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Ethics In Health Administration A Practical Approach For Decision Makers Eileen E. Morrison
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Practical Ethics for Psychologists: A Positive Approach
EILEEN E. MORRISON, EdD, MPH, LPC, CHES Professor, School of Health Administration
Texas State University, San Marcos San Marco, Texas
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Title: Ethics in health administration: a practical approach for decision makers / Eileen E. Morrison.
Description: Fourth edition. | Burlington, MA: Jones & Bartlett Learning, [2020] | Includes bibliographical references and index.
Identifiers: LCCN 2018049335 | ISBN 9781284156119 (paperback)
Subjects: | MESH: Health Services Administration—ethics | Ethics, Medical | Decision Making—ethics
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This edition is dedicated to those teachers who believed in me and students who chose to learn from me. Special thanks to my seventh-grade teacher, Prudence Clark, who believed that I could write, and to my family: Grant, Kate, Emery, and Morrigan. Thank you for believing in me.
Preface to the Fourth Edition
Practicing ethics in health care is always a challenge. First, administrators balance the ethics of service to patients with sound business decisions. The foundation for applying ethics offered in this new edition will not make doing the right thing less challenging. However, it will create awareness about doing the right thing in the right way.
Since change is a continuing theme in health care, this fourth edition includes chapters that include change-related challenges in health care. For example, Chapter 5: Ethics in the Epoch of Change introduces ethics implications of innovation, the technology revolution, practice models, and population health. In addition, the book includes many cases to engage the reader and illustrate the application of ethics in real world situations.
The need to address change and its challenges is also a theme for the chapters. The intent of this new edition is to provide an ethics foundation based on theory and principles of ethics. Applying this foundation can balance the business of health care with its mission for patient care. For example, chapters contain sections that reflect areas that pose new ethics challenges for health administrators. Chapter 8: Technology and Ethics, for instance, contains a section on emerging trends in technology, which includes the ethics challenges in genetic engineering, mhealth, and telemedicine. In addition, cases provide examples of ethics concerns that future healthcare leaders will face to provide patient-centered, ethics-based, health care.
Acknowledgments
Writing about ethics is both a challenging and humbling experience. Ethics is more than a subject matter; it is also a matter of supporting integrity and providing quality care. Therefore, ethics writing has to be both informational and inspirational. Given this challenge, the author acknowledges her debt to family, colleagues, and friends who made this edition possible. Not only did they provide encouragement, they also told stories that could be fictionalized to create great case studies. Special gratitude goes to her publisher, Mike Brown, and editor, Danielle Bessette, who provided feedback and advice. Their assistance improved the quality of this author’s writing and provided insight on its readability.
SECTION I Foundations for Ethics
Change happens whether we want it or not.
▸ Introduction
Health care is in a constant state of change and challenge, which is likely to continue into its future. Therefore, this quote from the ancient philosopher, Heraclitus, rings true for healthcare administrators (HCAs). In this introduction, consider an example of how change can affect care and its ethics. For example, the rapid growth of technology promises more efficient and effective care along with the ability to treat health conditions and improve outcomes. Of course, technology’s impressive outcomes will also bring challenges for health administrators in the areas of finance, staffing, and patient demands.
How does this climate of change affect the HCA’s ability to provide both fiscally sound and ethics-based health care? First, HCAs need to continue providing an environment where patients receive both appropriate and compassionate care. In addition, they must create, adapt, and support the complex healthcare system structure that responds to change. As stewards of current and future resources, HCAs are required to protect these resources and ensure that they are used ethically. These serious responsibilities can only increase in this epoch of change.
To address these concerns, HCAs must also be prepared to go beyond patient care. They must respond to the business needs of health care with respect to the patient, staff members, organization, and the community. This challenge requires HCAs to have a base in ethics and apply their professional knowledge and skills. In addition, these challenges mandate a deeper application of ethics through appropriate behaviors that maintain both personal integrity and that of their organizations.
In a time of great change, HCAs must also apply ethics that consider individual, organizational, and societal viewpoints.
To meet this challenge, they must be informed by both qualitative and quantitative data to make decisions that are both fiscally sound and ethically appropriate. In this epoch of change, ethics becomes more than a course that is forgotten upon graduation. It is an essential for the successful practice of healthcare administration.
▸ A Word About the Text
The Fourth Edition of Ethics and Health Administration: A Practical Approach for Decision Makers contains chapter revisions and new chapters to reflect the current state of health care. For example, Chapter 5 is new and is titled Ethics in the Epoch of Change. It discusses changes in healthcare culture and how they challenge ethics decision-making.
HCAs use theories and principles in their decision-making and daily practices. Therefore, this new edition begins with a foundation in theory and principles. It goes beyond theory to application by including discussions, examples, case studies, and exercises within its chapters. These inclusions are designed to increase a deeper understanding of how to make ethics an integral part of the administrative role.
Each chapter contains a “Key Terms” section to build concept recognition. Chapters also include case studies. These stories are based on fictionalized situations from many different healthcare experiences. Feedback from past students indicates these cases are helpful in applying ethics to the real world.
The model seen in FIGURE I-1 guides the organization and vision of this text. Since HCAs do not make decisions in a vacuum, the circle organizes its themes and reflects how ethics influences healthcare practice. The outer circle represents the theory and principles that form the foundations for ethical decision making. The next circle represents areas external to the organization that influence the operations of healthcare administration. Internal influences are represented by the next circle in the model. These factors strongly impact the day-to-day practice of ethics in an organization. Finally, the inner circle represents the HCA’s personal ethics and its influence on action and career success.
The circle model also serves as an organization plan for the chapters in the book. For example, the Foundations for Ethics section establishes a base in ethics theory and principles. The Practical Theory chapter explores founding theories of ethics that guide most of Western ethical thinking and includes a new section on the ethics of care theory. Using this theoretical groundwork, the Autonomy chapter explores one of the four key principles of healthcare ethics and discusses how it influences the practice of health care. The Nonmaleficence and Beneficence and Justice chapters focus on the remaining key principles and their relevance to healthcare administration. And a new chapter, Ethics in the Epoch of Change, examines the uncertainties of healthcare, the changing healthcare culture, and ethics challenges during major change events.
In the External Influences on Ethics section, the Market Forces and Ethics chapter considers the influence of various markets on the application of ethics in healthcare administration. The Healthcare Regulation and Ethics chapter addresses the relationship between regulation and ethics. It also includes advocacy and staff
Internal
External Influences
competency in relation to ethics theory and principles. Finally, the Technology and Ethics chapter presents an updated and in-depth view of technology’s impact on ethics decision-making, including emerging technologies.
The healthcare organization’s influence on an administrator’s ethical decisions is the focus of the Organizational Influences on Ethics section. The No Mission, No Margin: Fiscal Responsibility chapter presents the challenges of finance and its influence on ethical decisions. It also presents ethics issues related to the challenges of financing healthcare, nonprofit versus for-profit healthcare organizations, and stewardship of finances. The Healthcare Organizations: Culture and Ethics chapter features information on important patient culture and ethics challenges. There are also discussions about professional culture, ethics committees, and models for decision making.
The next chapter, The Ethics of Quality, is especially important in times of great change. It presents information about the organization’s response to quality and the nature of quality itself. In light of health care’s patient experience emphasis, The Patient Issues and Ethics chapter considers the organization’s responsibility to meet changing patient needs and expectations. This topic is presented from both the patient and organizational perspective. The Public Health and Ethics presents information on public health in action in the epoch of change and how it affects both community health and the healthcare system. It also introduces the mission of public health and professionals who are part of this important aspect of healthcare delivery. The Personal Ethics and Morality chapter investigates morality and its meaning for the busy HCA. It also includes discussions about the effects of ignoring morality and how to practice personal ethics as an administrator.
FIGURE I -1 A System of Healthcare Administration Ethics
The Inner Circle of Ethics section discusses how HCAs use ethics in their professional practice. The Codes of Ethics and Administrative Practice chapter provides an overview of organizational and professional codes of ethics and their application to administrative practice. Finally, Practicing as an Ethical Administrator chapter relates to the difficulties maintaining one’s base in ethics as an administrator who practices in a time of great change. It offers practical advice for balancing ethics with expediency and change.
This new edition assists readers in seeing the world through “ethical eyes” as well as through financial ones. By applying ethics, one can enhance the overall effectiveness of one’s organizations and better meet challenges in a trust-based industry. On a personal level, one can become a person of integrity with a reputation for practical wisdom. One can make decisions that are both fiscally sound and ethically based. In the end, ethics always matter.
CHAPTER 1
Practical Theory
Healthcare administrators without grounding in ethics theory are like boats without rudders. They keep going around in circles and go nowhere.
KEY TERMS
The following is a list of this chapter’s key terms. Look for them in bold.
Act utility
Categorical imperative
Consequentialism
Conventional
Deontology
Ethical egoism
Ethics of care
Eudaimonia
I–THOU
Liberty principle
Maximum principle
Moral development
Natural law
Normative ethics
Original position
Practical wisdom
Preconventional
Premoral
Principled moral reasoning
Rule utility
Sense of meaning
Utilitarianism
Virtue
▸ Introduction and Definitions
You watch your house fill with water as you enter a rescue boat. You visit your grandmother in a nursing home and you can still hear her asking to go home. You have to inform your staff about a new policy on infection control. You have to explain the copayments to a patient who is full of fear about her surgery. What do these scenarios have in common?
