Justice itself is a very elusive ethical principle, let alone defining justice during a pandemic that has been extremely difficult to navigate for a multitude of reasons. The COVID-19 pandemic is still testing our very limits of what it means to be “just” clinicians, “just” individuals, and “just” members of society. We often find ourselves trying to balance what is just with what is right clinically for our patients while also respecting the staff at the facilities where we work. We must set aside our own cultural, religious, and individual beliefs of what justice is and look at each situation in its own context. This can be a very challenging thing to do given the current climate in our society and in the health care system.
As we now move into the next phase of the pandemic, a review of the ethical principle of justice is warranted. Clinically, we understand the COVID-19 illness and have treatments (i.e., vaccines) that are very effective. We are now in the middle of the tremendous undertaking of attempting to vaccinate our entire health care workforce. In this next phase, we must learn to deal with the fallout of such an unprecedented pandemic. Topics such as vaccine mandates, re-examining how we care for frail and older adults, and coming to terms with how post-acute care frontline workers are compensated all have an underpinning of justice that needs to be wrestled with.
Societal Versus Individual Justice
Justice is the concept of fairness, either as it relates to a society and its institutions (societal justice) or to an individual person (individual justice). Fairness in health care, politics, education, and finances would all fall under societal justice, which relates to the fair and equal distribution of societal rights and opportunities. Just decisions may not necessarily be perceived as right, wrong, or the easy decision by all individuals, but they work to benefit (or harm) a society.
Individual justice includes how an individual then practices fairness within society and how that flows into his or her daily life. Individual justice should not be confused with individual rights, which is a distinct principle relating to an individual’s freedom within a society. Rather, individual justice sees the individual as an agent who acts within a particular society.
In other words, if societal justice is what a larger entity (society, facility, or organization) abides by, individual justice is the fairness of one person’s decision on a society, facility, or organization. For example, in the nursing home context, an individual staff member’s decision to lie about a bad outcome for a nursing home resident, even if staff member felt the lie was just, may have an adverse impact on the resident, the family, or the entire facility.
These two subtypes of justice can either work synergistically or create strife, which can in turn unravel how an institution functions. Unfortunately, many times during this horrible pandemic, these two types of justice have worked against one another, particularly in the United States. Large health systems, state and federal political bodies, and influential leaders have tried to make many decisions in the name of justice. However, I fear we have lost sight of what is truly just; each individual’s idea of justice is driving decisions rather than a sense of societal justice as defined by American society at large, both historically and through ongoing consensus.
The same can be said for institutions such as AMDA – The Society for Post-Acute and Long-Term Care Medicine, and also individual post-acute care facilities. As previously noted, sometimes the justice of a particular decision by an individual can impact or even override the justice of the larger facility. This can greatly impact the fairness that occurs within the facility and for the individuals within it. One could argue that this conflict is permissible, but the result may be a disruption to the facilities that were built to care for the patients we serve.
Finding an appropriate balance between individual justice and societal justice is necessary for these institutions to function. If the balance tips in one direction, the result could be a facility or organization that will not reach its full potential.
Justice Within Institutions
Justice is a very nuanced topic, and it has been rigorously discussed among ethicists for hundreds of years (David Miller, “Justice,” in The Stanford Encyclopedia of Philosophy,
Aug. 6, 2021; https://plato.stanford.edu/entries/justice/
). The complicating factor is how to determine whether an institution or individual is acting from a place of justice or one of pure self-interest. This is a very difficult distinction, but it needs to be recognized.
Modern ethicist John Rawls examines this concept in his work “Justice as Fairness” (Philos Rev 1958;67:164–194). He describes justice as “the first virtue of social institutions,” which would include post-acute care facilities. Rawls implies that if justice is not deeply rooted within the facilities and organizations in which we work, then they are doomed to fail. Justice needs to occur across all levels of a particular institution as well for it to function at its highest level.
The individual employee plays an important role in the greater institution being just and functioning properly. Therefore, we as individuals in a particular institution must speak up if something is unjust and not fair for the greater good, which in this setting directly impacts the patients we care for and at times the staff who care for them. As individuals we should not follow an unjust decision when we recognize that the institution is likely to suffer, regardless of the initial emotions associated with such a stance.
It follows that if a particular subset of individuals in an institution is being treated unjustly then the institution is at greater risk of failing. For example, with the long-standing topic of compensation for frontline workers in post-acute care, what is a fair wage for our frontline caregivers? What were these decisions based on? Are there unjust racial or cultural biases occurring in compensation decisions? If so, until the balance of justice is resolved within those individuals, the larger institution is likely to continue to be limited in its ability to serve its ultimate purpose. If solutions that are fair and just cannot be achieved, then the result will be much worse than what we are currently experiencing. And our patients will ultimately suffer because of it.
We all need to think long and hard regarding the ethical principle of justice, or I worry things will get worse for all of health care. Frail and vulnerable older adults in post-acute care facilities require a just and fair system to care for them. Justice is the key to appropriately transition into this new era of post-acute care that could be ripe with possibility.
Justice needs to be at the center of decisions that institutions — and the individuals working within them — make going forward. We can no longer confuse self-interest or self-preservation with social justice, or post-acute care as an institution will crumble along with its residents. That would be a significantly unjust outcome, regardless of the context or perspective.
Dr. Timothy Holahan DO, CMD is an Assistant Professor of Medicine at the University of Rochester. He is board certified in geriatric medicine and provides active clinical care/medical direction in both nursing homes and SNF ventilator units in Rochester, NY. He is the Vice Chair of the AMDA Ethics Committee and also is a member of the AMDA Public Policy Committee.