive justice, what principles would we apply if the original moral position was equality (the veil of ignorance), but then we delved deeper to reconcile the orange’s fate. We explored other components such as who is hungry, who needs or even wants it, and who did not like oranges and did not care either way. We determined that we should establish criteria based on need. Who needed it more? Did someone skip lunch and they were really hungry, did someone have scurvy? We discovered no one needed it to maintain or improve their health. Then we asked who liked oranges and wanted it more. One person enjoyed orange juice but not eating the meat of an orange, one person hated oranges and had no interest in it, and three people were indifferent to oranges, they could take them or leave them. The next criteria was utility. Who could use the orange for something other than eating? One person enjoyed gardening and would like to use seeds and pulp to plant and two people enjoyed cooking and had uses for the rind. We concluded that the most just approach was to break it out into its components: the “meat” juiced, the pulp and seeds for planting, the rind for cooking and fragrance. We believed that this was the most just approach to split out this orange. Other teams had different approaches. One team gave their entire orange to a person at another table who had missed lunch and was hungry. Just in case you were wondering, the person who did not like oranges agreed to portions of the food created by the two cooks using the rind.
I initially approached the experiment from more of an egalitarian approach, equal means equal. I am not sure why that was my default position, but it made me aware of two important issues: (1) an internal sense of privilege and (2) fairness in decision-making. As a sexual minority living in a world of heteronormativity, I advocate for fairness and equality. The LGBT community pushes for equality in the form equal access and fair treatment, such as the right to marriage. However, the movement does not always consider the impacts of trauma, individually or collectively, or vulnerable populations (youth, elderly, mentally ill, etc.) and is often laser focused on equal meaning equal. We have not paid enough attention to the health care and economic inequalities that exist within our community, such as the extreme violence that transwomen of color face in this country and all over the world. This may be why my first inclination was equal means equal. This thought experiment really brought to light in me a sense of privilege that I had never contemplated before and made me question if I am asking the right questions or fighting for the most justice and important issues.
The second moral avenue that the exercise led me down was fairness in decision-making. How the orange is divided-up is as important as everybody having an equal input on in this decision. Justice involves fairness in decision-making, as well as thoughtful consideration of the circumstance and context. Inequity in decision-making leads to fairness being relative to the majority’s interpretation.
As healthcare risk managers, should we consider how we make important decisions and utilize some common virtues, such temperance, judgment, and compassion? If so, and I would advocate for yes, how would this look? Utilizing ethical virtues for decision-making allows risk managers to incorporate meaningful and engaged dialogue into highly complex, values-based situations; thereby reducing liability through developing strong relationships with patients and demonstrating a meaningful attempt at collaboration.
Ethical and just decision-making models for risk management can be a professional paradigm shift. It involves delving into complex questions surrounding moral issues, which is time consuming and can be emotionally exhausting. But engagement with a bioethicist is helpful during these times. Take, for example, evaluating the role that racism can play in decision-making. When reviewing policies do we consider what vulnerable populations will be impacted by these choices? When we conduct a root cause analysis, do we question the role health inequity of the patient how vulnerable population status impact on the outcome? Evaluating ethical questions extends far beyond the Beauchamp and Childress principalism model of autonomy, beneficence, non-maleficence, and justice. It looks at values whether or not we are living up to our duty as a professional and as a human being.
As with the orange, consider your own personal inclinations and whether you can apply a more just lens. Can this “orange” raise someone up or impact their well-being? Just because I think I am entitled to something, like a quarter of an orange I do not really want, does not mean that I have to take it; rather, I should first be aware of circumstances beyond my control and knowledge and help to elevate those in need first. The team got there and devised one of many elegant solutions founded on context and moral consideration.
The impacts and parallels on social justice, as referenced in this experiment, are fundamental in the practice of bioethics, should risk management be the same? In my experience, justice is not a principle that is openly discussed when faced with a complex situation. The approaches often default to autonomy and operational considerations, noted exceptions include organ transplantation and triaging of patients in the emergency room. But even these situations are fraught with questions of justice, which explain the importance of regulations to enforce fairness like EMTALA and UNOS regulations. But like with the orange, implementing fairness while considering improving the well-being and capabilities of the individual should be of paramount concern.
As noted earlier, this thought experiment honed the idea of how social justice can be applied with multiple approaches and highlighted for me that there are inherent biases in how I think. Awareness of the biases will help me in approaching the question of justice, whether clinically or administratively, with a clearer focus on capabilities and well-being.
The “just” orange experiment is a learning experience that was derived from material developed by the excellent faculty of Harvard Medical School and brought to life in the Center for Bioethics’ Foundations Course of the Masters of Bioethics program. The faculty engaged the class with this exceptional thought experiment and helped to contextualize the complex nature of the questions surrounding justice. My peers and classmates helped me to see the world and nature of justice in a new way, for which I am highly grateful. I owe a huge debt of gratitude to both the Harvard faculty and my peers for this experience and the opportunity to share it with you.
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About the Author
Dr. Josh Hyatt is a healthcare risk manager, bioethicist, lecturer, and professor. He has been in healthcare and risk management for more than 25 years and has achieved the designation of certified professional in healthcare risk management (CPHRM). His academic interests include the relationships between health law and bioethics, risk management, and ethical and legal considerations in LGBT healthcare. Dr. Hyatt works at Coverys as a Manager in the Risk Management Department and as an adjunct and visiting professor with several universities, teaching on topics such as health law, bioethics, health leadership, health policy and analysis, health informatics, and strategic management. He has presented and published on topics of LGBT healthcare disparities and workplace issues, social media in healthcare, and bioethics.
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