First, they deeply connect to the core concepts of all of health care—trust. From the patients’ view, trust happens on both physical and emotional levels. For example, patients surrender their privacy, bodies, and even their lives for care and expect to have a quality outcome. They expect providers and those who address the business of health care to honor their trust, including treating them with respect and compassion. In the administrator role, trust is the basis for creating policies, procedures, workflow, and mechanisms that make health care happen. Healthcare administrators trust that healthcare personnel will provide competent care, serve patient needs, and
apply facility guidelines. In addition, they must also be aware of the needs of patients and fiscal responsibility and respect the autonomy of healthcare professionals.
How does this information relate to ethics? To the outside world, administration seems to be about policies, procedures, billing, patient satisfaction numbers, and compliance. While these areas are certainly relevant to the practice of healthcare administration, the center of its practice is making the best ethical decisions for patients, providers, and the organization. Because of the unique nature of health care, administrators must also be able to combine fiscally sound decisions with ethical practices. Decisions must also comply with regulation, standards, and other oversight efforts. In addition, healthcare administrators must defend their decisions to a myriad of audiences, including healthcare professionals, boards of trustees, community members, and government agencies. Certainly, making decisions that foster efficient and effective health care that is also ethically sound in not easy and requires knowledge and skill.
From an ethics standpoint, the first step to apply ethics in decision-making is to understand its definitions, theories, and principles. Therefore, this chapter begins with a section that presents examples of definitions associated with ethics, including ethics theory. Many sources provide deep exploration into the work of the ethics scholars; however, it is not possible to study all of their work in one comprehensive text. Therefore, the author chose eight key theorists who were instrumental in creating the foundation of ethics that relates to health care. This text provides a basic understanding of the key points of their theories, including their background and the application of their ideas to healthcare settings. However, the reader is encouraged to go beyond this summary.
To assist readers in their ability to apply theory to practice, the chapter begins with a brief biography of each theorist. This is followed by a summary that features a working knowledge of one’s theory. Finally, this chapter includes information on the application of the theories and additional resources for enhancing the learning process.
▸ Definitions of the Word Ethics
For this chapter, normative ethics (how one decides right from wrong) is featured because it relates to the application of theories and principles to practice. In addition, normative ethics assists in determining appropriate rules for decision-making (Summers, 2019). Darr (2011) explained that the definition of ethics involves more than just obeying the law. Law provides the minimum standard that society approves for actions or behaviors; ethics is broader and much more difficult to practice consistently. Therefore, a person could behave legally but not ethically.
Administrators must also consider the community’s definition of appropriate ethical behavior for individuals and organizations. This definition may not be founded on a theoretical framework, but “they know it when they see it.” Therefore, administrators understand community standards in making decisions and apply ethics as more than a carefully worded mission, value, and vision statement.
Normative ethics is also concerned with organizational ethics, which is commonly defined as “the way we do things here.” Knowing how organizational ethics is applied assists the understanding of acceptable behavior and action within the organization. However, healthcare organizations do not create operational
definitions of ethics—people do. Therefore, creating organizational ethics standards must include a dialogue about differing views regarding ethics and the formation of operational definitions.
Professionals provide health care and come from a variety of practice orientations. Healthcare administrators have the responsibility of the quality of care that these professionals provide. Therefore, it is necessary to understand how health professionals define ethics in their practices. Their standards of professional ethics are created when their professions establish definitions and guidelines for ethical behavior. This process typically results in a code of ethics. For example, different codes of ethics exist for nurses, physicians, physical therapists, occupational therapists, massage therapists, acupuncturists, and counselors. For their profession, healthcare administrators have guidance from the American College of Healthcare Executives (ACHE) on definitions of ethics, concepts of ethical behavior, a code of ethics, and policy development.
Of course, the practice of ethics is about people. To practice ethics as administrators, HCAs must consider theoretical, patient, community, and organizational ethics as they make decisions. They also have to be attuned to their own professional standards and those of the professionals who are part of their organizations. However, in their function as administrators, individuals must also own their decisions. Some might ask, “Isn’t ethics just doing what is right at the right time?” The answer is “yes, but….” In healthcare organizations, what is right is not always a simple matter. In developing ethics-based decisions for the bottom line, HCAs need to consider ethical egoism. This form of ethics has its base in the idea that actions should center on what will provide the best personal benefit (Summers, 2019). In other words, a person has the right to consider his/her own interests and benefits when making decisions. This idea is important when patients make decisions about their health care. However, in the healthcare system, the needs of all patients, employees, the organization, and the community must be considered as well.
Healthcare administrators are representatives of the mission and values of their organizations for the community. To be prepared for this role, they must understand both the ethics position of their organization and the community they serve. To best achieve this goal, health administrators must begin with the mission, vision, and values of their own organizations at a practice level. In addition, they must also investigate the ethics orientation of organizations that regulate their business, staff that serve their patients, and their own code of ethics. Finally, they must consider their personal values and ask themselves, “What is my ethics bottom line?” After considering all of these ideas, the HCA should create a personal ethics statement. This statement could serve as a guide in making the difficult decisions that are often part of health administration.
▸ Ethics Theory and Its Application
While there are many ethics theorists, eight are included here because of their influence on health care. They include Aquinas, Kant, Mill, Rawls, Aristotle, Buber, Kohlberg, and Gilligan. For the purpose of this discussion, these theorists are divided into two groups. The first group, which includes Aquinas, Kant, Mill, and Rawls, examined the global issues surrounding ethics and ethical decisions. The second
group, which consists of Aristotle, Buber, Kohlberg, and Gilligan, studied personal ethics and moral development. This chapter provides a summary of their works to assist in understanding their contributions to health care.
▸
Global Ethical Theories
St. Thomas Aquinas (1225–1274)
Biographical Influences on His Theory
According to family tradition, St. Thomas Aquinas, the youngest of four boys, was destined for a career in the church. Between the ages of 5 and 15, he served in the local Benedictine abbey and his family had great ambitions for his role in the church. They made sure that he was well instructed in the classic literature of his time. For example, during his studies at the University of Naples, he read a newly discovered version of Aristotle’s work, which influenced his thinking on many levels (Brown, 2018).
Early in his life, St. Thomas received a calling to become a member of the Dominican order of the Catholic Church. However, his family did not support this vocation and tried to prevent him from joining the order. They ordered his brother to bring him back to their castle and placed him under house arrest. When he would not renounce his calling, they tempted him by sending a prostitute to his room. Aquinas chased her out and slammed the door on her. Finally, his mother relented and allowed him to go to Cologne, join the Dominican order, and continue his study with the major scholars of his day (Brown, 2018).
Aquinas became a teacher of theology and prolific writer; the greatest of his writings in ethics was the Summa Theologiae. Part Two of this work was devoted entirely to ethics and combined Aristotelian and Christian thinking. This work helped establish the concepts of natural law (McInterny & O’Callaghan, 2016; Summers, 2019). St. Thomas was canonized in 1323 and his works have influenced philosophers in every century.
Concept Summary
Influenced by Christian theology and the writings of Aristotle and others, St. Thomas Aquinas’s genius was that he brought together faith, divine inspiration, and reason (Palmer, 2010). According to Aquinas, God is perfectly rational and He created the world in a rational manner (Summers, 2019). God also gave humans the ability to reason, evaluate what is good or evil, and make rational decisions. This ability for rational decision making is part of AQUINAS concept of natural law. Because humans have this gift, they have the potential to use moral judgment and choose good or evil (Darr, 2011; Palmer, 2010). Notice the word “potential.” This means that choosing good over evil is not automatic. Aquinas noted that people may violate natural law because they are also given the gift of free will. However, if people are true to their rational natures, they will listen to their consciences (i.e., the voice of God) and obey natural law by choosing goodness over evil.
How does Aquinas define goodness? His definitions stressed that the gift of rationality contributed to choosing what is good. Acts that preserve life and the human race are part of his definition of good. An action is also good if it advances knowledge and truth, helps people live in community, and respects the dignity of
all persons. Aquinas also believed that to find happiness, people must not look at pleasures, honors, wealth, or worldly power because these are not the true source of goodness. Truly understanding God is the ultimate good that all rational human beings seek (Kerr, 2009).
Aquinas also presented what he called four cardinal virtues, which included prudence, justice, temperance, and courage. These virtues are cardinal because they lead to actions that produce good. For example, prudence leads to making good judgments that positively affect the person and others. Temperance as humility constrains excessive ambition and greed. Courage restrains fear so that individuals can make decisions that benefit others. Justice influences policies and procedures that provide what patients need and considers more than legal requirements.
Theory Applications
How do Aquinas and his position on ethics apply to today’s world? Do you think people can choose to act against their “rational nature” (as defined by Aquinas) and cause harm to themselves and others? For example, it is not rational to text while driving. If people make this irrational decision, their actions can cause them harm to themselves and others or even death. In contrast, making rational decisions about one’s health benefits the quality of one’s life. For example, if everyone made the rational decision to protect themselves from the flu, it would reduce the overall cost of healthcare for the community.
Aquinas’s idea of “basic good” seems to be simple on the surface. All a person has to do is use reason to make the best choices, respect people’s dignity, and help them live in community. However, when one translates this concept into the healthcare system and its policies, matters become much more complex. Does health care have an obligation to those who do not make rational choices? Do they deserve the same level of care as those who make rational choices, or should they pay more for care because they are not making rational choices? How can the business of health care preserve the human race and still have enough money to keep its doors open? In the current healthcare environment, will these questions be even more difficult to answer?
Immanuel Kant (1724–1804)
Biographical Influences on His Theory
Immanuel Kant was born in Königsberg, Prussia, and was the son of a harness maker. His family was deeply religious, with an orientation toward piety and hard work. Kant completed initial studies at Königsberg University but did not have the finances to complete higher-level studies. In order to finance his education, he worked as a tutor for wealthy families. Once he completed his studies, he was accepted as an instructor at Königsberg University and taught there for over 40 years (Rohlf, 2016).
Kant began to publish in the area of metaphysics and moral philosophy and his interest in teleology, practical philosophy, and enlightenment led to his fame as a major German philosopher. His works include Groundwork of the Metaphysics of Morals (1785), Critique of Pure Reason (1787), and Critique of the Power of Judgment (1790). Kant’s work centered on ideas of autonomy, how the world should be, and one’s duty to make the world be as it should be (Rohlf, 2016).
Concept Summary
Kant’s writing in metaphysics and later on practical philosophy had a major impact on the field of ethics. He went beyond the description of what the world is (theoretical philosophy) to a discussion of what the world should be (practical philosophy). Through his thinking about morals and reasoning, Kant founded an entire area of ethics called deontology, or duty-based ethics (Summers, 2019).
To understand Kant’s theory of deontology, one must understand the idea of duty and the standards that determine a person’s duty. When an action is a moral duty, an ethical person seeks to meet this duty. However, Kant also stressed that there must be a way to identify one’s moral duties (Summers, 2019).
In order to understand moral duty, Kant considered the idea of what makes something universally good. He studied areas such as talent, beauty, money, and even happiness and determined that they are not good in themselves. Rather, a person can use any of these assets for good or evil. While society may value personal and intellectual attributes, any of socially acquired or genetic attributes are also not intrinsically good (Blackburn, 2001).
Then, what is a good? For Kant, the only good that can exist without clarification is something called good will. Acting with good will means that no ultimate end exists for the person who chooses it; it goes beyond what might be determined as a duty. In other words, acting with good will does not benefit those who choose to take such actions. They choose to do what they consider is the right thing to do. They are motivated by an inner sense of duty rather than any external influence or self-interest. This inner understanding of their sense of duty motivates them; it is motivation that counts. Therefore, good will is not a means to an end; it just is (Blackburn, 2001).
In the Kantian view, all humans have absolute worth simply because they exist. Because they have worth, they are not a means to accomplish what an individual wants or to meet a societal goal. Rather, they are an end in themselves. What does this mean in practice? For administrators, it means that they cannot use people as a way to get what they want and remain ethical. For Kant, it was also important to respect the dignity of others, including freedom, autonomy, and rationality (Palmer, 2010). How does this translate in health care? It means that there is a duty to act in moral ways and consider this duty in their choices.
How do healthcare professionals know what is good and what is not? First, Kant acknowledged that all people have the ability to think and make their own decisions. In fact, he said free will was essential to ethical behavior and to understanding what is good (Summers, 2019). Kant also acknowledged that humans are rational and can use reason to decide what rules apply to good.
Kant provided a tool to determine moral duties called the categorical imperative. This tool serves as vehicle to test actions, determine one’s duty, and make moral decisions. For Kant, decisions about duty-based ethical choices included universal application—that is, becoming a universal law. For example, an administrator can ask, “Would I want everyone to be able to do this without exception?” If the answer is “yes,” then the decision passes the test of universalization or the categorical imperative. It then becomes a categorical moral duty and carries a moral obligation to act in accordance with this duty (Blackburn, 2001; Palmer, 2010).
The categorical imperative has been compared to the Golden Rule (a part of many of the world’s religions). Kant, however, thought that it differed from the idea
of “do to others what you would do to yourself.” For example, one could apply the Golden Rule in ways that are not universal if feelings and needs, rather than reasoning, are used to determine actions. In his test, moral duty goes beyond people’s determination of fairness. For example, administrators who apply the categorical imperative would be required to treat patients, staff, and others as individuals and not as a means to an end (Blackburn, 2001; Palmer, 2010; Summers, 2019).
Theory Applications
Kantian, or duty-based, theory can apply to many situations in health care. One could agree that all human beings should be means unto themselves and deserve respect. All people in one’s daily work life—employees, patients, community members, and others—have absolute value simply by the fact that they exist. Just because they can accomplish more or less in society’s eyes does not change their value as human beings. This leads to the idea that for moral decision making in health care, all persons in similar circumstances deserve the same respectful treatment.
In addition, Kant’s categorical imperative assists in defining the moral obligations. Therefore, this tool can be useful in determining moral duty when developing healthcare policy and procedures. For example, when one develops a personnel policy, one can ask, “What is the reason behind this policy? Can this policy apply to everyone as it is written?” Using the categorical imperative, the answers to these questions can assist in determining whether the policy is universal. Making this determination can also assist in the implementation of the policy and avoid act utility versus rule utility.
Despite Kantian theory’s base in good will, one can see that being a strict Kantian might be a difficult for the HCA. To follow Kant in the strictest sense, an administrator should make decisions based on good will and not on profit, legal mandates, or pleasing stakeholders. Because these are factors in the business elements of health care, they must be considered when making policy and business decisions, but they do not negate the worth of individuals. In addition, Kantian moral theory may not provide answers to all of the complex issues in today’s healthcare system. For example, if a researcher uses human subjects to help find the cure for cancer, is he or she not using those individuals as a means to an end? Does this fail the categorical imperative test? In a strict Kantian sense, one could say that it does, yet there is potential benefit to a larger group from the knowledge gained.
John Stuart Mill (1806–1873)
Biographical Influences on His Theory
John Stuart Mill is one of the most influential ethics theorists in American health care. Born in London, he was the son of James Mill, a historian and economist. Mill’s father maintained strict discipline with respect to John’s learning; he studied Greek at age three. At 15, Mill studied major works of philosophy and psychology. Influenced by Bentham’s utility concepts, he began to write his own theory of utilitarianism before he was 20. However, his high level of achievement and intellectual activities led to a mental crisis (Macleod, 2017).
He was able to recover from this crisis because of his ability to explore new areas, including poetry, philosophy, and reform. Mill became a Member of Parliament
and represented the liberal party. In this role, he supported social causes, including suffrage for women (Wilson, 2007). Some of Mill’s major works on ethics include System of Logic, On Liberty.
Concept Summary
Based on the idea of telos, or ends, Mill’s theory of utilitarianism forms the ethical justification for many American healthcare policies. His moral philosophy is based on the idea of utilitarianism or consequentialism, which posits that that one should base ethical choices on their consequences and not on one’s intent or duty. When applying Mill’s utilitarianism concepts, administrators weigh the consequences of those actions and their effects on others’ happiness rather than on their intent or method. The results of this evaluation often influence healthcare cost analyses, policies, and practices (Darr, 2011).
How does one determine the utility of consequences? According to Summers (2019), Mill’s evaluation of utility began with the assumption that respect for individual autonomy is implied when seeking the greatest good. With that in mind, administrators must consider actions that give the greatest benefit (or happiness) to the greatest number of those affected by the consequence or decision. A decision is not ethical if it produces the greatest harm for the greatest number of those affected. Thus, the focus of an ethical decision is based not on the individual person or on the person’s intension, but rather on the best outcomes for all persons.
Writers often reduce Mill’s theory to the phrase “the greatest good for the greatest number” (Summers, 2019, p. 26). While this is a concise summary of the theory, it does not consider the idea of preventing the greatest harm to the greatest number, which is also part of utilitarianism. Preventing harm increases the opportunity for the greatest good and provides a rationale for policies related to disease prevention and reduction (Darr, 2011). Ashcroft, Dawson, Draper, and McMillan (2007) provide examples of the greatest good for the greatest number in healthcare settings, such as public health, quality of life efforts, and the work of healthcare economists. In addition, utilitarianism, in contrast to Kantian theory, allows a person to be a means to an end. However, this should occur only when there is a greater good. For example, suppose an individual decides to part of an experimental treatment that will not provide a cure for his ailment. However, he can contribute to cures for future generations. While he/she becomes a means to an end, the consequences of his/her decision create a greater good.
Healthcare administrators are often challenged to analyze consequences for their decisions by considering the utility of their consequences (Purtilo & Doherty, 2011). Their analysis can be assisted by dividing utility into two main groups. The first type of decision is to use act utility. This means that each decision is evaluated for its consequences and the decision based on its own merit. There is an analysis of the consequences for that specific case and, based on this analysis, one makes a decision. Also called classical utilitarianism, act utility is not always practical for healthcare administrators. The decisions that they make are often numerous, complex, and interrelated. For example, an exception for a personnel policy that is created for the greatest good of one person may not have merit for others (Summers, 2019).
The second type of decision-making using Mill’s theory is based on rule utility. With this approach, administrators assume that using rules (or policies)
provides the greatest benefit. They analyze the potential consequences of a decision before making a final decision on its action. This form of utilitarianism appeals to healthcare administrators because it allows for decisions that will be the best in most cases and contribute to the process of cost/benefit or gain/loss analysis for justifying decisions.
Theory Applications
Many healthcare administrators perceive Mill’s utilitarian principles of ethics to be a practical way to address the difficult decisions that are inherent in health care. Resources are never unlimited in health care; therefore, there is a need to make decisions based on universal benefit. Using the balance sheet approach of rule utility identifies consequences, determines merit, and assists in making a decision that will benefit the most number of people who are affected. Hopefully, this approach should make cost-benefit and ethics-based decisions easier.
The ability to ignore the needs of the minority to provide the greatest good for the majority is a limitation of Mill’s theory. In rule utility, the individual is not the focus of moral decision making; it is concerned with the greatest benefit to the greatest number of people. However, in using this decision-making, an administrator could violate the rights or needs of the individual. Summers (2019, p. 27) refers to these situations as the “tyranny of the majority.”
An example might clarify this point. Suppose an administrator created a policy and funded a screening program that served all the members of a community. This would seem to benefit the greatest number of people and meet the requirements of rule utility. However, to find the funds for this program, the administrator eliminated funding for a program that served a small group of uninsured patients who needed counseling. The funded program might provide the greatest good for the greatest number, but those affected by the defunded program might have good reason to disagree with its value.
John Rawls (1921–2002)
Biographical Influences on His Theory
John Rawls’s father was an attorney and his mother was active in the League of Women Voters. He attended an Episcopal preparatory school before beginning his studies at Princeton and Oxford. These studies led to his consideration of a vocation in priesthood. However, what he witnessed as an infantry soldier during World War II put a great strain on his faith. Perhaps his upbringing, education, and experiences influenced his concern with social justice and the integration of politics and ethics (Wenar, 2017). Rawls taught at Princeton, Oxford (Fulbright Scholar), and Massachusetts Institute of Technology. In his final academic appointment, he served as a professor at Harvard University for 40 years.
Rawls was concerned about justice within a society and the relationship between justice and fairness. His work, A Theory of Justice (1971), was centered on the relationship between a just society and its actions. His work in social justice continues to influence modern political, social, and ethical beliefs on how to define a just society (Wenar, 2017).
Concept Summary
Rawls’s theory was founded on what constituted a just society and fair treatment. It included egalitarian principles that addressed issues of moral equality and just treatment (Beauchamp & Childress, 2013). Rawls studied the previous works of philosophers and formulated his own theory of justice that included the concept of “justice as fairness” (Summers, 2019, p. 20).
What does this phrase mean? To explain his ideas, Rawls set up a hypothetical situation in which everyone is equal. He called this scenario the “original position” (Summers, 2019, p. 21). He also asked that a person assume the “veil of ignorance” (Summers, 2019, p. 21). In this situation, people would not know their “individual talents, intelligence, and social and economic situations” (Darr, 2011, p. 20). Given their original position and veil of ignorance, people would act to protect their own best interests and want everyone to be treated fairly (Blackburn, 2001). On a societal level, protection of self-interests would require a social contract to assure fair treatment for everyone (Rawls, 1999; Summers, 2019). This contract, as part of a just society, would identify what is necessary to protect the rights and self-interest of others.
Rawls also defined something called the liberty principle (Darr, 2011), which means that all people should have the same basic rights as all others in a society. For example, if the rich have a right to basic education, then so should everyone else. To be just, people must also address inequalities in a society to protect those who are in a lesser position. Although Rawls did not specifically address health care, this principle is used in healthcare policy and decisions related to children, poverty, and medical problems that affect quality of life (Beauchamp & Childress, 2013; Vaughn, 2010). In Rawls’s view, everyone has the potential to be in a lesser position. Therefore, acting to protect the rights of those who are less well off is actually part of one’s self-interest. In addition, societies need to take action to maximize efforts that benefit those in a lesser position. Rawls included actions to address inequalities in his maximum principle.
Further, social problems tend to be suffered more by those who are in lesser positions. For example, persons who are living in poverty are also more likely to be victims of crime or have more severe health problems. In addition, when people in a society are not treated for health problems, this failure can affect the entire society. For example, if a person has a communicable disease and does not receive treatment, that disease can infect others. Therefore, it is in everyone’s self-interest to provide prevention and treatment.
Rawls had a second principle of justice, called the difference principle, which addressed inequalities in the society. He postulated that differences and advantages exist in economic and social position but in a just society, the differences should provide benefit for that society. For example, a physician is paid more than others in a society and has greater status. However, this difference includes a responsibility to benefit those were in a lesser position by the application of their knowledge and skills (Beauchamp & Childress, 2013; Summers, 2019).
Rawls also addressed fairness of providing necessary services or benefits. He felt that it was rational and morally right to limit services when there is a greater need among certain groups. “It is also rational and self-interested for persons in the original position not to make every good or service available to everyone at all times” (Darr, 2011, p. 20). Therefore, health care can be limited for some groups, but this limitation must provide benefit for those who are in a lesser position in society.
For example, when a patient goes to the emergency department with a sprained ankle, there are many services available to diagnose and treat that person. However, the patient might not get immediate treatment or even the use of all of the available treatments. If a person with life-threatening conditions is simultaneously present in the emergency department, he/she would be treated first and with greater resources. It is in the self-interest of all who have healthcare needs to understand that those in critical situations receive treatment first. This is true because people assume that if they were in this position (lesser position), they would receive the same priority treatment.
Theory Applications
Rawls’s ideas about social justice greatly influenced political thinking, including the treatment of those in a lesser position. He used terms such as natural lottery and social lottery to explain how people can be in a lesser position (Beauchamp & Childress, 2013). He also believed that talents and disabilities could be the result of one’s biology and heredity (natural lottery) and one’s family status and wealth (social lottery). If a person does not enjoy the positive end of the lottery, he or she may be in an undeserved disadvantage. A just society would make an effort to address these disadvantages in an ethical manner. One can see the influence of Rawls’s thinking in programs such as Head Start and Medicaid/Medicare. Likewise, his theory has ramifications for many U.S. institutions, such as education and public health. According to Beauchamp and Childress (2013), Rawls’s ideas about social justice motivated other writers such to consider fairness in providing access to healthcare. In addition, he influenced research related to inequalities in health and their impact on indices of health, such as life expectancy. Rawls’s theory also supports the idea that “justice is a fundamental virtue of institutions” (Purtilo & Doherty, 2011). This means that healthcare organizations have an obligation to the just use of resources and respecting all that they serve. While patients are the obvious target for this respect, healthcare organizations have a responsibility to the community and the environment. An example of this responsibility would be the use of financial and physical resources in ways that avoid waste and a safe environment for patients and employees (Purtilo & Doherty, 2011).
However, the ethical challenge is not just in meeting the standards of Rawlsian justice. Within this challenge, there is also a need to maintain a healthy bottom line so that doors stay open and salaries are paid. Addressing this challenge requires ethical stewardship in a complex environment and in an ever-changing healthcare system. Integrating the principles of justice and fairness introduced by Rawls with those of fiscal responsibility will continue to present a major challenge for healthcare institutions now and in the future.
▸ Personal Ethical Theories
The section presents a consideration of personal ethical theorists. These theorists focused on individuals and their ethical and moral behavior and explored how they acquired their moral reasoning. The section begins with Aristotle, who provided a foundation for many of the great ethicists who followed him. Martin Buber is included because he described personal ethics in terms of moral relationships. Lawrence Kohlberg also examined personal development of ethics by looking at stages
of development. Finally, Carol Gilligan, a student of Kohlberg, approached moral development through the importance of relationships.
Aristotle (384–322 bce)
Biographical Influences on His Theory
Aristotle was one of the greatest philosophers of his time and is still an influence on writers in the current century. A child of privilege, he was sent to Athens to study with Plato at the age of 17. He remained part of Plato’s academy and continued his study for over 20 years. In 343, the king of Macedonia asked Aristotle to tutor his son, who later became Alexander the Great (Kraut, 2017).
Aristotle set up his own academy and also wrote more than 200 works in the areas of physics, logic, psychology, botany, metaphysics, politics, and ethics. He was also an innovator. For example, he was the first to write specifically about applying virtue and moral thinking to ethics decisions. Despite his fame, Aristotle faced a life-threatening situation. While he was living in Athens in 323, Alexander the Great died. Because of this death, he feared for his safety and was forced to leave the city (Kraut, 2017).
Concept Summary
Aristotle’s study of virtue ethics included principles for living a virtuous life. His definition of virtue derives from the Greek word areté, meaning “excellence.” This theory included information about how people made moral decisions in their lives. For Aristotle, people build their moral character through their decisions and by practicing both intellectual and moral virtues. In addition, virtue, practical wisdom, and eudaimonia were part of Aristotle’s concepts for living a moral life (Blackburn, 2001; Palmer, 2010; Summers, 2019).
Virtue
Following in the footsteps of Socrates and Plato, Aristotle believed that a well-lived life was one that was concentrated on virtue. This life went beyond meeting inner desires for happiness. It required the human ability to advance one’s intellect and reason and take action based on virtue (Blackburn, 2001). In addition, the choice to make virtue a habit was a requirement. Examples of virtue include practicing temperance, exhibiting courage in adversity, and providing assistance to someone without personal reward (Blackburn, 2001; Palmer, 2010).
Practical Wisdom
Since building a virtuous character requires action and choice, Aristotle included the concept of practical wisdom or phronesis as a way to make choices that lead to virtuous decisions (Summers, 2019). Using practical wisdom allows healthcare administrators to practice the “virtue of discernment” (Beauchamp & Childress, 2013, p. 39). This means that administrators can choose the best action without being influenced by fear, relationships with others, or personal considerations. Using practical wisdom also allows administrators to apply policies and rules that are balanced by principles of ethics.
Ethical challenges increase as administrators face the ever-changing healthcare system. This dynamic change indicates that there may not be a policy or answer in all situations. Therefore, healthcare administrators can apply Aristotle’s practical wisdom to discern the best action for the situation. Using practical wisdom requires that they need to be stronger than their impulse to act before they analyze. Discernment requires an assessment of how choices affect people in different situations and also how they reflect the mission of the organization. Using discernment, administrators can be guided by their investigation and character to choose the best option for the current situation. This option is often the middle ground. Practical wisdom can be also applied to groups and communities as they attempt to choose the best action for their situations. As Beauchamp and Childress (2013, p. 39) reminds, “the virtue of discernment brings sensitive insight, astute judgment, and understanding to bear on action.”
Eudaimonia
Eudaimonia has been translated as happiness or the idea of flourishing (Summers, 2019). However, the idea of modern definition of happiness does not explain what Aristotle meant by this term. Happiness in the modern sense is often interpreted as personal happiness. Instead, Aristotle’s concept of eudaimonia included the choice to live life as it was intended to be—that is, a life lived by practicing virtues and working to build one’s moral character. This choice requires the ability to contemplate and address difficult issues and how to live together in community. It also means that a person is concerned about living with others, developing personal excellence, and “becoming a person of character” (Summers, 2019, p. 9).
Theory Applications
Aristotle’s theory has applications in today’s healthcare environment and the socialization of professionals. Those who choose to be part of the healthcare system are educated in areas beyond their knowledge and skills. They must also be persons of moral character and virtue. They build their professional moral character through professional socialization (Summers, 2019). For example, Beauchamp and Childress (2013) include an entire chapter on the moral character of those who choose careers in the health professions. They feature “five focal virtues for health professionals: compassion, discernment, trustworthiness, integrity, and conscientiousness” (Beauchamp & Childress, 2013, p. 37). These virtues are linked to a healthcare professional’s ability to care for patients and the morality or excellence that is expected by patients, families, and communities.
Martin Buber (1878–1965)
Biographical Influences on His Theory
Martin Buber was a scholar and an activist in the Zionist movement. He spent much of his childhood with his grandparents in a traditional Jewish community where his grandfather was a well-respected rabbi and scholar. Buber’s extensive educational background included being fluent in Hebrew, Yiddish, Polish, German, Greek, Latin, French, Italian, and English (Zank & Braiteman, 2014).
In 1933, Buber served as the Director of the Central Office for Jewish Education during a time when Hitler would not allow Jews to go to school. In 1937, he was offered a position at Hebrew University in Jerusalem, an institution that he helped found. One of his most important works on philosophy and ethics is I and Thou (1996). This book began as a commentary on religion, but is now applied to ethics, psychology, medical anthropology, and politics (Zank & Braiteman, 2014).
Concept Summary
Buber’s powerful book, I–THOU (2010) centered on the idea of relationships and how they affect what it means to be a human being. In his book, he proposed that human beings need meaningful relationships and communication to survive. He began his study of relationships by defining the “I,” which is unique to human beings. Humans are capable of having relationships because they have the ability to recognize each other and the world. Humans are also capable of having dialogue in their relationships with others, and these variations demonstrate the depth of communication and understanding. Buber described the “I” as a singular human being. All humans are viewed as “I,” but development in understanding who they are requires the ability to relate to others. This ability includes communicating with fellow human beings, nature, and God (Scott, Scott, Miller, Stange, & Crabtree, 2009).
Buber also described relationships as existing in pairs (Buber, 2010). These pairs reflect depth of relationship and communication. The least effective human relationship is the “I–I” relationship. In this level, people have no real interest in others and live with themselves. If a person is recognized, he or she is not accepted as a individual person but may be seen as extension of the “I.” The needs of others simply do not exist, nor does the responsibility of ethical behavior toward them.
Buber’s next level is the “I–IT” relationship. In this case, people acknowledge that there are others, but they do not choose to have meaningful relationships with them. Because people are “Its,” they can be used as tools for personal benefit or the benefit of one’s organization. For Buber, I–IT relationships are morally wrong because they failed to accept people as having individuality and value. People serve only as a means to an end. Examples of I–IT relationships and their lack of respect for others and dialogue occur when administrators use the term “my people” or “my worker bees” to refer to their staff members. Another example happens when one refers to a patient as “the colon in 405” instead of by his/her name. Scott et al. (2009) discussed the need for I–IT relationships. For example, these relationships allow people to objectively study nature and medicine. However, they also acknowledge the danger of emphasizing these relationships because they limit the ability to establish relationships with others.
Kramer and Gawick (2003) also include US–THEM relationships in their application of Buber’s theory. This category of relationship coordinates well with the I–IT viewpoint. For example, the US–THEM relationship allows people to be categorized into in the right or in the wrong. This division makes society easier to understand because people can be grouped as “us” or “not us.” People who are in the “us” believe themselves to be superior and avoid dialogue with those in the “not us” category. In addition, it easier to attribute negative events or actions to those who are “not us.”
The I–YOU relationship has two categories and begins with the ability to recognize individuals as having value and unique talents, gifts, and ideas. These differences are not only recognized, but also accepted and respected. I–YOU
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you talked of Casa Di Bello. Do you think it was for that I married you?”
“Wait, wait, my Juno. Pazienza. The day will come when you will be padrona of that house.”
“Enough,” she said. “I am tired of this nonsense. What are you going to do?”
“Listen,” said Bertino, delighted at the success of his garbled version of Di Bello’s threat. “This is my idea: You do not like Mulberry too well, nor do I. Moreover, rents are very high here, because these animals find it hard to get in anywhere else, and the landlords rob them. But with us it is different. We, for example, are signori, are we not?”
“Ah, yes; I am a signora.”
“Very well. Now I will tell you the rest: In the upper city there are apartments, small and fine, that we could take. You know Giacomo Goldoni, the cornetist at La Scala? Well, he lives in a place like that, he and his wife, just like Americans.”
“Where is it?”
“In One Hundred and Eleventh Street of the East. Do you know where that is? Well, you can find it. To-day you shall go and choose the place. Here is money, the first that you have received from your husband. Do you think I have been fool enough to give the money I brought from Italy to the pothouses? Not I. When I need money I go to the Bank of Risparmio. See what kind of a husband you have! Neither you nor any one else knows how much I have in the bank. I will tell you. Before drawing this five yesterday I had fifty-three dollars.”
Juno expressed her contempt in a glance, but she closed her fingers on the greenback.
“Very well. I go to look for the apartment. This evening we meet. Where? At the Caffè of the Beautiful Sicilian?”
“No, no; not there!” said Bertino. “You must not come to Mulberry.”
“Why?” she demanded, eying him closely
He made the only answer that could have satisfied her:
“It is no place for such a signora as you.”
They appointed another meeting place—one that lay beyond the zone of Signor Di Bello’s nightly revels, and with a wave of the hand Juno took leave of her husband. He watched her proudly as her stately figure moved toward the Bowery She carried her head with the dignity of the ladies she had seen driving in the Chiaja of Naples on a sunny afternoon.
Bertino returned to the shop in Paradise Park. As he picked his way through the swarms of children on the sidewalk he thought of his uncle sitting in the sunlight, all unwary that the prize he coveted had passed to another. And the elation of the conqueror gave a spring to his step, and a swagger, until he turned a corner and beheld the sign of the Wooden Bunch. Then misgiving filled his soul and restored his trudging pace, his peasant gait—misgiving that the vanquished one might exact an accounting.
“Soul of a lobster!” cried Di Bello, springing from his chair, when the young man appeared at the door. “Where the crocodile have you been? Animal! To keep me waiting like this, and a grand game of bastoni to be played at the Three Gardens. By the Dragon, you are going too far!”
He flung out of the shop, not waiting to hear Bertino’s lame excuse.
That evening, after the shop was closed, Bertino and Juno visited a large instalment house in the Bowery and made their selection of furniture.
“We shall not need much,” he said, mindful of his balance in the bank, “for in a little while we shall live in Casa Di Bello.”
“Casa Di Bello!” sneered Juno. “Do you think I am a fool?”
Nevertheless, when two months of living in the little dark flat had brought her no nearer the inside of the Di Bello house, where her husband continued to live in order to avert suspicion, she became
impatient, disgusted. The few hours a week that he could steal from the shop to visit her were not the happiest in his life. She grew sullen and entertained him with fault-finding. Of his poverty she never lost an opportunity to twit him, and called him a cheat for marrying her. At last she declared that she would not stay there alone any longer. If a man took a wife and could not live with her and support her like a Christian he had better give her up. And he talked of money! Why did he not bring her good things from the grocery? For two months she had lived on bread and salame half the time, with an occasional feast of lupine beans and veal that he brought her from Mulberry And what veal! In Naples it would not be permitted to sell such young meat. Perhaps it was good enough for the wives of the Mulberry cattle, but it would not do for her to live that way. She had been a fool to put up with it as long as she had—a woman like her!—when she could go on the stage and live as a signora should. Yes, she could get a place on the stage, and it would not be an Italian theatre either. Goldoni the cornetist had left La Scala and was playing in the orchestra of a Broadway theatre, the great Titania. The other day she met him, and she did not let on that she was married. See how well she could keep a secret!—but she was a fool for doing so. Well, Goldoni was a man. He said that he could get her a place in the Titania without any trouble. In fact, the impresario would be glad to engage her. She would be the finest shape in the company. It would be twelve dollars a week sure for a figure such as hers, Signor Goldoni had assured her. Why, then, should she remain at home nights waiting for a good-for-nothing of a husband, who never brought her anything better than bob veal?
Bertino pleaded with her to be patient and all would end well. By the Feast of San Giovanni, if not before, it would be safe to reveal the secret of his marriage, when, he could promise her, his goodtempered uncle would forgive him, and invite them both to make their home in Casa Di Bello. As for his aunt, she would not be here to interfere.
“Your aunt will not be here?” asked Juno, who recognised in Carolina her bitterest foe.
“No. She has broken her leg, and will not return to America for a long time. The news came yesterday.”
When Bertino pressed the bell button of the flat a week afterward the electric lock of the street door did not click its customary “come in.” For several minutes he kept up a serenade. At length a thunderous voice sounded through the speaking tube:
“She’s out. Get out!”
It was Juno’s first night on the stage of the Titania. She had taken the engagement without deeming it worth while to inform her husband. Bertino returned to Mulberry, at first greatly alarmed for her safety, but in turn filled with most dreadful imaginings as to the cause of her absence. The following night he got a similar response to his sonata on the bell, but, instead of going away in a half-distracted state of mind, he lingered in the doorway, or paced to and fro before the house. To-night he was not merely a husband worried because his wife was missing. His alert eye and grimly patient air bespoke a more serious matter Whether walking, standing, or sitting on the steps he was careful not to take one of his hands—the right—out of his coat pocket. It was after midnight when he caught sight of her. The white glare of an electric light brought her suddenly into view as she turned the corner. He tightened his grip on the thing in his pocket, but as she drew near and it was certain that she had no companion save a small valise, he came forth from the shadow in which he had crouched when the purpose of dealing her a deadly thrust was full upon him. She started back, but quickly regained her frigid calm.
“You’ve had a fine wait,” she said.
“Where have you been?” he demanded, for the first time speaking to her in a tone that smacked of authority.
“Working and earning money,” she answered—“money that you ought to give me.”
“Working? Where?”
“In the theatre—the great Titania. Bah! You never even heard of it. Do you know where Broadway is?”
He did not resent her scornful words. The motive for killing her having passed, he was again her blind worshipper. Producing her latchkey she opened the door.
“Come in,” she said. “I have something to say to you.” And when they had entered the flat: “You must come to the theatre and walk home with me every night after the representation. At the stage door you must wait. There are beasts who will not let a woman be when she is alone at night. I have been annoyed enough.”
“Who has annoyed you?” said Bertino, springing up and putting his hand in the stiletto pocket, now as eager to slay the offender as he had been to knife her a few minutes before.
“No matter. To-morrow night and every night you be there at the stage door.”
Signor Di Bello sought in vain to get a trace of Juno. The impresario of La Scala could not give him any clew. He visited all the concert halls and singing caffès of Mulberry, as well as the Italian theatres of Little Italy in the Upper East End. Not a soul knew anything about her. One day he said to Bertino:
“That woman Juno has flown like the bluebird that used to light on the Garibaldi statue. Do you know where she is?”
“How should I know? You threaten to kill me if I do not keep away from her, and then ask me where she is!”
“It is a grand mystery,” mused Di Bello, throwing out his legs and lying back in his chair. “Just when I am ready to marry her she takes wing.”
“Ah, si,” said Bertino meditatively—“a grand mystery.”
CHAPTER XII
THE PEACE PRESERVED
A Juno’s sudden disappearance the theatre and the caffès of Mulberry lost their charm for Signor Di Bello. He began to roam abroad evenings in quest of amusement. There came to him a newborn desire to explore the region of American life that lay beyond the colony’s border. For twelve years he had dwelt in its heart and felt the throb of the big city; but never before had it struck his mind to know more of this terra misteriosa than he could learn from the morning Araldo and the evening Bolletino, two local scions of the corybantic press, which bawled the news of Mulberry in doublecolumn scares, but only whispered in paragraphs of the affairs of New York. With sixty thousand others Mulberry was his world. He had never sought acquaintance with the great American monster whose roar filled the surrounding air by day and whose million eyes at night gave the northern sky a dim, false dawn.
From visiting Bowery shows he became a patron of the vaudeville theatres farther up town. At length he discovered the Tenderloin, with its dazzling electric displays at the doors of theatres and drinking places, its phantom gaiety. Resolved to sound the depths of this ocean of lights, he went along with a current that flowed to the box office of the Titania, where the glittering Aztec spectacle, “Zapeaca” was the magnet, charged with “one hundred American beauties.”
“By Cristoforo Colombo, it is she!” the grocer exclaimed, as the woman he had hunted in a cityful marched across the stage, bringing up the rear of a long column of high-heeled warriors. Though disguised in a tin spear, a pasteboard shield, and a sheening helmet set jauntily upon her bounteous raven mane, he knew her at first sight. No mistaking that snub nose, that grand carriage, the plethora of her line, the Eastern warmth of her colour.
“Brava!” he cried out, from his seat near the footlights whenever the row of beauties to which she belonged showed themselves in marching order. It was a renewal of the transport into which her presence had thrown him when in solitary pride she held the stage of La Scala and bleated “Santa Lucia.” To the jeers of the people about him he paid no heed, but gave wild, vociferous expression to his delight at finding her and feasting his eyes upon her, as she stood there in all the truth of the ballet’s scant drapery.
After the performance he waited in front of the theatre until the lights were extinguished and the big doors slammed in his face. Well it was for the public peace that his education did not include a knowledge of the stage door, for had he gone round the corner to that entrance not only would he have encountered Juno, but he would have witnessed the infuriating afterpiece of Bertino taking her arm and carrying her off toward the East side. It is not unlikely that one steel blade at least would have gleamed in the half light of that by-street. But his innocence as to the right door at which to await a lady of the ballet caused a postponement of the tragedy. When at last he sought the advice of a cabman and was directed to the proper place it was too late.
“Satana porco!” he growled as he started homeward. “I am a grand donkey. This is Saturday. To-morrow is festa. Two whole days must I go without seeing her. But on Monday night we shall meet, and then she shall be my promised wife.”
At the same time Juno was telling Bertino of her determination to go with the “Zapeaca” company in a tour of the country. They talked as they moved along on foot toward the Third Avenue Elevated. “It is only ten dollars a week,” she said, “with all expenses save the railroad to pay; but what would you have? Is it not better than living here the way you support me? Perhaps you think I will spend my money. Not even in a dream! A woman expects her husband to support her. To-morrow night, then, I go.”
“How long shall you be absent?” asked Bertino humbly.
“Goldoni says six months anyway; perhaps longer.”
“You will come back to me?”
“Yes”—and after a pause—“when you can support me like a signora.”
“In six months!” said Bertino exultantly. “Ha! then I shall be my own padrone. Then you shall see what a man your husband is.”
“Why?”
“Armando’s bust will be here. Don’t you remember? The bust that shall bring us both fortune. Patience, patience, my precious. Mark what I say: With the grand marble of the First Lady of the Land once in my hands I shall quickly put my uncle in a sack. In his face I will snap my fingers and say, ‘I beg to inform you, signore, that Juno is my wife.’”
She made no answer, and Bertino went on building airy mansions of the golden harvest to follow the sale of the sculpture then under way as well as that to be reaped from other marbles to be turned out of Armando’s far-off workshop. His words affected Juno in a manner that he little kenned. She had given herself only a fugitive thought as to what might happen when the bust should arrive and Bertino should find it an image of his own wife instead of the wife of the President of the United States. When the critical moment came, when the fruit of her roguery stood unveiled, she felt that she should be equal to it—that she could shrug her shoulders and meet Bertino’s suspicions with a simple plea of ignorance, and trust to his believing that he himself sent the wrong photograph by mistake. Now she perceived that it behooved her to keep friends with him, to guile him with affection, else his suspicion when he should discover the fraud might take the cast of sullen conviction, and in Mulberry who can tell what a husband may do with a false wife, whatever the shade of her duplicity may be? Moreover, she wanted the bust. Her rude self-conceit thirsted for that effigy in stone of her own dear self. To lose it would be to miss the prize on which she had set her desire when she said “Yes” that day in the Caffè of the Beautiful Sicilian.
“Ah, yes,” she replied when they stood on the Elevated platform. “We shall put your uncle in a sack and get along well together when
the bust is here.”
“Brava, my wife!” said Bertino, and they entered the train.
Next day being the Feast of Sunday, Bertino and his uncle met at the noon repast in Casa Di Bello, as they had done every Sunday since Carolina’s absence. The grocer was in jubilant spirits, unable to contain his joy over the finding of Juno.
“Ah, nephew mine,” he said, when Angelica had set a large bowl of steaming chestnut soup on the board and retired to her listening place. “Not many days, caro mio, and we shall have a fine woman at table with us. Yes, a woman truly magnificent.”
“Who is she?”
“The woman who is to be my wife. I told you once. Can you not divine?”
“No.”
“Well, I will tell you, though it is a great secret: Juno the Superb.”
A spoonful of soup that Bertino was in the act of swallowing took the wrong course and choked him, while Angelica was thrown from her balance at the head of the kitchen stairs and almost fell to the bottom. When Bertino had stopped coughing he gasped:
“Juno the Superb?”
“Yes. Is it not famous?”
“Your wife?”
“Yes. Ah, what joy!”
“But it is impossible!”
“Not at all, nephew mine. I have found her. I saw her last night for the first time since the Feast of San Giorgio. Ah, how I had searched! It was in the theatre that I saw her—at the Titania, a grand spectacle. So many women, and beautiful! But not one was the equal of Juno.
My word of honour for that. Well, I waited after the representation, but did not see her. To-morrow night, though, I shall say to her: ‘Juno, be my wife. In three months come to my house, to Casa Di Bello.’ These words will I say to her, and I shall wait at the stage door until she comes out.”
“You will wait many months, then,” said Bertino to himself with a smothered chuckle as he fell upon a patty of codfish that Angelica had just brought in.
“Grand trouble, grand trouble,” sighed Angelica, as she prepared the after-dinner zabaglioni[B] for her master. “If the signorina were here he would not dare bring her to the house. And when she comes and finds the singer has been in Casa Di Bello! O Maria— grandissimo trouble!”
In the evening Bertino accompanied Juno to the Grand Central Depot, whence she left for Buffalo with the rest of the hundred American beauties of the “Zapeaca” aggregation.
On Tuesday morning Bertino regarded his uncle quizzically across the breakfast table, but of his second fruitless visit to the Titania’s stage door the signore was as silent as the figure of San Patrizio that looked down upon Casa Di Bello from the architrave of the church on the opposite side of Mulberry Street. And for many a day thereafter not a word did he utter concerning any magnificent woman that was to become his wife.
CHAPTER XIII
THE PEACE DISTURBED
T bluebird came again to perch on Garibaldi’s cap, the baby maples put forth their leaves, and Signor Di Bello told Bertino it was time to give the Wooden Bunch a new coat of yellow. Once more the fire-escapes on either side of Corso di Mulberry bloomed with potted geraniums; glistening radishes lent their vernal blush to the vegetable stalls, and the thoughts of Sara the Frier of Pepper Pods turned to summer profits. The building trades had set the winter idlers to work, and the Alley of the Moon resounded no longer with the wild shouts of mora players. The hokey-pokey man, tiding over the cold months with an ancient hand organ, yearned to put away The Blue Danube and The Marseillaise, and wheel out his gorgeous ice-cream cart. The old gondolier, selling pine-cone seeds at the foot of China Hill, could leave his toe-toaster at home now, and let the May sunshine economize the charcoal.
Bertino mixed the paint, selected a cheap brush from the stock of the shop, and set to work on the Bunch. It is doubtful that he heard the swish, swish of the brush. His thoughts were of Juno. Her absence had extended long over the six months, and for more than thirty days he had not heard from her. There was no excuse for this neglect, he reasoned, since her education had been so liberal that she could spell and write as well as any woman in Mulberry. Of the few letters received from her, each had contained a tale of woe—the woe of a ballet lady striving to live on the road with a salary of ten dollars a week. The missives, rich in terms of endearment, always touched his pocket as well as his heart, and by return mail he never failed to send her a dollar or two. But why had she been silent this last month of the tour, instead of writing to tell him where to meet her when she should reach the city? Already she ought to be here. What if she never came back—if she forsook him? In the shock of this
terrible thought he upset the pail of yellow just as Signor Di Bello stepped out of the shop.
“Soul of a cat!” exclaimed the grocer, the toe of one of his black shoes tipped with the paint. “What the rhinoceros are you about? Gran Dio, what stupendous stupidity!”
Re-entering the shop, he cleaned off the paint, fuming the while and growling. Then he flew out, scowling at Bertino as he passed, and made straight for the Caffè of the Three Gardens.
“The monkey!” said Bertino to himself. “When the bust arrives I’ll be rid of him.”
A moment afterward the letter carrier handed him a large envelope addressed in a big, round hand to “Bertino Manconi, Esq.” It was from a customhouse agent, announcing the arrival of the bust, and offering to attend to the business of clearing it. To this end it would be necessary for Bertino to forward the amount of the duty, a hundred and forty dollars. He put the letter in his pocket, filled with apprehension of trouble, for his English was so weak that he could not make out the meaning of the part about the duty, though he suspected that the sum of a hundred and forty dollars was in some way required of him. That evening, after he had lugged in the Wooden Bunch and locked the shop door, he took the mysterious paper to Signor Tomato, who told him the awful truth.
“It must be a great work of art,” said the banker; “very valuable.”
“Valuable!” said Bertino. “Ah, caro mio, if you only knew! Well, I will tell you. It is a bust of her Majesty the Presidentessa.”
“What Presidentessa?”
“Of the United States.”
“St. Januarius! Is it possible?”
One hundred and forty dollars! The sum rose like an impassable mountain between Bertino and the hopes he had cherished so long and fervidly As well have been forty thousand. He could not pay the duty. Marriage had eaten up the savings brought from Italy and what he had earned since. When Signor Tomato told him that the
Government would retain the marble until the impost were paid, he blotted out the poor lad’s fondest anticipations—his dreams of release from Signor Di Bello and the misery of his secret marriage, the freedom to say to his uncle, “Juno is my wife.” To the bust he had looked forward as to a loyal friend, who should come some day to lift him to the plane whereon a man ought to stand. But now that the friend was near, some power which he comprehended but vaguely had clapped her in a prison, from which the future held no promise of letting her go. There came over him the terrible throbbing of blood and the fire of brain that he felt the night he crouched, burning with suspicion, in the doorway with a ready knife waiting for Juno. He could not have answered if asked just now whom he wished to kill. Some infernal prank was playing at his expense, and the time had come to end it. A strange calm possessed him as he began to cast about for the joker. He had been walking in Mulberry Street. At the corner of Spring Street he entered the Caffè of the Three Gardens. Dropping into a chair near the door, he ordered a glass of Marsala; but before the waiter had returned with the wine, Bertino sprang up and darted out of the place. At a table in the caffè’s depth he had seen Juno and Signor Di Bello with their heads together! Holy blood of the angels!
No need of looking further for the joker. His wife returns after six months, does not let her husband know, and goes first to meet another. Yes, the prank has gone far enough.
It was only a block to Casa Di Bello. In a few minutes he was there and in his room. When he came into the street again he had his right hand in his coat pocket.
The meeting of Juno and Signor Di Bello came about in this manner: The signore was walking in Mulberry Street, on his way to the caffè to smoke an after-dinner Cavour, and help some good comrades empty a flask of Chianti. Suddenly he stopped, stood still, his eyes staring and his mouth a gulf of astonishment.
“By the Egg of Columbus!” he exclaimed. “It is she, or I am dreaming!”
There she was, moving toward him on the same side of the street, dressed no better than when he last came face to face with her, but her grand air not a whit impaired.
“At last, at last I find you!” he cried, catching up her hand and kissing it with a loud smack. “Ah! the good God knows how I have hunted for you. But joy, joy! I find you! I see you! My eyes look into yours! Come, away from here! Ah, the Three Gardens! Let us enter. I have something to say—something very important.”
He drew her into the caffè, and sought a table far from the door.
“What do you want to say to me?” asked Juno. She had responded not at all to Signor Di Bello’s passionate greeting.
“Ah, my angel! I want to say to you what I would have said long ago if I had found you. The hunt I have had! And once when I caught sight of you, it was only to have you vanish again like a wine bubble. Where have you been? How beautiful you are! Oh, the grand hunt!”
“Why have you hunted for me?” she said, releasing her hand from his, and moving her chair.
“To offer you what you demanded—a wedding ring.”
“You wish to make me your wife?”
“Yes. Before the Madonna, it is true! Months and months ago I was ready.”
For a moment Juno was silent, contemplative. Then she said, eying him steadily:
“Would you have married me before I left Mulberry?”
“Yes; Dio my witness.”
“Why did you not come to me and say so?”
“But I could not find you. My nephew, Bertino, will tell you that I speak truth. I told him that I intended to make you my wife.”
“When did you tell him that?” she asked quickly, leaning forward and awaiting the answer eagerly, while Signor Di Bello strove to recollect.
“Ah, yes, now I have it,” he said at length. “I remember because it was the day after my sister Carolina sailed for Genova—two days after the Feast of San Giorgio, my saint.”
The recollection rose clear to Juno that it was on the day following Carolina’s departure that she and Bertino went to the little rectory in Second Avenue. And equally vivid to her consciousness stood forth the inflaming truth that Bertino, with full knowledge of Signor Di Bello’s purpose to take her for wife, had hastened their union in order to checkmate his rival. So this moneyless clerk had tricked her into marriage, and cheated her of a rich husband!
“Maledetto!” she said in a half-stifled voice. At the same instant there flashed in her brain a resolve to rid herself of Bertino.
“Why maledetto?” asked the signore. “Do you not accept my offer?”
“Another time I will give you my answer,” she said, rising. “I must go.”
They stood outside, he holding her hand and looking up into her face with worshipful eyes. Suddenly she drew back, and without a parting word took herself off. A face that she had seen in a near-by doorway made her eager to end the interview. She had gone but a few paces when Bertino was by her side.
“So you are here, and putting horns on your husband?” he said, gripping her arm. “Welcome, signora, welcome!” A smile of hellish mockery played on his livid face.
“No, I am not,” she pleaded, a tremor in her voice, because she knew her race.
He laughed, and gripped her arm tighter.
“I know,” he said. “You want a rich man.” Then, with his lips close to her ear: “Do you think you will live?”
“It is not my fault,” she said, still pleading. “What can a woman do when a man plays the fool and annoys her?”
“He annoys you?”
“Yes,” she answered, seizing her chance. “If you were a man you would make him leave me alone. I do not want him.”
“I will kill the dog!” said Bertino, letting go of her arm. A moment he regarded her with the old tenderness, but a black look settled again on his face, and he asked slowly, “Why did you not let me know you were back?”
“I have not been in the city an hour. The shop was closed. Luigia the Garlic Woman will tell you that I asked her if she knew where you had gone. I was going to send a note to Casa Di Bello. We met in the street and—he annoyed me.” She thought now only of saving herself.
“By the heart of Mary!” he said, “this shall stop. I will go to him and tell him you are my wife.”
“No, no! Don’t do that. Wait—wait until you are rid of him—until you are your own padrone—until the bust is here and you have sold it and are a free man.”
“The bust?” he said hopelessly. “It is here, but as well might it have remained in Armando’s studio.”
“What?” she said. “It is here? Where? Let me see it.”
“No; I can not. The Government has it, and will keep it until I pay one hundred and forty dollars. Seven hundred lire! Gesù Bambino! Where shall I get them?”
As they walked on he recounted the distress that had overtaken the supposed First Lady of the Land; her captivity in the hands of revenue officials, and his inability to pay the kingly ransom demanded. This news was a cut and thrust at the hope whereon Juno’s crude self-love had fed for many a month, and it killed the solitary motive that made her hold to Bertino. By neither word nor sign, however, did she betray her disgust and anger; she even feigned sympathy, and bade him be of good cheer, saying tenderly
that ill fortune would not dog them forever; that by luck or pluck they should get possession of the bust, and carry out his plan for moneymaking. These were the first heartening words she had ever spoken to him—the first kindness he could recall as coming from her lips. Despite the black cloud that had risen so suddenly from behind the customhouse, a sweet rapture filled his soul. What mattered it all?— his wife loved him. Their joys and griefs were one. The loneliness that had burdened his spirit since the day of his marriage departed, and his heart lost its bitterness.
“True, my precious,” he said, pressing her hand, “we love each other, and shall know how to manage in spite of the Government.”
At the same time Juno said to herself, “How can I get rid of the fool and marry his uncle?”
They came to a halt at the mouth of the Alley of the Moon, a wide passage between two tenements that led to a rear court heaped with push-carts laid up for the night. Halfway up the alley a large gas lamp with a sputtering light hung over a doorway. On its green glass showed the words, Restaurant of Santa Lucia. In three dingy rooms above, Luigia the Garlic Woman lived with a lodger known to the public of Mulberry as Chiara the Hair Comber. The latter had her shop and living apartment in the “front” room, looking on the alley, and directly over the green light, which shed its rays on her sign, Hair Combing in Signora Style, Two Cents. The remaining room of the trio had been engaged that day by Juno, who had merely fibbed when she told Bertino that she had been in town only an hour. It was the same humble chamber she had occupied during her brief career of starhood on the stage of La Scala.
“I have come here because it costs only twenty soldi a day,” she said to Bertino, “and here I shall remain until—until we can do better. Good night, my dear husband. Courage. Be allegro, and our fortune will sing.”
“Ah, yes; allegro I will be. Good night, my precious wife. Until tomorrow.”
In the solitude of her dreary little coop, while the hoarse shouts of mora players in the restaurant below sounded in her ears, Juno set her wits calmly to the knotty puzzle that the day had brought forth: How to get rid of her husband that she might accept Signor Di Bello’s offer of marriage? A few grains of poison dropped in wine for Bertino to drink would accomplish the needful state of widowhood, but this method, she discerned, had its faults. It was likely to bring manhunters from the Central Office about one’s head, and detectives were given to putting awkward questions. Moreover, they had a trick of locking up persons whose answers did not suit them. No; in a strictly private matter of this kind it would never do to have the police meddling. That might spoil all. She thought of other plans of removal that she had heard talked about in the Porto quarter of Naples. And while she considered these there darted into her mind one of those mystic shafts of memory that come unbidden by cognate suggestion. It was a Sunday afternoon, and she and Bertino, walking in the suburbs, stood upon Washington Bridge. From the height of the great span she looked down again on the slopes of the Harlem Valley beautiful in the gold and flame of autumn; the sedge marshes that waved to the temperate wind, and far below, growing narrow in the distance, the silvery ribbon of water that glimmered yet faintly in the gloam of sunset. It was one of those Sundays that Bertino brought her a package of bob veal, and she recalled the desire that had seized her to throw him over the parapet. Had she done so in the darkness that soon fell not a soul would have known. What she could have done then she could do now. By this method there would be no police knocking at one’s door and prying into secrets. The quicker he were out of the way the better, and next Sunday, if no moon shone, the thing could be done. With deep satisfaction she viewed her brawny arms and stalwart frame and felt sure of the strength needful to execute the task without bungling. Then she went to bed and slept soundly.
But the morrow had in its teeth a fine marplot for her little tragedy. It happened in the evening in this wise: The shutters of the shop put up, Bertino hastened to the Restaurant of Santa Lucia, where Juno had promised to await him. He opened the door, and what he saw caused him to pause on the threshold, but for only a moment. She
was not alone. Seated by her side on the rough wooden bench that flanked the long oil-clothed table was Signor Di Bello. Their backs were turned to the door, but Bertino knew both at first glance. On the opposite side of the board the gaslight fell upon a row of dusky faces, into the caverns of which large quantities of spaghetti coiled about forks were being despatched. In other parts of the low-ceiled room, muggy with smoke of two-cent cigars, coatless men, engaged in furious combats at cards, shouted and rained sledge-hammer blows on the tables. Before any one had seen him enter, Bertino sprang across the floor like a jaguar and snatched from his uncle’s hand a knife with which he was in the act of conveying a bit of sheep’s-milk cheese to his mouth. Then without ado the gudgeon who believed that his wife was annoyed fell to the performance of a husband’s duty. It was a wild thrust, but well enough aimed to have found a mortal course had the tool been of the standard pattern used in Mulberry for odd jobs of this kind—the long thin steel, fine tempered, and needlelike of point. As it chanced, Signor Di Bello’s left shoulder blade was stabbed flesh deep, and a second lunge only slit his coat sleeve, because he dropped sidewise out of harm’s way just as Bertino brought down the knife again. Every eye in the restaurant had witnessed the second blow and the fall of Signor Di Bello from the end of the bench, so the conclusion was instant and general that the odd job had been finished.
It was a wild thrust.
“Fly!” they cried, one and all, rising and pointing to the door. “Your work is done.”
Bertino stood a moment, grasping the knife and looking at Juno; then he flung it down and made for the door. One of the card players held it open for him as he passed out; for the vendetta is a man’s sacred right—a strictly private matter to be settled by him in his own way, free of outside interference. Enough that he use the genteel knife and not the clumsy pistol, which is seldom sure of its mark, and brings the police to make trouble for one’s friends.
